42 USC 1395 - Payment of benefits

1 So in original.

(E) with respect to services furnished to individuals who have been determined to have end stage renal disease, the amounts paid shall be determined subject to the provisions of

2 So in original. The word “and” probably should not appear.

(J) with respect to expenses incurred for radiologist services (as defined in

3 So in original. Probably should be followed by a comma.

(FF) with respect to marriage and family therapist services and mental health counselor services under

4 See 2010 Amendment note for subsec. (a)(2)(F) to (H) below.

if such services are furnished by a public provider of services, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this provision), free of charge or at nominal charges to the public, the amount determined in accordance with

5 So in original. Probably should be followed by “to”.

a COVID–19 vaccine and its administration described in

6 So in original. There is no subpar. (D).

In place of the manual medical review process under subparagraph (C)(i), the Secretary shall implement a process for medical review under this subparagraph under which the Secretary shall identify and conduct medical review for services described in subparagraph (C)(i) furnished by a provider of services or supplier (in this subparagraph referred to as a “therapy provider”) using such factors as the Secretary determines to be appropriate.

7 So in original. Probably should be preceded by “a”.

that includes another therapy provider identified using the factors determined under this subparagraph.

8 So in original. The comma after “subclause (II))” probably should follow “is performed”.

receives requests for testing during the year in which the test is performed 

9 So in original. Probably should be “such paragraph applies”.

with respect to a physician. Paragraph (4) of such section shall apply in this subparagraph in the same manner as such paragraph applies to such section.

10 So in original. The word “this” probably should not appear.

subparagraph (A)(iii)(II), the term “eye or eye and ear unit” means a physically separate or distinct unit containing separate surgical suites devoted solely to eye or eye and ear services.

11 So in original. The closing parenthesis preceding the comma probably should not appear.

including the second sentence of subparagraph (C) of such paragraph, to payment for services under this subsection, and make such revisions under this paragraph, in an appropriate manner (as determined by the Secretary).

12 So in original. Probably should be “are—”.

13 So in original. Probably should be “subparagraph”.

(A)(iii), exceed the conversion factor used to determine the amount paid for physicians’ services that are anesthesia services in the area or locality.

14 So in original. No par. (2) has been enacted.

The aggregate amount of the payments to be made for all or part of a cost reporting period for services described in subsection (a)(2)(E)(i) furnished under this part on or after

15 So in original. Probably should be “a covered OPD”.

service (or group of services) furnished during the period beginning on

16 So in original. Probably should be preceded by “under”.

subsection.

17 So in original. Probably should be “paragraphs”.

(2) and (4) of subsection (m) shall apply to the determination of additional payments under this subsection in the same manner as such provisions apply to the determination of additional payments under subsection (m).

18 So in original. Probably should be “exceed”.

expected aggregate expenditures; or

19 So in original. Probably should be preceded by “section”.

of this title, or otherwise, of the following:

Editorial Notes

References in Text

Section 626(d) of Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to in subsec. (i)(2)(D)(i), is section 626(d) of Puspan. L. 108–173, which is set out as a note under this section.

Section 9320(k) of the Omnibus Budget Reconciliation Act of 1986, as amended by section 6132 of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (l)(1)(C), is section 9320(k) of Puspan. L. 99–509, as amended, which is set out as a note under section 1395k of this title.

The amendments made by section 9320 of the Omnibus Budget Reconciliation Act of 1986, referred to in subsec. (l)(3)(B), are amendments made by section 9320 of Puspan. L. 99–509, which amended sections 1395k, 1395l, 1395u, 1395x, 1395y, 1395aa, 1395bspan, 1395cc, 1395ww, 1396a, and 1396n of this title and provisions set out as a note under section 1395ww of this title.

Section 4521 of The Balanced Budget Act of 1997, referred to in subsec. (t)(7)(F), is section 4521 of Puspan. L. 105–33, Aug. 5, 1997, 111 Stat. 444, which amended this section and enacted provisions set out as a note under this section.

Codification

Puspan. L. 111–148, § 10221(a), enacted into law S. 1790, One Hundred Eleventh Congress, as reported by the Committee on Indian Affairs of the Senate in Dec. 2009, “[e]xcept as provided in” section 10221(span) of Puspan. L. 111–148. Section 201(span) of S. 1790 would have amended this section but was stricken out by section 10221(span)(4) of Puspan. L. 111–148.

Amendments

2024—Subsec. (z)(1)(A). Puspan. L. 118–42, § 304(a)(1), substituted “with 2026” for “with 2025” and inserted “, or, with respect to 2026, 1.88 percent” after “3.5 percent” in introductory provisions.

Subsec. (z)(2)(B). Puspan. L. 118–42, § 304(a)(2)(A), substituted “2026” for “2025” in span and introductory provisions.

Subsec. (z)(2)(C). Puspan. L. 118–42, § 304(a)(2)(B), substituted “2027” for “2026” in span and introductory provisions.

Subsec. (z)(2)(D). Puspan. L. 118–42, § 304(a)(2)(C), substituted “2025, and 2026” for “and 2025”.

Subsec. (z)(4)(B). Puspan. L. 118–42, § 304(a)(3), inserted “, or, with respect to 2026, 1.88 percent” after “3.5 percent”.

2022—Subsec. (a). Puspan. L. 117–169, § 11407(span)(2), inserted at end of concluding provisions “The Secretary shall make such adjustments as may be necessary to the amounts paid as specified under paragraph (1)(S)(ii) for insulin furnished on or after July 1, 2023, through an item of durable medical equipment covered under section 1395x(n) of this title, such that the amount of coinsurance payable by an individual enrolled under this part for a month’s supply of such insulin does not exceed $35.”

Subsec. (a)(1)(G). Puspan. L. 117–169, § 11101(span)(1)(A), inserted “, subject to subsection (i)(9),” after “the amounts paid”.

Subsec. (a)(1)(S). Puspan. L. 117–169, § 11407(span)(1), designated existing provisions as cl. (i), inserted “except as provided in clause (ii),” before “with respect to drugs and biologicals”, and added cl. (ii).

. Puspan. L. 117–169, § 11101(span)(1)(B), substituted “subject to subparagraph (EE), with respect to” for “with respect to”.

Subsec. (a)(1)(EE). Puspan. L. 117–169, § 11101(span)(1)(C), (D), added subpar. (EE).

Subsec. (a)(1)(FF). Puspan. L. 117–328, § 4121(a)(3), added subpar. (FF).

Subsec. (a)(1)(GG). Puspan. L. 117–328, § 4133(a)(2)(A), added subpar. (GG).

Subsec. (a)(1)(HH). Puspan. L. 117–328, § 4134(d), added subpar. (HH).

Subsec. (span)(13). Puspan. L. 117–169, § 11407(a), added par. (13).

Subsec. (c)(2). Puspan. L. 117–328, § 4124(span)(3), inserted “or intensive outpatient services” after “partial hospitalization services”.

Subsec. (i)(9). Puspan. L. 117–169, § 11101(span)(2), added par. (9).

Subsec. (i)(10). Puspan. L. 117–328, § 4135(span), added par. (10).

Subsec. (t)(2)(E). Puspan. L. 117–328, § 4135(a)(1), inserted “and temporary additional payments for non-opioid treatments for pain relief under paragraph (16)(G),” after “payments under paragraph (6)”.

Subsec. (t)(6)(B)(iii). Puspan. L. 117–328, § 4141(a)(1), substituted “Subject to subparagraph (K), a category” for “A category” in introductory provisions.

Subsec. (t)(6)(K). Puspan. L. 117–328, § 4141(a)(2), added subpar. (K).

Subsec. (t)(8)(F). Puspan. L. 117–169, § 11101(span)(3), added subpar. (F).

Subsec. (t)(16)(G). Puspan. L. 117–328, § 4135(a)(2), added subpar. (G).

Subsec. (z)(1)(A). Puspan. L. 117–328, § 4111(a)(1), substituted “2025” for “2024” and inserted “(or, with respect to 2025, 3.5 percent)” after “5 percent” in introductory provisions.

Subsec. (z)(2)(B). Puspan. L. 117–328, § 4111(a)(2)(A), substituted “2025” for “2024” in span and introductory provisions.

Subsec. (z)(2)(C). Puspan. L. 117–328, § 4111(a)(2)(B), substituted “2026” for “2025” in span and introductory provisions.

Subsec. (z)(2)(D). Puspan. L. 117–328, § 4111(a)(2)(C), substituted “2023, 2024, and 2025” for “2023 and 2024”.

Subsec. (z)(4)(B). Puspan. L. 117–328, § 4111(a)(3), inserted “(or, with respect to 2025, 3.5 percent)” after “5 percent”.

Subsec. (bspan)(3)(B). Puspan. L. 117–328, § 1262(span)(5), which directed substitution of “first begins prescribing narcotic drugs in schedule III, IV, or V of section 812 of title 21 for the purpose of maintenance or detoxification treatment on or after January 1, 2021” for “first receives a waiver under section 823(g) of title 21 on or after January 1, 2019”, was executed by making the substitution for “first receives a waiver under section 823(h) of title 21 on or after January 1, 2019”, to reflect the probable intent of Congress and the intervening amendment by Puspan. L. 117–215. See note below.

Puspan. L. 117–215 substituted “823(h)” for “823(g)”.

2021—Subsec. (f)(3)(A)(i). Puspan. L. 117–7, § 2(a)(1)(A)(i), added subcls. (I) and (II) and struck out former subcls. (I) and (II) which read as follows:

“(I) the per visit payment amount applicable to such rural health clinic for rural health clinic services furnished in 2020, increased by the percentage increase in the MEI applicable to primary care services furnished as of the first day of 2021; or

“(II) the limit described in paragraph (2)(A); and”.

Subsec. (f)(3)(A)(ii)(I). Puspan. L. 117–7, § 2(a)(1)(A)(ii), substituted “under subclause (I) or (II) of clause (i), as applicable,” for “under clause (i)(I)”.

Subsec. (f)(3)(B). Puspan. L. 117–7, § 2(a)(1)(B), added subpar. (B) and struck out former subpar. (B) which read as follows:

“(B) A rural health clinic described in this subparagraph is a rural health clinic that, as of December 31, 2019, was—

“(i) in a hospital with less than 50 beds; and

“(ii) enrolled under section 1395cc(j) of this title.”

2020—Subsec. (a). Puspan. L. 116–260, § 122(a), in concluding provisions, substituted “section 1395m(o) of this title” for “section 1395m(0) of this title”, realigned margins, and inserted at end “For services furnished on or after January 1, 2022, paragraph (1)(Y) shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test.”

Subsec. (a)(1)(Y). Puspan. L. 116–260, § 122(span)(1), inserted “subject to subsection (dd),” before “with respect to”.

Subsec. (a)(1)(DD). Puspan. L. 116–127, § 6002(a)(1), which directed adding subpar. (DD) before the period at the end of par. (1), was executed by adding it before the semicolon at the end, to reflect the probable intent of Congress.

Subsec. (a)(10). Puspan. L. 116–260, § 125(a)(2)(A), added par. (10).

Subsec. (span)(11). Puspan. L. 116–127, § 6002(a)(2), added par. (11).

Subsec. (span)(12). Puspan. L. 116–136 added par. (12).

Subsec. (f). Puspan. L. 116–260, § 130(2), (3)(A), (4), designated existing provisions as par. (1), redesignated former pars. (1) and (2) as subpars. (A) and (B), respectively, of par. (1), and added pars. (2) and (3).

Subsec. (f)(1). Puspan. L. 116–260, § 130(3)(B), which directed insertion of “prior to April 1, 2021” after “services provided”, was executed by making the insertion after “services provided” the second place appearing, to reflect the probable intent of Congress.

Subsec. (f)(2). Puspan. L. 116–260, § 130(1), inserted “(before April 1, 2021)” after “in a subsequent year” and substituted “this paragraph” for “this subsection”.

Subsec. (j). Puspan. L. 116–159 inserted before period at end “(or, in the case of such a determination made with respect to a payment made on or after March 27, 2020, and during the emergency period described in section 1320span–5(g)(1)(B) of this title under the program described in section 421.214 of title 42, Code of Federal Regulations (or any successor regulation), at a rate of 4 percent)”.

Subsec. (z)(2)(B). Puspan. L. 116–260, § 114(a)(1), substituted “through 2024” for “and 2022” in span and “each of 2021 through 2024” for “2021 and 2022” in introductory provisions.

Subsec. (z)(2)(C). Puspan. L. 116–260, § 114(a)(2), substituted “2025” for “2023” in span and introductory provisions.

Subsec. (z)(2)(D). Puspan. L. 116–260, § 114(a)(3), inserted at end “With respect to 2023 and 2024, the Secretary shall use the same percentage criteria for counts of patients that are used in 2022.”

Subsec. (cc). Puspan. L. 116–127, § 6002(a)(3), added subsec. (cc).

Subsec. (dd). Puspan. L. 116–260, § 122(span)(2), added subsec. (dd).

2019—Subsec. (t)(6)(E)(i). Puspan. L. 116–94, § 107(a)(1), substituted “2018 or 2020” for “2018”.

Subsec. (t)(6)(J). Puspan. L. 116–94, § 107(a)(2), added subpar. (J).

2018—Subsec. (a)(1)(CC). Puspan. L. 115–271, § 2005(c)(1), added subpar. (CC).

Subsec. (g)(1). Puspan. L. 115–123, § 50202(1), designated existing provisions as subpar. (A), inserted “The preceding sentence shall not apply to expenses incurred with respect to services furnished after December 31, 2017.” after “for purposes of subsections (a) and (span).”, and added subpar. (B).

Subsec. (g)(3). Puspan. L. 115–123, § 50202(2), designated existing provisions as subpar. (A), inserted “The preceding sentence shall not apply to expenses incurred with respect to services furnished after December 31, 2017.” after “for purposes of subsections (a) and (span).”, and added subpar. (B).

Subsec. (g)(5)(D). Puspan. L. 115–123, § 50202(3)(A), redesignated subpar. (D) as par. (8) of subsec. (g).

Subsec. (g)(5)(E)(iv). Puspan. L. 115–123, § 50202(3)(B), inserted “, except as such process is applied under paragraph (7)(B)” before period at end.

Subsec. (g)(7). Puspan. L. 115–123, § 50202(4), added par. (7).

Subsec. (g)(8). Puspan. L. 115–123, § 50202(3)(A), redesignated par. (5)(D) as par. (8).

Subsec. (i)(8). Puspan. L. 115–271, § 6082(span), added par. (8).

Subsec. (t)(6)(C)(i). Puspan. L. 115–141, § 1301(a)(1)(A), substituted “Subject to subparagraph (G), the payment” for “The payment” in introductory provisions.

Subsec. (t)(6)(D)(i). Puspan. L. 115–141, § 1301(a)(1)(B), inserted “subject to subparagraph (H),” before “in the case”.

Subsec. (t)(6)(E)(i). Puspan. L. 115–141, § 1301(a)(2), inserted at end “This clause shall not apply for 2018.”

Subsec. (t)(6)(G) to (I). Puspan. L. 115–141, § 1301(a)(1)(C), inserted subpars. (G) to (I).

Subsec. (t)(22). Puspan. L. 115–271, § 6082(a), added par. (22).

Subsecs. (z), (aa). Puspan. L. 115–271, § 6083(span)(1), redesignated subsec. (z), relating to medical review of spinal subluxation services, as (aa).

Subsec. (bspan). Puspan. L. 115–271, § 6083(span)(2), added subsec. (bspan).

2016—Subsec. (a)(1)(BB). Puspan. L. 114–255, § 5012(c)(1), added subpar. (BB).

Subsec. (t)(18)(B). Puspan. L. 114–255, § 16002(span)(1), inserted “, subject to subparagraph (C),” after “shall”.

Subsec. (t)(18)(C). Puspan. L. 114–255, § 16002(span)(2), added subpar. (C).

Subsec. (t)(21)(B)(i). Puspan. L. 114–255, § 16001(a)(1)(A), substituted “the subsequent provisions of this subparagraph” for “clause (ii)”.

Subsec. (t)(21)(B)(iii) to (v). Puspan. L. 114–255, § 16001(a)(1)(B), added cls. (iii) to (v).

Subsec. (t)(21)(B)(vi). Puspan. L. 114–255, § 16002(a)(1), added cl. (vi).

Subsec. (t)(21)(B)(vii). Puspan. L. 114–255, § 16002(a)(2), inserted after first sentence “Not later than 2 years after the date the Secretary receives an attestation under clause (vi) relating to compliance of a department of a provider with requirements referred to in such clause, the Secretary shall audit the compliance with such requirements with respect to the department.”

Puspan. L. 114–255, § 16001(a)(1)(B), added cl. (vii).

Subsec. (t)(21)(B)(viii). Puspan. L. 114–255, § 16001(a)(1)(B), added cl. (viii).

Subsec. (t)(21)(B)(viii)(III). Puspan. L. 114–255, § 16002(a)(3), inserted at end “For purposes of carrying out this subparagraph with respect to clause (vi) (and clause (vii) insofar as it relates to such clause), $2,000,000 shall be available from the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title, to remain available until expended.”

Subsec. (t)(21)(E)(iv). Puspan. L. 114–255, § 16001(a)(2), added cl. (iv).

2015—Subsec. (a)(1)(AA). Puspan. L. 114–113, § 504(span)(1), added subpar. (AA).

Subsec. (g)(5)(A). Puspan. L. 114–10, § 202(a)(1), substituted “December 31, 2017” for “March 31, 2015”.

Subsec. (g)(5)(C)(i). Puspan. L. 114–10, § 202(span)(1)(A), inserted “, subject to subparagraph (E),” after “manual medical review process that”.

Subsec. (g)(5)(E). Puspan. L. 114–10, § 202(span)(1)(B), added subpar. (E).

Subsec. (g)(6)(A). Puspan. L. 114–10, § 202(a)(2), substituted “December 31, 2017” for “March 31, 2015” and “2012 through 2017” for “2012, 2013, 2014, or the first three months of 2015”.

Subsec. (t)(1)(B)(v). Puspan. L. 114–74, § 603(1), added cl. (v).

Subsec. (t)(16)(F). Puspan. L. 114–113, § 502(span), added subpar. (F).

Subsec. (t)(21). Puspan. L. 114–74, § 603(2), added par. (21).

Subsec. (x)(3). Puspan. L. 114–10, § 101(e)(3)(A), inserted at end “The amount of the additional payment for a service under this subsection and subsection (z) shall be determined without regard to any additional payment for the service under subsection (z) and this subsection, respectively.”

Subsec. (y)(3). Puspan. L. 114–10, § 101(e)(3)(B), inserted at end “The amount of the additional payment for a service under this subsection and subsection (z) shall be determined without regard to any additional payment for the service under subsection (z) and this subsection, respectively.”

Subsec. (z). Puspan. L. 114–10, § 514(a), added subsec. (z) relating to medical review of spinal subluxation services.

Puspan. L. 114–10, § 101(e)(2), added subsec. (z) relating to incentive payments for participation in eligible alternative payment models.

2014—Subsec. (a)(1)(D)(i). Puspan. L. 113–93, § 216(span)(1)(A)(i)–(iii), designated existing provisions as subcl. (I), substituted “subsection (h)(1) (for tests furnished before January 1, 2017)” for “subsection (h)(1)”, and added subcl. (II).

Subsec. (a)(1)(D)(ii). Puspan. L. 113–93, § 216(span)(1)(A)(iv), substituted “for tests furnished before January 1, 2017, on the basis” for “on the basis”.

Subsec. (a)(2)(D)(i). Puspan. L. 113–93, § 216(span)(1)(B)(i)–(iii), designated existing provisions as subcl. (I), substituted “subsection (h)(1) (for tests furnished before January 1, 2017)” for “subsection (h)(1)”, and added subcl. (II).

Subsec. (a)(2)(D)(ii). Puspan. L. 113–93, § 216(span)(1)(B)(iv), substituted “for tests furnished before January 1, 2017, on the basis” for “on the basis”.

Subsec. (span)(3)(B). Puspan. L. 113–93, § 216(span)(1)(C), substituted “for tests furnished before January 1, 2017, on the basis” for “on the basis”.

Subsec. (g)(5)(A). Puspan. L. 113–93, § 103(1), substituted “March 31, 2015” for “March 31, 2014”.

Subsec. (g)(6)(A). Puspan. L. 113–93, § 103(2), substituted “March 31, 2015” for “March 31, 2014” and “2012, 2013, 2014, or the first three months of 2015” for “2012, 2013, or the first three months of 2014”.

Subsec. (h)(2)(A)(i). Puspan. L. 113–93, § 216(span)(1)(D), substituted “and, for tests furnished before April 1, 2014, subject to” for “and subject to”.

Subsec. (h)(3). Puspan. L. 113–93, § 216(span)(1)(E), in introductory provisions, substituted “fee schedules (for tests furnished before January 1, 2017) or under section 1395m–1 of this title (for tests furnished on or after January 1, 2017), subject to subsection (span)(5) of such section” for “fee schedules”.

Subsec. (h)(6). Puspan. L. 113–93, § 216(span)(1)(F), substituted “For tests furnished before January 1, 2017, in the case” for “In the case”.

Subsec. (h)(7). Puspan. L. 113–93, § 216(span)(1)(G), substituted “and (4) and section 1395m–1 of this title” for “and (4)” and “under this part” for “under this subsection”.

Subsec. (t)(16)(E). Puspan. L. 113–93, § 218(span)(2), added subpar. (E).

Subsec. (t)(20). Puspan. L. 113–93, § 218(a)(2)(A), added par. (20).

2013—Subsec. (g)(5)(A). Puspan. L. 113–67, § 1103(1), substituted “March 31, 2014” for “December 31, 2013” in first sentence.

Puspan. L. 112–240, § 603(a)(1), substituted “December 31, 2013” for “December 31, 2012” in first sentence.

Subsec. (g)(5)(D). Puspan. L. 112–240, § 603(c), added subpar. (D).

Subsec. (g)(6). Puspan. L. 112–240, § 603(span), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (g)(6)(A). Puspan. L. 113–67, § 1103(2), substituted “March 31, 2014” for “December 31, 2013” and “, 2013, or the first three months of 2014” for “or 2013”.

Puspan. L. 112–240, § 603(a)(2), substituted “December 31, 2013” for “December 31, 2012” and inserted “or 2013” after “during 2012”.

Subsec. (t)(16)(D). Puspan. L. 112–240, § 634, added subpar. (D).

2012—Subsec. (g)(1), (3). Puspan. L. 112–96, § 3005(span)(1), substituted “but (except as provided in paragraph (6)) not described in subsection (a)(8)(B)” for “but not described in subsection (a)(8)(B) of this section”.

Subsec. (g)(5). Puspan. L. 112–96, § 3005(a), designated existing provisions as subpar. (A), substituted “December 31, 2012” for “February 29, 2012”, inserted “and if the requirement of subparagraph (B) is met” after “determined to be medically necessary” and “made in accordance with such requirement” after “receipt of the request”, and added subpars. (B) and (C).

Subsec. (g)(6). Puspan. L. 112–96, § 3005(span)(2), added par. (6).

Subsec. (h)(2)(A)(i). Puspan. L. 112–96, § 3202(1), substituted “clause (v), subparagraph (B), and paragraph (4)” for “paragraph (4)”.

Subsec. (h)(2)(A)(iv). Puspan. L. 112–96, § 3202(2), realigned margins.

Subsec. (h)(2)(A)(v). Puspan. L. 112–96, § 3202(3), added cl. (v).

Subsec. (t)(7)(D)(i)(II). Puspan. L. 112–96, § 3002(a)(1), substituted “January 1, 2013” for “March 1, 2012” and “or 2012” for “or the first two months of 2012”.

Subsec. (t)(7)(D)(i)(III). Puspan. L. 112–96, § 3002(a)(2), substituted “January 1, 2013, for which” for “March 1, 2012, for which”.

2011—Subsec. (g)(5). Puspan. L. 112–78, § 304, substituted “February 29, 2012” for “December 31, 2011”.

Subsec. (t)(7)(D)(i)(II). Puspan. L. 112–78, § 308(1), substituted “March 1, 2012” for “January 1, 2012” and “2011, or the first two months of 2012” for “or 2011”.

Subsec. (t)(7)(D)(i)(III). Puspan. L. 112–78, § 308(2), substituted “2009, and before March 1, 2012, for which” for “2009, and before January 1, 2012, for which” and “2010, and before March 1, 2012, the preceding” for “2010, and before January 1, 2012, the preceding”.

2010—Subsec. (a). Puspan. L. 111–148, § 10501(i)(3)(C)(ii), inserted concluding provisions.

Subsec. (a)(1)(K). Puspan. L. 111–148, § 3114, inserted “(or 100 percent for services furnished on or after January 1, 2011)” after “1992, 65 percent”.

Subsec. (a)(1)(N). Puspan. L. 111–148, § 4103(c)(1)(A), inserted “other than personalized prevention plan services (as defined in section 1395x(hhh)(1) of this title)” after “(as defined in section 1395w–4(j)(3) of this title)”.

Subsec. (a)(1)(T). Puspan. L. 111–148, § 4104(span)(1), as amended by Puspan. L. 111–148, § 10406, inserted “(or 100 percent if such services are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual)” after “80 percent”.

Subsec. (a)(1)(W). Puspan. L. 111–148, § 4104(span)(2), as amended by Puspan. L. 111–148, § 10406, inserted “(if such subparagraph were applied, by substituting ‘100 percent’ for ‘80 percent’)” after “subparagraph (D)” in cl. (i) and substituted “100 percent” for “80 percent” in cl. (ii).

Subsec. (a)(1)(X). Puspan. L. 111–148, § 4103(c)(1)(B), (C), added subpar. (X).

Subsec. (a)(1)(Y). Puspan. L. 111–148, § 4104(span)(3), (4), as amended by Puspan. L. 111–148, § 10406, added subpar. (Y).

Subsec. (a)(1)(Z). Puspan. L. 111–148, § 10501(i)(3)(B), added subpar. (Z).

Subsec. (a)(2)(F) to (H). Puspan. L. 111–148, § 4103(c)(3)(B), which directed amendment of par. (2) by striking “and” at end of subpar. (F), substituting “; and” for comma at end of subpar. (G)(ii), and adding subpar. (H) after subpar. (G)(ii), was executed as directed despite the presence of concluding provisions following subpar. (G)(ii), which were added as part of subpar. (G) by Puspan. L. 105–33, § 4603(c)(2)(A)(iv).

Subsec. (a)(3)(B)(i). Puspan. L. 111–148, § 10501(i)(3)(C)(i)(I), inserted subcl. (I) designation after “otherwise been provided” and “, or (II) in the case of such services furnished on or after the implementation date of the prospective payment system under section 1395m(o) of this title, under such section (calculated as if ‘100 percent’ were substituted for ‘80 percent’ in such section) for such services if the individual had not been so enrolled” after “been so enrolled”.

Subsec. (span). Puspan. L. 111–148, § 4104(c)(2), inserted at end “Paragraph (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test.”

Subsec. (span)(1). Puspan. L. 111–148, § 4104(c)(1), substituted “preventive services described in subparagraph (A) of section 1395x(ddd)(3) of this title that are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual.” for “items and services described in section 1395x(s)(10)(A) of this title”.

Subsec. (span)(10). Puspan. L. 111–148, § 4103(c)(4), added par. (10).

Subsec. (g)(5). Puspan. L. 111–309, § 104, substituted “and ending on December 31, 2011” for “and ending on March 31, 2010”.

Puspan. L. 111–148, § 3103, which directed substitution of “December 31, 2010” for “December 31, 2009”, could not be executed because “December 31, 2009” did not appear subsequent to amendment by Puspan. L. 111–144. See note below.

Puspan. L. 111–144 substituted “March 31, 2010” for “December 31, 2009”.

Subsec. (h)(2)(A)(i). Puspan. L. 111–148, § 3401(l)(1), inserted “, subject to clause (iv),” after “year) by” and substituted “and 2010” for “through 2013”.

Subsec. (h)(2)(A)(iv). Puspan. L. 111–148, § 3401(l)(2), added cl. (iv).

Subsec. (i)(2)(D)(v), (vi). Puspan. L. 111–148, § 3401(k), added cl. (v) and redesignated former cl. (v) as (vi).

Subsec. (t)(1)(B)(iv). Puspan. L. 111–148, § 4103(c)(3)(A), substituted “, diagnostic mammography, or personalized prevention plan services (as defined in section 1395x(hhh)(1) of this title)” for “and diagnostic mammography”.

Subsec. (t)(2)(D). Puspan. L. 111–148, § 10324(span)(1), substituted “subject to paragraph (19), the Secretary” for “the Secretary”.

Subsec. (t)(3)(C)(iv). Puspan. L. 111–148, § 3401(i)(1), inserted “and subparagraph (F) of this paragraph” after “(17)”.

Subsec. (t)(3)(F). Puspan. L. 111–148, § 3401(i)(2), added subpar. (F).

Subsec. (t)(3)(G). Puspan. L. 111–152, § 1105(e)(3), struck out cl. (i) designation and span, redesignated subcls. (I) to (V) of former cl. (i) as cls. (i) to (v), respectively, and realigned margins.

Puspan. L. 111–148, § 3401(i)(2), added subpar. (G).

Subsec. (t)(3)(G)(i)(I). Puspan. L. 111–148, § 10319(g)(1), struck out “and” at end.

Subsec. (t)(3)(G)(i)(II). Puspan. L. 111–152, § 1105(e)(1)(A), placed subcl. (II), which was directed to be inserted after subcl. (II) by Puspan. 111–148, § 10319(g)(3), immediately after subcl. (I) and struck out “and” at end. See Amendment note below.

Puspan. L. 111–148, § 10319(g)(3), which directed addition of subcl. (II) “after subclause (II)”, could not be executed. See Amendment note above.

Subsec. (t)(3)(G)(i)(III). Puspan. L. 111–152, § 1105(e)(1), added subcl. (III) and struck out former subcl. (III) which read as follows: “subject to clause (ii), for each of 2014 through 2019, 0.2 percentage point.”

Puspan. L. 111–148, § 10319(g)(4), substituted “2014” for “2012”.

Puspan. L. 111–148, § 10319(g)(2), redesignated subcl. (II) as (III).

Subsec. (t)(3)(G)(i)(IV), (V). Puspan. L. 111–152, § 1105(e)(1)(B), added subcls. (IV) and (V).

Subsec. (t)(3)(G)(ii). Puspan. L. 111–152, § 1105(e)(2), struck out cl. (ii). Prior to amendment, text read as follows: “Clause (i)(II) shall be applied with respect to any of 2014 through 2019 by substituting ‘0.0 percentage points’ for ‘0.2 percentage point’, if for such year—

“(I) the excess (if any) of—

“(aa) the total percentage of the non-elderly insured population for the preceding year (based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over

“(bspan) the total percentage of the non-elderly insured population for such preceding year (as estimated by the Secretary); exceeds

“(II) 5 percentage points.”

Subsec. (t)(7)(D)(i)(II). Puspan. L. 111–309, § 108(1), substituted “2012” for “2011” in first sentence and “2010, or 2011” for “or 2010” in second sentence.

Puspan. L. 111–148, § 3121(a)(1)(B), substituted “, 2009, or 2010” for “or 2009”.

Puspan. L. 111–148, § 3121(a)(1)(A), substituted “2011” for “2010”.

Subsec. (t)(7)(D)(i)(III). Puspan. L. 111–309, § 108(2), which directed substitution of “January 1, 2012” for “January 1, 2011”, was executed by making the substitution in two places to reflect the probable intent of Congress.

Puspan. L. 111–148, § 3121(span), inserted at end “In the case of covered OPD services furnished on or after January 1, 2010, and before January 1, 2011, the preceding sentence shall be applied without regard to the 100-bed limitation.”

Puspan. L. 111–148, § 3121(a)(2), substituted “2009, and before January 1, 2011” for “2009, and before January 1, 2010”.

Subsec. (t)(18), (19). Puspan. L. 111–148, §§ 3138, 10324(span)(2), added pars. (18) and (19).

Subsecs. (x), (y). Puspan. L. 111–148, § 5501(a)(1), (span)(1), added subsecs. (x) and (y).

2008—Subsec. (a)(1)(D)(iii). Puspan. L. 110–275, § 145(a)(2), before comma at end of subpar. (D), struck out cl. (iii), which read “on the basis of a rate established under a demonstration project under section 1395w–3(e) of this title, the amount paid shall be equal to 100 percent of such rate”.

Subsec. (a)(1)(W). Puspan. L. 110–275, § 101(a)(2), added subpar. (W).

Subsec. (a)(8)(A), (B). Puspan. L. 110–275, § 143(span)(2), substituted “, outpatient speech-language pathology services,” for “(which includes outpatient speech-language pathology services)” in introductory provisions.

Subsec. (span)(9). Puspan. L. 110–275, § 101(span)(2), added par. (9) at end of first sentence.

Subsec. (c). Puspan. L. 110–275, § 102, amended subsec. (c) generally. Prior to amendment, text read as follows: “Notwithstanding any other provision of this part, with respect to expenses incurred in any calendar year in connection with the treatment of mental, psychoneurotic, and personality disorders of an individual who is not an inpatient of a hospital at the time such expenses are incurred, there shall be considered as incurred expenses for purposes of subsections (a) and (span) of this section only 62½ percent of such expenses. For purposes of this subsection, the term ‘treatment’ does not include brief office visits (as defined by the Secretary) for the sole purpose of monitoring or changing drug prescriptions used in the treatment of such disorders or partial hospitalization services that are not directly provided by a physician.”

Subsec. (g)(1). Puspan. L. 110–275, § 143(span)(3), inserted “and speech-language pathology services of the type described in such section through the application of section 1395x(ll)(2) of this title” after “1395x(p) of this title” and “and speech-language pathology services” after “and physical therapy services”.

Subsec. (g)(5). Puspan. L. 110–275, § 141, substituted “December 31, 2009” for “June 30, 2008”.

Subsec. (h)(2)(A)(i). Puspan. L. 110–275, § 145(span), inserted “minus, for each of the years 2009 through 2013, 0.5 percentage points” after “city average)”.

Subsec. (t)(7)(D)(i)(II). Puspan. L. 110–275, § 147(1), substituted “January 1, 2010” for “January 1, 2009” and “For purposes of the preceding sentence, the applicable percentage shall be 95 percent with respect to covered OPD services furnished in 2006, 90 percent with respect to such services furnished in 2007, and 85 percent with respect to such services furnished in 2008 or 2009.” for “For purposes of the previous sentence, with respect to covered OPD services furnished during 2006, 2007, or 2008, the applicable percentage shall be 95 percent, 90 percent, and 85 percent, respectively.”

Subsec. (t)(7)(D)(i)(III). Puspan. L. 110–275, § 147(2), added subcl. (III).

Subsec. (t)(16)(C). Puspan. L. 110–275, § 142, substituted “January 1, 2010” for “July 1, 2008” in two places.

Subsec. (v). Puspan. L. 110–275, § 151(a), added subsec. (v).

Subsec. (w). Puspan. L. 110–275, § 184, added subsec. (w).

2007—Subsec. (g)(5). Puspan. L. 110–173, § 105, substituted “June 30, 2008” for “December 31, 2007”.

Subsec. (h)(9). Puspan. L. 110–173, § 113, added par. (9).

Subsec. (t)(16)(C). Puspan. L. 110–173, § 106, in span, inserted “and therapeutic radiopharmaceuticals” before “at charges”, in first sentence, substituted “July 1, 2008” for “January 1, 2008” and inserted “and for therapeutic radiopharmaceuticals furnished on or after January 1, 2008, and before July 1, 2008,” after “July 1, 2008,” and “or therapeutic radiopharmaceutical” after “the device” and after “each device”, and, in second sentence, inserted “or therapeutic radiopharmaceuticals” after “such devices”.

Subsec. (u)(1). Puspan. L. 110–173, § 102(1), substituted “before July 1, 2008” for “before January 1, 2008” in introductory provisions.

Subsec. (u)(4)(D), (E). Puspan. L. 110–173, § 102(2), added subpar. (D) and redesignated former subpar. (D) as (E).

2006—Subsec. (span)(7). Puspan. L. 109–171, § 5112(e), added par. (7) at end of first sentence.

Subsec. (span)(8). Puspan. L. 109–171, § 5113(a), added par. (8) at end of first sentence.

Subsec. (g)(1), (3). Puspan. L. 109–171, § 5107(a)(1)(A), substituted “paragraphs (4) and (5)” for “paragraph (4)”.

Subsec. (g)(5). Puspan. L. 109–432, § 201, substituted “the period beginning on January 1, 2006, and ending on December 31, 2007,” for “2006”.

Puspan. L. 109–171, § 5107(a)(1)(B), added par. (5).

Subsec. (i)(2)(A). Puspan. L. 109–171, § 5103(1), inserted “subject to subparagraph (E),” after “subparagraph (D),”.

Subsec. (i)(2)(D)(ii). Puspan. L. 109–171, § 5103(2), inserted “and taking into account reduced expenditures that would apply if subparagraph (E) were to continue to apply, as estimated by the Secretary” before period at end.

Subsec. (i)(2)(D)(iv), (v). Puspan. L. 109–432, § 109(span)(1), added cl. (iv) and redesignated former cl. (iv) as (v).

Subsec. (i)(2)(E). Puspan. L. 109–171, § 5103(3), added subpar. (E).

Subsec. (i)(7). Puspan. L. 109–432, § 109(span)(2), added par. (7).

Subsec. (t)(2)(H). Puspan. L. 109–432, § 107(span)(1), inserted “and for stranded and non-stranded devices furnished on or after July 1, 2007” before period at end.

Subsec. (t)(3)(C)(iv). Puspan. L. 109–432, § 109(a)(1)(A), inserted “subject to paragraph (17),” after “this subparagraph,”.

Subsec. (t)(7)(D)(i). Puspan. L. 109–171, § 5105, designated existing provisions as subcl. (I) and added subcl. (II).

Subsec. (t)(16)(C). Puspan. L. 109–432, § 107(a), substituted “2008” for “2007”.

Subsec. (t)(17). Puspan. L. 109–432, § 109(a)(1)(B), added par. (17).

2003—Subsec. (a)(1)(D)(iii). Puspan. L. 108–173, § 302(span)(2)(C), added cl. (iii).

Subsec. (a)(1)(G). Puspan. L. 108–173, § 626(c), added subpar. (G).

Subsec. (a)(1)(S). Puspan. L. 108–173, § 642(span), inserted “(including intravenous immune globulin (as defined in section 1395x(zz) of this title))” after “with respect to drugs and biologicals”.

Puspan. L. 108–173, § 303(i)(3)(A), inserted “(or, if applicable, under section 1395w–3, 1395w–3a, or 1395w–3span of this title)” after “1395u(o) of this title”.

Subsec. (a)(1)(V). Puspan. L. 108–173, § 302(span)(2)(A), (B), added subpar. (V).

Subsec. (a)(2)(E)(i). Puspan. L. 108–173, § 614(span), inserted “and, for services furnished on or after January 1, 2005, diagnostic mammography” after “screening mammography”.

Subsec. (a)(3). Puspan. L. 108–173, § 237(a), amended par. (3) generally. Prior to amendment, par. (3) read as follows: “in the case of services described in section 1395k(a)(2)(D) of this title, the costs which are reasonable and related to the cost of furnishing such services or which are based on such other tests of reasonableness as the Secretary may prescribe in regulations, including those authorized under section 1395x(v)(1)(A) of this title, less the amount a provider may charge as described in clause (ii) of section 1395cc(a)(2)(A) of this title, but in no case may the payment for such services (other than for items and services described in section 1395x(s)(10)(A) of this title) exceed 80 percent of such costs;”.

Subsec. (span). Puspan. L. 108–173, § 629, substituted “, $100 for 1991 through 2004, $110 for 2005, and for a subsequent year the amount of such deductible for the previous year increased by the annual percentage increase in the monthly actuarial rate under section 1395r(a)(1) of this title ending with such subsequent year (rounded to the nearest $1)” for “and $100 for 1991 and subsequent years” before semicolon in first sentence.

Subsec. (g)(4). Puspan. L. 108–173, § 624(a)(1), substituted “2002, 2004, and 2005” for “and 2002”.

Subsec. (h)(2)(A)(ii)(IV). Puspan. L. 108–173, § 628, substituted “, 1998 through 2002, and 2004 through 2008” for “and 1998 through 2002”.

Subsec. (h)(5)(D). Puspan. L. 108–173, § 736(span)(1), substituted “clinic,” for “clinic,,”.

Subsec. (h)(8). Puspan. L. 108–173, § 942(span), added par. (8).

Subsec. (i)(2)(A). Puspan. L. 108–173, § 626(span)(1)(A), substituted “For services furnished prior to the implementation of the system described in subparagraph (D), the” for “The” in introductory provisions.

Subsec. (i)(2)(A)(i). Puspan. L. 108–173, § 626(span)(1)(B), struck out “taken not later than January 1, 1995, and every 5 years thereafter,” before “of the actual audited costs”.

Subsec. (i)(2)(C). Puspan. L. 108–173, § 626(a), amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: “Notwithstanding the second sentence of subparagraph (A) or the second sentence of subparagraph (B), if the Secretary has not updated amounts established under such subparagraphs with respect to facility services furnished during a fiscal year (beginning with fiscal year 1996), such amounts shall be increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) as estimated by the Secretary for the 12-month period ending with the midpoint of the year involved. In each of the fiscal years 1998 through 2002, the increase under this subparagraph shall be reduced (but not below zero) by 2.0 percentage points.”

Subsec. (i)(2)(D). Puspan. L. 108–173, § 626(span)(2), added subpar. (D).

Subsec. (m). Puspan. L. 108–173, § 413(span)(1), designated existing provisions as par. (1), inserted “in a year” after “In the case of physicians’ services furnished” and “as identified by the Secretary prior to the beginning of such year” after “as a health professional shortage area”, and added pars. (2) to (4).

Subsec. (o)(1)(B). Puspan. L. 108–173, § 627(a)(1), substituted “no more than the amount of payment applicable under paragraph (2)” for “no more than the limits established under paragraph (2)”.

Subsec. (o)(2). Puspan. L. 108–173, § 627(a)(2), amended par. (2) generally, substituting provisions relating to determination of amount of payments pursuant to section 1395m of this title for provisions specifying dollar amounts of payments.

Subsec. (t)(1)(B)(iv). Puspan. L. 108–173, § 614(a), inserted before period at end “and does not include screening mammography (as defined in section 1395x(jj) of this title) and diagnostic mammography”.

Subsec. (t)(2)(H). Puspan. L. 108–173, § 621(span)(2), which directed the amendment of par. (2) by adding a new subpar. (H) at the end, was executed by adding subpar. (H) after subpar. (G), to reflect the probable intent of Congress.

Subsec. (t)(3)(C)(ii). Puspan. L. 108–173, § 736(span)(2), substituted “clause (iv)” for “clause (iii)”.

Subsec. (t)(5)(E). Puspan. L. 108–173, § 621(a)(3), added subpar. (E).

Subsec. (t)(6)(D)(i). Puspan. L. 108–173, § 621(a)(4), inserted “(or if the drug or biological is covered under a competitive acquisition contract under section 1395w–3span of this title, an amount determined by the Secretary equal to the average price for the drug or biological for all competitive acquisition areas and year established under such section as calculated and adjusted by the Secretary for purposes of this paragraph)” after “under section 1395u(o) of this title”.

Subsec. (t)(6)(F). Puspan. L. 108–173, § 622, added subpar. (F).

Subsec. (t)(7)(D)(i). Puspan. L. 108–173, § 411(a)(1)(A), (C), substituted “certain” for “small” in span and “2006” for “2004” in text.

Puspan. L. 108–173, § 411(a)(1)(B), inserted “or a sole community hospital (as defined in section 1395ww(d)(5)(D)(iii) of this title) located in a rural area” after “100 beds”.

Subsec. (t)(9)(B). Puspan. L. 108–173, § 621(a)(5), inserted at end “In determining adjustments under the preceding sentence for 2004 and 2005, the Secretary shall not take into account under this subparagraph or paragraph (2)(E) any expenditures that would not have been made but for the application of paragraph (14).”

Subsec. (t)(13). Puspan. L. 108–173, § 411(span)(2), added par. (13). Former par. (13) redesignated (16).

Subsec. (t)(14), (15). Puspan. L. 108–173, § 621(a)(1), added pars. (14) and (15).

Subsec. (t)(16). Puspan. L. 108–173, § 411(span)(1), redesignated par. (13) as (16).

Subsec. (t)(16)(B). Puspan. L. 108–173, § 621(a)(2), added subpar. (B).

Subsec. (t)(16)(C). Puspan. L. 108–173, § 621(span)(1), added subpar. (C).

Subsec. (u). Puspan. L. 108–173, § 413(a), added subsec. (u).

2000—Subsec. (a)(1)(D)(i). Puspan. L. 106–554, § 1(a)(6) [title II, § 201(span)(1)], struck out “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.

Subsec. (a)(1)(R). Puspan. L. 106–554, § 1(a)(6) [title II, § 205(span)], substituted “ambulance services, (i)” for “ambulance service,” and inserted before comma at end “and (ii) with respect to ambulance services described in section 1395m(l)(8) of this title, the amounts paid shall be the amounts determined under section 1395m(g) of this title for outpatient critical access hospital services”.

Subsec. (a)(1)(T). Puspan. L. 106–554, § 1(a)(6) [title I, § 105(c)], added subpar. (T).

Subsec. (a)(1)(U). Puspan. L. 106–554, § 1(a)(6) [title II, § 223(c)], added subpar. (U).

Subsec. (a)(2)(D)(i). Puspan. L. 106–554, § 1(a)(6) [title II, § 201(span)(1)], struck out “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.

Subsec. (f). Puspan. L. 106–554, § 1(a)(6) [title II, § 224(a)], substituted “hospitals” for “rural hospitals” in introductory provisions.

Subsec. (g)(4). Puspan. L. 106–554, § 1(a)(6) [title IV, § 421(a)], substituted “2000, 2001, and 2002.” for “2000 and 2001.”

Subsec. (h)(4)(B)(viii). Puspan. L. 106–554, § 1(a)(6) [title V, § 531(a)], inserted before period at end “(or 100 percent of such median in the case of a clinical diagnostic laboratory test performed on or after January 1, 2001, that the Secretary determines is a new test for which no limitation amount has previously been established under this subparagraph)”.

Subsec. (t)(2)(G). Puspan. L. 106–554, § 1(a)(6) [title IV, § 430(a)], added subpar. (G).

Subsec. (t)(3)(C)(iii). Puspan. L. 106–554, § 1(a)(6) [title IV, § 401(span)(1)(B)], added cl. (iii). Former cl. (iii) redesignated (iv).

Puspan. L. 106–554, § 1(a)(6) [title IV, § 401(a)], substituted “in each of 2000 and 2002” for “in each of 2000, 2001, and 2002”.

Subsec. (t)(3)(C)(iv). Puspan. L. 106–554, § 1(a)(6) [title IV, § 401(span)(1)(A)], redesignated cl. (iii) as (iv).

Subsec. (t)(6)(A)(ii). Puspan. L. 106–554, § 1(a)(6) [title IV, § 406(a)], inserted “or temperature monitored cryoablation” after “device of brachytherapy”.

Subsec. (t)(6)(A)(iv)(II). Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(span)(1)], substituted “the cost of the drug or biological or the average cost of the category of devices” for “the cost of the device, drug, or biological”.

Subsec. (t)(6)(B). Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(a)(2)], added subpar. (B) and struck out span and text of former subpar. (B). Text read as follows: “The payment under this paragraph with respect to a medical device, drug, or biological shall only apply during a period of at least 2 years, but not more than 3 years, that begins—

“(i) on the first date this subsection is implemented in the case of a drug, biological, or device described in clause (i), (ii), or (iii) of subparagraph (A) and in the case of a device, drug, or biological described in subparagraph (A)(iv) and for which payment under this part is made as an outpatient hospital service before such first date; or

“(ii) in the case of a device, drug, or biological described in subparagraph (A)(iv) not described in clause (i), on the first date on which payment is made under this part for the device, drug, or biological as an outpatient hospital service.”

Subsec. (t)(6)(C). Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(a)(2)], added subpar. (C). Former subpar. (C) redesignated (D).

Subsec. (t)(6)(D). Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(span)(2)], substituted “subparagraph (E)(iii)” for “subparagraph (D)(iii)” in introductory provisions.

Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(a)(1)], redesignated subpar. (C) as (D). Former subpar. (D) redesignated (E).

Subsec. (t)(6)(E). Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(a)(1)], redesignated subpar. (D) as (E).

Subsec. (t)(7)(D)(ii). Puspan. L. 106–554, § 1(a)(6) [title IV, § 405(a)], in span, inserted “and children’s hospitals” after “cancer hospitals” and in text, substituted “clause (iii) or (v) of section 1395ww(d)(1)(B) of this title” for “section 1395ww(d)(1)(B)(v) of this title”.

Subsec. (t)(7)(F)(ii)(I). Puspan. L. 106–554, § 1(a)(6) [title IV, § 403(a)], inserted “(or in the case of a hospital that did not submit a cost report for such period, during the first subsequent cost reporting period ending before 2001 for which the hospital submitted a cost report)” after “1996”.

Subsec. (t)(8)(C). Puspan. L. 106–554, § 1(a)(6) [title I, § 111(a)(1)], amended span and text of subpar. (C) generally. Prior to amendment, text read as follows: “In no case shall the copayment amount for a procedure performed in a year exceed the amount of the inpatient hospital deductible established under section 1395e(span) of this title for that year.”

Subsec. (t)(11). Puspan. L. 106–554, § 1(a)(6) [title IV, § 405(a)(2)], substituted “clause (iii) or (v) of section 1395ww(d)(1)(B) of this title” for “section 1395ww(d)(1)(B)(v) of this title” in introductory provisions.

Subsec. (t)(12)(E). Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(span)(3)], substituted “additional payments, the determination and deletion of initial and new categories (consistent with subparagraphs (B) and (C) of paragraph (6))” for “additional payments (consistent with paragraph (6)(B))”.

1999—Subsec. (a)(1)(D)(i). Puspan. L. 106–113, § 1000(a)(6) [title IV, § 403(e)(1)], inserted “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.

Subsec. (a)(1)(O). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(2)], substituted a comma for the semicolon at end.

Subsec. (a)(2)(D)(i). Puspan. L. 106–113, § 1000(a)(6) [title IV, § 403(e)(1)], inserted “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.

Subsec. (g)(1), (3). Puspan. L. 106–113, § 1000(a)(6) [title II, § 221(a)(1)(A)], substituted “Subject to paragraph (4), in the case” for “In the case”.

Subsec. (g)(4). Puspan. L. 106–113, § 1000(a)(6) [title II, § 221(a)(1)(B)], added par. (4).

Subsec. (h)(5)(A)(iii). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(g)(2)], substituted “, critical access hospital, or skilled nursing facility,” for “or critical access hospital,” and inserted “or skilled nursing facility” before period at end.

Subsec. (h)(7). Puspan. L. 106–113, § 1000(a)(6) [title II, § 224(a)], added par. (7).

Subsec. (l)(4)(A)(i)(VII). Puspan. L. 106–113, § 1000(a)(6) [title II, § 211(a)(3)(B)], substituted “1395w–4(d) of this title” for “1395w–4(d)(3) of this title”.

Subsec. (t)(1)(B)(ii). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(e)(1)(A)], substituted “clause (iv)” for “clause (iii)” and directed the striking out of “but” which was executed by striking out “but” after semicolon at end to reflect the probable intent of Congress.

Subsec. (t)(1)(B)(iii), (iv). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(e)(1)(B)], added cl. (iii) and redesignated former cl. (iii) as (iv).

Subsec. (t)(2). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(g)], inserted concluding provisions.

Subsec. (t)(2)(B). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(e)(1)(C)], inserted “and so that an implantable item is classified to the group that includes the service to which the item relates” before semicolon at end.

Subsec. (t)(2)(C). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(f)], inserted “(or, at the election of the Secretary, mean)” after “median”.

Subsec. (t)(2)(E). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(c)], substituted “, in a budget neutral manner, outlier adjustments under paragraph (5) and transitional pass-through payments under paragraph (6) and other adjustments as determined to be necessary to ensure equitable payments, such as” for “other adjustments, in a budget neutral manner, as determined to be necessary to ensure equitable payments, such as outlier adjustments or”.

Subsec. (t)(4). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(1)], inserted “, subject to paragraph (7),” after “is determined” in introductory provisions.

Subsec. (t)(4)(C). Puspan. L. 106–113, § 1000(a)(6) [title II, § 204(span)], inserted “, plus the amount of any reduction in the copayment amount attributable to paragraph (8)(C)” before period at end.

Subsec. (t)(5). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(a)(2)], added par. (5). Former par. (5) redesignated (7).

Subsec. (t)(6). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(span)], added par. (6). Former par. (6) redesignated (8).

Subsec. (t)(7). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(3)], added par. (7). Former par. (7) redesignated (8).

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (5) as (7). Former par. (7) redesignated (9).

Subsec. (t)(7)(D). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(i)], added subpar. (D).

Subsec. (t)(8). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (7) as (8). Former par. (8) redesignated (9).

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (6) as (8). Former par. (8) redesignated (10).

Subsec. (t)(8)(A). Puspan. L. 106–113, § 1000(a)(6) [title II, § 204(a)(1)], substituted “subparagraphs (B) and (C)” for “subparagraph (B)”.

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(h)(1)(B)], inserted at end “The Secretary shall consult with an expert outside advisory panel composed of an appropriate selection of representatives of providers to review (and advise the Secretary concerning) the clinical integrity of the groups and weights. Such panel may use data collected or developed by entities and organizations (other than the Department of Health and Human Services) in conducting such review.”

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(h)(1)(A)], substituted “shall review not less often than annually” for “may periodically review”.

Subsec. (t)(8)(C) to (E). Puspan. L. 106–113, § 1000(a)(6) [title II, § 204(a)(2), (3)], added subpar. (C) and redesignated former subpars. (C) and (D) as (D) and (E), respectively.

Subsec. (t)(9). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (8) as (9). Former par. (9) redesignated (10).

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(j)], substituted “section 1395x(v)(1)(U) of this title” for “the matter in subsection (a)(1) of this section preceding subparagraph (A)”.

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (7) as (9). Former par. (9) redesignated (11).

Subsec. (t)(10). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (9) as (10). Former par. (10) redesignated (11).

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (8) as (10).

Subsec. (t)(11). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (10) as (11). Former par. (11) redesignated (12).

Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (9) as (11).

Subsec. (t)(11)(E). Puspan. L. 106–113, § 1000(a)(6) [title II, § 201(d)], added subpar. (E).

Subsec. (t)(12). Puspan. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (11) as (12).

Subsec. (t)(13). Puspan. L. 106–113, § 1000(a)(6) [title IV, § 401(span)(1)], added par. (13).

1997—Subsec. (a)(1)(A). Puspan. L. 105–33, § 4002(j)(1)(A), inserted “(and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services)” after “prepayment basis”.

Subsec. (a)(1)(D). Puspan. L. 105–33, § 4104(c), inserted “or section 1395m(d)(1) of this title” after “subsection (h)(1)”.

Subsec. (a)(1)(O). Puspan. L. 105–33, § 4512(span)(1), substituted “section 1395x(s)(2)(K) of this title” for “section 1395x(s)(2)(K)(ii) of this title” and “services furnished by physician assistants, nurse practitioners, or clinic nurse specialists” for “nurse practitioner or clinical nurse specialist services”.

Puspan. L. 105–33, § 4511(span)(1), amended subpar. (O) generally. Prior to amendment, subpar. (O) read as follows: “with respect to services described in section 1395x(s)(2)(K)(iii) of this title (relating to nurse practitioner or clinical nurse specialist services provided in a rural area), the amounts paid shall be 80 percent of the lesser of the actual charge or the prevailing charge that would be recognized (or, for services furnished on or after January 1, 1992, the fee schedule amount provided under section 1395w–4 of this title) if the services had been performed by a physician (subject to the limitation described in subsection (r)(2) of this section),”.

Subsec. (a)(1)(Q). Puspan. L. 105–33, § 4315(span), added subpar. (Q).

Subsec. (a)(1)(R). Puspan. L. 105–33, § 4531(span)(1), added subpar. (R).

Subsec. (a)(1)(S). Puspan. L. 105–33, § 4556(span), added subpar. (S).

Subsec. (a)(2). Puspan. L. 105–33, § 4541(a)(1)(A), inserted “(C),” before “(D)” in introductory provisions.

Subsec. (a)(2)(A). Puspan. L. 105–33, § 4603(c)(2)(A)(i), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: “with respect to home health services (other than a covered osteoporosis drug (as defined in section 1395x(kk) of this title)) and to items and services described in section 1395x(s)(10)(A) of this title, the lesser of—

“(i) the reasonable cost of such services, as determined under section 1395x(v) of this title, or

“(ii) the customary charges with respect to such services,

or, if such services are furnished by a public provider of services, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this provision), free of charge or at nominal charges to the public, the amount determined in accordance with section 1395f(span)(2) of this title;”.

Subsec. (a)(2)(B). Puspan. L. 105–33, § 4432(span)(5)(C), inserted “or section 1395yy(e)(9) of this title” after “1395ww of this title” in introductory provisions.

Puspan. L. 105–33, § 4523(d)(3), inserted “furnished before January 1, 1999,” after “(i)” in cl. (i), inserted “before January 1, 1999,” after “furnished” in cl. (ii), added cl. (iii), and redesignated former cl. (iii) as (iv).

Subsec. (a)(2)(D). Puspan. L. 105–33, § 4104(c)(1), inserted “or section 1395m(d)(1) of this title” after “subsection (h)(1)”.

Subsec. (a)(2)(E). Puspan. L. 105–33, § 4523(d)(2)(B), inserted “or, for services or procedures performed on or after January 1, 1999, subsection (t)” before semicolon at end.

Subsec. (a)(2)(G). Puspan. L. 105–33, § 4603(c)(2)(A)(ii)–(iv), added subpar. (G).

Subsec. (a)(3). Puspan. L. 105–33, § 4541(a)(1)(B), substituted “section 1395k(a)(2)(D) of this title” for “subparagraphs (D) and (E) of section 1395k(a)(2) of this title”.

Subsec. (a)(4). Puspan. L. 105–33, § 4523(d)(1)(B), inserted “or subsection (t)” before semicolon at end.

Subsec. (a)(6). Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (a)(8), (9). Puspan. L. 105–33, § 4541(a)(1)(C)–(E), added pars. (8) and (9).

Subsec. (span)(5). Puspan. L. 105–33, § 4101(span), added par. (5) at end of first sentence.

Subsec. (span)(6). Puspan. L. 105–33, § 4102(span), added par. (6) at end of first sentence.

Subsec. (f). Puspan. L. 105–33, § 4205(a)(1)(A), substituted “rural health clinics (other than such clinics in rural hospitals with less than 50 beds)” for “independent rural health clinics” in introductory provisions.

Subsec. (f)(1). Puspan. L. 105–33, § 4205(a)(2), inserted “per visit” after “$46”.

Subsec. (g). Puspan. L. 105–33, § 4541(d)(1), substituted “the amount specified in paragraph (2) for the year” for “$900” in two places, redesignated first sentence as par. (1) and last sentence as par. (3), and added par. (2).

Puspan. L. 105–33, § 4541(c), (d)(1)(A), substituted, in first sentence, “physical therapy services of the type described in section 1395x(p) of this title, but not described in subsection (a)(8)(B) of this section, and physical therapy services of such type which are furnished by a physician or as incident to physicians’ services” for “services described in the second sentence of section 1395x(p) of this title”, and substituted, in last sentence, “occupational therapy services (of the type that are described in section 1395x(p) of this title (but not described in subsection (a)(8)(B) of this section) through the operation of section 1395x(g) of this title and of such type which are furnished by a physician or as incident to physicians’ services)” for “outpatient occupational therapy services which are described in the second sentence of section 1395x(p) of this title through the operation of section 1395x(g) of this title”.

Subsec. (h)(1)(A). Puspan. L. 105–33, § 4104(c)(2), substituted “Subject to section 1395m(d)(1) of this title, the Secretary” for “The Secretary”.

Puspan. L. 105–33, § 4103(span), inserted “(including prostate cancer screening tests under section 1395x(oo) of this title consisting of prostate-specific antigen blood tests)” after “laboratory tests”.

Subsec. (h)(2)(A)(ii)(IV). Puspan. L. 105–33, § 4553(a), inserted “and 1998 through 2002” after “1995”.

Subsec. (h)(4)(B)(vii). Puspan. L. 105–33, § 4553(span)(2)(A), inserted “and before January 1, 1998,” after “December 31, 1995,”.

Subsec. (h)(4)(B)(viii). Puspan. L. 105–33, § 4553(span)(1), (2)(B), (3), added cl. (viii).

Subsec. (h)(5)(A)(iii). Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (i)(1)(A). Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (i)(2)(C). Puspan. L. 105–33, § 4555, inserted at end “In each of the fiscal years 1998 through 2002, the increase under this subparagraph shall be reduced (but not below zero) by 2.0 percentage points.”

Subsec. (i)(3)(A). Puspan. L. 105–33, § 4523(d)(1)(A)(i), inserted “before January 1, 1999,” after “furnished” and struck out “in a cost reporting period” after “paragraph (1)(A)”.

Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (i)(3)(B)(i)(II). Puspan. L. 105–33, § 4521(a), struck out “of 80 percent” before “of the standard overhead amount” and inserted before period at end “, less the amount a provider may charge as described in clause (ii) of section 1395cc(a)(2)(A) of this title”.

Subsec. (l)(5). Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care” wherever appearing.

Subsec. (n)(1)(A). Puspan. L. 105–33, § 4523(d)(2)(A), inserted “and before January 1, 1999,” after “October 1, 1988,” and after “October 1, 1989,”.

Subsec. (n)(1)(B)(i)(II). Puspan. L. 105–33, § 4521(span), struck out “of 80 percent” before “of the prevailing charge” and inserted before period at end “, less the amount a provider may charge as described in clause (ii) of section 1395cc(a)(2)(A) of this title”.

Subsec. (r)(1). Puspan. L. 105–33, § 4511(span)(2)(A), substituted “section 1395x(s)(2)(K)(ii) of this title (relating to nurse practitioner or clinical nurse specialist services)” for “section 1395x(s)(2)(K)(iii) of this title (relating to nurse practitioner or clinical nurse specialist services provided in a rural area)”.

Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (r)(2). Puspan. L. 105–33, § 4511(span)(2)(B), (D), redesignated par. (3) as (2) and struck out former par. (2) which read as follows:

“(2)(A) For purposes of subsection (a)(1)(O) of this section, the prevailing charge for services described in section 1395x(s)(2)(K)(iii) of this title may not exceed the applicable percentage (as defined in subparagraph (B)) of the prevailing charge (or, for services furnished on or after January 1, 1992, the fee schedule amount provided under section 1395w–4 of this title) determined for such services performed by physicians who are not specialists.

“(B) In subparagraph (A), the term ‘applicable percentage’ means—

“(i) 75 percent in the case of services performed in a hospital, and

“(ii) 85 percent in the case of other services.”

Subsec. (r)(3). Puspan. L. 105–33, § 4511(span)(2)(C), (D), redesignated par. (3) as (2) and substituted “section 1395x(s)(2)(K)(ii) of this title” for “section 1395x(s)(2)(K)(iii) of this title”.

Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (t). Puspan. L. 105–33, § 4523(a), added subsec. (t).

1994—Subsec. (a)(1)(D)(i). Puspan. L. 103–432, § 156(a)(2)(B)(i), struck out “, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” after “assignment-related basis”.

Subsec. (a)(1)(G). Puspan. L. 103–432, § 156(a)(2)(B)(ii), struck out subpar. (G) which read as follows: “with respect to items and services (other than clinical diagnostic laboratory tests) furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion), the amounts paid shall be 100 percent of the reasonable charges for such items and services,”.

Subsec. (a)(2)(A). Puspan. L. 103–432, § 156(a)(2)(B)(iii), struck out “, to items and services (other than clinical diagnostic laboratory tests) furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion),” before “and to items and services” in introductory provisions.

Puspan. L. 103–432, § 147(f)(6)(C)(i), substituted “health services (other than a covered osteoporosis drug (as defined in section 1395x(kk) of this title))” for “health services” in introductory provisions.

Subsec. (a)(2)(D)(i). Puspan. L. 103–432, § 156(a)(2)(B)(iv), substituted “assignment-related basis or” for “assignment-related basis,” and struck out “, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” after “section 1395cc of this title”.

Subsec. (a)(2)(F). Puspan. L. 103–432, § 147(f)(6)(C)(ii)–(iv), added subpar. (F).

Subsec. (a)(3). Puspan. L. 103–432, § 156(a)(2)(B)(v), struck out “and for items and services furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title, or a third opinion, if the second opinion was in disagreement with the first opinion)” after “section 1395x(s)(10)(A) of this title”.

Subsec. (span)(2). Puspan. L. 103–432, § 147(f)(6)(D), inserted “(other than a covered osteoporosis drug (as defined in section 1395x(kk) of this title))” after “services”.

Subsec. (span)(4), (5). Puspan. L. 103–432, § 156(a)(2)(B)(vi), redesignated par. (5) as (4) and struck out former par. (4) which read as follows: “such deductible shall not apply with respect to items and services furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion),”.

Subsec. (h)(5)(D). Puspan. L. 103–432, § 123(e), substituted “paragraph (2) of section 1395u(j)” for “paragraphs (2) and (3) of section 1395u(j)” and inserted at end “Paragraph (4) of such section shall apply in this subparagraph in the same manner as such paragraph applies to such section.”

Subsec. (i)(1). Puspan. L. 103–432, § 141(a)(3), inserted before period at end of last sentence “, in consultation with appropriate trade and professional organizations”.

Subsec. (i)(2)(A). Puspan. L. 103–432, § 141(a)(2)(A), struck out “and may be adjusted by the Secretary, when appropriate,” after “annually thereafter” in last sentence.

Subsec. (i)(2)(A)(i). Puspan. L. 103–432, § 141(a)(1), inserted before comma at end “, as determined in accordance with a survey (based upon a representative sample of procedures and facilities) taken not later than January 1, 1995, and every 5 years thereafter, of the actual audited costs incurred by such centers in providing such services”.

Subsec. (i)(2)(B). Puspan. L. 103–432, § 141(a)(2)(A), struck out “and may be adjusted by the Secretary, when appropriate,” after “annually thereafter” in last sentence.

Subsec. (i)(2)(C). Puspan. L. 103–432, § 141(a)(2)(B), added subpar. (C).

Subsec. (i)(3)(B)(ii). Puspan. L. 103–432, § 141(c)(1), in subcls. (I) and (II) substituted “for portions of cost reporting periods” for “for reporting periods” and “and ending on or before December 31, 1990” for “and on or before December 31, 1990”.

Subsec. (l)(5)(B), (C). Puspan. L. 103–432, § 123(span)(2)(A)(i), redesignated subpar. (C) as (B) and struck out former subpar. (B) which read as follows:

“(B)(i) Payment for the services of a certified registered nurse anesthetist under this part may be made only on an assignment-related basis, and any such assignment agreed to by a certified registered nurse anesthetist shall be binding upon any other person presenting a claim or request for payment for such services.

“(ii) Except for deductible and coinsurance amounts applicable under this section, any person who knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services of a certified registered nurse anesthetist for which payment may be made under this part only on an assignment-related basis is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (span)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

Subsec. (n)(1)(B)(i)(II). Puspan. L. 103–432, § 147(d)(2), substituted “April 1, 1989” for “January 1, 1989”.

Puspan. L. 103–432, § 147(d)(1), inserted “and for services described in subsection (a)(2)(E)(ii) furnished on or after January 1, 1992” after “January 1, 1989” and “(or, in the case of services furnished on or after January 1, 1992, under section 1395w–4 of this title)” before period at end.

Subsec. (p). Puspan. L. 103–432, § 123(span)(2)(A)(ii), struck out subsec. (p) which read as follows: “In the case of certified nurse-midwife services for which payment may be made under this part only pursuant to section 1395x(s)(2)(L) of this title, in the case of qualified psychologists services for which payment may be made under this part only pursuant to section 1395x(s)(2)(M) of this title, and in the case of clinical social worker services for which payment may be made under this part only pursuant to section 1395x(s)(2)(N) of this title, payment may only be made under this part for such services on an assignment-related basis. Except for deductible and coinsurance amounts applicable under this section, whoever knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services described in the previous sentence, is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (span)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

Subsec. (q)(1). Puspan. L. 103–432, § 147(a), substituted “unique physician identification number” for “provider number” and struck out “and indicate whether or not the referring physician is an interested investor (within the meaning of section 1395nn(h)(5) of this title)” after “for the referring physician”.

Subsec. (r). Puspan. L. 103–432, § 160(d)(1), redesignated subsec. (r), relating to other prepaid organizations, as (s).

Subsec. (r)(1). Puspan. L. 103–432, § 147(e)(2), substituted “or ambulatory” for “ambulatory” in two places and “center” for “center,” before “with which the nurse”.

Subsec. (r)(2)(A). Puspan. L. 103–432, § 147(e)(3), substituted “subsection (a)(1)(O) of this section” for “subsection (a)(1)(M) of this section”.

Subsec. (r)(3), (4). Puspan. L. 103–432, § 123(span)(2)(A)(iii), redesignated par. (4) as (3) and struck out former par. (3) which read as follows:

“(3)(A) Payment under this part for services described in section 1395x(s)(2)(K)(iii) of this title may be made only on an assignment-related basis, and any such assignment agreed to by a nurse practitioner or clinical nurse specialist shall be binding upon any other person presenting a claim or request for payment for such services.

“(B) Except for deductible and coinsurance amounts applicable under this section, any person who knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services described in section 1395x(s)(2)(K)(iii) of this title in violation of subparagraph (A) is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (span)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

Subsec. (s). Puspan. L. 103–432, § 160(d)(1), redesignated subsec. (r), relating to other prepaid organizations, as (s).

1993—Subsec. (a)(1). Puspan. L. 103–66, § 13544(span)(2), redesignated subpar. (M) relating to nurse practitioner and clinical nurse specialist services as (O), inserted comma before “(O)”, transferred and inserted such subpar. to appear before semicolon at end, struck out “and” before “(N)”, and inserted “, and” and subpar. (P) following subpar. (O) and before semicolon at end.

Subsec. (g). Puspan. L. 103–66, § 13555(a), substituted “$900” for “$750” in two places.

Subsec. (h)(2)(A)(ii)(IV). Puspan. L. 103–66, § 13551(a), added subcl. (IV).

Subsec. (h)(4)(B)(iv) to (vii). Puspan. L. 103–66, § 13551(span), added cls. (iv) to (vii), and struck out former cl. (iv) which read as follows: “after December 31, 1990, is equal to 88 percent of the median of all the fee schedules established for that test for that laboratory setting under paragraph (1).”

Subsec. (i)(3)(B)(ii). Puspan. L. 103–66, § 13532(a)(1), in introductory provisions substituted “paragraph (4)” for “the last sentence of this clause” and struck out concluding provisions which read as follows: “In the case of a hospital that makes application to the Secretary and demonstrates that it specializes in eye services or eye and ear services (as determined by the Secretary), receives more than 30 percent of its total revenues from outpatient services and was an eye specialty hospital or an eye and ear specialty hospital on October 1, 1987, the cost proportion and ASC proportion in effect under subclauses (I) and (II) for cost reporting periods beginning in fiscal year 1988 shall remain in effect for cost reporting periods beginning on or after October 1, 1988, and before January 1, 1995.”

Subsec. (i)(4). Puspan. L. 103–66, § 13532(a)(2), added par. (4).

Subsec. (l)(4)(B)(i). Puspan. L. 103–66, § 13516(span)(1), inserted “and before January 1, 1994,” after “1991,”.

Subsec. (l)(4)(B)(ii). Puspan. L. 103–66, § 13516(span)(2), inserted “and” at end of subcl. (II), substituted a period for the comma at end of subcl. (III), and struck out subcls. (IV) to (VII) which read as follows:

“(IV) for services furnished in 1994, $11.25,

“(V) for services furnished in 1995, $11.50,

“(VI) for services furnished in 1996, $11.70, and

“(VII) for services furnished in calendar years after 1997, the previous year’s conversion factor increased by the update determined under section 1395w–4(d)(3) of this title for physician anesthesia services for that year.”

Subsec. (l)(4)(B)(iii). Puspan. L. 103–66, § 13516(span)(3), added cl. (iii).

1990—Subsec. (a)(1)(H). Puspan. L. 101–508, § 4118(f)(2)(D), struck out “, as the case may be” after “section 1395w–4 of this title”.

Subsec. (a)(1)(J). Puspan. L. 101–508, § 4104(span)(1), struck out “or physician pathology services” after “1395m(span)(6) of this title)” and “or section 1395m(f) of this title, respectively” after “1395m(span) of this title”.

Subsec. (a)(1)(K). Puspan. L. 101–508, § 4155(span)(2)(A), which directed amendment of subpar. (K) by striking “and” at the end, could not be executed because of prior amendment by Puspan. L. 101–508, § 4153(a)(2)(B)(i), see below.

Puspan. L. 101–508, § 4153(a)(2)(B)(i), struck out “and” after “by a physician),”.

Subsec. (a)(1)(L). Puspan. L. 101–508, § 4153(a)(2)(B)(ii), substituted “subparagraph,” for “subparagraph and” at end.

Subsec. (a)(1)(M). Puspan. L. 101–508, § 4155(span)(2)(B), added subpar. (M) relating to nurse practitioner and clinical nurse specialist services.

Puspan. L. 101–508, § 4153(a)(2)(B)(ii), added subpar. (M) relating to prosthetic devices and orthotics.

Subsec. (a)(2). Puspan. L. 101–508, § 4153(a)(2)(C)(i), substituted “(H), and (I)” for “and (H)” in introductory provisions.

Subsec. (a)(2)(E)(i). Puspan. L. 101–508, § 4163(d)(1), inserted “, but excluding screening mammography” after “imaging services”.

Subsec. (a)(7). Puspan. L. 101–508, § 4153(a)(2)(C)(ii)–(iv), added par. (7).

Subsec. (span). Puspan. L. 101–508, § 4302, inserted “for calendar years before 1991 and $100 for 1991 and subsequent years” after “$75”.

Subsec. (span)(5). Puspan. L. 101–508, § 4161(a)(3)(B), added par. (5) at end of first sentence.

Subsec. (h)(2)(A)(ii). Puspan. L. 101–508, § 4154(a)(1), substituted “clause (i)” for “any other provision of this subsection” in introductory provisions.

Subsec. (h)(2)(A)(ii)(III). Puspan. L. 101–508, § 4154(a)(2)–(4), added subcl. (III).

Subsec. (h)(4)(B). Puspan. L. 101–508, § 4154(span)(1)(B), struck out “and” at end of cl. (ii), inserted “and before January 1, 1991,” after “1989,” in cl. (iii), substituted “, and” for period at end of cl. (iii), and added cl. (iv).

Subsec. (h)(5)(A)(ii)(II). Puspan. L. 101–508, § 4154(e)(1)(A), substituted “wholly owned by” for “a wholly-owned subsidiary of”.

Subsec. (h)(5)(A)(ii)(III). Puspan. L. 101–508, § 4154(e)(1)(C), substituted “receives requests for testing during the year in which the test is performed” for “submits bills or requests for payment in any year”.

Puspan. L. 101–508, § 4154(e)(1)(B), which directed substitution of “laboratory (but not including a laboratory described in subclause (II)),” for “laboratory”, was executed by making the substitution for “laboratory” the second time appearing to reflect the probable intent of Congress.

Subsec. (h)(5)(A)(iii). Puspan. L. 101–508, § 4008(m)(2)(C), which directed technical correction to Puspan. L. 101–239, § 6003(g)(3)(C)(vii)(I), was executed by making technical correction to Puspan. L. 101–239, § 6003(g)(3)(D)(vii)(I), resulting in no change in text. See 1989 Amendment note below.

Subsec. (h)(5)(C). Puspan. L. 101–508, § 4154(c)(1)(A), substituted “test, including a test performed in a physician’s office but excluding a test performed by a rural health clinic” for “test performed by a laboratory other than a rural health clinic”.

Subsec. (h)(5)(D). Puspan. L. 101–508, § 4154(c)(1)(B), substituted “test, including a test performed in a physician’s office but excluding a test performed by a rural health clinic,” for “test performed by a laboratory, other than a rural health clinic”.

Subsec. (i)(3)(B)(ii). Puspan. L. 101–508, § 4151(c)(1)(B), substituted “on or after October 1, 1988, and before January 1, 1995” for “in fiscal year 1989 or fiscal year 1990” in last sentence.

Subsec. (i)(3)(B)(ii)(I). Puspan. L. 101–508, § 4151(c)(1)(A)(i), substituted “50 percent for reporting periods beginning on or after October 1, 1988, and on or before December 31, 1990, and 42 percent for portions of cost reporting periods beginning on or after January 1, 1991” for “and 50 percent for other cost reporting periods”.

Subsec. (i)(3)(B)(ii)(II). Puspan. L. 101–508, § 4151(c)(1)(A)(ii), substituted “50 percent for reporting periods beginning on or after October 1, 1988, and on or before December 31, 1990, and 58 percent for portions of cost reporting periods beginning on or after January 1, 1991” for “and 50 percent for other cost reporting periods”.

Subsec. (l)(1). Puspan. L. 101–508, § 4160(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).

Subsec. (l)(2). Puspan. L. 101–508, § 4160(2), struck out at end “The fee schedule shall be adjusted annually (to become effective on January 1 of each calendar year) by the percentage increase in the MEI (as defined in section 1395u(i)(3) of this title) for that year.”

Subsec. (l)(4). Puspan. L. 101–508, § 4160(3), added par. (4) and struck out former par. (4) which read as follows: “In establishing the fee schedule under paragraph (1), the Secretary may utilize a system of time units, a system of base and time units, or any appropriate methodology. The Secretary may establish a nationwide fee schedule or adjust the fee schedule for geographic areas (as the Secretary may determine to be appropriate).”

Subsec. (m). Puspan. L. 101–597 substituted “health professional shortage area” for “health manpower shortage area”.

Subsec. (n)(1)(B)(ii)(I). Puspan. L. 101–508, § 4151(c)(2), inserted before period at end “, and such term means 42 percent in the case of outpatient radiology services for portions of cost reporting periods beginning on or after January 1, 1991”.

Subsec. (r). Puspan. L. 101–508, § 4206(span)(2), added subsec. (r) relating to other prepaid organizations.

Puspan. L. 101–508, § 4155(span)(3), added subsec. (r) relating to cap on prevailing charge and billing on assignment-related basis.

1989—Subsec. (a). Puspan. L. 101–234, § 202(a), repealed Puspan. L. 100–360, § 212(c)(2), and provided that the provisions of law amended or repealed by such section are restored or revised as if such section had not been enacted, see 1988 Amendment note below.

Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 205(c)(3), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

Subsec. (a)(1)(F). Puspan. L. 101–239, § 6113(span)(3)(A), added subpar. (F).

Subsec. (a)(1)(H). Puspan. L. 101–239, § 6102(e)(5), inserted “(or, for services furnished on or after January 1, 1992, the fee schedule amount provided under section 1395w–4 of this title, as the case may be)” after “prevailing charge that would be recognized”.

Subsec. (a)(1)(J). Puspan. L. 101–239, § 6102(f)(2), inserted “or physician pathology services” after “1395m(span)(6) of this title)” and “or section 1395m(f) of this title, respectively” after “1395m(span) of this title”.

Puspan. L. 101–239, § 6102(e)(6)(A), inserted “subject to section 1395w–4 of this title,” before “the amounts”.

Subsec. (a)(1)(K). Puspan. L. 101–239, § 6102(e)(7), inserted “, or, for services furnished on or after January 1, 1992, 65 percent of the fee schedule amount provided under section 1395w–4 of this title for the same service performed by a physician” after “for the same service performed by a physician”.

Subsec. (a)(1)(M). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 201(span)(1), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

Subsec. (a)(1)(N). Puspan. L. 101–239, § 6102(e)(1)(B), added subpar. (N).

Subsec. (a)(2). Puspan. L. 101–239, § 6116(span)(1)(A), substituted “(G), and (H)” for “and (G)” in introductory provisions.

Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, §§ 202(span)(2), 203(c)(1)(A)–(D), 204(d)(1), and 205(c)(1), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.

Subsec. (a)(3). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 205(c)(2), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

Subsec. (a)(6). Puspan. L. 101–239, § 6116(span)(1)(B)–(D), added par. (6).

Subsec. (span). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, §§ 202(span)(3), 203(c)(1)(E), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.

Subsec. (c). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 201(a)(1), (4), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.

Subsec. (d). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 201(a)(1)(D), (2), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.

Subsec. (d)(1). Puspan. L. 101–239, § 6113(d), substituted “62½ percent of such expenses.” for “whichever of the following amounts is the smaller:

“(A) $1375.00, or

“(B) 62½ percent of such expenses.”

Subsec. (g). Puspan. L. 101–239, § 6133(a), substituted “$750” for “$500” in two places.

Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 201(a)(3), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

Subsec. (h)(1)(B), (C). Puspan. L. 101–239, § 6111(a)(1), substituted “on or after July 1, 1984” for “during the period beginning on July 1, 1984, and ending on December 31, 1989. For such tests furnished on or after January 1, 1990, the fee schedule shall be established on a nationwide basis.”

Subsec. (h)(1)(D). Puspan. L. 101–239, § 6003(e)(2)(A), substituted “section 1395ww(d)(5)(D)(iii) of this title” for “the last sentence of section 1395ww(d)(5)(C)(ii) of this title”.

Subsec. (h)(4)(B)(ii). Puspan. L. 101–239, § 6111(a)(3)(A), (B), substituted “after March 31, 1988, and before January 1, 1990,” for “after March 31, 1988, and so long as a fee schedule for the test has not been established on a nationwide basis,”.

Subsec. (h)(4)(B)(iii). Puspan. L. 101–239, § 6111(a)(2), (3)(C), (4), added cl. (iii).

Subsec. (h)(5)(A)(ii). Puspan. L. 101–239, § 6111(span)(1), substituted “referring laboratory but only if—” for “referring laboratory, and” in introductory provisions, and added subcls. (I) through (III).

Subsec. (h)(5)(A)(iii). Puspan. L. 101–239, § 6003(g)(3)(D)(vii)(I), as amended by Puspan. L. 101–508, § 4008(m)(2)(C), substituted “hospital or rural primary care hospital,” for “hospital,”.

Subsec. (i)(1)(A). Puspan. L. 101–239, § 6003(g)(3)(D)(vii)(II), inserted “, rural primary care hospital,” after “section 1395k(a)(2)(F)(i) of this title)”.

Subsec. (i)(3)(A). Puspan. L. 101–239, § 6003(g)(3)(D)(vii)(III), inserted “or rural primary care hospital services” after “facility services” in introductory provisions.

Subsec. (l)(5)(A). Puspan. L. 101–239, § 6003(g)(3)(D)(vii)(IV), inserted “rural primary care hospital,” after “hospital,” in two places.

Subsec. (l)(5)(C). Puspan. L. 101–239, § 6003(g)(3)(D)(vii)(V), substituted “hospital or rural primary care hospital” for “hospital” in two places.

Subsec. (m). Puspan. L. 101–239, § 6102(c)(1), struck out “class 1 or class 2” before “health manpower shortage area” and substituted “10 percent” for “5 percent”.

Subsec. (o)(1). Puspan. L. 101–239, § 6131(a)(1)(C), inserted “(or inserts)” after “shoes” in two places in last sentence.

Subsec. (o)(1)(A). Puspan. L. 101–239, § 6131(a)(1)(A), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: “no payment may be made under this part for the furnishing of more than one pair of shoes for any individual for any calendar year, and”.

Subsec. (o)(1)(B), (2)(A). Puspan. L. 101–239, § 6131(a)(1)(B), substituted “limits” for “limit”.

Subsec. (o)(2)(A)(i). Puspan. L. 101–239, § 6131(a)(1)(D), amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: “for the furnishing of one pair of custom molded shoes is $300”.

Subsec. (o)(2)(A)(ii)(II). Puspan. L. 101–239, § 6131(a)(1)(E), inserted “any pairs of” after “$50 for”.

Subsec. (o)(2)(D). Puspan. L. 101–239, § 6131(span), added subpar. (D).

Subsec. (p). Puspan. L. 101–239, § 6113(span)(3)(B), substituted “1395x(s)(2)(L) of this title,” for “1395x(s)(2)(L) of this title and” and inserted “and in the case of clinical social worker services for which payment may be made under this part only pursuant to section 1395x(s)(2)(N) of this title,” after “section 1395x(s)(2)(M) of this title,”.

Subsec. (q). Puspan. L. 101–239, § 6204(span), added subsec. (q).

1988—Subsec. (a). Puspan. L. 100–360, § 212(c)(2), inserted “or, as provided in section 1395t–1(c) of this title, from the Federal Catastrophic Drug Insurance Trust Fund” after “Fund” in introductory provisions.

Puspan. L. 100–360, § 205(c)(3), inserted provision at end relating to payment for in-home care for chronically dependent individuals.

Subsec. (a)(1)(D)(i). Puspan. L. 100–360, § 411(i)(4)(C)(i), amended Puspan. L. 100–203, § 4085(i)(1)(A), see 1987 Amendment note below.

Subsec. (a)(1)(F). Puspan. L. 100–360, § 411(f)(12)(A), (14), added and renumbered Puspan. L. 100–203, § 4055(a)(1), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(i)(4)(C)(iv), made technical amendment to directory language of Puspan. L. 100–203, § 4085(i)(21)(D)(i), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(i)(4)(C)(ii), repealed Puspan. L. 100–203, § 4085(i)(1)(B), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(h)(4)(B)(i), (ii), redesignated and amended directory language of Puspan. L. 100–203, § 4073(span)(1)(A), see 1987 Amendment note below.

Subsec. (a)(1)(G). Puspan. L. 100–360, § 411(h)(7)(C)(ii), repealed Puspan. L. 100–203, § 4077(span)(3)(A), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(h)(4)(B)(iii), repealed Puspan. L. 100–203, § 4073(span)(2)(B), see 1987 Amendment note below.

Subsec. (a)(1)(H). Puspan. L. 100–360, § 411(h)(7)(C)(ii), repealed Puspan. L. 100–203, § 4077(span)(3)(B), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(g)(1)(E), which directed the amendment of subpar. (H) by striking “and” before “(I)” could not be executed because of the prior amendment by section 4049(a)(1) of Puspan. L. 100–203, see 1987 Amendment note below.

Puspan. L. 100–360, § 411(i)(3), added Puspan. L. 100–203, § 4084(c)(2), see 1987 Amendment note below.

Subsec. (a)(1)(J). Puspan. L. 100–360, § 411(f)(8)(B)(i), made technical amendment to directory language of Puspan. L. 100–203, § 4049(a)(1), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(f)(8)(C), substituted “section 1395m(span)(6) of this title” for “section 1395m(span)(5) of this title”.

Subsec. (a)(1)(K). Puspan. L. 100–360, § 411(h)(7)(C)(iii), (F), redesignated and amended Puspan. L. 100–203, § 4077(span)(2)(A), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(h)(4)(B)(i), (iv), (v), redesignated and amended Puspan. L. 100–203, § 4073(span)(1)(B), see 1987 Amendment note below.

Subsec. (a)(1)(L). Puspan. L. 100–360, § 411(h)(7)(C)(i), (iv), (v), (F), redesignated and amended Puspan. L. 100–203, § 4077(span)(2)(B), see 1987 Amendment note below.

Subsec. (a)(1)(M). Puspan. L. 100–360, § 202(span)(1), added subpar. (M) relating to expenses incurred for covered outpatient drugs.

Subsec. (a)(2). Puspan. L. 100–360, § 205(c)(1), inserted “(A)(ii),” after “subparagraphs” in introductory provisions.

Puspan. L. 100–360, § 202(span)(2), inserted “(other than covered outpatient drugs)” after “in the case of services” in introductory provisions.

Subsec. (a)(2)(B). Puspan. L. 100–360, § 203(c)(1)(A), substituted “(E), or (F)” for “or (E)” in introductory provisions.

Subsec. (a)(2)(D)(i). Puspan. L. 100–360, § 411(i)(4)(C)(i), amended Puspan. L. 100–203, § 4085(i)(1)(A), see 1987 Amendment note below.

Subsec. (a)(2)(E)(i). Puspan. L. 100–360, § 204(d)(1), inserted “, but excluding screening mammography” after “imaging services”.

Subsec. (a)(2)(F). Puspan. L. 100–360, § 203(c)(1)(B)–(D), added subpar. (F) relating to home intravenous drug therapy services.

Subsec. (a)(3). Puspan. L. 100–360, § 205(c)(2), substituted “subparagraphs (A)(ii), (D),” for “subparagraphs (D)”.

Subsec. (span). Puspan. L. 100–360, § 104(d)(7), as added by Puspan. L. 100–485, § 608(d)(3)(G), inserted at end “The deductible under the previous sentence for blood or blood cells furnished an individual in a year shall be reduced to the extent that a deductible has been imposed under section 1395e(a)(2) of this title to blood or blood cells furnished the individual in the year.”

Subsec. (span)(1). Puspan. L. 100–360, § 202(span)(3)(A), inserted “or for covered outpatient drugs” after “section 1395x(s)(10)(A) of this title”.

Subsec. (span)(2). Puspan. L. 100–360, § 203(c)(1)(E), substituted “services and home intravenous drug therapy services” for “services”.

Puspan. L. 100–360, § 202(span)(3)(B), inserted “or with respect to covered outpatient drugs” after “home health services”.

Subsec. (span)(3) to (5). Puspan. L. 100–360, § 411(f)(12)(A), (14), added and renumbered Puspan. L. 100–203, § 4055(a)(2), see 1987 Amendment note below.

Subsec. (c). Puspan. L. 100–360, § 201(a)(4), added subsec. (c) relating to limitation on out-of-pocket catastrophic cost-sharing, adjustment, buy-out plans, and conditions for payments with respect to plans other than buy-out plans. Former subsec. (c) redesignated (d)(1).

Puspan. L. 100–360, § 411(h)(1)(A), substituted “monitoring or changing drug prescriptions” for “prescribing or monitoring prescription drugs” in last sentence.

Puspan. L. 100–360, § 201(a)(1)(A), as amended by Puspan. L. 100–485, § 608(d)(4), substituted “subsections (a) through (c)” for “subsections (a) and (span)” in introductory provisions.

Puspan. L. 100–360, § 201(a)(1)(B), (C), redesignated former pars. (1) and (2) as subpars. (A) and (B) and substituted “this paragraph” for “this subsection” in last sentence.

Subsec. (d)(1). Puspan. L. 100–360, § 201(a)(1)(D), redesignated former subsec. (c) as subsec. (d)(1). Former subsec. (d) redesignated subsec. (d)(2).

Subsec. (d)(2). Puspan. L. 100–360, § 201(a)(2), redesignated former subsec. (d) as subsec. (d)(2).

Subsec. (f). Puspan. L. 100–360, § 411(g)(5), substituted “MEI (as defined in section 1395u(i)(3) of this title) applicable to primary care services (as defined in section 1395u(i)(4) of this title)” for “medicare economic index (referred to in the fourth sentence of section 1395u(span)(3) of this title) applicable to physicians’ services”.

Subsec. (g). Puspan. L. 100–360, § 201(a)(3), substituted “subsections (a) through (c) of this section” for “subsections (a) and (span) of this section” in two places.

Subsec. (h)(1)(D). Puspan. L. 100–360, § 411(g)(3)(E), (F), amended and redesignated Puspan. L. 100–203, § 4064(c)(1), see 1987 Amendment note below.

Subsec. (h)(2)(A)(i). Puspan. L. 100–360, § 411(g)(3)(A), added Puspan. L. 100–203, § 4064(a)(1), see 1987 Amendment note below.

Subsec. (h)(2)(A)(ii). Puspan. L. 100–360, § 411(g)(3)(A), added Puspan. L. 100–203, § 4064(a)(3), see 1987 Amendment note below.

Subsec. (h)(2)(A)(iii). Puspan. L. 100–360, § 411(g)(3)(B), (C), amended Puspan. L. 100–203, § 4064(span)(1), see 1987 Amendment note below.

Subsec. (h)(2)(B). Puspan. L. 100–360, § 411(g)(3)(A), added Puspan. L. 100–203, § 4064(a)(2), see 1987 Amendment note below.

Subsec. (h)(3). Puspan. L. 100–647, § 8421(a), inserted at end “In establishing a fee to cover the transportation and personnel expenses for trained personnel to travel to the location of an individual to collect a sample, the Secretary shall provide a method for computing the fee based on the number of miles traveled and the personnel costs associated with the collection of each individual sample, but the Secretary shall only be required to apply such method in the case of tests furnished during the period beginning on April 1, 1989, and ending on December 31, 1990, by a laboratory that establishes to the satisfaction of the Secretary (based on data for the 12-month period ending June 30, 1988) that (i) the laboratory is dependent upon payments under this subchapter for at least 80 percent of its collected revenues for clinical diagnostic laboratory tests, (ii) at least 85 percent of its gross revenues for such tests are attributable to tests performed with respect to individuals who are homebound or who are residents in a nursing facility, and (iii) the laboratory provided such tests for residents in nursing facilities representing at least 20 percent of the number of such facilities in the State in which the laboratory is located.”

Subsec. (h)(4)(B)(ii). Puspan. L. 100–360, § 411(g)(3)(D), inserted “after” before “March 31, 1988”.

Subsec. (h)(5)(A). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(22)(B), see 1987 Amendment note below.

Subsec. (h)(5)(C). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(22)(B), see 1987 Amendment note below.

Subsec. (h)(5)(D). Puspan. L. 100–360, § 411(i)(4)(B), substituted “A person may not bill for a clinical diagnostic laboratory test performed by a laboratory, other than a rural health clinic, other than on an assignment-related basis. If a person knowingly and willfully and on a repeated basis bills for a clinical diagnostic laboratory test in violation of the previous sentence” for “If a person knowingly and willfully and on a repeated basis bills an individual enrolled under this part for charges for a clinical diagnostic laboratory test for which payment may only be made on an assignment-related basis under subparagraph (C)” and “paragraphs (2) and (3) of section 1395u(j) of this title in the same manner such paragraphs apply with respect to a physician” for “section 1395u(j)(2) of this title”.

Subsec. (i)(2)(A)(iii). Puspan. L. 100–360, § 411(g)(2)(D), substituted “insertion” for “implantation” and inserted “or subsequent to” after “during”.

Subsec. (i)(4). Puspan. L. 100–360, § 411(f)(12)(A), (14), added and renumbered Puspan. L. 100–203, § 4055(a)(3), see 1987 Amendment note below.

Subsec. (i)(6). Puspan. L. 100–485, § 608(d)(22)(B), substituted “Any person, including” for “Any person, other than”.

Puspan. L. 100–360, § 411(g)(2)(E), added Puspan. L. 100–203, § 4063(e)(1), see 1987 Amendment note below.

Subsec. (l)(2). Puspan. L. 100–360, § 411(f)(2)(D), added Puspan. L. 100–203, § 4042(span)(2)(B), see 1987 Amendment note below.

Subsec. (l)(3)(B). Puspan. L. 100–647, § 8422(a), inserted “plus applicable coinsurance” after “would have been paid”.

Subsec. (l)(5)(B)(ii). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(23), see 1987 Amendment note below.

Subsec. (n)(1)(A). Puspan. L. 100–360, § 411(g)(4)(C)(i), as amended by Puspan. L. 100–485, § 608(d)(22)(D), substituted “for services described in subsection (a)(2)(E)(i) furnished under this part on or after October 1, 1988, and for services described in subsection (a)(2)(E)(ii) furnished under this part on or after October 1, 1989,” for “beginning on or after October 1, 1988 under this part for services described in subsection (a)(2)(E)” in introductory provisions.

Subsec. (n)(1)(B)(i)(II). Puspan. L. 100–360, § 411(g)(4)(C)(ii), inserted “or (for services described in subsection (a)(2)(E)(i) furnished on or after January 1, 1989) the fee schedule amount established” after “the prevailing charge”.

Subsec. (n)(1)(B)(ii). Puspan. L. 100–360, § 411(g)(4)(C)(iii), amended subcls. (I) and (II) generally. Prior to amendment, subcls. (I) and (II) read as follows:

“(I) The term ‘cost proportion’ means 65 percent for all or any part of cost reporting periods which occur in fiscal year 1989 and 50 percent for other cost reporting periods.

“(II) The term ‘charge proportion’ means 35 percent for all or any parts of cost reporting periods which occur in fiscal year 1989 and 50 percent for other cost reporting periods.”

Subsec. (o). Puspan. L. 100–360, § 411(h)(3)(B), as amended by Puspan. L. 100–485, § 608(d)(23)(A), amended Puspan. L. 100–203, § 4072(span), see 1987 Amendment note below.

Subsec. (p). Puspan. L. 100–360, § 411(h)(7)(D), (F), redesignated and amended Puspan. L. 100–203, § 4077(span)(3), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(h)(4)(C), redesignated and amended Puspan. L. 100–203, § 4073(span)(2), see 1987 Amendment note below.

1987—Subsec. (a)(1)(D)(i). Puspan. L. 100–203, § 4085(i)(1)(A), as amended by Puspan. L. 100–360, § 411(i)(4)(C)(i), substituted “on an assignment-related basis,” for “on the basis of an assignment described in section 1395u(span)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title,”.

Subsec. (a)(1)(F). Puspan. L. 100–203, § 4055(a)(1), formerly § 4054(a)(1), as added and renumbered by Puspan. L. 100–360, § 411(f)(12)(A), (14), struck out subpar. (F) which read as follows: “with respect to expenses incurred for services described in subsection (i)(4) of this section under the conditions specified in such subsection, the amounts paid shall be the reasonable charge for such services,”.

Puspan. L. 100–203, § 4085(i)(21)(D)(i), as amended by Puspan. L. 100–360, § 411(i)(4)(C)(iv), amended Puspan. L. 99–509, § 9343(e)(2)(A), see 1986 Amendment note below.

Puspan. L. 100–203, § 4085(i)(1)(B), which directed striking out “and” at end, was repealed by Puspan. L. 100–360, § 411(i)(4)(C)(ii).

Puspan. L. 100–203, § 4073(span)(1)(A), formerly § 4073(span)(2)(A), as redesignated and amended by Puspan. L. 100–360, § 411(h)(4)(B)(i), (ii), struck out “and” at end.

Subsec. (a)(1)(G). Puspan. L. 100–203, § 4077(span)(3)(A), which directed striking out “and” at end, was repealed by Puspan. L. 100–360, § 411(h)(7)(C)(ii).

Puspan. L. 100–203, § 4073(span)(2)(B), which directed substituting “services,” for “services; and”, was repealed by Puspan. L. 100–360, § 411(h)(4)(B)(iii).

Puspan. L. 100–203, § 4062(d)(3)(A)(i), substituted “services,” for “services; and”.

Subsec. (a)(1)(H). Puspan. L. 100–203, § 4077(span)(3)(B), which directed substituting “services,” for “services; and”, was repealed by Puspan. L. 100–360, § 411(h)(7)(C)(ii).

Puspan. L. 100–203, § 4084(c)(2), as added by Puspan. L. 100–360, § 411(i)(3), substituted “least of the actual charge, the prevailing charge that would be recognized if the services had been performed by an anesthesiologist,” for “lesser of the actual charge”.

Puspan. L. 100–203, § 4062(d)(3)(A)(ii), inserted “and” before the subpar. (I) added by section 4062(d)(3)(A)(ii) of Puspan. L. 100–203, see below.

Puspan. L. 100–203, § 4049(a)(1), struck out “and” before the subpar. (I) added by section 4062(d)(3)(A)(ii) of Puspan. L. 100–203, see below.

Subsec. (a)(1)(I). Puspan. L. 100–203, § 4062(d)(3)(A)(ii), added subpar. (I).

Subsec. (a)(1)(J). Puspan. L. 100–203, § 4049(a)(1), as amended by Puspan. L. 100–360, § 411(f)(8)(B)(i), added subpar. (J).

Subsec. (a)(1)(K). Puspan. L. 100–203, § 4077(span)(2)(A), formerly § 4077(span)(3)(C), as redesignated and amended by Puspan. L. 100–360, § 411(h)(7)(C)(iii), (F), inserted “and” after “performed by a physician),”.

Puspan. L. 100–203, § 4073(span)(1)(B), formerly § 4073(span)(2)(C), as redesignated and amended by Puspan. L. 100–360, § 411(h)(4)(B)(i), (iv), (v), added subpar. (K), formerly (I), relating to amounts paid with respect to certified nurse-midwife services under section 1395x(s)(2)(L) of this title.

Subsec. (a)(1)(L). Puspan. L. 100–203, § 4077(span)(2)(B), formerly § 4077(span)(3)(D), as redesignated and amended by Puspan. L. 100–360, § 411(h)(7)(C)(i), (iv), (v), (F), added subpar. (L), formerly (J), relating to amounts paid with respect to qualified psychologist services under section 1395x(s)(2)(M) of this title.

Subsec. (a)(2). Puspan. L. 100–203, § 4062(d)(3)(B)(i), inserted reference to subpar. (G).

Subsec. (a)(2)(A). Puspan. L. 100–203, § 4062(d)(3)(B)(ii), struck out “(other than durable medical equipment)” after “home health services”.

Subsec. (a)(2)(B). Puspan. L. 100–203, § 4066(span), inserted reference to subpar. (E).

Subsec. (a)(2)(D)(i). Puspan. L. 100–203, § 4085(i)(1)(A), as amended by Puspan. L. 100–360, § 411(i)(4)(C)(i), substituted “on an assignment-related basis,” for “on the basis of an assignment described in section 1395u(span)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title,”.

Subsec. (a)(2)(E). Puspan. L. 100–203, § 4066(a)(1), added subpar. (E).

Subsec. (a)(5). Puspan. L. 100–203, § 4062(d)(3)(C)–(E), added par. (5).

Subsec. (span)(3). Puspan. L. 100–203, § 4055(a)(2), formerly § 4054(a)(2), as added and renumbered by Puspan. L. 100–360, § 411(f)(12)(A), (14), redesignated par. (4) as (3) and struck out former par. (3) which read as follows: “such total amount shall not include expenses incurred for services the amount of payment for which is determined under subsection (a)(1)(F) of this section,”.

Puspan. L. 100–203, § 4085(i)(21)(D)(i), amended Puspan. L. 99–509, § 9343(e)(2)(A), see 1986 Amendment note below.

Subsec. (span)(4). Puspan. L. 100–203, § 4055(a)(2), formerly § 4054(a)(2), as added and renumbered by Puspan. L. 100–360, § 411(f)(12)(A), (14), redesignated par. (5) as (4). Former par. (4) redesignated (3).

Subsec. (span)(4)(A). Puspan. L. 100–203, § 4085(i)(1)(C), substituted “on an assignment-related basis” for “on the basis of an assignment described in section 1395u(span)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title”.

Subsec. (span)(5). Puspan. L. 100–203, § 4055(a)(2), formerly § 4054(a)(2), as added and renumbered by Puspan. L. 100–360, § 411(f)(12)(A), (14), redesignated par. (5) as (4).

Subsec. (c). Puspan. L. 100–203, § 4070(span)(4), inserted “or partial hospitalization services that are not directly provided by a physician” before period at end of last sentence.

Puspan. L. 100–203, § 4070(a)(2), inserted sentence at end defining “treatment”.

Subsec. (c)(1). Puspan. L. 100–203, § 4070(a)(1), substituted “$1375.00” for “$312.50”.

Subsec. (f). Puspan. L. 100–203, § 4067(a), added subsec. (f).

Subsec. (h)(1)(C). Puspan. L. 100–203, § 4085(i)(2), inserted before period at end “, and ending on December 31, 1989. For such tests furnished on or after January 1, 1990, the fee schedule shall be established on a nationwide basis”.

Subsec. (h)(1)(D). Puspan. L. 100–203, § 4064(c)(1), formerly § 4064(c), as amended and redesignated by Puspan. L. 100–360, § 411(g)(3)(E), (F), inserted “, in a sole community hospital (as defined in the last sentence of section 1395ww(d)(5)(C)(ii) of this title),”.

Subsec. (h)(2). Puspan. L. 100–203, § 4064(c), which had directed that “laboratory in a sole community hospital” be substituted for “hospital laboratory” in subsec. (h)(2), was redesignated § 4064(c)(1) by section 411(g)(3)(F) of Puspan. L. 100–360 and amended by section 411(g)(3)(E) of Puspan. L. 100–360 to provide for amendment of subsec. (h)(1)(D) instead of subsec. (h)(2).

Subsec. (h)(2)(A)(i). Puspan. L. 100–203, § 4064(a)(1), as added by Puspan. L. 100–360, § 411(g)(3)(A), inserted “(A)(i)” after “(2)”.

Subsec. (h)(2)(A)(ii). Puspan. L. 100–203, § 4064(a)(3), as added by Puspan. L. 100–360, § 411(g)(3)(A), added cl. (ii).

Subsec. (h)(2)(A)(iii). Puspan. L. 100–203, § 4064(span)(1), as amended by Puspan. L. 100–360, § 411(g)(3)(B), (C), set out as cl. (iii) provisions formerly set out in an otherwise undesignated sentence in par. (2) relating to the rebasing of fee schedules for certain automated and similar tests for 1988 and for the continuation of such reduced fee schedules as the base for 1989 and subsequent years.

Subsec. (h)(2)(B). Puspan. L. 100–203, § 4064(a)(2), as added by Puspan. L. 100–360, § 411(g)(3)(A), inserted subpar. (B) designation preceding second sentence and redesignated former subpars. (A) and (B) of par. (2) as cls. (i) and (ii).

Subsec. (h)(4)(B)(i). Puspan. L. 100–203, § 4064(span)(2)(A), substituted “April” for “January”.

Subsec. (h)(4)(B)(ii). Puspan. L. 100–203, § 4064(span)(2)(B), amended cl. (ii) generally. Prior to amendment, cl. (ii) read as follows: “after December 31, 1987, and so long as a fee schedule for the test has not been established on a nationwide basis, is equal to 110 percent of the median of all the fee schedules established for that test for that laboratory setting under paragraph (1).”

Subsec. (h)(5)(A). Puspan. L. 100–203, § 4085(i)(22)(B), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), substituted “on an assignment-related basis” for “on the basis of an assignment described in section 1395u(span)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title,” in introductory provisions.

Subsec. (h)(5)(A)(iii). Puspan. L. 100–203, § 4085(i)(3), added cl. (iii).

Subsec. (h)(5)(C). Puspan. L. 100–203, § 4085(i)(22)(B), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), substituted “on an assignment-related basis” for “on the basis of an assignment described in section 1395u(span)(3)(B)(ii) of this title, in accordance with section 1395u(span)(6)(B) of this title, under the procedure described in section 1395gg(f)(1) of this title,”.

Subsec. (h)(5)(D). Puspan. L. 100–203, § 4085(span)(1), added subpar. (D).

Subsec. (i)(2)(A)(iii). Puspan. L. 100–203, § 4063(span), added cl. (iii).

Subsec. (i)(3)(B)(ii). Puspan. L. 100–203, § 4068(a)(1), substituted “Subject to the last sentence of this clause, in” for “In”.

Puspan. L. 100–203, § 4068(a)(2), inserted sentence at end relating to cost and ASC proportions in the case of an eye or eye and ear specialty hospital.

Subsec. (i)(4). Puspan. L. 100–203, § 4055(a)(3), formerly § 4054(a)(3), as added and renumbered by Puspan. L. 100–360, § 411(f)(12)(A), (14), struck out par. (4) which read as follows: “In the case of services (including all pre- and post-operative services) described in paragraphs (1) and (2)(A) of section 1395x(s) of this title and furnished in connection with surgical procedures (specified pursuant to paragraph (1) of this subsection) in a physician’s office, an ambulatory surgical center described in such paragraph, or a hospital outpatient department, payment for such services shall be determined in accordance with subsection (a)(1)(F) of this section if the physician accepts an assignment described in section 1395u(span)(3)(B)(ii) of this title with respect to payment for such services.”

Subsec. (i)(6). Puspan. L. 100–203, § 4063(e)(1), as added by Puspan. L. 100–360, § 411(g)(2)(E), added par. (6).

Subsec. (l)(2). Puspan. L. 100–203, § 4084(a)(1), substituted “1985 and such other data as the Secretary determines necessary” for “1985”.

Puspan. L. 100–203, § 4042(span)(2)(B), as added by Puspan. L. 100–360, § 411(f)(2)(D), substituted “1395u(i)(3)” for “1395u(span)(4)(E)(ii)”.

Subsec. (l)(5)(A). Puspan. L. 100–203, § 4084(a)(2), substituted “group practice, or ambulatory surgical center” for “or group practice” in two places.

Subsec. (l)(5)(B)(ii). Puspan. L. 100–203, § 4085(i)(23), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), substituted “money penalty” for “monetary penalty” and amended second sentence generally. Prior to amendment, second sentence read as follows: “Such a penalty shall be imposed in the same manner as civil monetary penalties are imposed under section 1320a–7a of this title with respect to actions described in subsection (a) of that section.”

Subsec. (l)(6). Puspan. L. 100–203, § 4045(c)(2)(A)(i), (ii), struck out subpar. (A) designation and substituted “after the effective date of the reduction, the physician’s actual charge is subject to a limit under section 1395u(j)(1)(D) of this title.” for “(subject to subparagraph (D)), the physician may not charge the individual more than the limiting charge (as defined in subparagraph (B)) plus (for services furnished during the 12-month period beginning on the effective date of the reduction) ½ of the amount by which the physician’s actual charges for the service for the previous 12-month period exceeds the limiting charge.”

Puspan. L. 100–203, § 4045(c)(2)(A)(iii), struck out subpars. (B) to (D) which read as follows:

“(B) In subparagraph (A), the term ‘limiting charge’ means, with respect to a service, 125 percent of the prevailing charge for the service after the reduction referred to in subparagraph (A).

“(C) If a physician knowingly and willfully imposes charges in violation of subparagraph (A), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2) of this section.

“(D) This paragraph shall not apply to services furnished after the earlier of (i) December 31, 1990, or (ii) one-year after the date the Secretary reports to Congress, under section 1395w–1(e)(3) of this title, on the development of the relative value scale under section 1395w–1 of this title.”

Subsec. (m). Puspan. L. 100–203, § 4043(a), added subsec. (m).

Subsec. (n). Puspan. L. 100–203, § 4066(a)(2), added subsec. (n).

Subsec. (o). Puspan. L. 100–203, § 4072(span), as amended by Puspan. L. 100–360, § 411(h)(3)(B), as amended by Puspan. L. 100–485, § 608(d)(23)(A), added subsec. (o) [originally added as subsec. (f)].

Subsec. (p). Puspan. L. 100–203, § 4077(span)(3), formerly § 4077(span)(4), as redesignated and amended by Puspan. L. 100–360, § 411(h)(7)(D), (F), inserted “and in the case of qualified psychologists services for which payment may be made under this part only pursuant to section 1395x(s)(2)(M) of this title”.

Puspan. L. 100–203, § 4073(span)(2), formerly § 4073(span)(3), as redesignated and amended by Puspan. L. 100–360, § 411(h)(4)(C), added subsec. (p) [originally added as subsec. (m)] and inserted provision relating to monetary penalty for whoever knowingly and willfully presents, or causes to be presented, to an enrolled individual a bill or request for payment for described services.

1986—Subsec. (a)(1)(D). Puspan. L. 99–272, § 9401(span)(2)(B), substituted “, under the procedure described in section 1395gg(f)(1) of this title, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” for “or under the procedure described in section 1395gg(f)(1) of this title”.

Subsec. (a)(1)(D)(i). Puspan. L. 99–272, § 9303(span)(1), inserted “, the limitation amount for that test determined under subsection (h)(4)(B),” after “lesser of the amount determined under such fee schedule”.

Subsec. (a)(1)(F). Puspan. L. 99–509, § 9343(e)(2)(A), as amended by Puspan. L. 100–203, § 4085(i)(21)(D)(i), substituted “(i)(4)” for “(i)(3)”.

Subsec. (a)(1)(G). Puspan. L. 99–272, § 9401(span)(2)(A), added subpar. (G).

Subsec. (a)(1)(H). Puspan. L. 99–509, § 9320(e)(1), added subpar. (H).

Subsec. (a)(2)(A). Puspan. L. 99–272, § 9401(span)(2)(C), inserted “, to items and services (other than clinical diagnostic laboratory tests) furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion),” after “(other than durable medical equipment)”.

Subsec. (a)(2)(D). Puspan. L. 99–272, § 9401(span)(2)(D), substituted “to a provider having an agreement under section 1395cc of this title, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” for “or to a provider having an agreement under section 1395cc of this title”.

Subsec. (a)(2)(D)(i). Puspan. L. 99–272, § 9303(span)(1), inserted “, the limitation amount for that test determined under subsection (h)(4)(B),” after “lesser of the amount determined under such fee schedule”.

Subsec. (a)(3). Puspan. L. 99–272, § 9401(span)(2)(E), inserted “and for items and services furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title, or a third opinion, if the second opinion was in disagreement with the first opinion” after “1395x(s)(10)(A) of this title”.

Subsec. (a)(4). Puspan. L. 99–509, § 9343(a)(1)(A), amended par. (4) generally. Prior to amendment, par. (4) read as follows: “in the case of facility services described in subparagraph (F) of section 1395k(a)(2) of this title, the applicable amount described in paragraph (2) of subsection (i) of this section.”

Subsec. (span)(3). Puspan. L. 99–509, § 9343(e)(2)(A), as amended by Puspan. L. 100–203, § 4085(i)(21)(D)(i), which directed that par. (3) be amended by striking “or under subsection (i)(2) or (i)(4) of this section”, was executed by striking “or under subsection (i)(2) or (i)(5) of this section”, to reflect the probable intent of Congress and an earlier amendment by Puspan. L. 99–509, § 9343(a)(2), see below.

Puspan. L. 99–509, § 9343(a)(2), substituted “(i)(5)” for “(i)(4)”.

Subsec. (span)(5). Puspan. L. 99–272, § 9401(span)(1), added par. (5).

Subsec. (g). Puspan. L. 99–509, § 9337(span), substituted “second sentence” for “next to last sentence”, and inserted at end “In the case of outpatient occupational therapy services which are described in the second sentence of section 1395x(p) of this title through the operation of section 1395x(g) of this title, with respect to expenses incurred in any calendar year, no more than $500 shall be considered as incurred expenses for purposes of subsections (a) and (span).”

Subsec. (h)(1)(B). Puspan. L. 99–509, § 9339(span)(1), substituted “December 31, 1989” and “January 1, 1990” for “December 31, 1987” and “January 1, 1988”, respectively.

Puspan. L. 99–509, § 9339(a)(1)(A), substituted “qualified hospital laboratory (as defined in subparagraph (D))” for “hospital laboratory”.

Puspan. L. 99–272, § 9303(a)(1)(A), substituted “December 31, 1987” for “June 30, 1987” and “January 1, 1988” for “July 1, 1987”.

Subsec. (h)(1)(C). Puspan. L. 99–509, § 9339(a)(1)(B), substituted “qualified hospital laboratory (as defined in subparagraph (D))” for “hospital laboratory”, struck out “, and ending on December 31, 1987” after “July 1, 1984”, and struck out “For such tests furnished on or after January 1, 1988, the fee schedule under subparagraph (A) shall not apply with respect to clinical diagnostic laboratory tests performed by a hospital laboratory for outpatients of such hospital.” which constituted second sentence.

Puspan. L. 99–272, § 9303(a)(1)(A), substituted “December 31, 1987” for “June 30, 1987” and “January 1, 1988” for “July 1, 1987”.

Subsec. (h)(1)(D). Puspan. L. 99–509, § 9339(a)(1)(C), added subpar. (D).

Subsec. (h)(2). Puspan. L. 99–509, § 9339(span)(2), struck out “(or, effective January 1, 1988, for the United States)” after “applicable region, State, or area”.

Puspan. L. 99–509, § 9339(a)(1)(D), substituted “qualified hospital laboratory (as defined in paragraph (1)(D))” for “hospital laboratory”.

Puspan. L. 99–272, § 9303(a)(1), substituted “January 1, 1988” for “July 1, 1987”, and inserted “(to become effective on January 1 of each year)” after “adjusted annually”.

Subsec. (h)(3). Puspan. L. 99–509, § 9339(c)(1), inserted subpar. (A) designation after “provide for and establish”, and added subpar. (B).

Subsec. (h)(4). Puspan. L. 99–272, § 9303(span)(2), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (h)(5)(C). Puspan. L. 99–272, § 9303(span)(3), substituted “laboratory other than” for “laboratory which is independent of a physician’s office or”.

Subsec. (i)(1). Puspan. L. 99–509, § 9343(span)(2), inserted at end “The lists of procedures established under subparagraphs (A) and (B) shall be reviewed and updated not less often than every 2 years.”

Subsec. (i)(2). Puspan. L. 99–509, § 9343(e)(2)(B), inserted “80 percent of” before “a standard overhead amount” in introductory provisions of subpars. (A) and (B).

Puspan. L. 99–509, § 9343(span)(1), substituted “shall be reviewed and updated not later than July 1, 1987, and annually thereafter” for “shall be reviewed periodically” in concluding provisions of subpars. (A) and (B).

Subsec. (i)(3) to (5). Puspan. L. 99–509, § 9343(a)(1)(B), added par. (3) and redesignated former pars. (3) and (4) as (4) and (5), respectively.

Subsec. (l). Puspan. L. 99–509, § 9320(e)(2), added subsec. (l).

1984—Subsec. (a)(1). Puspan. L. 98–369, § 2354(span)(7), struck out “and” at the end.

Subsec. (a)(1)(B). Puspan. L. 98–369, § 2323(span)(1), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.

Subsec. (a)(1)(D). Puspan. L. 98–369, § 2303(a), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: “with respect to diagnostic tests performed in a laboratory for which payment is made under this part to the laboratory, the amounts paid shall be equal to 100 percent of the negotiated rate for such tests (as determined pursuant to subsection (h) of this section),”.

Subsec. (a)(1)(F), (G). Puspan. L. 98–369, § 2305(a), redesignated subpar. (G) as (F), and struck out former subpar. (F) which related to payment of reasonable charges for preadmission diagnostic services furnished by a physician to individuals enrolled under this part which are furnished in the outpatient department of a hospital within seven days of such individual’s admission to the same hospital or another hospital or furnished in the physician’s office within seven days of such individual’s admission to a hospital as an inpatient.

Subsec. (a)(2). Puspan. L. 98–369, § 2305(c), struck out “and in paragraph (5) of this subsection” after “of such section”.

Subsec. (a)(2)(A). Puspan. L. 98–617, § 3(span)(2), inserted “, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this provision),”.

Puspan. L. 98–369, § 2354(span)(5), realigned margin of subpar. (A).

Puspan. L. 98–369, § 2321(span)(1), inserted in provision preceding cl. (i) “(other than durable medical equipment)”.

Puspan. L. 98–369, § 2323(span)(1), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.

Subsec. (a)(2)(B). Puspan. L. 98–369, § 2354(span)(5), realigned margin of subpar. (B).

Puspan. L. 98–369, § 2321(span)(2), inserted in provision preceding cl. (i) “items and” after “to other”.

Puspan. L. 98–369, § 2303(span)(1), inserted “or (D)” after “subparagraph (C)”.

Subsec. (a)(2)(B)(ii). Puspan. L. 98–369, § 2308(span)(2)(B), inserted “, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this clause),”.

Subsec. (a)(2)(D). Puspan. L. 98–369, § 2303(span)(2)–(4), added subpar. (D).

Subsec. (a)(3). Puspan. L. 98–369, § 2323(span)(1), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.

Subsec. (a)(5). Puspan. L. 98–369, § 2305(span), struck out par. (5) which related to payment of reasonable costs for preadmission diagnostic services described in section 1395x(s)(2)(C) of this title furnished to an individual by the outpatient department of a hospital within seven days of such individual’s admission to the same hospital as an inpatient or to another hospital.

Subsec. (span)(1). Puspan. L. 98–369, § 2323(span)(2), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.

Subsec. (span)(3). Puspan. L. 98–369, § 2305(d), substituted “subsection (a)(1)(F)” for “subsection (a)(1)(G)”.

Subsec. (span)(4). Puspan. L. 98–369, § 2303(c), added par. (4).

Subsec. (f). Puspan. L. 98–369, § 2321(d)(4)(A), transferred subsec. (f) to part C of this subchapter and redesignated its provisions as section 1889 of the Social Security Act, which is classified to section 1395zz of this title.

Subsec. (h). Puspan. L. 98–369, § 2303(d), amended subsec. (h) generally, substituting provisions directing the Secretary to establish fee schedules for clinical diagnostic laboratory tests at a percentage of the prevailing charge level and nominal fees to cover costs in collecting samples and authorizing the Secretary to make adjustments in the fee schedule, setting forth the recipients of payments, and authorizing the Secretary to establish a negotiated payment rate for provision authorizing the Secretary to establish a negotiated rate of payment with the laboratory which would be considered the full charge for such tests.

Subsec. (h)(5)(C). Puspan. L. 98–617, § 3(span)(3), inserted a comma before “under the procedure described in section”.

Subsec. (i)(3). Puspan. L. 98–369, § 2305(d), substituted “subsection (a)(1)(F)” for “subsection (a)(1)(G)”.

Subsec. (k). Puspan. L. 98–369, § 2323(span)(4), added subsec. (k).

1982—Subsec. (a)(1)(B). Puspan. L. 97–248, § 112(a)(1), substituted provisions that with respect to items and services described in section 1395x(s)(10) of this title, amounts paid shall be 100 percent of reasonable charges for such items and services for provision that with respect to expenses incurred for radiological or pathological services for which payment could be made under this part, furnished to any inpatient of a hospital by a physician in field of radiology or pathology who had in effect an agreement with Secretary by which the physician agreed to accept an assignment (as provided for in section 1395u(span)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients enrolled under this part, the amounts paid would be equal to 100 percent of the reasonable charges for such services.

Subsec. (a)(1)(H). Puspan. L. 97–248, § 112(a)(2), (3), struck out subpar. (H) which provided that, with respect to items and services described in section 1395x(s)(10) of this title, the amount of benefits paid would be 100 percent of reasonable charges for such items and services.

Subsec. (a)(2)(B). Puspan. L. 97–248, § 101(c)(2), inserted “and except as may be provided in section 1395ww of this title”.

Subsec. (span)(1). Puspan. L. 97–248, § 112(span), struck out subpar. (A) provision that total amount of expenses shall not include expenses incurred for radiological or pathological services furnished an individual as an inpatient of a hospital by a physician in field of radiology or pathology who has an agreement with Secretary by which physician agrees to accept an assignment (as provided for in section 1395u(span)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients under this part, and redesignated subpar. (B) provisions as par. (1).

Subsec. (i)(1). Puspan. L. 97–248, § 148(d), struck out requirement of consultation with National Professional Standards Review Council.

Subsec. (j). Puspan. L. 97–248, § 117(a)(2), added subsec. (j).

1981—Subsec. (a)(2)(A). Puspan. L. 97–35, § 2106(a), substituted provisions that with respect to home health services and to items and services described in section 1395x(s)(10) of this title, the lesser of reasonable cost of such services as determined under section 1395x(v) of this title or customary charges with respect to such services, or if such services are furnished by a public provider of services free of charge or at nominal charges to the public, the amount determined in accordance with section 1395f(span)(2) of this title for provisions that with respect to home health services and to items and services described in section 1395x(s)(10) of this title, the reasonable cost of such services, as determined under section 1395x(v) of this title.

Subsec. (a)(2)(B). Puspan. L. 97–35, § 2106(a), substituted new formula in cls. (i) to (iii) with respect to other services for provisions providing for reasonable costs of such services less the amount a provider may charge as described in section 1395cc(a)(2)(A) of this title and that in no case may payment for such other services exceed 80 percent of such costs.

Subsec. (span). Puspan. L. 97–35, §§ 2133(a), 2134(a), redesignated pars. (2) to (4) as (1) to (3), and struck out former par. (1), which provided that amount of deductible for such calendar year as so determined shall first be reduced by amount of any expenses incurred by such individual in last three months of preceding calendar year and applied toward such individual’s deductible under this section for such preceding year.

Puspan. L. 97–35, § 2134(a), substituted “by a deductible of $75” for “by a deductible of $60”.

1980—Subsec. (a)(1)(B). Puspan. L. 96–499, § 943(a), inserted “who has in effect an agreement with the Secretary by which the physician agrees to accept an assignment (as provided for in section 1395u(span)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients enrolled under this part” after “radiology or pathology”.

Subsec. (a)(1)(D). Puspan. L. 96–499, § 918(a)(4), substituted “subsection (h)” for “subsection (g)”.

Subsec. (a)(1)(F). Puspan. L. 96–499, § 932(a)(1)(B), added subpar. (F).

Subsec. (a)(1)(G). Puspan. L. 96–499, § 934(d)(1), added subpar. (G).

Subsec. (a)(1)(H). Puspan. L. 96–611, § 1(span)(1)(A), (B), added subpar. (H).

Subsec. (a)(2). Puspan. L. 96–611, § 1(span)(1)(C), inserted in subpar. (A) “and to items and services described in section 1395x(s)(10) of this title”.

Puspan. L. 96–499, § 942, authorized payment of reasonable cost of home health services and prescribed formulae for determining payment amounts for services other than home health services.

Subsec. (a)(3). Puspan. L. 96–611, § 1(span)(1)(D), inserted “(other than for items and services described in section 1395x(s)(10) of this title)”.

Puspan. L. 96–499, § 942, prescribed a formula for determining payment amounts for services described in subpars. (D) and (E) of section 1395k(a)(2) of this title.

Subsec. (a)(4), (5). Puspan. L. 96–499, § 942, added pars. (4) and (5).

Subsec. (span)(2). Puspan. L. 96–611, § 1(span)(2), inserted “(A)” after “expenses incurred” and added subpar. (B).

Puspan. L. 96–499, § 943(a), inserted “who has in effect an agreement with the Secretary by which the physician agrees to accept an assignment (as provided for in section 1395u(span)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients enrolled under this part”.

Subsec. (span)(3). Puspan. L. 96–499, § 930(h)(2), added par. (3).

Subsec. (span)(4). Puspan. L. 96–499, § 934(d)(3), added par. (4).

Subsec. (g). Puspan. L. 96–499, § 935(a), substituted “$500” for “$100”.

Subsec. (h). Puspan. L. 96–473 redesignated subsec. (g) as added by section 279(span) of Puspan. L. 92–603 as (h), which for purposes of codification had been editorially set out as subsec. (h), thereby requiring no change in text. See 1972 Amendment note below.

Subsec. (i). Puspan. L. 96–499, § 934(span), added subsec. (i).

1978—Subsec. (a)(1)(E). Puspan. L. 95–292, § 4(span)(2), added subpar. (E).

Subsec. (a)(2). Puspan. L. 95–292, § 4(c), inserted “(unless otherwise specified in section 1395rr of this title)” after “and with respect to other services” in provisions preceding subpar. (A).

1977—Subsec. (a)(2). Puspan. L. 95–210, § 1(span)(2), inserted parenthetical provisions preceding subpar. (A) excepting those services described in subpar. (D) of section 1395k(a)(2) of this title.

Subsec. (a)(3). Puspan. L. 95–210, § 1(span)(1), (3), (4), added par. (3).

Subsec. (f)(1). Puspan. L. 95–142 substituted provisions relating to determinations by Secretary with respect to presumptions regarding purchase price or practicality of buying or renting durable medical equipment, for provisions relating to purchase price of durable medical equipment authorized to be paid by Secretary.

Subsec. (f)(2). Puspan. L. 95–142 substituted provisions relating to waiver of coinsurance amount in purchase of used durable medical equipment, for provisions relating to reimbursement procedures established by Secretary in cases of rental of durable medical equipment.

Subsec. (f)(3), (4). Puspan. L. 95–142 added pars. (3) and (4).

1972—Subsec. (a). Puspan. L. 92–603, § 226(c)(2), inserted reference to section 1395mm of this title in provisions preceding par. (1).

Subsec. (a)(1). Puspan. L. 92–603, §§ 211(c)(4), 279(a), added subpars. (C) and (D).

Subsec. (a)(2). Puspan. L. 92–603, §§ 233(span), 251(a)(3), 299K(a), substituted subpars. (A) and (B) for provisions relating to the amount payable by reference to section 1395x(v) of this title, added subpar. (C), and in provisions preceding subpar. (A), inserted “with respect to home health services, 100 percent, and with respect to other services,” before “80 percent”.

Subsec. (span). Puspan. L. 92–603, § 204(a), substituted “$60” for “$50”.

Subsec. (f). Puspan. L. 92–603, § 245(d), designated existing provisions as par. (1)(A) and added par. (1)(B) and (2).

Subsec. (g). Puspan. L. 92–603, § 251(a)(2), added subsec. (g).

Subsec. (h). Puspan. L. 92–603, § 279(span), added subsec. (h). Subsec. was in the original (g) and was changed to accommodate subsec. (g) as added by section 251(a)(2) of Puspan. L. 92–603.

1968—Subsec. (a)(1). Puspan. L. 90–248, § 131(a)(1), (2), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (span). Puspan. L. 90–248, §§ 129(c)(7), 131(span), struck out reference in par. (1) to expenses regarded under former par. (2) as incurred for services furnished in last three months of preceding year, struck out former par. (2) which provided that amount of any deduction imposed by section 1395e(a)(2)(A) of this title for outpatient hospital diagnostic services furnished in any calendar year is to be regarded as an incurred expense for such year; and added par. (2).

Puspan. L. 90–248, § 135(c), inserted last sentence providing that there shall be a deductible equal to expenses incurred for first three pints of whole blood (or equivalent quantities of packed red blood cells as defined under regulations) furnished to an individual during a calendar year which deductible is to be appropriately reduced to extent that such blood has been replaced, and such blood will be deemed to have been replaced when institution or person furnishing such blood is given one pint of blood for each pint of blood (or equivalent quantities of packed red blood cells) furnished individual to which three pint deductible applies.

Subsec. (d). Puspan. L. 90–248, § 129(c)(8), struck out reference to subsection (a)(2)(A) of section 1395e of this title.

Subsec. (f). Puspan. L. 90–248, § 132(span), added subsec. (f).

Statutory Notes and Related Subsidiaries

Effective Date of 2022 Amendment

Puspan. L. 117–328, div. FF, title IV, § 4121(c), Dec. 29, 2022, 136 Stat. 5903, provided that: “The amendments made by this section [amending this section and sections 1395u, 1395x, and 1395yy of this title] shall apply with respect to services furnished on or after January 1, 2024.”

Amendment by section 4124(span)(3) of Puspan. L. 117–328 applicable with respect to items and services furnished on or after Jan. 1, 2024, see section 4124(d) of Puspan. L. 117–328, set out as a note under section 1395k of this section.

Effective Date of 2021 Amendment

Puspan. L. 117–7, § 2(a)(2), Apr. 14, 2021, 135 Stat. 252, provided that: “The amendments made by this subsection [amending this section] shall take effect as if included in the enactment of the Consolidated Appropriations Act, 2021 (Public Law 116–260).”

Effective Date of 2020 Amendment

Puspan. L. 116–260, div. CC, title I, § 114(c), Dec. 27, 2020, 134 Stat. 2948, provided that: “The amendments made by this section [amending this section and section 1395w–4 of this title] shall take effect on the date of the enactment of this Act [Dec. 27, 2020].”

Puspan. L. 116–260, div. CC, title I, § 125(g), Dec. 27, 2020, 134 Stat. 2966, provided that: “The amendments made by this section [amending this section and sections 1395m, 1395x, 1395aa, 1395cc, and 1395dd of this title] shall apply to items and services furnished on or after January 1, 2023.”

Puspan. L. 116–136, div. A, title III, § 3713(d), Mar. 27, 2020, 134 Stat. 424, provided that: “The amendments made by this section [amending this section and sections 1395w–22 and 1395x of this title] shall take effect on the date of enactment of this Act [Mar. 27, 2020] and shall apply with respect to a COVID–19 vaccine beginning on the date that such vaccine is licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).”

Effective Date of 2016 Amendment

Puspan. L. 114–255, div. A, title V, § 5012(d), Dec. 13, 2016, 130 Stat. 1202, as amended by Puspan. L. 115–123, div. E, title IV, § 50401(span)(2), Fespan. 9, 2018, 132 Stat. 217, provided that: “The amendments made by this section [amending this section and sections 1395m, 1395u, and 1395x of this title] shall apply to items and services furnished on or after January 1, 2021, except that the amendments made by paragraphs (1) and (2) of subsection (c) shall apply to items and services furnished on or after January 1, 2019.”

Puspan. L. 114–255, div. C, title XVI, § 16001(span), Dec. 13, 2016, 130 Stat. 1325, provided that: “The amendments made by this section [amending this section] shall be effective as if included in the enactment of section 603 of the Bipartisan Budget Act of 2015 (Public Law 114–74).”

Puspan. L. 114–255, div. C, title XVI, § 16002(c), Dec. 13, 2016, 130 Stat. 1326, provided that: “The amendments made by this section [amending this section] shall be effective as if included in the enactment of section 603 of the Bipartisan Budget Act of 2015 (Public Law 114–74).”

Effective Date of 2015 Amendment

Puspan. L. 114–113, div. O, title V, § 504(d), Dec. 18, 2015, 129 Stat. 3023, provided that: “The amendments made by this section [amending this section and sections 1395m and 1395x of this title] shall apply to items furnished on or after January 1, 2017.”

Puspan. L. 114–10, title II, § 202(span)(2), Apr. 16, 2015, 129 Stat. 144, provided that: “The amendments made by this subsection [amending this section] shall apply with respect to requests described in section 1833(g)(5)(C)(i) of the Social Security Act (42 U.S.C. 1395l(g)(5)(C)(i)) with respect to which the Secretary of Health and Human Services has not conducted medical review under such section by a date (not later than 90 days after the date of the enactment of this Act [Apr. 16, 2015]) specified by the Secretary.”

Effective Date of 2012 Amendment

Puspan. L. 112–96, title III, § 3005(e), Fespan. 22, 2012, 126 Stat. 189, provided that: “The requirement of subparagraph (B) of section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)), as added by subsection (a), shall apply to services furnished on or after March 1, 2012.”

Effective Date of 2010 Amendment

Puspan. L. 111–148, title IV, § 4103(e), Mar. 23, 2010, 124 Stat. 557, provided that: “The amendments made by this section [amending this section and sections 1395w–4, 1395x, and 1395y of this title] shall apply to services furnished on or after January 1, 2011.”

Puspan. L. 111–148, title IV, § 4104(d), Mar. 23, 2010, 124 Stat. 558, provided that: “The amendments made by this section [amending this section and section 1395x of this title] shall apply to items and services furnished on or after January 1, 2011.”

Effective Date of 2008 Amendment

Puspan. L. 110–275, title I, § 101(c), July 15, 2008, 122 Stat. 2498, provided that: “The amendments made by this section [amending this section and sections 1395x and 1395y of this title] shall apply to services furnished on or after January 1, 2009.”

Amendment by section 143(span)(2), (3), of Puspan. L. 110–275 applicable to services furnished on or after July 1, 2009, see section 143(c) of Puspan. L. 110–275, set out as a note under section 1395k of this title.

Puspan. L. 110–275, title I, § 145(a)(3), July 15, 2008, 122 Stat. 2547, provided that: “The amendments made by this subsection [amending this section and section 1395w–3 of this title] shall take effect on the date of the enactment of this Act [July 15, 2008].”

Effective Date of 2006 Amendment

Puspan. L. 109–432, div. B, title I, § 109(c), Dec. 20, 2006, 120 Stat. 2985, provided that: “The amendments made by this section [amending this section and section 1395ww of this title] shall apply to payment for services furnished on or after January 1, 2009.”

Puspan. L. 109–171, title V, § 5112(f), Fespan. 8, 2006, 120 Stat. 44, provided that: “The amendments made by this section [amending this section and sections 1395w–4, 1395x, and 1395y of this title] shall apply to services furnished on or after January 1, 2007.”

Puspan. L. 109–171, title V, § 5113(c), Fespan. 8, 2006, 120 Stat. 44, provided that: “The amendments made by this section [amending this section and section 1395m of this title] shall apply to services furnished on or after January 1, 2007.”

Effective Date of 2003 Amendment

Amendment by section 237(a) of Puspan. L. 108–173 applicable to services provided on or after Jan. 1, 2006, and contract years beginning on or after such date, see section 237(e) of Puspan. L. 108–173, set out as a note under section 1320a–7span of this title.

Puspan. L. 108–173, title IV, § 411(a)(2), Dec. 8, 2003, 117 Stat. 2274, provided that: “The amendment made by paragraph (1)(B) [amending this section] shall apply with respect to cost reporting periods beginning on and after January 1, 2004.”

Puspan. L. 108–173, title IV, § 413(span)(2), Dec. 8, 2003, 117 Stat. 2277, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to physicians’ services furnished on or after January 1, 2005.”

Puspan. L. 108–173, title VI, § 614(c), Dec. 8, 2003, 117 Stat. 2306, provided that: “The amendments made by this section [amending this section] shall apply—

“(1) in the case of screening mammography, to services furnished on or after the date of the enactment of this Act [Dec. 8, 2003]; and

“(2) in the case of diagnostic mammography, to services furnished on or after January 1, 2005.”

Puspan. L. 108–173, title VI, § 621(a)(6), Dec. 8, 2003, 117 Stat. 2310, provided that: “The amendments made by this subsection [amending this section] shall apply to items and services furnished on or after January 1, 2004.”

Puspan. L. 108–173, title VI, § 627(c), Dec. 8, 2003, 117 Stat. 2321, provided that: “The amendments made by this section [amending this section and sections 1395m and 1395u of this title] shall apply to items furnished on or after January 1, 2005.”

Puspan. L. 108–173, title VI, § 642(c), Dec. 8, 2003, 117 Stat. 2322, provided that: “The amendments made by this section [amending this section and section 1395x of this title] shall apply to items furnished administered [sic] on or after January 1, 2004.”

Effective Date of 2000 Amendment

Puspan. L. 106–554, § 1(a)(6) [title I, § 105(e)], Dec. 21, 2000, 114 Stat. 2763, 2763A–472, provided that: “The amendments made by this section [amending this section and sections 1395u and 1395x of this title] shall apply to services furnished on or after January 1, 2002.”

Puspan. L. 106–554, § 1(a)(6) [title I, § 111(a)(2)], Dec. 21, 2000, 114 Stat. 2763, 2763A–473, provided that: “The amendment made by paragraph (1) [amending this section] shall apply with respect to services furnished on or after April 1, 2001.”

Puspan. L. 106–554, § 1(a)(6) [title II, § 201(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–481, provided that: “The amendment made—

“(1) by subsection (a) [amending section 1395m of this title] shall apply to services furnished on or after the date of the enactment of BBRA [Puspan. L. 106–113, § 1000(a)(6), approved Nov. 29, 1999];

“(2) by subsection (span)(1) [amending this section] shall apply as if included in the enactment of section 403(e)(1) of BBRA (113 Stat. 1501A–371) [Puspan. L. 106–113, § 1000(a)(6) [title IV, § 403(e)(1)]]; and

“(3) by subsection (span)(2) [amending provisions set out as a note under section 1395m of this title] shall apply as if included in the enactment of section 403(d)(2) of BBRA (113 Stat. 1501A–371) [Puspan. L. 106–113, § 1000(a)(6) [title IV, § 403(d)(2)], set out as a note under section 1395m of this title].”

Puspan. L. 106–554, § 1(a)(6) [title II, § 205(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–483, provided that: “The amendments made by this section [amending this section and section 1395m of this title] shall apply to services furnished on or after the date of the enactment of this Act [Dec. 21, 2000].”

Puspan. L. 106–554, § 1(a)(6) [title II, § 223(e)], Dec. 21, 2000, 114 Stat. 2763, 2763A–490, provided that: “The amendments made by subsections (span) and (c) [amending this section and section 1395m of this title] shall be effective for services furnished on or after October 1, 2001.”

Puspan. L. 106–554, § 1(a)(6) [title II, § 224(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–490, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after July 1, 2001.”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 401(span)(2)], Dec. 21, 2000, 114 Stat. 2763, 2763A–503, provided that: “The amendments made by paragraph (1) [amending this section] shall take effect as if included in the enactment of BBA [Puspan. L. 105–33].”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–505, provided that: “The amendments made by this section [amending this section] take effect on the date of the enactment of this Act [Dec. 21, 2000].”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 403(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–506, provided that: “The amendment made by subsection (a) [amending this section] shall take effect as if included in the enactment of BBRA [Puspan. L. 106–113, § 1000(a)(6)].”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 405(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–507, provided that: “The amendments made by subsection (a) [amending this section] shall apply as if included in the enactment of section 202 of BBRA [Puspan. L. 106–113, § 1000(a)(6) [title II, § 202]] (113 Stat. 1501A–342).”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 406(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–508, provided that: “The amendment made by subsection (a) [amending this section] shall apply to devices furnished on or after April 1, 2001.”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 430(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–525, provided that: “The amendments made by this section [amending this section and section 1395x of this title] apply to items and services furnished on or after July 1, 2001.”

Effective Date of 1999 Amendment

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(h)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–340, provided that: “The Secretary of Health and Human Services shall first conduct the annual review under the amendment made by paragraph (1)(A) [amending this section] in 2001 for application in 2002 and the amendment made by paragraph (1)(B) [amending this section] takes effect on the date of the enactment of this Act [Nov. 29, 1999].”

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(m)], Nov. 29, 1999, 113 Stat. 1536, 1501A–341, provided that: “Except as provided in this section, the amendments made by this section [amending this section and sections 1395m and 1395x of this title] shall be effective as if included in the enactment of BBA [the Balanced Budget Act of 1997, Puspan. L. 105–33].”

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 202(span)], Nov. 29, 1999, 113 Stat. 1536, 1501A–344, provided that: “The amendments made by this section [amending this section] shall be effective as if included in the enactment of BBA [the Balanced Budget Act of 1997, Puspan. L. 105–33].”

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 204(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–345, provided that: “The amendments made by this section [amending this section] apply as if included in the enactment of BBA [the Balanced Budget Act of 1997, Puspan. L. 105–33] and shall only apply to procedures performed for which payment is made on the basis of the prospective payment system under section 1833(t) of the Social Security Act [42 U.S.C. 1395l(t)].”

Amendment by section 1000(a)(6) [title III, § 321(g)(2), (k)(2)] of Puspan. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Puspan. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Puspan. L. 106–113, set out as a note under section 1395d of this title.

Amendment by section 1000(a)(6) [title IV, § 401(span)(1)] of Puspan. L. 106–113 effective Jan. 1, 2000, see section 1000(a)(6) [title IV, § 401(c)] of Puspan. L. 106–113, set out as a note under section 1395i–4 of this title.

Puspan. L. 106–113, div. B, § 1000(a)(6) [title IV, § 403(e)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–371, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to services furnished on or after the date of the enactment of this Act [Nov. 29, 1999].”

Effective Date of 1997 Amendment

Puspan. L. 105–33, title IV, § 4002(j)(1)(B), Aug. 5, 1997, 111 Stat. 330, provided that: “The amendment made by subparagraph (A) [amending this section] applies to new contracts entered into after the date of enactment of this Act [Aug. 5, 1997] and, with respect to contracts in effect as of such date, shall apply to payment for services furnished after December 31, 1998.”

Puspan. L. 105–33, title IV, § 4101(d), Aug. 5, 1997, 111 Stat. 360, provided that: “The amendments made by this section [amending this section and section 1395m of this title] shall apply to items and services furnished on or after January 1, 1998.”

Puspan. L. 105–33, title IV, § 4102(e), Aug. 5, 1997, 111 Stat. 361, provided that: “The amendments made by this section [amending this section and sections 1395w–4, 1395x, and 1395y of this title] shall apply to items and services furnished on or after January 1, 1998.”

Puspan. L. 105–33, title IV, § 4103(e), Aug. 5, 1997, 111 Stat. 362, provided that: “The amendments made by this section [amending this section and sections 1395w–4, 1395x, and 1395y of this title] shall apply to items and services furnished on or after January 1, 2000.”

Puspan. L. 105–33, title IV, § 4104(e), Aug. 5, 1997, 111 Stat. 366, provided that: “The amendments made by this section [amending this section and sections 1395m, 1395w–4, 1395x, and 1395y of this title] shall apply to items and services furnished on or after January 1, 1998.”

Amendment by section 4201(c)(1) of Puspan. L. 105–33 applicable to services furnished on or after Oct. 1, 1997, see section 4201(d) of Puspan. L. 105–33, set out as a note under section 1395f of this title.

Puspan. L. 105–33, title IV, § 4205(a)(1)(B), Aug. 5, 1997, 111 Stat. 376, provided that: “The amendment made by subparagraph (A) [amending this section] applies to services furnished on or after January 1, 1998.”

Puspan. L. 105–33, title IV, § 4315(c), Aug. 5, 1997, 111 Stat. 390, provided that: “The amendments made by this section [amending this section and section 1395u of this title] to the extent such amendments substitute fee schedules for reasonable charges, shall apply to particular services as of the date specified by the Secretary of Health and Human Services.”

Amendment by section 4432(span)(5)(C) of Puspan. L. 105–33 applicable to items and services furnished on or after July 1, 1998, see section 4432(d) of Puspan. L. 105–33, set out as a note under section 1395i–3 of this title.

Amendment by section 4511(span) of Puspan. L. 105–33 applicable with respect to services furnished and supplies provided on and after Jan. 1, 1998, see section 4511(e) of Puspan. L. 105–33, set out as a note under section 1395k of this title.

Puspan. L. 105–33, title IV, § 4512(d), Aug. 5, 1997, 111 Stat. 444, provided that: “The amendments made by this section [amending this section and sections 1395u and 1395x of this title] shall apply with respect to services furnished and supplies provided on and after January 1, 1998.”

Puspan. L. 105–33, title IV, § 4521(c), Aug. 5, 1997, 111 Stat. 444, provided that: “The amendments made by this section [amending this section] shall apply to services furnished during portions of cost reporting periods occurring on or after October 1, 1997.”

Puspan. L. 105–33, title IV, § 4523(d)(1)(A)(ii), Aug. 5, 1997, 111 Stat. 449, provided that: “The amendment made by clause (i) [amending this section] shall apply to services furnished on or after January 1, 1999.”

Puspan. L. 105–33, title IV, § 4531(span)(3), Aug. 5, 1997, 111 Stat. 452, provided that: “The amendments made by this subsection [amending this section and section 1395m of this title] shall apply to services furnished on or after January 1, 2000.”

Puspan. L. 105–33, title IV, § 4541(e), Aug. 5, 1997, 111 Stat. 457, provided that:

“(1) The amendments made by subsections (a)(1), (a)(2), and (span) [amending this section and sections 1395m and 1395y of this title] apply to services furnished on or after January 1, 1998, including portions of cost reporting periods occurring on or after such date, except that section 1834(k) of the Social Security Act [42 U.S.C. 1395m(k)] (as added by subsection (a)(2)) shall not apply to services described in section 1833(a)(8)(B) of such Act [42 U.S.C. 1395l(a)(8)(B)] (as added by subsection (a)(1)) that are furnished during 1998.

“(2) The amendments made by subsections (a)(3) and (c) [amending this section and section 1395cc of this title] apply to services furnished on or after January 1, 1999.

“(3) The amendments made by subsection (d)(1) [amending this section] apply to expenses incurred on or after January 1, 1999.”

Puspan. L. 105–33, title IV, § 4556(d), Aug. 5, 1997, 111 Stat. 463, provided that: “The amendments made by subsections (a) and (span) [amending this section and section 1395u of this title] shall apply to drugs and biologicals furnished on or after January 1, 1998.”

Amendment by section 4603(c)(2)(A) of Puspan. L. 105–33 applicable to cost reporting periods beginning on or after Oct. 1, 1999, except as otherwise provided, see section 4603(d) of Puspan. L. 105–33, set out as an Effective Date note under section 1395fff of this title.

Effective Date of 1994 Amendment

Puspan. L. 103–432, title I, § 123(f)(1), (2), Oct. 31, 1994, 108 Stat. 4412, provided that:

“(1)Enforcement; miscellaneous and technical amendments.—The amendments made by subsections (a) and (e) [amending this section and section 1395w–4 of this title] shall apply to services furnished on or after the date of the enactment of this Act [Oct. 31, 1994]; except that the amendments made by subsection (a) [amending section 1395w–4 of this title] shall not apply to services of a nonparticipating supplier or other person furnished before January 1, 1995.

“(2)Practitioners.—The amendments made by subsection (span) [amending this section and section 1395u of this title] shall apply to services furnished on or after January 1, 1995.”

Puspan. L. 103–432, title I, § 141(c)(2), Oct. 31, 1994, 108 Stat. 4425, provided that: “The amendments made by paragraph (1) [amending this section] shall take effect as if included in the enactment of OBRA–1990 [Puspan. L. 101–508].”

Amendment by section 147(a), (e)(2), (3), (f)(6)(C), (D) of Puspan. L. 103–432 effective as if included in the enactment of Puspan. L. 101–508, see section 147(g) of Puspan. L. 103–432, set out as a note under section 1320a–3a of this title.

Puspan. L. 103–432, title I, § 147(d)(1), (2), Oct. 31, 1994, 108 Stat. 4429, provided that the amendment made by that section is effective as if included in the enactment of Puspan. L. 101–239.

Amendment by section 156(a)(2)(B) of Puspan. L. 103–432 applicable to services provided on or after Oct. 31, 1994, see section 156(a)(3) of Puspan. L. 103–432, set out as a note under section 1320c–3 of this title.

Effective Date of 1993 Amendment

Puspan. L. 103–66, title XIII, § 13532(span), Aug. 10, 1993, 107 Stat. 587, provided that: “The amendments made by subsection (a) [amending this section] shall apply to portions of cost reporting periods beginning on or after January 1, 1994.”

Puspan. L. 103–66, title XIII, § 13544(span)(3), Aug. 10, 1993, 107 Stat. 590, provided that: “The amendments made by this subsection [amending this section and section 1395m of this title] shall apply to items furnished on or after January 1, 1994.”

Puspan. L. 103–66, title XIII, § 13555(span), Aug. 10, 1993, 107 Stat. 592, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after January 1, 1994.”

Effective Date of 1990 Amendment

Puspan. L. 101–508, title IV, § 4104(d), Nov. 5, 1990, 104 Stat. 1388–59, provided that: “The amendments made by this section [amending this section and sections 1395m and 1395w–4 of this title] shall apply to services furnished on or after January 1, 1991.”

Amendment by section 4153(a)(2)(B), (C) of Puspan. L. 101–508 applicable to items furnished on or after Jan. 1, 1991, see section 4153(a)(3) of Puspan. L. 101–508, set out as a note under section 1395k of this title.

Puspan. L. 101–508, title IV, § 4154(span)(2), Nov. 5, 1990, 104 Stat. 1388–85, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to tests furnished on or after January 1, 1991.”

Puspan. L. 101–508, title IV, § 4154(c)(2), Nov. 5, 1990, 104 Stat. 1388–85, provided that: “The amendment made by paragraph (1)(A) [amending this section] shall take effect as if included in the enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985 [Puspan. L. 99–272], and the amendment made by paragraph (1)(B) [amending this section] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Puspan. L. 100–203].”

Puspan. L. 101–508, title IV, § 4154(e)(5), Nov. 5, 1990, 104 Stat. 1388–86, as amended by Puspan. L. 103–432, title I, § 147(f)(2), Oct. 31, 1994, 108 Stat. 4431, provided that: “The amendments made by paragraphs (1)(A), (1)(B), (2), and (4) [amending this section, section 1395w–2 of this title, and provisions set out as a note below] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1989 [Puspan. L. 101–239], and the amendment made by paragraph (1)(C) [amending this section] shall take effect January 1, 1991.”

Amendment by section 4155(span)(2), (3) of Puspan. L. 101–508 applicable to services furnished on or after Jan. 1, 1991, see section 4155(e) of Puspan. L. 101–508, set out as a note under section 1395k of this title.

Amendment by section 4161(a)(3)(B) of Puspan. L. 101–508 applicable to services furnished on or after Oct. 1, 1991, see section 4161(a)(8) of Puspan. L. 101–508, set out as a note under section 1395k of this title.

Puspan. L. 101–508, title IV, § 4163(e), Nov. 5, 1990, 104 Stat. 1388–100, as amended by Puspan. L. 103–432, title I, § 147(f)(5)(B), Oct. 31, 1994, 108 Stat. 4431, provided that: “Except as provided in subsection (d)(3) [enacting provisions set out as a note under section 1395y of this title], the amendments made by this section [amending this section and sections 1395m, 1395x, 1395y, 1395z, 1395aa, and 1395bspan of this title] shall apply to screening mammography performed on or after January 1, 1991.”

Puspan. L. 101–508, title IV, § 4206(e)(2), Nov. 5, 1990, 104 Stat. 1388–117, provided that: “The amendments made by subsection (span) [amending this section and section 1395mm of this title] shall apply to contracts under section 1876 of the Social Security Act [42 U.S.C. 1395mm] and payments under section 1833(a)(1)(A) of such Act [42 U.S.C. 1395l(a)(1)(A)] as of first day of the first month beginning more than 1 year after the date of the enactment of this Act [Nov. 5, 1990].”

Effective Date of 1989 Amendment

Puspan. L. 101–239, title VI, § 6102(c)(2), Dec. 19, 1989, 103 Stat. 2185, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to services furnished on or after January 1, 1991.”

Puspan. L. 101–239, title VI, § 6102(f)(3), Dec. 19, 1989, 103 Stat. 2189, provided that: “The amendments made by this subsection [amending this section and section 1395m of this title] shall apply to services furnished on or after January 1, 1991.”

Puspan. L. 101–239, title VI, § 6102(g), Dec. 19, 1989, 103 Stat. 2189, provided that: “Except as otherwise provided in this section, this section, and the amendments made by this section [enacting section 1395w–4 of this title, amending this section and sections 1395m, 1395u, and 1395rr of this title, and enacting provisions set out as notes under this section and sections 1395m, 1395u, and 1395w–4 of this title], shall take effect on the date of the enactment of this Act [Dec. 19, 1989].”

Puspan. L. 101–239, title VI, § 6111(span)(2), Dec. 19, 1989, 103 Stat. 2214, as amended by Puspan. L. 101–508, title IV, § 4154(e)(4), Nov. 5, 1990, 104 Stat. 1388–86, provided that: “The amendment made by paragraph (1) [amending this section] shall apply with respect to clinical diagnostic laboratory tests performed on or after May 1, 1990.”

Puspan. L. 101–239, title VI, § 6113(e), Dec. 19, 1989, 103 Stat. 2217, provided that: “The amendments made by this section [amending this section and section 1395x of this title], and the provisions of subsection (c) [set out below], shall apply to services furnished on or after July 1, 1990, and the amendments made by subsection (d) [amending this section] shall apply to expenses incurred in a year beginning with 1990.”

Puspan. L. 101–239, title VI, § 6131(c), Dec. 19, 1989, 103 Stat. 2221, provided that:

“(1) The amendments made by this section [amending this section and section 1395x of this title] shall apply with respect to therapeutic shoes and inserts furnished on or after July 1, 1989.

“(2) In applying the amendments made by this section, the increase under subparagraph (C) of section 1833(o)(2) of the Social Security Act [42 U.S.C. 1395l(o)(2)(C)] shall apply to the dollar amounts specified under subparagraph (A) of such section (as amended by this section) in the same manner as the increase would have applied to the dollar amounts specified under subparagraph (A) of such section (as in effect before the date of the enactment of this Act [Dec. 19, 1989]).”

Puspan. L. 101–239, title VI, § 6133(span), Dec. 19, 1989, 103 Stat. 2222, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after January 1, 1990.”

Amendment by section 6204(span) of Puspan. L. 101–239 effective with respect to referrals made on or after Jan. 1, 1992, see section 6204(c) of Puspan. L. 101–239, set out as a note under section 1395nn of this title.

Amendment by section 201(a) of Puspan. L. 101–234 effective Jan. 1, 1990, see section 201(c) of Puspan. L. 101–234, set out as a note under section 1320a–7a of this title.

Amendment by section 202(a) of Puspan. L. 101–234 effective Jan. 1, 1990, see section 202(span) of Puspan. L. 101–234, set out as a note under section 401 of this title.

Effective Date of 1988 Amendment

Puspan. L. 100–647, title VIII, § 8422(span), Nov. 10, 1988, 102 Stat. 3802, provided that: “The amendment made by subsection (a) [amending this section] shall become effective as if included in the amendment made by section 9320(e)(2) of the Omnibus Budget Reconciliation Act of 1986 [Puspan. L. 99–509].”

Amendment by Puspan. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Puspan. L. 100–360, see section 608(g) of Puspan. L. 100–485, set out as a note under section 704 of this title.

Amendment by section 202(span)(1)–(3) of Puspan. L. 100–360 applicable to items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Puspan. L. 100–360, set out as a note under section 1395u of this title.

Amendment by section 203(c)(1)(A)–(E) of Puspan. L. 100–360 applicable to items and services furnished on or after Jan. 1, 1990, see section 203(g) of Puspan. L. 100–360, set out as a note under section 1320c–3 of this title.

Amendment by section 204(d)(1) of Puspan. L. 100–360 applicable to screening mammography performed on or after Jan. 1, 1990, see section 204(e) of Puspan. L. 100–360, set out as a note under section 1395m of this title.

Amendment by section 205(c) of Puspan. L. 100–360 applicable to items and services furnished on or after Jan. 1, 1990, see section 205(f) of Puspan. L. 100–360, set out as a note under section 1395k of this title.

Except as specifically provided in section 411 of Puspan. L. 100–360, amendment by section 411(f)(2)(D), (8)(B)(i), (C), (12)(A), (14), (g)(1)(E), (2)(D), (E), (3)(A)–(F), (4)(C), (5), (h)(1)(A), (3)(B), (4)(B), (C), (7)(C), (D), (F), (i)(3), (4)(B)–(C)(ii), (iv), and (vi) of Puspan. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, effective as if included in the enactment of that provision in Puspan. L. 100–203, see section 411(a) of Puspan. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

Effective Date of 1987 Amendment

Puspan. L. 100–203, title IV, § 4043(c), Dec. 22, 1987, 101 Stat. 1330–86, provided that: “The amendments made by this [sic] subsection (a) [amending this section] shall apply with respect to services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act [42 U.S.C. 1395ww(d)(2)(D)]) on or after January 1, 1989, and to other services furnished on or after January 1, 1991.”

Amendment by section 4045(c)(2)(A) of Puspan. L. 100–203 applicable to items and services furnished on or after Apr. 1, 1988, see section 4045(d) of Puspan. L. 100–203, set out as a note under section 1395u of this title.

Amendment by section 4049(a)(1) of Puspan. L. 100–203 applicable to services performed on or after Apr. 1, 1989, see section 4049(span)(2) of Puspan. L. 100–203, as amended, set out as a note under section 1395m of this title.

Puspan. L. 100–203, title IV, § 4055(span), formerly § 4054(span), as added and renumbered by Puspan. L. 100–360, title IV, § 411(f)(12)(A), (14), July 1, 1988, 102 Stat. 781, provided that: “The amendments made by subsection (a) [amending this section] shall apply to services furnished on or after April 1, 1988.”

Amendment by section 4062(d)(3) of Puspan. L. 100–203 applicable to covered items (other than oxygen and oxygen equipment) furnished on or after Jan. 1, 1989, and to oxygen and oxygen equipment furnished on or after June 1, 1989, see section 4062(e) of Puspan. L. 100–203, as amended, set out as a note under section 1395f of this title.

Puspan. L. 100–203, title IV, § 4063(c), Dec. 22, 1987, 101 Stat. 1330–110, provided that: “The amendments made by this section [amending this section and section 1395u of this title] shall apply to items furnished on or after July 1, 1988.”

Puspan. L. 100–203, title IV, § 4064(span)(3), Dec. 22, 1987, 101 Stat. 1330–110, provided that: “The amendments made by paragraphs (1) and (2) [amending this section] shall apply with respect to services furnished on or after April 1, 1988.”

Puspan. L. 100–203, title IV, § 4064(c)(2), as added by Puspan. L. 100–360, title IV, § 411(g)(3)(F), July 1, 1988, 102 Stat. 784, provided that: “The amendment made by paragraph (1) [amending this section] shall apply with respect to diagnostic laboratory tests furnished on or after April 1, 1988.”

Puspan. L. 100–203, title IV, § 4066(c), Dec. 22, 1987, 101 Stat. 1330–113, provided that: “The amendments made by subsection (a) [amending this section] shall apply with respect to outpatient hospital radiology services furnished on or after October 1, 1988, and other diagnostic procedures performed on or after October 1, 1989.”

Puspan. L. 100–203, title IV, § 4067(c), Dec. 22, 1987, 101 Stat. 1330–113, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after April 1, 1988.”

Puspan. L. 100–203, title IV, § 4068(c), Dec. 22, 1987, 101 Stat. 1330–114, provided that: “The amendments made by subsection (a) [amending this section] shall be effective as if included in the amendment made by section 9343(a)(1)(B) of the Omnibus Budget Reconciliation Act of 1986 [Puspan. L. 99–509].”

Puspan. L. 100–203, title IV, § 4070(c)(1), Dec. 22, 1987, 101 Stat. 1330–115, provided that: “The amendment made by subsection (a)(1) [amending this section] shall apply with respect to calendar years beginning with 1988; except that with respect to 1988, any reference in section 1833(c) of the Social Security Act [42 U.S.C. 1395l(c)], as amended by subsection (a), to ‘$1375.00’ is deemed a reference to ‘$562.50’. The amendment made by subsection (a)(2) [amending this section] shall apply to services furnished on or after January 1, 1989.”

For effective date of amendment by section 4072(span) of Puspan. L. 100–203, see section 4072(e) of Puspan. L. 100–203, set out as a note under section 1395x of this title.

Amendment by section 4073(span) of Puspan. L. 100–203 effective with respect to services performed on or after July 1, 1988, see section 4073(e) of Puspan. L. 100–203, set out as a note under section 1395k of this title.

Amendment by section 4077(span)(2), (3) of Puspan. L. 100–203 effective with respect to services performed on or after July 1, 1988, see section 4077(span)(5) of Puspan. L. 100–203, set out as a note under section 1395k of this title.

Puspan. L. 100–203, title IV, § 4084(span), Dec. 22, 1987, 101 Stat. 1330–129, provided that: “The amendments made by subsection (a) [amending this section] shall apply as if included in the amendment made by section 9320(e)(2) of the Omnibus Budget Reconciliation Act of 1986 [Puspan. L. 99–509].”

Puspan. L. 100–203, title IV, § 4084(c)(3), as added by Puspan. L. 100–360, title IV, § 411(i)(3), July 1, 1988, 102 Stat. 788, provided that: “The amendments made by this subsection [amending this section and section 1395x of this title] shall apply to services furnished after December 31, 1988.”

Puspan. L. 100–203, title IV, § 4085(span)(2), Dec. 22, 1987, 101 Stat. 1330–130, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to procedures performed on or after January 1, 1988.”

Puspan. L. 100–203, title IV, § 4085(i)(21), Dec. 22, 1987, 101 Stat. 1330–133, provided that the amendment to section 9343 of Puspan. L. 99–509 by section 4085(i)(21)(D) of Puspan. L. 100–203, amending this section and provisions set out as an Effective Date of 1986 Amendments note below, is effective as if included in the enactment of Puspan. L. 99–509.

Effective Date of 1986 Amendment

Amendment by section 9320(e)(1), (2) of Puspan. L. 99–509 applicable to services furnished on or after Jan. 1, 1989, with exceptions for hospitals located in rural areas which meet certain requirements related to certified registered nurse anesthetists, see section 9320(i), (k) of Puspan. L. 99–509, as amended, set out as notes under section 1395k of this title.

Amendment by section 9337(span) of Puspan. L. 99–509 applicable to expenses incurred for outpatient occupational therapy services furnished on or after July 1, 1987, see section 9337(e) of Puspan. L. 99–509, set out as a note under section 1395k of this title.

Puspan. L. 99–509, title IX, § 9339(a)(2), Oct. 21, 1986, 100 Stat. 2036, provided that: “The amendments made by this subsection [amending this section] apply to clinical diagnostic laboratory tests performed on or after January 1, 1987.”

Puspan. L. 99–509, title IX, § 9339(c)(2), Oct. 21, 1986, 100 Stat. 2037, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to samples collected on or after January 1, 1987.”

Puspan. L. 99–509, title IX, § 9343(h), Oct. 21, 1986, 100 Stat. 2042, as amended by Puspan. L. 100–203, title IV, § 4085(i)(21)(D)(ii), (iii), Dec. 22, 1987, 101 Stat. 1330–134; Puspan. L. 100–360, title IV, § 411(i)(4)(C)(v), July 1, 1988, 102 Stat. 789, provided that:

“(1) The amendments made by subsection (a)(1) [amending this section] shall apply to cost reporting periods beginning on or after October 1, 1987.

“(2) The amendments made by subsections (span)(1) and (c) [amending this section and sections 1395y and 1395cc of this title] shall apply to services furnished after June 30, 1987.

“(3) The Secretary of Health and Human Services shall first provide, under the amendment made by subsection (span)(2) [amending this section], for the review and update of procedure lists within 6 months after the date of the enactment of this Act [Oct. 21, 1986].

“(4) The amendments made by subsection (d) [amending section 1320c–3 of this title] shall apply to contracts entered into or renewed after January 1, 1987.”

Puspan. L. 99–272, title IX, § 9303(a)(2), Apr. 7, 1986, 100 Stat. 188, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to clinical laboratory diagnostic tests performed on or after July 1, 1986.”

Puspan. L. 99–272, title IX, § 9303(span)(5)(A), (B), Apr. 7, 1986, 100 Stat. 189, provided that:

“(A) The amendments made by paragraphs (1) and (2) [amending this section] shall apply to clinical diagnostic laboratory tests performed on or after July 1, 1986.

“(B) The amendment made by paragraph (3) [amending this section] shall apply to clinical diagnostic laboratory tests performed on or after January 1, 1987.”

Effective Date of 1984 Amendment

Amendment by Puspan. L. 98–617 effective as if originally included in the Deficit Reduction Act of 1984, Puspan. L. 98–369, see section 3(c) of Puspan. L. 98–617, set out as a note under section 1395f of this title.

Puspan. L. 98–369, div. B, title III, § 2303(j), July 18, 1984, 98 Stat. 1067, provided that:

“(1) Except as provided in paragraphs (2) and (3), the amendments made by this section [amending this section and sections 1395u, 1395cc, 1396a, and 1396span of this title and enacting provisions set out as notes under this section and section 1395u of this title] shall apply to clinical diagnostic laboratory tests furnished on or after July 1, 1984.

“(2) The amendments made by subsection (g)(2) [amending section 1396span of this title] shall apply to payments for calendar quarters beginning on or after October 1, 1984.

“(3) The amendments made by this section shall not apply to clinical diagnostic laboratory tests furnished to inpatients of a provider operating under a waiver granted pursuant to section 602(k) of the Social Security Amendments of 1983 [section 602(k) of Puspan. L. 98–21, set out as a note under section 1395y of this title]. Payment for such services shall be made under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] at 80 percent (or 100 percent in the case of such tests for which payment is made on the basis of an assignment described in section 1842(span)(3)(B)(ii) of the Social Security Act [42 U.S.C. 1395u(span)(3)(B)(ii)] or under the procedure described in section 1870(f)(1) of such Act [42 U.S.C. 1395gg(f)(1)]) of the reasonable charge for such service. The deductible under section 1833(span) of such Act [42 U.S.C. 1395l(span)] shall not apply to such tests if payment is made on the basis of such an assignment or procedure.”

Puspan. L. 98–369, div. B, title III, § 2305(e), July 18, 1984, 98 Stat. 1070, provided that: “The amendments made by this section [amending this section and enacting provisions set out below] shall apply to services performed after the date of the enactment of this Act [July 18, 1984].”

Amendment by section 2321(span), (d)(4)(A) of Puspan. L. 98–369 applicable to items and services furnished on or after July 18, 1984, see section 2321(g) of Puspan. L. 98–369, set out as a note under section 1395f of this title.

Puspan. L. 98–369, div. B, title III, § 2323(d), July 18, 1984, 98 Stat. 1086, provided that: “The amendments made by this section [amending this section and sections 1395x, 1395cc, and 1395rr of this title and enacting provisions set out below] apply to services furnished on or after September 1, 1984.”

Amendment by section 2354(span)(5), (7) of Puspan. L. 98–369 effective July 18, 1984, but not to be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2354(e)(1) of Puspan. L. 98–369, set out as a note under section 1320a–1 of this title.

Effective Date of 1982 Amendment

Puspan. L. 97–248, title I, § 112(c), Sept. 3, 1982, 96 Stat. 340, provided that: “The amendments made by this section [amending this section] shall apply with respect to items and services furnished on or after October 1, 1982.”

Amendment by section 117(a)(2) of Puspan. L. 97–248 applicable to final determinations made on or after Sept. 3, 1982, see section 117(span) of Puspan. L. 97–248, set out as a note under section 1395g of this title.

Amendment by section 148(d) of Puspan. L. 97–248 effective with respect to contracts entered into or renewed on or after Sept. 3, 1982, see section 149 of Puspan. L. 97–248, set out as an Effective Date note under section 1320c of this title.

Effective Date of 1981 Amendment

Puspan. L. 97–35, title XXI, § 2106(c), Aug. 13, 1981, 95 Stat. 792, provided that: “The amendment made by subsection (a) [amending this section] is effective as of December 5, 1980, and the amendment made by subsection (span)(2) [amending section 1395q(span) of this title], is effective as of April 1, 1981.”

Puspan. L. 97–35, title XXI, § 2133(span), Aug. 13, 1981, 95 Stat. 797, provided that: “The amendments made by subsection (a) [amending this section] first apply to the deductible for calendar year 1982 with respect to expenses incurred on or after October 1, 1981.”

Puspan. L. 97–35, title XXI, § 2134(span), Aug. 13, 1981, 95 Stat. 797, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on January 1, 1982, and shall apply to the deductible for calendar years beginning with 1982.”

Effective Date of 1980 Amendment

Puspan. L. 96–611, § 2, Dec. 28, 1980, 94 Stat. 3567, provided that: “The amendments made by this Act [probably should be the amendments made by section 1 of this Act, which amended this section and sections 1395x, 1395y, 1395aa, and 1395cc of this title] shall take effect on, and apply to services furnished on or after, July 1, 1981.”

Amendment by section 930(h) of Puspan. L. 96–499, effective with respect to services furnished on or after July 1, 1981, see section 930(s)(1) of Puspan. L. 96–499, set out as a note under section 1395x of this title.

Puspan. L. 96–499, title IX, § 935(span), Dec. 5, 1980, 94 Stat. 2639, provided that: “The amendment made by subsection (a) [amending this section] shall apply to expenses incurred in calendar years beginning with calendar year 1982.”

Puspan. L. 96–499, title IX, § 943(span), Dec. 5, 1980, 94 Stat. 2642, provided that: “The amendments made by subsection (a) [amending this section] shall apply to services furnished after the sixth calendar month beginning after the date of the enactment of this Act [Dec. 5, 1980].”

Effective Date of 1978 Amendment

Amendment by Puspan. L. 95–292 effective with respect to services, supplies, and equipment furnished after the third calendar month beginning after June 13, 1978, except that provisions for the implementation of an incentive reimbursement system for dialysis services furnished in facilities and providers to become effective with respect to a facility’s or provider’s first accounting period beginning after the last day of the twelfth month following the month of June 1978, and except that provisions for reimbursement rates for home dialysis to become effective on Apr. 1, 1979, see section 6 of Puspan. L. 95–292, set out as a note under section 426 of this title.

Effective Date of 1977 Amendment

Amendment by Puspan. L. 95–210 applicable to services rendered on or after first day of third calendar month which begins after Dec. 31, 1977, see section 1(j) of Puspan. L. 95–210, set out as a note under section 1395k of this title.

Puspan. L. 95–142, § 16(span), Oct. 25, 1977, 91 Stat. 1201, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to durable medical equipment purchased or rented on or after October 1, 1977.”

Effective Date of 1972 Amendment

Puspan. L. 92–603, title II, § 204(c), Oct. 30, 1972, 86 Stat. 1377, provided that: “The amendments made by this section [amending this section and section 1395n of this title] shall be effective with respect to calendar years after 1972 (except that, for purposes of applying clause (1) of the first sentence of section 1833(span) of the Social Security Act [42 U.S.C. 1395l(span)], such amendments shall be deemed to have taken effect on January 1, 1972).”

Amendment by section 211(c)(4) of Puspan. L. 92–603 applicable to services furnished with respect to admissions occurring after Dec. 31, 1972, see section 211(d) of Puspan. L. 92–603, set out as a note under section 1395f of this title.

Amendment by section 226(c)(2) of Puspan. L. 92–603 effective with respect to services provided on or after July 1, 1973, see section 226(f) of Puspan. L. 92–603, set out as an Effective Date note under section 1395mm of this title.

Amendment by section 233(span) of Puspan. L. 92–603 applicable to services furnished by hospitals, extended care facilities, and home health agencies in accounting periods beginning after Dec. 31, 1972, see section 233(f) of Puspan. L. 92–603, set out as a note under section 1395f of this title. See, also, Puspan. L. 93–233, § 16, Dec. 31, 1973, 87 Stat. 967, set out as a note under section 1395f of this title.

Amendment by section 251(a)(2), (3) of Puspan. L. 92–603 applicable with respect to services furnished on or after July 1, 1973, see section 251(d)(1) of Puspan. L. 92–603, set out as a note under section 1395x of this title.

Puspan. L. 92–603, title II, § 299K(span), Oct. 30, 1972, 86 Stat. 1464, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished by home health agencies in accounting periods beginning after December 31, 1972.”

Effective Date of 1968 Amendment

Amendment by section 129(c)(7), (8) of Puspan. L. 90–248 applicable with respect to services furnished after Mar. 31, 1968, see section 129(d) of Puspan. L. 90–248, set out as a note under section 1395d of this title.

Puspan. L. 90–248, title I, § 131(c), Jan. 2, 1968, 81 Stat. 850, provided that: “The amendments made by this section [amending this section] shall apply with respect to services furnished after March 31, 1968.”

Puspan. L. 90–248, title I, § 132(c), Jan. 2, 1968, 81 Stat. 850, provided that: “The amendments made by this section [amending this section and section 1395x of this title] shall apply only with respect to items purchased after December 31, 1967.”

Amendment by section 135(c) of Puspan. L. 90–248 applicable with respect to payment for blood (or packed red blood cells) furnished an individual after Dec. 31, 1967, see section 135(d) of Puspan. L. 90–248, set out as a note under section 1395e of this title.

Construction of 2008 Amendment

Puspan. L. 110–275, title I, § 101(a)(4), July 15, 2008, 122 Stat. 2497, provided that: “Nothing in the provisions of, or amendments made by, this subsection [amending this section and sections 1395x and 1395y of this title] shall be construed to provide coverage under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] of items and services for the treatment of a medical condition that is not otherwise covered under such title.”

Construction Regarding Limiting Increases in Cost-Sharing

Puspan. L. 106–554, § 1(a)(6) [title I, § 111(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–473, provided that: “Nothing in this Act [H.R. 5661, as enacted by section 1(a)(6) of Puspan. L. 106–554, see Tables for classification] or the Social Security Act [this chapter] shall be construed as preventing a hospital from waiving the amount of any coinsurance for outpatient hospital services under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] that may have been increased as a result of the implementation of the prospective payment system under section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)).”

Implementation of 2022 Amendment

Puspan. L. 117–328, div. FF, title IV, § 4141(span), Dec. 29, 2022, 136 Stat. 5929, provided that: “Notwithstanding any other provision of law, the Secretary of Health and Human Service may implement the amendments made by subsection (a) [amending this section] by program instruction or otherwise.”

Puspan. L. 117–169, title I, § 11407(c), Aug. 16, 2022, 136 Stat. 1905, provided that: “The Secretary of Health and Human Services shall implement this section [amending this section] for 2023 by program instruction or other forms of program guidance.”

Provider Outreach and Reporting on Certain Behavioral Health Integration Services

Puspan. L. 117–328, div. FF, title IV, § 4128, Dec. 29, 2022, 136 Stat. 5916, provided that:

“(a)Outreach.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall conduct outreach to physicians and appropriate non-physician practitioners participating under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) with respect to behavioral health integration services described by any of HCPCS codes 99492 through 99494 or 99484 (or any successor code). Such outreach shall include a comprehensive, one-time education initiative to inform such physicians and practitioners of the inclusion of such services as a covered benefit under the Medicare program, including describing the requirements to bill for such codes and the requirements for beneficiary eligibility for such services.

“(span)Reports to Congress.—

“(1)Provider outreach.—Not later than 1 year after the date of the completion of the education initiative described in subsection (a), the Secretary shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the outreach conducted under such subsection. Such report shall include a description of the methods used for such outreach.

“(2)Utilization rates.—Not later than 18 months after the date of the completion of the education initiative described in subsection (a), and two years thereafter, the Secretary shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the number of Medicare beneficiaries (including those beneficiaries accessing services in rural and underserved areas) who, during the preceding year, were furnished services described in subsection (a) for which payment was made under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).”

Outreach and Reporting on Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs

Puspan. L. 117–328, div. FF, title IV, § 4129, Dec. 29, 2022, 136 Stat. 5916, provided that:

“(a)Outreach.—

“(1)Provider outreach.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall conduct outreach to physicians and appropriate non-physician practitioners participating under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) with respect to opioid use disorder treatment services furnished by an opioid treatment program (as defined in section 1861(jjj) of the Social Security Act (42 U.S.C. 1395x(jjj))). Such outreach shall include a comprehensive, one-time education initiative to inform such physicians and practitioners of the inclusion of such services as a covered benefit under the Medicare program, including describing the requirements for billing and the requirements for beneficiary eligibility for such services.

“(2)Beneficiary outreach.—The Secretary shall conduct outreach to Medicare beneficiaries with respect to opioid use disorder treatment services furnished by an opioid treatment program (as defined in section 1861(jjj) of the Social Security Act (42 U.S.C. 1395x(jjj))), including a comprehensive, one-time education initiative informing such beneficiaries about the eligibility requirements to receive such services.

“(span)Reports to Congress.—

“(1)Outreach.—Not later than 1 year after the date of the completion of the education initiatives described in subsection (a), the Secretary shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the outreach conducted under such subsection. Such report shall include a description of the methods used for such outreach.

“(2)Utilization rates.—Not later than 18 months after the date of the completion of the education initiatives described in subsection (a), and two years thereafter, the Secretary shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the number of Medicare beneficiaries who, during the preceding year, were furnished opioid use disorder treatment services by an opioid treatment program (as defined in section 1861(jjj) of the Social Security Act (42 U.S.C. 1395x(jjj))) for which payment was made under title XVIII of such Act (42 U.S.C. 1395 et seq.).”

Centers for Medicare & Medicaid Services Provider Outreach and Reporting on Cognitive Assessment and Care Plan Services

Puspan. L. 116–260, div. CC, title I, § 116, Dec. 27, 2020, 134 Stat. 2949, provided that:

“(a)Outreach.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall conduct outreach to physicians and appropriate non-physician practitioners participating under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) with respect to Medicare payment for cognitive assessment and care plan services furnished to individuals with cognitive impairment such as Alzheimer’s disease and related dementias, identified as of January 1, 2018, by HCPCS code 99483, or any successor to such code (in this section referred to as ‘cognitive assessment and care plan services’). Such outreach shall include a comprehensive, one-time education initiative to inform such physicians and practitioners of the addition of such services as a covered benefit under the Medicare program, including the requirements for eligibility for such services.

“(span)Reports.—

“(1)HHS report on provider outreach.—Not later than one year after the date of enactment of this Act [Dec. 27, 2020], the Secretary of Health and Human Services shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the outreach conducted under subsection (a). Such report shall include a description of the methods used for such outreach.

“(2)GAO report on utilization rates.—Not later than 3 years after such date of enactment, the Comptroller General of the United States shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the number of Medicare beneficiaries who were furnished cognitive assessment and care plan services for which payment was made under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such report shall include information on barriers Medicare beneficiaries face to access such services, and recommendations for such legislative and administrative action as the Comptroller General deems appropriate.”

Implementation of 2020 Amendment

Puspan. L. 116–136, div. A, title III, § 3713(e), Mar. 27, 2020, 134 Stat. 424, provided that: “Notwithstanding any other provision of law, the Secretary [probably means Secretary of Health and Human Services] may implement the provisions of, and the amendments made by, this section [amending this section and sections 1395w–22 and 1395x of this title] by program instruction or otherwise.”

Claims Modifier

Puspan. L. 116–127, div. F, § 6002(span), Mar. 18, 2020, 134 Stat. 203, provided that: “The Secretary of Health and Human Services shall provide for an appropriate modifier (or other identifier) to include on claims to identify, for purposes of subparagraph (DD) of section 1833(a)(1) [probably means section 1833(a)(1)(DD) of the Social Security Act, 42 U.S.C. 1395l(a)(1)(DD)], as added by subsection (a), specified COVID–19 testing-related services described in paragraph (1) of section 1833(cc) of the Social Security Act [42 U.S.C. 1395l(cc)], as added by subsection (a), for which payment may be made under a specified outpatient payment provision described in paragraph (2) of such subsection.”

Implementation of Provisions of Puspan. L. 116–127

Puspan. L. 116–127, div. F, § 6002(c), Mar. 18, 2020, 134 Stat. 203, provided that: “Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, including amendments made by, this section [amending this section and enacting provisions set out as a note above] through program instruction or otherwise.”

Implementation of 2019 Amendment

Puspan. L. 116–94, div. N, title I, § 107(span), Dec. 20, 2019, 133 Stat. 3102, provided that: “Notwithstanding any other provision of law, the Secretary of Health and Human Service may implement the amendments made by subsection (a) [amending this section] by program instruction or otherwise.”

Implementation of 2018 Amendment

Puspan. L. 115–141, div. S, title XIII, § 1301(a)(3), Mar. 23, 2018, 132 Stat. 1150, provided that: “Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the amendments made by paragraphs (1) and (2) [amending this section] by program instruction or otherwise.”

Improving Documentation of Services

Puspan. L. 114–10, title V, § 514(span), Apr. 16, 2015, 129 Stat. 173, provided that:

“(1)In general.—The Secretary of Health and Human Services shall, in consultation with stakeholders (including the American Chiropractic Association) and representatives of medicare administrative contractors (as defined in section 1874A(a)(3)(A) of the Social Security Act (42 U.S.C. 1395kk–1(a)(3)(A))), develop educational and training programs to improve the ability of chiropractors to provide documentation to the Secretary of services described in section 1861(r)(5) [42 U.S.C. 1395x(r)(5)] in a manner that demonstrates that such services are, in accordance with section 1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

“(2)Timing.—The Secretary shall make the educational and training programs described in paragraph (1) publicly available not later than January 1, 2016.

“(3)Funding.—The Secretary shall use funds made available under paragraph (10) of section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)), as added by section 505, to carry out this subsection.”

Medicare Patient IVIG Access Demonstration Project

Puspan. L. 112–242, title I, § 101, Jan. 10, 2013, 126 Stat. 2374, as amended by Puspan. L. 115–63, title III, § 302, Sept. 29, 2017, 131 Stat. 1172; Puspan. L. 116–260, div. CC, title I, § 104, Dec. 27, 2020, 134 Stat. 2943, provided that:

“(a)Establishment.—The Secretary shall establish and implement a demonstration project under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] to evaluate the benefits of providing payment for items and services needed for the in-home administration of intravenous immune globin for the treatment of primary immune deficiency diseases.

“(span)Duration and Scope.—

“(1)Duration.—Beginning not later than one year after the date of enactment of this Act [Jan. 10, 2013], the Secretary shall conduct the demonstration project for a period of 3 years and, subject to the availability of funds under subsection (g), the period beginning on October 1, 2017, and ending on December 31, 2023.

“(A) if the date of enactment of the Disaster Tax Relief and Airport and Airway Extension Act of 2017 is on or before September 30, 2017 [Puspan. L. 115–63 was approved Sept. 29, 2017], for the period beginning on October 1, 2017, and ending on December 31, 2020; and

“(B) if the date of enactment of such Act is after September 30, 2017, for the period beginning on the date of enactment of such Act and ending on December 31, 2020.

“(2)Scope.—The Secretary shall enroll for participation in the demonstration project for the period beginning on October 1, 2014, and ending on September 30, 2020, not more than 4,000 Medicare beneficiaries who have been diagnosed with primary immunodeficiency disease and for the period beginning on October 1, 2014, and ending on December 31, 2023, not more than 6,500 Medicare beneficiaries who have been so diagnosed. A Medicare beneficiary may participate in the demonstration project on a voluntary basis and may terminate participation at any time. Subject to the preceding sentence, a Medicare beneficiary enrolled in the demonstration project on September 30, 2017, shall be automatically enrolled during the period beginning on the date of the enactment of the Disaster Tax Relief and Airport and Airway Extension Act of 2017 and ending on December 31, 2023, without submission of another application.

“(c)Coverage.—Except as otherwise provided in this section, items and services for which payment may be made under the demonstration program shall be treated and covered under part B of title XVIII of the Social Security Act in the same manner as similar items and services covered under such part.

“(d)Payment.—The Secretary shall establish a per visit payment amount for items and services needed for the in-home administration of intravenous immune globin based on the national per visit low-utilization payment amount under the prospective payment system for home health services established under section 1895 of the Social Security Act (42 U.S.C. 1395fff).

“(e)Waiver Authority.—The Secretary may waive such requirements of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] as may be necessary to carry out the demonstration project.

“(f)Study and Report to Congress.—

“(1)Interim evaluation and report.—Not later than three years after the date of enactment of this Act, the Secretary shall submit to Congress a report that contains an interim evaluation of the impact of the demonstration project on access for Medicare beneficiaries to items and services needed for the in-home administration of intravenous immune globin.

“(2)Updated evaluation and report.—Not later than 2 years after the date of the enactment of [the] Consolidated Appropriations Act, 2021 [Dec. 27, 2020], the Secretary shall submit to Congress an updated report that contains the following:

“(A) The total number of beneficiaries enrolled in the demonstration project during the updated report period.

“(B) The total number of claims submitted for services during the updated report period, disaggregated by month.

“(C) An analysis of the impact of the demonstration on beneficiary access to the in-home administration of intravenous immune globin, including the impact on beneficiary health.

“(D) An analysis of the impact of in-home administration of intravenous immune globin on overall costs to Medicare, including the cost differential between in-home administration of intravenous immune globin and administration of intravenous immune globin in a healthcare facility.

“(E) To the extent practicable, a survey of providers and enrolled beneficiaries that participated in the demonstration project that identifies barriers to accessing services, including reimbursement for items and services.

“(F) Recommendations to Congress on the appropriateness of establishing a permanent bundled services payment for the in-home administration of intravenous immune globin for Medicare beneficiaries.

“(3)Final evaluation and report.—Not later than one year after the date of completion of the demonstration project, the Secretary shall submit to Congress a report that contains the following:

“(A) A final evaluation of the impact of the demonstration project on access for Medicare beneficiaries to items and services needed for the in-home administration of intravenous immune globin.

“(B) An analysis of the appropriateness of implementing a new methodology for payment for intravenous immune globulins in all care settings under part B of title XVIII of the Social Security Act (42 U.S.C. 1395k [1395j] et seq.).

“(C) An update to the report entitled ‘Analysis of Supply, Distribution, Demand, and Access Issues Associated with Immune Globulin Intravenous (IGIV)’, issued in February 2007 by the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services.

“(g)Funding.—There shall be made available to the Secretary to carry out the demonstration project not more than $45,000,000 from the Federal Supplementary Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t).

“(h)Definitions.—In this section:

“(1)Demonstration project.—The term ‘demonstration project’ means the demonstration project conducted under this section.

“(2)Medicare beneficiary.—The term ‘Medicare beneficiary’ means an individual who is enrolled for benefits under part B of title XVIII of the Social Security Act.

“(3)Secretary.—The term ‘Secretary’ means the Secretary of Health and Human Services.

“(4)Updated report period.—The term ‘updated report period’ means the period beginning on October 1, 2014, and ending on September 30, 2020.”

[Puspan. L. 116–260, § 104(span), (c), which directed amendment of section 101 without specifying the Act to be amended, was executed to section 101 of Puspan. L. 112–242, set out above, to reflect the probable intent of Congress.]

Implementation of 2013 Amendment

Puspan. L. 112–240, title VI, § 603(d), Jan. 2, 2013, 126 Stat. 2347, provided that: “Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, and the amendments made by, this section [amending this section] by program instruction or otherwise.”

Implementation of 2012 Amendment

Puspan. L. 112–96, title III, § 3005(d), Fespan. 22, 2012, 126 Stat. 189, provided that: “The Secretary of Health and Human Services shall implement such claims processing edits and issue such guidance as may be necessary to implement the amendments made by this section [amending this section and section 1395u of this title] in a timely manner. Notwithstanding any other provision of law, the Secretary may implement the amendments made by this section by program instruction. Of the amount of funds made available to the Secretary for fiscal year 2012 for program management for the Centers for Medicare & Medicaid Services, not to exceed $9,375,000 shall be available for such fiscal year and the first 3 months of fiscal year 2013 to carry out section 1833(g)(5)(C) of the Social Security Act [42 U.S.C. 1395l(g)(5)(C)] (relating to manual medical review), as added by subsection (a).”

Collection of Additional Data

Puspan. L. 112–96, title III, § 3005(g), Fespan. 22, 2012, 126 Stat. 189, provided that:

“(1)Strategy.—The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes.

“(2)Consultation.—In proposing and implementing such strategy, the Secretary shall consult with relevant stakeholders.”

Treatment of Certain Complex Diagnostic Laboratory Tests

Puspan. L. 111–148, title III, § 3113, Mar. 23, 2010, 124 Stat. 422, provided that:

“(a)Demonstration Project.—

“(1)In general.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall conduct a demonstration project under part B [of] title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] under which separate payments are made under such part for complex diagnostic laboratory tests provided to individuals under such part. Under the demonstration project, the Secretary shall establish appropriate payment rates for such tests.

“(2)Covered complex diagnostic laboratory test defined.—In this section, the term ‘complex diagnostic laboratory test’ means a diagnostic laboratory test—

“(A) that is an analysis of gene protein expression, topographic genotyping, or a cancer chemotherapy sensitivity assay;

“(B) that is determined by the Secretary to be a laboratory test for which there is not an alternative test having equivalent performance characteristics;

“(C) which is billed using a Health Care Procedure Coding System (HCPCS) code other than a not otherwise classified code under such Coding System;

“(D) which is approved or cleared by the Food and Drug Administration or is covered under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]; and

“(E) is described in section 1861(s)(3) of the Social Security Act (42 U.S.C. 1395x(s)(3)).

“(3)Separate payment defined.—In this section, the term ‘separate payment’ means direct payment to a laboratory (including a hospital-based or independent laboratory) that performs a complex diagnostic laboratory test with respect to a specimen collected from an individual during a period in which the individual is a patient of a hospital if the test is performed after such period of hospitalization and if separate payment would not otherwise be made under title XVIII of the Social Security Act by reason of sections 1862(a)(14) and 1866(a)(1)(H)(i) of the such [sic] Act (42 U.S.C. 1395y(a)(14); 42 U.S.C. 1395cc(a)(1)(H)(i)).

“(span)Duration.—Subject to subsection (c)(2), the Secretary shall conduct the demonstration project under this section for the 2-year period beginning on July 1, 2011.

“(c)Payments and Limitation.—Payments under the demonstration project under this section shall—

“(1) be made from the Federal Supplemental [probably should be “Supplementary”] Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t); and

“(2) may not exceed $100,000,000.

“(d)Report.—Not later than 2 years after the completion of the demonstration project under this section, the Secretary shall submit to Congress a report on the project. Such report shall include—

“(1) an assessment of the impact of the demonstration project on access to care, quality of care, health outcomes, and expenditures under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] (including any savings under such title); and

“(2) such recommendations as the Secretary determines appropriate.

“(e)Implementation Funding.—For purposes of administering this section (including preparing and submitting the report under subsection (d)), the Secretary shall provide for the transfer, from the Federal Supplemental [probably should be “Supplementary”] Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t), to the Centers for Medicare & Medicaid Services Program Management Account, of $5,000,000. Amounts transferred under the preceding sentence shall remain available until expended.”

Treatment of Certified Registered Nurse Anesthetists

Puspan. L. 110–275, title I, § 139(span), July 15, 2008, 122 Stat. 2541, provided that: “With respect to items and services furnished on or after January 1, 2010, the Secretary of Health and Human Services shall make appropriate adjustments to payments under the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for teaching certified registered nurse anesthetists to implement a policy with respect to teaching certified registered nurse anesthetists that—

“(1) is consistent with the adjustments made by the special rule for teaching anesthesiologists under section 1848(a)(6) of the Social Security Act [42 U.S.C. 1395w–4(a)(6)], as added by subsection (a); and

“(2) maintains the existing payment differences between teaching anesthesiologists and teaching certified registered nurse anesthetists.”

Implementation of 2006 Amendment

Puspan. L. 109–432, div. B, title I, § 107(span)(2), Dec. 20, 2006, 120 Stat. 2983, provided that: “The Secretary of Health and Human Services may implement the amendment made by paragraph (1) [amending this section] by program instruction or otherwise.”

Puspan. L. 109–171, title V, § 5107(a)(2), Fespan. 8, 2006, 120 Stat. 42, provided that: “The Secretary of Health and Human Services shall waive such provisions of law and regulation (including those described in section 110(c) of Public Law 108–173 [set out as a note under section 1395w–101 of this title]) as are necessary to implement the amendments made by paragraph (1) [amending this section] on a timely basis and, notwithstanding any other provision of law, may implement such amendments by program instruction or otherwise. There shall be no administrative or judicial review under section 1869 or section 1878 of the Social Security Act (42 U.S.C. 1395ff and 1395oo), or otherwise of the process (including the establishment of the process) under section 1833(g)(5) of such Act [42 U.S.C. 1395l(g)(5)], as added by paragraph (1).”

Implementation of Clinically Appropriate Code Edits In Order To Identify and Eliminate Improper Payments for Therapy Services

Puspan. L. 109–171, title V, § 5107(span), Fespan. 8, 2006, 120 Stat. 43, provided that: “By not later than July 1, 2006, the Secretary of Health and Human Services shall implement clinically appropriate code edits with respect to payments under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for physical therapy services, occupational therapy services, and speech-language pathology services in order to identify and eliminate improper payments for such services, including edits of clinically illogical combinations of procedure codes and other edits to control inappropriate billings.”

Application of 2003 Amendment to Physician Specialties

Amendment by section 303 of Puspan. L. 108–173, insofar as applicable to payments for drugs or biologicals and drug administration services furnished by physicians, is applicable only to physicians in the specialties of hematology, hematology/oncology, and medical oncology under this subchapter, see section 303(j) of Puspan. L. 108–173, set out as a note under section 1395u of this title.

Notwithstanding section 303(j) of Puspan. L. 108–173 (see note above), amendment by section 303 of Puspan. L. 108–173 also applicable to payments for drugs or biologicals and drug administration services furnished by physicians in specialties other than the specialties of hematology, hematology/oncology, and medical oncology, see section 304 of Puspan. L. 108–173, set out as a note under section 1395u of this title.

GAO Study of Medicare Payment for Inhalation Therapy

Puspan. L. 108–173, title III, § 305(span), Dec. 8, 2003, 117 Stat. 2255, required the Comptroller General of the United States to conduct a study to examine the adequacy of reimbursements for inhalation therapy under the medicare program, and to submit to Congress a report on this study not later than 1 year after Dec. 8, 2003.

Treatment of Certain Clinical Diagnostic Laboratory Tests Furnished to Hospital Outpatients in Certain Rural Areas

Puspan. L. 108–173, title IV, § 416, Dec. 8, 2003, 117 Stat. 2282, as amended by Puspan. L. 109–432, div. B, title I, § 105, Dec. 20, 2006, 120 Stat. 2981; Puspan. L. 110–173, title I, § 107, Dec. 29, 2007, 121 Stat. 2496; Puspan. L. 111–148, title III, § 3122, Mar. 23, 2010, 124 Stat. 423; Puspan. L. 111–309, title I, § 109, Dec. 15, 2010, 124 Stat. 3288, provided that:

“(a)In General.—Notwithstanding subsections (a), (span), and (h) of section 1833 of the Social Security Act (42 U.S.C. 1395l) and section 1834(d)(1) of such Act (42 U.S.C. 1395m(d)(1)), in the case of a clinical diagnostic laboratory test covered under part B of title XVIII of such Act [42 U.S.C. 1395j et seq.] that is furnished during a cost reporting period described in subsection (span) by a hospital with fewer than 50 beds that is located in a qualified rural area (identified under paragraph (12)(B)(iii) of section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), as added by section 414(c)) as part of outpatient services of the hospital, the amount of payment for such test shall be 100 percent of the reasonable costs of the hospital in furnishing such test.

“(span)Application.—A cost reporting period described in this subsection is a cost reporting period beginning during the period beginning on July 1, 2004, and ending on June 30, 2008 or during the 2-year period beginning on July 1, 2010.

“(c)Provision as Part of Outpatient Hospital Services.—For purposes of subsection (a), in determining whether clinical diagnostic laboratory services are furnished as part of outpatient services of a hospital, the Secretary [of Health and Human Services] shall apply the same rules that are used to determine whether clinical diagnostic laboratory services are furnished as an outpatient critical access hospital service under section 1834(g)(4) of the Social Security Act (42 U.S.C. 1395m(g)(4)).”

[Puspan. L. 109–432, div. B, title I, § 105, Dec. 20, 2006, 120 Stat. 2981, provided that the amendment made by that section to section 416(span) of Puspan. L. 108–173, set out above, is effective as if included in the enactment of section 416 of Puspan. L. 108–173.]

GAO Report on Payments for Brachytherapy Devices

Puspan. L. 108–173, title VI, § 621(span)(3), Dec. 8, 2003, 117 Stat. 2311, provided that: “The Comptroller General of the United States shall conduct a study to determine appropriate payment amounts under section 1833(t)(16)(C) of the Social Security Act [42 U.S.C. 1395l(t)(16)(C)], as added by paragraph (1), for devices of brachytherapy. Not later than January 1, 2005, the Comptroller General shall submit to Congress and the Secretary [of Health and Human Services] a report on the study conducted under this paragraph, and shall include specific recommendations for appropriate payments for such devices.”

Moratorium on Physical Therapy Services Caps in 2003

Puspan. L. 108–173, title VI, § 624(a)(2), Dec. 8, 2003, 117 Stat. 2317, provided that: “For the period beginning on the date of the enactment of this Act [Dec. 8, 2003] and ending of [sic] December 31, 2003, the Secretary [of Health and Human Services] shall not apply the provisions of paragraphs (1), (2), and (3) of section 1833(g) [42 U.S.C. 1395l(g)] to expenses incurred with respect to services described in such paragraphs during such period. Nothing in the preceding sentence shall be construed as affecting the application of such paragraphs by the Secretary before the date of the enactment of this Act.”

Prompt Submission of Overdue Reports on Payment and Utilization of Outpatient Therapy Services

Puspan. L. 108–173, title VI, § 624(span), Dec. 8, 2003, 117 Stat. 2317, provided that: “Not later than March 31, 2004, the Secretary [of Health and Human Services] shall submit to Congress the reports required under section 4541(d)(2) of the Balanced Budget Act of 1997 (Public Law 105–33; 111 Stat. 457) [set out as a note under this section] (relating to alternatives to a single annual dollar cap on outpatient therapy) and under section 221(d) of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (Appendix F, 113 Stat. 1501A–352), as enacted into law by section 1000(a)(6) of Public Law 106–113 [set out as a note under this section] (relating to utilization patterns for outpatient therapy).”

GAO Study of Ambulatory Surgical Center Payments

Puspan. L. 108–173, title VI, § 626(d), Dec. 8, 2003, 117 Stat. 2319, provided that:

“(1)Study.—

“(A)In general.—The Comptroller General of the United States shall conduct a study that compares the relative costs of procedures furnished in ambulatory surgical centers to the relative costs of procedures furnished in hospital outpatient departments under section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)). The study shall also examine how accurately ambulatory payment categories reflect procedures furnished in ambulatory surgical centers.

“(B)Consideration of asc data.—In conducting the study under paragraph (1), the Comptroller General shall consider data submitted by ambulatory surgical centers regarding the matters described in clauses (i) through (iii) of paragraph (2)(B).

“(2)Report and recommendations.—

“(A)Report.—Not later than January 1, 2005, the Comptroller General shall submit to Congress a report on the study conducted under paragraph (1).

“(B)Recommendations.—The report submitted under subparagraph (A) shall include recommendations on the following matters:

“(i) The appropriateness of using the groups of covered services and relative weights established under the outpatient prospective payment system as the basis of payment for ambulatory surgical centers.

“(ii) If the relative weights under such hospital outpatient prospective payment system are appropriate for such purpose—

“(I) whether the payment rates for ambulatory surgical centers should be based on a uniform percentage of the payment rates or weights under such outpatient system; or

“(II) whether the payment rates for ambulatory surgical centers should vary, or the weights should be revised, based on specific procedures or types of services (such as ophthalmology and pain management services).

“(iii) Whether a geographic adjustment should be used for payment of services furnished in ambulatory surgical centers, and if so, the labor and nonlabor shares of such payment.”

Demonstration Project for Coverage of Certain Prescription Drugs and Biologicals

Puspan. L. 108–173, title VI, § 641, Dec. 8, 2003, 117 Stat. 2321, provided that:

“(a)Demonstration Project.—The Secretary [of Health and Human Services] shall conduct a demonstration project under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] under which payment is made for drugs or biologicals that are prescribed as replacements for drugs and biologicals described in section 1861(s)(2)(A) or 1861(s)(2)(Q) of such Act (42 U.S.C. 1395x(s)(2)(A), 1395x(s)(2)(Q)), or both, for which payment is made under such part. Such project shall provide for cost-sharing applicable with respect to such drugs or biologicals in the same manner as cost-sharing applies with respect to part D [part D of this subchapter] drugs under standard prescription drug coverage (as defined in section 1860D–2(span) of the Social Security Act [42 U.S.C. 1395w–102(span)], as added by section 101(a)).

“(span)Demonstration Project Sites.—The project established under this section shall be conducted in sites selected by the Secretary.

“(c)Duration.—The Secretary shall conduct the demonstration project for the 2-year period beginning on the date that is 90 days after the date of the enactment of this Act [Dec. 8, 2003], but in no case may the project extend beyond December 31, 2005.

“(d)Limitation.—Under the demonstration project over the duration of the project, the Secretary may not provide—

“(1) coverage for more than 50,000 patients; and

“(2) more than $500,000,000 in funding.

“(e)Report.—Not later than July 1, 2006, the Secretary shall submit to Congress a report on the project. The report shall include an evaluation of patient access to care and patient outcomes under the project, as well as an analysis of the cost effectiveness of the project, including an evaluation of the costs savings (if any) to the medicare program attributable to reduced physicians’ services and hospital outpatient departments services for administration of the biological.”

Payment for Pancreatic Islet Cell Investigational Transplants for Medicare Beneficiaries in Clinical Trials

Puspan. L. 108–173, title VII, § 733, Dec. 8, 2003, 117 Stat. 2352, provided that:

“(a)Clinical Trial.—

“(1)In general.—The Secretary [of Health and Human Services], acting through the National Institute of Diabetes and Digestive and Kidney Disorders, shall conduct a clinical investigation of pancreatic islet cell transplantation which includes medicare beneficiaries.

“(2)Authorization of appropriations.—There are authorized to be appropriated to the Secretary such sums as may be necessary to conduct the clinical investigation under paragraph (1).

“(span)Medicare Payment.—Not earlier than October 1, 2004, the Secretary shall pay for the routine costs as well as transplantation and appropriate related items and services (as described in subsection (c)) in the case of medicare beneficiaries who are participating in a clinical trial described in subsection (a) as if such transplantation were covered under title XVIII of such Act [42 U.S.C. 1395 et seq.] and as would be paid under part A or part B of such title [42 U.S.C. 1395c et seq., 1395j et seq.] for such beneficiary.

“(c)Scope of Payment.—For purposes of subsection (span):

“(1) The term ‘routine costs’ means reasonable and necessary routine patient care costs (as defined in the Centers for Medicare & Medicaid Services Coverage Issues Manual, section 30–1), including immunosuppressive drugs and other followup care.

“(2) The term ‘transplantation and appropriate related items and services’ means items and services related to the acquisition and delivery of the pancreatic islet cell transplantation, notwithstanding any national noncoverage determination contained in the Centers for Medicare & Medicaid Services Coverage Issues Manual.

“(3) The term ‘medicare beneficiary’ means an individual who is entitled to benefits under part A of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], or enrolled under part B of such title [42 U.S.C. 1395j et seq.], or both.

“(d)Construction.—The provisions of this section shall not be construed—

“(1) to permit payment for partial pancreatic tissue or islet cell transplantation under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] other than payment as described in subsection (span); or

“(2) as authorizing or requiring coverage or payment conveying—

“(A) benefits under part A of such title [42 U.S.C. 1395c et seq.] to a beneficiary not entitled to such part A; or

“(B) benefits under part B of such title [42 U.S.C. 1395j et seq.] to a beneficiary not enrolled in such part B.”

GAO Study of Reduction in Medigap Premium Levels Resulting From Reductions in Coinsurance

Puspan. L. 106–554, § 1(a)(6) [title I, § 111(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–473, related to GAO study of reduction in medigap premium levels resulting from reductions in coinsurance and subsequent report to Congress, prior to repeal by Puspan. L. 114–301, § 2(span), Dec. 16, 2016, 130 Stat. 1514.

MedPAC Study on Low-Volume, Isolated Rural Health Care Providers

Puspan. L. 106–554, § 1(a)(6) [title II, § 225], Dec. 21, 2000, 114 Stat. 2763, 2763A–490, provided that:

“(a)Study.—The Medicare Payment Advisory Commission shall conduct a study on the effect of low patient and procedure volume on the financial status of low-volume, isolated rural health care providers participating in the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].

“(1) whether low-volume, isolated rural health care providers are having, or may have, significantly decreased medicare margins or other financial difficulties resulting from any of the payment methodologies described in subsection (c);

“(2) whether the status as a low-volume, isolated rural health care provider should be designated under the medicare program and any criteria that should be used to qualify for such a status; and

“(3) any changes in the payment methodologies described in subsection (c) that are necessary to provide appropriate reimbursement under the medicare program to low-volume, isolated rural health care providers (as designated pursuant to paragraph (2)).

“(c)Payment Methodologies Described.—The payment methodologies described in this subsection are the following:

“(1) The prospective payment system for hospital outpatient department services under section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)).

“(2) The fee schedule for ambulance services under section 1834(l) of such Act (42 U.S.C. 1395m(l)).

“(3) The prospective payment system for inpatient hospital services under section 1886 of such Act (42 U.S.C. 1395ww).

“(4) The prospective payment system for routine service costs of skilled nursing facilities under section 1888(e) of such Act (42 U.S.C. 1395yy(e)).

“(5) The prospective payment system for home health services under section 1895 of such Act (42 U.S.C. 1395fff).”

Special Rule for Payment for 2001

Puspan. L. 106–554, § 1(a)(6) [title IV, § 401(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–503, provided that: “Notwithstanding the amendment made by subsection (a) [amending this section], for purposes of making payments under section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) for covered OPD services furnished during 2001, the medicare OPD fee schedule amount under such section—

“(1) for services furnished on or after January 1, 2001, and before April 1, 2001, shall be the medicare OPD fee schedule amount for 2001 as determined under the provisions of law in effect on the day before the date of the enactment of this Act [Dec. 21, 2000]; and

“(2) for services furnished on or after April 1, 2001, and before January 1, 2002, shall be the fee schedule amount (as determined taking into account the amendment made by subsection (a)), increased by a transitional percentage allowance equal to 0.32 percent (to account for the timing of implementation of the full market basket update).”

Transition Provisions Applicable to Subsection (t)(6)(B)

Puspan. L. 106–554, § 1(a)(6) [title IV, § 402(d)], Dec. 21, 2000, 114 Stat. 2763, 2763A–506, provided that:

“(1)In general.—In the case of a medical device provided as part of a service (or group of services) furnished during the period before initial categories are implemented under subparagraph (B)(i) of section 1833(t)(6) of the Social Security Act [42 U.S.C. 1395l(t)(6)(B)(i)] (as amended by subsection (a)), payment shall be made for such device under such section in accordance with the provisions in effect before the date of the enactment of this Act [Dec. 21, 2000]. In addition, beginning on the date that is 30 days after the date of the enactment of this Act, payment shall be made for such a device that is not included in a program memorandum described in such subparagraph if the Secretary of Health and Human Services determines that the device (including a device that would have been included in such program memoranda but for the requirement of subparagraph (A)(iv)(I) of that section) is likely to be described by such an initial category.

“(2)Application of current process.—Notwithstanding any other provision of law, the Secretary shall continue to accept applications with respect to medical devices under the process established pursuant to paragraph (6) of section 1833(t) of the Social Security Act [42 U.S.C. 1395l(t)(6)] (as in effect on the day before the date of the enactment of this Act [Dec. 21, 2000]) through December 1, 2000, and any device—

“(A) with respect to which an application was submitted (pursuant to such process) on or before such date; and

“(B) that meets the requirements of clause (ii) or (iv) of subparagraph (A) of such paragraph (as determined pursuant to such process),

shall be treated as a device with respect to which an initial category is required to be established under subparagraph (B)(i) of such paragraph (as amended by subsection (a)(2)).”

Study on Standards for Supervision of Physical Therapist Assistants

Puspan. L. 106–554, § 1(a)(6) [title IV, § 421(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–516, required the Secretary of Health and Human Services to conduct a study of the implications of eliminating the “in the room” supervision requirement for medicare payment for services of physical therapy assistants who are supervised by physical therapists and of such requirement on the cap imposed under subsec. (g) of this section on physical therapy services, and to submit to Congress a report on the study no later than 18 months after Dec. 21, 2000.

Delay in Implementation of Prospective Payment System for Ambulatory Surgical Centers

Puspan. L. 106–554, § 1(a)(6) [title IV, § 424(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–518, provided that: “The Secretary of Health and Human Services may not implement a revised prospective payment system for services of ambulatory surgical facilities under section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) before January 1, 2002.”

MedPAC Study and Report on Medicare Reimbursement for Services Provided by Certain Providers

Puspan. L. 106–554, § 1(a)(6) [title IV, § 434], Dec. 21, 2000, 114 Stat. 2763, 2763A–526, provided that:

“(a)Study.—The Medicare Payment Advisory Commission shall conduct a study on the appropriateness of the current payment rates under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for services provided by a—

“(1) certified nurse-midwife (as defined in subsection (gg)(2) of section 1861 of such Act (42 U.S.C. 1395x));

“(2) physician assistant (as defined in subsection (aa)(5)(A) of such section);

“(3) nurse practitioner (as defined in such subsection); and

“(4) clinical nurse specialist (as defined in subsection (aa)(5)(B) of such section).

The study shall separately examine the appropriateness of such payment rates for orthopedic physician assistants, taking into consideration the requirements for accreditation, training, and education.

“(span)Report.—Not later than 18 months after the date of the enactment of this Act [Dec. 21, 2000], the Commission shall submit to Congress a report on the study conducted under subsection (a), together with any recommendations for legislation that the Commission determines to be appropriate as a result of such study.”

MedPAC Study on Access to Outpatient Pain Management Services

Puspan. L. 106–554, § 1(a)(6) [title IV, § 438], Dec. 21, 2000, 114 Stat. 2763, 2763A–528, provided that:

“(a)Study.—The Medicare Payment Advisory Commission shall conduct a study on the barriers to coverage and payment for outpatient interventional pain medicine procedures under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]. Such study shall examine—

“(1) the specific barriers imposed under the medicare program on the provision of pain management procedures in hospital outpatient departments, ambulatory surgery centers, and physicians’ offices; and

“(2) the consistency of medicare payment policies for pain management procedures in those different settings.

“(span)Report.—Not later than 1 year after the date of the enactment of this Act [Dec. 21, 2000], the Commission shall submit to Congress a report on the study.”

Establishment of Coding and Payment Procedures for New Clinical Diagnostic Laboratory Tests and Other Items on a Fee Schedule

Puspan. L. 106–554, § 1(a)(6) [title V, § 531(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–547, provided that: “Not later than 1 year after the date of the enactment of this Act [Dec. 21, 2000], the Secretary of Health and Human Services shall establish procedures for coding and payment determinations for the categories of new clinical diagnostic laboratory tests and new durable medical equipment under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] that permit public consultation in a manner consistent with the procedures established for implementing coding modifications for ICD–9–CM.”

Report on Procedures Used for Advanced, Improved Technologies

Puspan. L. 106–554, § 1(a)(6) [title V, § 531(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–547, provided that: “Not later than 1 year after the date of the enactment of this Act [Dec. 21, 2000], the Secretary of Health and Human Services shall submit to Congress a report that identifies the specific procedures used by the Secretary under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] to adjust payments for clinical diagnostic laboratory tests and durable medical equipment which are classified to existing codes where, because of an advance in technology with respect to the test or equipment, there has been a significant increase or decrease in the resources used in the test or in the manufacture of the equipment, and there has been a significant improvement in the performance of the test or equipment. The report shall include such recommendations for changes in law as may be necessary to assure fair and appropriate payment levels under such part for such improved tests and equipment as reflects increased costs necessary to produce improved results.”

Congressional Intention Regarding Base Amounts in Applying HOPD PPS

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(l)], Nov. 29, 1999, 113 Stat. 1536, 1501A–341, provided that: “With respect to determining the amount of copayments described in paragraph (3)(A)(ii) of section 1833(t) of the Social Security Act [42 U.S.C. 1395l(t)(3)(A)(ii)], as added by section 4523(a) of BBA [the Balanced Budget Act of 1997, Puspan. L. 105–33], Congress finds that such amount should be determined without regard to such section, in a budget neutral manner with respect to aggregate payments to hospitals, and that the Secretary of Health and Human Services has the authority to determine such amount without regard to such section.”

Study and Report to Congress Regarding Special Treatment of Rural and Cancer Hospitals in Prospective Payment System for Hospital Outpatient Department Services

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 203], Nov. 29, 1999, 113 Stat. 1536, 1501A–344, provided that:

“(a)Study.—

“(1)In general.—The Medicare Payment Advisory Commission (referred to in this section as ‘MedPAC’) shall conduct a study to determine the appropriateness (and the appropriate method) of providing payments to hospitals described in paragraph (2) for covered OPD services (as defined in paragraph (1)(B) of section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t))) based on the prospective payment system established by the Secretary in accordance with such section.

“(2)Hospitals described.—The hospitals described in this paragraph are the following:

“(A) A medicare-dependent, small rural hospital (as defined in section 1886(d)(5)(G)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)(iv))).

“(B) A sole community hospital (as defined in section 1886(d)(5)(D)(iii) of such Act (42 U.S.C. 1395ww(d)(5)(D)(iii))).

“(C) Rural health clinics (as defined in section 1861(aa)(2) of such Act (42 U.S.C. 1395x(aa)(2)).

“(D) Rural referral centers (as so classified under section 1886(d)(5)(C) of such Act (42 U.S.C. 1395ww(d)(5)(C)).

“(E) Any other rural hospital with not more than 100 beds.

“(F) Any other rural hospital that the Secretary determines appropriate.

“(G) A hospital described in section 1886(d)(1)(B)(v) of such Act (42 U.S.C. 1395ww(d)(1)(B)(v)).

“(span)Report.—Not later than 2 years after the date of the enactment of this Act [Nov. 29, 1999], MedPAC shall submit a report to the Secretary of Health and Human Services and Congress on the study conducted under subsection (a), together with any recommendations for legislation that MedPAC determines to be appropriate as a result of such study.

“(c)Comments.—Not later than 60 days after the date on which MedPAC submits the report under subsection (span) to the Secretary of Health and Human Services, the Secretary shall submit comments on such report to Congress.”

GAO Study on Resources Required To Provide Safe and Effective Outpatient Cancer Therapy

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 213], Nov. 29, 1999, 113 Stat. 1536, 1501A–350, provided that:

“(a)Study.—The Comptroller General of the United States shall conduct a nationwide study to determine the physician and non-physician clinical resources necessary to provide safe outpatient cancer therapy services and the appropriate payment rates for such services under the medicare program. In making such determination, the Comptroller General shall—

“(1) determine the adequacy of practice expense relative value units associated with the utilization of those clinical resources;

“(2) determine the adequacy of work units in the practice expense formula; and

“(3) assess various standards to assure the provision of safe outpatient cancer therapy services.

“(span)Report to Congress.—The Comptroller General shall submit to Congress a report on the study conducted under subsection (a). The report shall include recommendations regarding practice expense adjustments to the payment methodology under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.], including the development and inclusion of adequate work units to assure the adequacy of payment amounts for safe outpatient cancer therapy services. The study shall also include an estimate of the cost of implementing such recommendations.”

Focused Medical Reviews of Claims During Moratorium Period

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–351, as amended by Puspan. L. 106–554, § 1(a)(6) [title IV, § 421(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–516, provided that: “During years in which paragraph (4) of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)) applies, the Secretary of Health and Human Services shall conduct focused medical reviews of claims for reimbursement for services described in paragraph (1) or (3) of such section, with an emphasis on such claims for services that are provided to residents of skilled nursing facilities.”

Study and Report on Utilization

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(d)], Nov. 29, 1999, 113 Stat. 1536, 1501A–352, provided that:

“(1)Study.—

“(A)In general.—The Secretary of Health and Human Services shall conduct a study which compares—

“(i) utilization patterns (including nationwide patterns, and patterns by region, types of settings, and diagnosis or condition) of outpatient physical therapy services, outpatient occupational therapy services, and speech-language pathology services that are covered under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395) [42 U.S.C. 1395 et seq.] and provided on or after January 1, 2000; with

“(ii) such patterns for such services that were provided in 1998 and 1999.

“(B)Review of claims.—In conducting the study under this subsection the Secretary of Health and Human Services shall review a statistically significant number of claims for reimbursement for the services described in subparagraph (A).

“(2)Report.—Not later than June 30, 2001, the Secretary of Health and Human Services shall submit a report to Congress on the study conducted under paragraph (1), together with any recommendations for legislation that the Secretary determines to be appropriate as a result of such study.”

Phase-in of PPS for Ambulatory Surgical Centers

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 226], Nov. 29, 1999, 113 Stat. 1536, 1501A–354, as amended by Puspan. L. 106–554, § 1(a)(6) [title IV, § 424(span), (c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–518, 2763A–519, provided that:

“If the Secretary of Health and Human Services implements a revised prospective payment system for services of ambulatory surgical facilities under section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i)), prior to incorporating data from the 1999 Medicare cost survey or a subsequent cost survey, such system shall be implemented in a manner so that—

“(1) in the first year of its implementation, only a proportion (specified by the Secretary and not to exceed one-fourth) of the payment for such services shall be made in accordance with such system and the remainder shall be made in accordance with current regulations; and

“(2) in each of the following 2 years a proportion (specified by the Secretary and not to exceed one-half and three-fourths, respectively) of the payment for such services shall be made under such system and the remainder shall be made in accordance with current regulations.

By not later than January 1, 2003, the Secretary shall incorporate data from a 1999 medicare cost survey or a subsequent cost survey for purposes of implementing or revising such system.”

MedPAC Study on Postsurgical Recovery Care Center Services

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 229(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A–356, provided that:

“(1)In general.—The Medicare Payment Advisory Commission shall conduct a study on the cost-effectiveness and efficacy of covering under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] services of a post-surgical recovery care center (that provides an intermediate level of recovery care following surgery). In conducting such study, the Commission shall consider data on these centers gathered in demonstration projects.

“(2)Report.—Not later than 1 year after the date of the enactment of this Act [Nov. 29,1999], the Commission shall submit to Congress a report on such study and shall include in the report recommendations on the feasibility, costs, and savings of covering such services under the medicare program.”

Medicare Reimbursement for Telehealth Services

Puspan. L. 105–33, title IV, § 4206, Aug. 5, 1997, 111 Stat. 377, as amended by Puspan. L. 106–554, § 1(a)(6) [title II, § 223(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–487, provided that:

“(a)In General.—For services furnished on and after January 1, 1999, and before October 1, 2001, the Secretary of Health and Human Services shall make payments from the Federal Supplementary Medical Insurance Trust Fund under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) in accordance with the methodology described in subsection (span) for professional consultation via telecommunications systems with a physician (as defined in section 1861(r) of such Act (42 U.S.C. 1395x(r)) or a practitioner (described in section 1842(span)(18)(C) of such Act (42 U.S.C. 1395u(span)(18)(C)) furnishing a service for which payment may be made under such part to a beneficiary under the medicare program residing in a county in a rural area (as defined in section 1886(d)(2)(D) of such Act (42 U.S.C. 1395ww(d)(2)(D))) that is designated as a health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)), notwithstanding that the individual physician or practitioner providing the professional consultation is not at the same location as the physician or practitioner furnishing the service to that beneficiary.

“(span)Methodology for Determining Amount of Payments.—Taking into account the findings of the report required under section 192 of the Health Insurance Portability and Accountability Act of 1996 (Public Law 104–191; 110 Stat. 1988), the findings of the report required under paragraph (c), and any other findings related to the clinical efficacy and cost-effectiveness of telehealth applications, the Secretary shall establish a methodology for determining the amount of payments made under subsection (a) within the following parameters:

“(1) The payment shall [be] shared between the referring physician or practitioner and the consulting physician or practitioner. The amount of such payment shall not be greater than the current fee schedule of the consulting physician or practitioner for the health care services provided.

“(2) The payment shall not include any reimbursement for any telephone line charges or any facility fees, and a beneficiary may not be billed for any such charges or fees.

“(3) The payment shall be made subject to the coinsurance and deductible requirements under subsections (a)(1) and (span) of section 1833 of the Social Security Act (42 U.S.C. 1395l).

“(4) The payment differential of section 1848(a)(3) of such Act (42 U.S.C. 1395w–4(a)(3)) shall apply to services furnished by non-participating physicians. The provisions of section 1848(g) of such Act (42 U.S.C. 1395w–4(g)) and section 1842(span)(18) of such Act (42 U.S.C. 1395u(span)(18)) shall apply. Payment for such service shall be increased annually by the update factor for physicians’ services determined under section 1848(d) of such Act (42 U.S.C. 1395w–4(d)).

“(c)Supplemental Report.—Not later than January 1, 1999, the Secretary shall submit a report to Congress which shall contain a detailed analysis of—

“(1) how telemedicine and telehealth systems are expanding access to health care services;

“(2) the clinical efficacy and cost-effectiveness of telemedicine and telehealth applications;

“(3) the quality of telemedicine and telehealth services delivered; and

“(4) the reasonable cost of telecommunications charges incurred in practicing telemedicine and telehealth in rural, frontier, and underserved areas.

“(d)Expansion of Telehealth Services for Certain Medicare Beneficiaries.—

“(1)In general.—Not later than January 1, 1999, the Secretary shall submit a report to Congress that examines the possibility of making payments from the Federal Supplementary Medical Insurance Trust Fund under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) for professional consultation via telecommunications systems with such a physician or practitioner furnishing a service for which payment may be made under such part to a beneficiary described in paragraph (2), notwithstanding that the individual physician or practitioner providing the professional consultation is not at the same location as the physician or practitioner furnishing the service to that beneficiary.

“(2)Beneficiary described.—A beneficiary described in this paragraph is a beneficiary under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) who does not reside in a rural area (as so defined) that is designated as a health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)), who is homebound or nursing homebound, and for whom being transferred for health care services imposes a serious hardship.

“(3)Report.—The report described in paragraph (1) shall contain a detailed statement of the potential costs and savings to the medicare program of making the payments described in that paragraph using various reimbursement schemes.”

Report on Coverage of Outpatient Occupational Therapy Services

Puspan. L. 105–33, title IV, § 4541(d)(2), Aug. 5, 1997, 111 Stat. 457, as amended by Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(c)(1)], Nov. 29, 1999, 113 Stat. 1536, 1501A–351, provided that:

“Not later than January 1, 2001, the Secretary of Health and Human Services shall submit to Congress a report that includes recommendations on—

“(A) the establishment of a mechanism for assuring appropriate utilization of outpatient physical therapy services, outpatient occupational therapy services, and speech-language pathology services that are covered under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395) [42 U.S.C. 1395 et seq.]; and

“(B) the establishment of an alternative payment policy for such services based on classification of individuals by diagnostic category, functional status, prior use of services (in both inpatient and outpatient settings), and such other criteria as the Secretary determines appropriate, in place of the uniform dollar limitations specified in section 1833(g) of such Act [42 U.S.C. 1395l(g)], as amended by paragraph (1).

The recommendations shall include how such a mechanism or policy might be implemented in a budget-neutral manner.”

[Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(c)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–352, provided that: “The amendment made by paragraph (1) [amending section 4541(d)(2) of Puspan. L. 105–33, set out above] shall take effect as if included in the enactment of section 4541 of BBA [the Balanced Budget Act of 1997, Puspan. L. 105–33].”]

Study and Report on Clinical Laboratory Tests

Puspan. L. 105–33, title IV, § 4553(c), Aug. 5, 1997, 111 Stat. 460, required the Secretary to request the Institute of Medicine of the National Academy of Sciences to conduct a study of payments under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) for clinical laboratory tests, including a review of the adequacy of the current methodology and recommendations regarding alternative payment systems analysis and of the relationship between such payment systems and access to high quality laboratory tests for medicare beneficiaries, including availability and access to new testing methodologies, and to report to Congress the results of the study and any recommendations for legislation not later than 2 years after Aug. 5, 1997..”

Adjustments to Payment Amounts for New Technology Intraocular Lenses

Puspan. L. 103–432, title I, § 141(span), Oct. 31, 1994, 108 Stat. 4425, provided that:

“(1)Establishment of process for review of amounts.—Not later than 1 year after the date of the enactment of this Act [Oct. 31, 1994], the Secretary of Health and Human Services (in this subsection referred to as the ‘Secretary’) shall develop and implement a process under which interested parties may request review by the Secretary of the appropriateness of the reimbursement amount provided under section 1833(i)(2)(A)(iii) of the Social Security Act [42 U.S.C. 1395l(i)(2)(A)(iii)] with respect to a class of new technology intraocular lenses. For purposes of the preceding sentence, an intraocular lens may not be treated as a new technology lens unless it has been approved by the Food and Drug Administration.

“(2)Factors considered.—In determining whether to provide an adjustment of payment with respect to a particular lens under paragraph (1), the Secretary shall take into account whether use of the lens is likely to result in reduced risk of intraoperative or postoperative complication or trauma, accelerated postoperative recovery, reduced induced astigmatism, improved postoperative visual acuity, more stable postoperative vision, or other comparable clinical advantages.

“(3)Notice and comment.—The Secretary shall publish notice in the Federal Register from time to time (but no less often than once each year) of a list of the requests that the Secretary has received for review under this subsection, and shall provide for a 30-day comment period on the lenses that are the subjects of the requests contained in such notice. The Secretary shall publish a notice of the Secretary’s determinations with respect to intraocular lenses listed in the notice within 90 days after the close of the comment period.

“(4)Effective date of adjustment.—Any adjustment of a payment amount (or payment limit) made under this subsection shall become effective not later than 30 days after the date on which the notice with respect to the adjustment is published under paragraph (3).”

Study of Medicare Coverage of Patient Care Costs Associated With Clinical Trials of New Cancer Therapies

Puspan. L. 103–432, title I, § 142, Oct. 31, 1994, 108 Stat. 4426, directed Secretary of Health and Human Services to conduct a study, and to submit a report to Congress not later than 2 years after Oct. 31, 1994, of effects of expressly covering under medicare program patient care costs for beneficiaries enrolled in clinical trials of new cancer therapies, where protocol for the trial has been approved by the National Cancer Institute or met similar scientific and ethical standards, including approval by an institutional review board.

Study of Annual Cap on Amount of Medicare Payment for Outpatient Physical Therapy and Occupational Therapy Services

Puspan. L. 103–432, title I, § 143, Oct. 31, 1994, 108 Stat. 4426, directed Secretary of Health and Human Services to submit to Congress, not later than Jan. 1, 1996, study and report on appropriateness of continuing annual limitation on amount of payment for outpatient services of independently practicing physical and occupational therapists under medicare program, which was to include such recommendations for changes in such annual limitation as Secretary found appropriate.

Ambulatory Surgical Center Services; Inflation Update

Puspan. L. 103–66, title XIII, § 13531, Aug. 10, 1993, 107 Stat. 586, provided that: “The Secretary of Health and Human Services shall not provide for any inflation update in the payment amounts under subparagraphs (A) and (B) of section 1833(i)(2) of the Social Security Act [42 U.S.C. 1395l(i)(2)(A), (B)] for fiscal year 1994 or for fiscal year 1995.”

Freeze in Allowance for Intraocular Lenses

Puspan. L. 103–66, title XIII, § 13533, Aug. 10, 1993, 107 Stat. 587, provided that: “Notwithstanding section 1833(i)(2)(A)(iii) of the Social Security Act [42 U.S.C. 1395l(i)(2)(A)(iii)], the amount of payment determined under such section for an intraocular lens inserted subsequent to or during cataract surgery in an ambulatory surgical center on or after January 1, 1994, and before January 1, 1999, shall be equal to $150.”

Puspan. L. 101–508, title IV, § 4151(c)(3), Nov. 5, 1990, 104 Stat. 1388–73, as amended by Puspan. L. 103–432, title I, § 141(d), Oct. 31, 1994, 108 Stat. 4426, provided that: “Notwithstanding section 1833(i)(2)(A)(iii) of the Social Security Act [42 U.S.C. 1395l(i)(2)(A)(iii)], the amount of payment determined under such section for an intraocular lens inserted during or subsequent to cataract surgery furnished to an individual in an ambulatory surgical center on or after the date of the enactment of this Act [Nov. 5, 1990] and on or before December 31, 1992, shall be equal to $200.”

[Puspan. L. 103–432, title I, § 141(d), Oct. 31, 1994, 108 Stat. 4426, provided that the amendment made by that section to section 4151(c)(3) of Puspan. L. 101–508, set out above, is effective as if included in the enactment of Puspan. L. 101–508.]

Reduction in Payments Under Part B During Final Two Months of 1990

Puspan. L. 101–508, title IV, § 4158, Nov. 5, 1990, 104 Stat. 1388–89, provided that:

“(a)In General.—Notwithstanding any other provision of law (including any other provision of this Act, other than subsection (span)(4)), payments under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for items and services furnished during the period beginning on November 1, 1990, and ending on December 31, 1990, shall be reduced by 2 percent, in accordance with subsection (span).

“(span)Special Rules for Application of Reduction.—

“(1)Payment on the basis of cost reporting periods.—In the case in which payment for services of a provider of services is made under part B of such title on a basis relating to the reasonable cost incurred for the services during a cost reporting period of the provider, the reduction made under subsection (a) shall be applied to payment for costs for such services incurred at any time during each cost reporting period of the provider any part of which occurs during the period described in such subsection, but only in the same proportion as the fraction of the cost reporting period that occurs during such period.

“(2)No increase in beneficiary charges in assignment-related cases.—If a reduction in payment amounts is made under subsection (a) for items or services for which payment under part B of such title is made on an assignment-related basis (as defined in section 1842(i)(1) of the Social Security Act [42 U.S.C. 1395u(i)(1)]), the person furnishing the items or services shall be considered to have accepted payment of the reasonable charge for the items or services, less any reduction in payment amount made under subsection (a), as payment in full.

“(3)Treatment of payments to health maintenance organizations.—Subsection (a) shall not apply to payments under risk-sharing contracts under section 1876 of the Social Security Act [42 U.S.C. 1395mm] or under similar contracts under section 402 of the Social Security Amendments of 1967 [Puspan. L. 90–248, enacting section 1395span–1 of this title and amending section 1395ll of this title] or section 222 of the Social Security Amendments of 1972 [Puspan. L. 92–603, amending sections 1395span–1 and 1395ll of this title and enacting provisions set out as a note under section 1395span–1 of this title].”

Effect on State Law

Conscientious objections of health care provider under State law unaffected by enactment of subsecs. (a)(1)(Q) and (f) of this section, see section 4206(c) of Puspan. L. 101–508, set out as a note under section 1395cc of this title.

Development of Criteria Regarding Consultation With a Physician

Puspan. L. 101–239, title VI, § 6113(c), Dec. 19, 1989, 103 Stat. 2217, as amended by Puspan. L. 103–432, title I, § 147(span), Oct. 31, 1994, 108 Stat. 4429, provided that: “The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for qualified psychologist services and clinical social worker services for which payment may be made directly to the psychologist or clinical social worker under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] under which such a psychologist or clinical social worker must agree to consult with a patient’s attending physician in accordance with such criteria.”

[Puspan. L. 103–432, title I, § 147(span), Oct. 31, 1994, 108 Stat. 4429, provided that the amendment made by that section to section 6113(c) of Puspan. L. 101–239, set out above, is effective with respect to services furnished on or after Jan. 1, 1991.]

Study of Reimbursement for Ambulance Services

Puspan. L. 101–239, title VI, § 6136, Dec. 19, 1989, 103 Stat. 2222, directed Secretary of Health and Human Services to conduct a study to determine adequacy and appropriateness of payment amounts under this subchapter for ambulance services and, not later than one year after Dec. 19, 1989, submit a report to Congress on results of the study, with report to include such recommendations for changes in medicare payment policy with respect to ambulance services as may be needed to ensure access by medicare beneficiaries to quality ambulance services in metropolitan and rural areas.

PROPAC Study of Payments for Services in Hospital Outpatient Departments

Puspan. L. 101–239, title VI, § 6137, Dec. 19, 1989, 103 Stat. 2223, directed Prospective Payment Assessment Commission to conduct a study on payment under this subchapter for hospital outpatient services and, not later than July 1, 1990, and not later than Mar. 1, 1991, to submit reports to Congress on specified portions of the study, with the reports to include such recommendations as the Commission deemed appropriate, prior to repeal by Puspan. L. 103–432, title I, § 147(c)(1), Oct. 31, 1994, 108 Stat. 4429.

Budget Neutrality

Puspan. L. 100–647, title VIII, § 8421(span), Nov. 10, 1988, 102 Stat. 3802, provided that: “The Secretary of Health and Human Services shall adjust the fees for transportation and personnel established under section 1833(h)(3)(B) of the Social Security Act [42 U.S.C. 1395l(h)(3)(B)] for tests not covered under the amendment made by subsection (a) [amending this section] in such manner that the total cost of fees under such section is the same as would have been the case without such amendment.”

Adjustment of Contracts With Prepaid Health Plans

For requirement that Secretary of Health and Human Services modify contracts under subsection (a)(1)(A) of this section to take into account amendments made by Puspan. L. 100–360 and that such organizations make appropriate adjustments in their agreements with medicare beneficiaries to take into account such amendments, see section 222 of Puspan. L. 100–360, set out as a note under section 1395mm of this title.

Study and Report to Congress Respecting Incentive Payments for Physicians’ Services Furnished in Underserved Areas

Puspan. L. 100–203, title IV, § 4043(span), Dec. 22, 1987, 101 Stat. 1330–86, directed Secretary of Health and Human Services to study and report to Congress, by not later than Jan. 1, 1990, on feasibility of making additional payments described in section 1395l(m) of this title with respect to physician services performed in health manpower shortage areas located in urban areas, prior to repeal by Puspan. L. 101–508, title IV, § 4118(g)(1), Nov. 5, 1990, 104 Stat. 1388–70.

Fee Schedules for Physician Pathology Services

Puspan. L. 100–203, title IV, § 4050, Dec. 22, 1987, 101 Stat. 1330–92, directed Secretary of Health and Human Services to develop a relative value scale and fee schedules with updating index for payment of physician pathology services under this part, and to report to committees of Congress not later than Apr. 1, 1989, on the scale, schedules, and index, prior to repeal by Puspan. L. 101–508, title IV, § 4104(span)(3), Nov. 5, 1990, 104 Stat. 1388–59.

Applying Copayment and Deductible to Certain Outpatient Physicians’ Services

Puspan. L. 100–203, title IV, § 4054, Dec. 22, 1987, 101 Stat. 1330–98, relating to payment under part B of title XVIII of the Social Security Act (this part) for physicians’ services specified in subsec. (i) of this section and furnished on or after Apr. 1, 1988, in an ambulatory surgical center or hospital outpatient department on an assignment-related basis, was negated in the amendment of section 4054 by Puspan. L. 100–360, title IV, § 411(f)(12)(A), July 1, 1988, 102 Stat. 781.

Other Physician Payment Studies

Puspan. L. 100–203, title IV, § 4056(c), formerly § 4055(c), Dec. 22, 1987, 101 Stat. 1330–99, as renumbered by Puspan. L. 100–360, title IV, § 411(f)(14), July 1, 1988, 102 Stat. 781, provided directed Secretary to (1) conduct a study of changes in the payment system for physicians’ services, under part B, that would be required for the implementation of a national fee schedule for such services furnished on or after Jan. 1, 1990, and report to Congress on such study by not later than July 1, 1989, (2) conduct a study of issues relating to the volume and intensity of physicians’ services under part B and submit to Congress an interim report on such study not later than May 1, 1988, and a final report on such study not later than May 1, 1989, and (3) conduct a survey to determine distribution of (A) the liabilities and expenditures for health care services of individuals entitled to benefits under this subchapter, including liabilities for charges (not paid on an assignment-related basis) in excess of the reasonable charge recognized, and (B) the collection rates among different classes of physicians for such liabilities, including collection rates for required coinsurance and for charges (not paid on an assignment-related basis) in excess of the reasonable charge recognized, report to Congress on such study by not later than July 1, 1990.

Study of Payment for Chemotherapy in Physicians’ Offices

Puspan. L. 100–203, title IV, § 4056(d), formerly § 4055(d), Dec. 22, 1987, 101 Stat. 1330–99, as renumbered by Puspan. L. 100–360, title IV, § 411(f)(14), July 1, 1988, 102 Stat. 781, directed Secretary to study ways of modifying part B to permit adequate payment under such part for costs associated with providing chemotherapy to cancer patients in physicians’ offices, with the Secretary to report to Congress on results of study by not later than Apr. 1, 1989, prior to repeal by Puspan. L. 105–362, title VI, § 601(span)(7), Nov. 10, 1998, 112 Stat. 3286.

Clinical Diagnostic Laboratory Tests; Limitation on Changes in Fee Schedules

Puspan. L. 100–203, title IV, § 4064(a), Dec. 22, 1987, 101 Stat. 1330–110, which provided 3-month freeze in fee schedules for clinical laboratory diagnostic laboratory tests under part B of title XVIII of the Social Security Act (this part) and directed the Secretary of Health and Human Services to not adjust the fee schedules established under subsec. (h) of this section to take into account any increase in the consumer price index, was negated in the amendment of section 4064(a) by Puspan. L. 100–360, title IV, § 411(g)(3)(A), July 1, 1988, 102 Stat. 783.

GAO Study of Fee Schedules

Puspan. L. 100–203, title IV, § 4064(span)(4), Dec. 22, 1987, 101 Stat. 1330–110, directed Comptroller General to conduct a study of level of fee schedules established for clinical diagnostic laboratory services under subsec. (h)(2) of this section to determine, based on costs of, and revenues received for, such tests the appropriateness of such schedules, with Comptroller General to report to Congress on results of such study by not later than Jan. 1, 1990, and with provision that suppliers of such tests which fail to provide Comptroller General with reasonable access to necessary records to carry out study being subject to exclusion from the medicare program under section 1320a–7(a) of this title.

Amounts Paid for Independent Rural Health Clinic Services

Puspan. L. 100–203, title IV, § 4067(span), Dec. 22, 1987, 101 Stat. 1330–113, provided that: “The Secretary of Health and Human Services shall report to Congress, by not later than March 1, 1989, on the adequacy of the amounts paid under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for rural health clinic services provided by independent rural health clinics.”

Report on Establishment of National Fee Schedules for Payment of Clinical Diagnostic Laboratory Tests

Puspan. L. 99–509, title IX, § 9339(span)(3), Oct. 21, 1986, 100 Stat. 2036, directed Secretary of Health and Human Services to report to Congress, by not later than Apr. 1, 1988, on advisability and feasibility of, and methodology for, establishing national fee schedules for payment for clinical diagnostic laboratory tests under section 1395l(h) of this title, prior to repeal by Puspan. L. 101–508, title IV, § 4154(e)(3), Nov. 5, 1990, 104 Stat. 1388–86, effective as if included in enactment of Puspan. L. 99–509.

State Standards for Directors of Clinical Laboratories

Puspan. L. 99–509, title IX, § 9339(d), Oct. 21, 1986, 100 Stat. 2037, provided that:

“(1)In general.—If a State (as defined for purposes of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]) provides for the licensing or other standards with respect to the operation of clinical laboratories (including such laboratories in hospitals) in the State under which such a laboratory may be directed by an individual with certain qualifications, nothing in such title shall be construed as authorizing the Secretary of Health and Human Services to require such a laboratory, as a condition of payment or participation under such title, to be directed by an individual with other qualifications.

“(2)Effective date.—Paragraph (1) shall take effect on January 1, 1987.”

Transitional Provisions for Payment of Fees for Clinical Diagnostic Laboratory Tests

Puspan. L. 99–272, title IX, § 9303(a)(3), Apr. 7, 1986, 100 Stat. 188, provided that: “The Secretary of Health and Human Services shall provide that the annual adjustment under section 1833(h) of the Social Security Act [42 U.S.C. 1395l(h)] for 1986—

“(A) shall take effect on January 1, 1987,

“(B) shall apply for the 12-month period beginning on that date, and

“(C) shall take into account the percentage increase or decrease in the Consumer Price Index for all urban consumers (United States city average) occurring over an 18-month period, rather than over a 12-month period.”

Extension of Medicare Physician Payment Provisions

Amount of payment under this part for physicians’ services furnished between Oct. 1, 1985, and Mar. 14, 1986, to be determined on the same basis as the amount of such services furnished on Sept. 30, 1985, see section 5(span) of Puspan. L. 99–107, as amended, set out as a note under section 1395ww of this title.

Fee Schedules for Diagnostic Laboratory Tests and Feasibility of Direct Payments to Physicians; Report to Congress

Puspan. L. 98–369, div. B, title III, § 2303(i), July 18, 1984, 98 Stat. 1066, provided that:

“(1) The Comptroller General shall report to the Congress on—

“(A) the appropriateness of the fee schedules under section 1833(h) of the Social Security Act [42 U.S.C. 1395l(h)] and their impact on the volume and quality of clinical diagnostic laboratory tests;

“(B) the potential impact of the adoption of a national fee schedule; and

“(C) the potential impact of applying a national fee schedule to clinical diagnostic laboratory tests provided by hospitals to their outpatients.

“(2) The Secretary of Health and Human Services shall report to the Congress with respect to the advisability and feasibility of a system of direct payment to any physician for all clinical diagnostic laboratory tests ordered by such physician.

“(3) The reports required by paragraphs (1) and (2) shall be submitted not later than January 1, 1987.”

Pacemaker Reimbursement Review and Reform

Puspan. L. 98–369, div. B, title III, § 2304(a), July 18, 1984, 98 Stat. 1067, provided that:

“(1) The Secretary of Health and Human Services shall issue revisions to the current guidelines for the payment under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for the transtelephonic monitoring of cardiac pacemakers. Such revised guidelines shall include provisions regarding the specifications for and frequency of transtelephonic monitoring procedures which will be found to be reasonable and necessary.

“(2)

(A) Except as provided in subparagraph (B), if the guidelines required by paragraph (1) have not been issued and put into effect by October 1, 1984, and until such guidelines have been issued and put into effect, payment may not be made under part B of title XVIII of the Social Security Act for transtelephonic monitoring procedures, with respect to a single-chamber cardiac pacemaker powered by lithium batteries, conducted more frequently than—

“(i) weekly during the first month after implantation,

“(ii) once every two months during the period representing 80 percent of the estimated life of the implanted device, and

“(iii) monthly thereafter.

“(B) Subparagraph (A) shall not apply in cases where the Secretary determines that special medical factors (including possible evidence of pacemaker or lead malfunction) justify more frequent transtelephonic monitoring procedures.”

Payment for Preadmission Diagnostic Testing Performed in Physician’s Office

Puspan. L. 98–369, div. B, title III, § 2305(f), July 18, 1984, 98 Stat. 1070, provided that: “The amendments made by this section [amending this section and enacting provisions set out above] shall not be construed as prohibiting payment, subject to the applicable copayments, under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for preadmission diagnostic testing performed in a physician’s office to the extent such testing is otherwise reimbursable under regulations of the Secretary.”

Providers of Services To Calculate and Report Lesser-of-Cost-or-Charges Determinations Separately With Respect to Payments Under Parts A and B of This Subchapter; Issuance of Regulations

For provision directing the Secretary to issue regulations requiring providers of services to calculate and report the lesser-of-cost-or-charges determinations separately with respect to payments for services under parts A and B of this subchapter other than diagnostic tests under subsec. (h) of this section, see section 2308(a) of Puspan. L. 98–369, set out as a note under section 1395f of this title.

Determination of Nominal Charges for Applying Nominality Test

For provision directing the Secretary to provide, in addition to other rules deemed appropriate, that charges representing 60 percent or less of costs be considered nominal for purposes of applying the nominality test under subsec. (a)(2)(B)(ii) of this section, see section 2308(span)(1) of Puspan. L. 98–369, set out as a note under section 1395f of this title.

Study of Medicare Part B Payments; Compilation of Centralized Charge Data Base; Report to Congress

Puspan. L. 98–369, div. B, title III, § 2309, July 18, 1984, 98 Stat. 1074, directed Director of Office of Technology Assessment to conduct a study of physician reimbursement under the Medicare program and make a report not later than Dec. 31, 1985, covering findings and recommendations on methods by which payment amounts and other program policies under the program might be modified, and directed that Secretary of Health and Human Services compile a centralized Medicare part B charge data base to aid in the study.

Monitoring Provision of Hepatitis B Vaccine; Review of Changes in Medical Technology

Puspan. L. 98–369, div. B, title III, § 2323(e), July 18, 1984, 98 Stat. 1086, provided that: “The Secretary shall monitor the provision of hepatitis B vaccine under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.], and shall review any changes in medical technology which may have an effect on the amounts which should be paid for such service.”

Report on Preadmission Diagnostic Testing Expenses

Puspan. L. 96–499, title IX, § 932(span), Dec. 5, 1980, 94 Stat. 2635, required a report to Congress, no later than one year after Dec. 5, 1980, on the policy respecting expenses incurred for preadmission diagnostic testing furnished to an individual at a hospital within seven days of an individual’s admission to another hospital.

Study of Feasibility and Desirability of Imposing Copayment Requirement on Rural Health Clinic Visits; Report Not Later Than December 13, 1978

Puspan. L. 95–210, § 1(c), Dec. 13, 1977, 91 Stat. 1485, directed Secretary of Health, Education, and Welfare to conduct a study of the feasibility and desirability of imposing a copayment for each visit to a rural health clinic for rural health clinic services under this part and that Secretary report to appropriate committee of Congress, not later than one year after Dec. 13, 1977, on such study.

Prohibition Against Payments in Cases of Nonentitlement to Monthly Benefits Under Subchapter II or Suspension of Benefits of Aliens Outside the United States

Puspan. L. 89–97, title I, § 104(span)(1), July 30, 1965, 79 Stat. 334, provided that: “No payments shall be made under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] with respect to expenses incurred by an individual during any month for which such individual may not be paid monthly benefits under title II of such Act [42 U.S.C. 401 et seq.] (or for which such monthly benefits would be suspended if he were otherwise entitled thereto) by reason of section 202(t) of such Act [42 U.S.C. 402(t)] (relating to suspension of benefits of aliens who are outside the United States).”