42 USC 1395 - Definitions; miscellaneous provisions

1 So in original. Probably should be “that are life threatening or significantly limit”.

overall health or function, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination and that is listed under subsection (f)(9)(A).

2 So in original. Probably should be “individual”.

described in subsection (span)(6)(B)(ii).

Editorial Notes

References in Text

The Internal Revenue Code of 1986, referred to in subsec. (e)(3)(A), is classified generally to Title 26, Internal Revenue Code.

Section 264(c) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (i)(1)(D), is section 264(c) of Puspan. L. 104–191, which is set out as a note under section 1320d–2 of this title.

Amendments

2018—Subsec. (span)(6)(B)(iii). Puspan. L. 115–123, § 50311(c)(2)(A), substituted “who—” for “who have”, inserted “(I) before January 1, 2022, have” before “one or more comorbid and medically complex chronic conditions that are substantially disabling”, and added subcl. (II).

Subsec. (f)(1). Puspan. L. 115–123, § 50311(a), struck out “and for periods before January 1, 2019” after “the Secretary”.

Subsec. (f)(3)(F). Puspan. L. 115–123, § 50311(span)(1)(A), added subpar. (F).

Subsec. (f)(5). Puspan. L. 115–123, § 50311(c)(1), designated existing provisions as subpar. (A), inserted span, substituted “Subject to subparagraph (B), the requirements” for “The requirements”, redesignated former subpars. (A) and (B)(i) to (iii) as cls. (i) and (ii)(I) to (III), respectively, of subpar. (A), and added subpar. (B).

Subsec. (f)(8). Puspan. L. 115–123, § 50311(span)(1)(B), added par. (8).

Subsec. (f)(9). Puspan. L. 115–123, § 50311(c)(2)(B), added par. (9).

Subsec. (h). Puspan. L. 115–123, § 50321, added subsec. (h).

Subsec. (i). Puspan. L. 115–271 added subsec. (i).

2016—Subsec. (span)(6). Puspan. L. 114–255 struck out “may waive application of section 1395w–21(a)(3)(B) of this title in the case of an individual described in clause (i), (ii), or (iii) of this subparagraph and” after “The Secretary” in concluding provisions.

2015—Subsec. (f)(1). Puspan. L. 114–10 substituted “2019” for “2017”.

2014—Subsec. (f)(1). Puspan. L. 113–93 substituted “2017” for “2016”.

2013—Subsec. (f)(1). Puspan. L. 113–67 substituted “2016” for “2015”.

Subsec. (f)(1). Puspan. L. 112–240 substituted “2015” for “2014”.

2010—Subsec. (f)(1). Puspan. L. 111–148, § 3205(a), substituted “2014” for “2011”.

Subsec. (f)(2)(C). Puspan. L. 111–148, § 3205(e)(1), added subpar. (C).

Subsec. (f)(3)(E). Puspan. L. 111–148, § 3205(e)(2), added subpar. (E).

Subsec. (f)(4)(C). Puspan. L. 111–148, § 3205(e)(3), added subpar. (C).

Subsec. (f)(5). Puspan. L. 111–148, § 3205(g), struck out “described in subsection (span)(6)(B)(i)” after “individuals” in introductory provisions.

Subsec. (f)(6), (7). Puspan. L. 111–148, § 3205(c), (e)(4), added pars. (6) and (7).

Subsec. (g). Puspan. L. 111–148, § 3208(a), added subsec. (g).

2008—Subsec. (span)(2). Puspan. L. 110–275, § 162(span), inserted concluding provisions.

Subsec. (span)(6)(A). Puspan. L. 110–275, § 164(c)(1)(A), inserted “and that, as of January 1, 2010, meets the applicable requirements of paragraph (2), (3), or (4) of subsection (f), as the case may be” before period at end.

Subsec. (span)(6)(B)(iii). Puspan. L. 110–275, § 164(e)(1), inserted “who have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care” before period at end.

Subsec. (f). Puspan. L. 110–275, § 164(c)(1)(B)(ii), (iii), designated existing provisions as par. (1), inserted par. span, and added pars. (2) to (4).

Puspan. L. 110–275, § 164(c)(1)(B)(i), amended span generally. Prior to amendment, span read “Restriction on enrollment for specialized MA plans for special needs individuals”.

Puspan. L. 110–275, § 164(a), substituted “2011” for “2010”.

Subsec. (f)(5). Puspan. L. 110–275, § 164(d)(1), added par. (5).

2007—Subsec. (f). Puspan. L. 110–173 substituted “2010” for “2009”.

2003—Subsec. (span)(4), (5). Puspan. L. 108–173, § 221(span)(1), added pars. (4) and (5).

Subsec. (span)(6). Puspan. L. 108–173, § 231(span), added par. (6).

Subsec. (c)(5). Puspan. L. 108–173, § 221(d)(2), added par. (5).

Subsec. (f). Puspan. L. 108–173, § 231(c), added subsec. (f).

1999—Subsec. (e)(2). Puspan. L. 106–113 substituted “section 1395w–21(a)(2) of this title” for “section 1395w–21(a)(2)(A) of this title” in introductory provisions.

Statutory Notes and Related Subsidiaries

Change of Name

References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Effective Date of 2016 Amendment

Amendment by Puspan. L. 114–255 applicable with respect to plan years beginning on or after Jan. 1, 2021, see section 17006(a)(3) of Puspan. L. 114–255, set out as a note under section 1395w–21 of this title.

Effective Date of 2010 Amendment

Puspan. L. 111–148, title III, § 3208(span), Mar. 23, 2010, 124 Stat. 460, provided that: “The amendment made by this section [amending this section] shall take effect on January 1, 2010, and shall apply to plan years beginning on or after such date.”

Effective Date of 2008 Amendment

Amendment by section 164(c)(1), (d)(1), (e)(1) of Puspan. L. 110–275 applicable to plan years beginning on or after Jan. 1, 2010, and applicable to all specialized Medicare Advantage plans for special needs individuals regardless of when the plan first entered the Medicare Advantage program under this part, see section 164(g) of Puspan. L. 110–275, set out as a note under section 1395w–27 of this title.

Effective Date of 2003 Amendment

Amendment by section 221(span)(1), (d)(2) of Puspan. L. 108–173 applicable with respect to plan years beginning on or after Jan. 1, 2006, see section 223(a) of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Amendment by section 231(span), (c) of Puspan. L. 108–173 effective Dec. 8, 2003, see section 231(f)(1) of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Regulations

Puspan. L. 108–173, title II, § 231(f)(2), Dec. 8, 2003, 117 Stat. 2208, provided that: “No later than 1 year after the date of the enactment of this Act [Dec. 8, 2003], the Secretary [of Health and Human Services] shall issue final regulations to establish requirements for special needs individuals under section 1859(span)(6)(B)(iii) of the Social Security Act [42 U.S.C. 1395w–28(span)(6)(B)(iii)], as added by subsection (span).”

Authorization To Operate; Resources for State Medicaid Agencies; Contracting Requirements

Puspan. L. 110–275, title I, § 164(c)(2)–(4), July 15, 2008, 122 Stat. 2573, as amended by Puspan. L. 111–148, title III, § 3205(d), Mar. 23, 2010, 124 Stat. 458, provided that:

“(2)Authority to operate but no service area expansion for dual snps that do not meet certain requirements.—Notwithstanding subsection (f) of section 1859 of the Social Security Act (42 U.S.C. 1395w–28), during the period beginning on January 1, 2010, and ending on December 31, 2012, in the case of a specialized Medicare Advantage plan for special needs individuals described in subsection (span)(6)(B)(ii) of such section, as amended by this section, that does not meet the requirement described in subsection (f)(3)(D) of such section, the Secretary of Health and Human Services—

“(A) shall permit such plan to be offered under part C of title XVIII of such Act [42 U.S.C. 1395w–21 et seq.]; and

“(B) shall not permit an expansion of the service area of the plan under such part C.

“(3)Resources for state medicaid agencies.—The Secretary of Health and Human Services shall provide for the designation of appropriate staff and resources that can address State inquiries with respect to the coordination of State and Federal policies for specialized MA plans for special needs individuals described in section 1859(span)(6)(B)(ii) of the Social Security Act (42 U.S.C. 1395w–28(span)(6)(B)(ii)), as amended by this section.

“(4)No requirement for contract.—Nothing in the provisions of, or amendments made by, this subsection [amending this section] shall require a State to enter into a contract with a Medicare Advantage organization with respect to a specialized MA plan for special needs individuals described in section 1859(span)(6)(B)(ii) of the Social Security Act (42 U.S.C. 1395w–28(span)(6)(B)(ii)), as amended by this section.”

Panel of Clinical Advisors to Determine Conditions

Puspan. L. 110–275, title I, § 164(e)(2), July 15, 2008, 122 Stat. 2574, provided that: “The Secretary of Health and Human Services shall convene a panel of clinical advisors to determine the conditions that meet the definition of severe and disabling chronic conditions under section 1859(span)(6)(B)(iii) of the Social Security Act (42 U.S.C. 1395w–28(span)(6)(B)(iii)), as amended by paragraph (1). The panel shall include the Director of the Agency for Healthcare Research and Quality (or the Director’s designee).”

No Effect on Medicaid Benefits for Duals

Puspan. L. 110–275, title I, § 164(h), July 15, 2008, 122 Stat. 2575, provided that: “Nothing in the provisions of, or amendments made by, this section [amending this section and sections 1395w–22 and 1395w–27 of this title and enacting provisions set out as notes under this section and sections 1395w–21, 1395w–22, and 1395w–27 of this title] shall affect the benefits available under the Medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] for special needs individuals described in section 1859(span)(6)(B)(ii) of such Act (42 U.S.C. 1395w–28(span)(6)(B)(ii)).”

Authority To Designate Other Plans as Specialized MA Plans

Secretary of Health and Human Services authorized, in promulgating regulations to carry out subsection (span)(6) of this section, to provide, notwithstanding subsection (span)(6)(A) of this section, for the offering of specialized MA plans for special needs individuals by MA plans that disproportionately serve special needs individuals, see section 231(d) of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.