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NOTES:
Source
(Aug. 14, 1935, ch. 531, title XVIII, § 1842, as added , title I, § 102(a), July 30, 1965, ; amended , title I, §§ 125(a),
154
(d), Jan. 2, 1968, , 863; , title II, §§ 211(c)(3),
,
,
,
,
,
,
, Oct. 30, 1972, , 1395, 1407, 1414, 1447–1449, 1455; , title III, § 307, Oct. 16, 1974, ; , title I, § 101(a), Dec. 31, 1975, ; , §§ 2,
, (b), July 16, 1976, ; , § 2(a)(1), Oct. 25, 1977, ; , title V, § 501(b), Dec. 20, 1977, ; , title IX, §§ 918(a)(1),
946
(a), (b),
948
(b), Dec. 5, 1980, , 2642, 2643; , title XXI, § 2142(b), Aug. 13, 1981, ; , title I, §§ 104(a),
,
128
(d)(1), Sept. 3, 1982, , 340, 367; , div. B, title III, §§ 2303(e),
, (b)(1), (c),
, (2),
, (d)(2),
2339,
2354
(b)(13), (14), title VI, 2663(j)(2)(F)(iv), July 18, 1984, , 1070, 1071, 1073, 1087, 1088, 1093, 1101, 1170; , § 3(a)(1), (b)(5), (6), Nov. 8, 1984, , 3296; , title IX, §§ 9219(b)(1)(A), (2)(A),
, (2), (c)(2)–(4), (d)(1)–(3), 9304(a), 9306(a), 9307(c), Apr. 7, 1986, , 190, 193, 194; , title IX, §§ 9307(c)(2)(A),
,
9320
(e)(3),
9331
(a)(1)–(3), (b)(1)–(3), (c)(3)(A), 9332(a)(1), (b)(1), (2), (c)(1), (d)(1), 9333(a), (b), 9334(a), 9338(b), (c), 9341(a)(2), Oct. 21, 1986, , 1998, 2015, 2018–2026, 2028, 2035, 2038; , title XVIII, § 1895(b)(14)(A), (15), (16)(A), Oct. 22, 1986, ; , § 8(c)(2), Aug. 18, 1987, ; , title IV, §§ 4031(a)(2),
4035
(a)(2),
, (3)(A),
4042
(a), (b)(1), (2)(A), (c),
4044
(a),
4045
(a), (c)(1), (2)(B), (D),
4046
(a),
4047
(a),
4048
(a), (e),
,
, formerly 4052(a), 4054(a), formerly 4053(a), 4063(a), 4081(a), 4082(c), 4085(g)(1), (i)(5)–(7), (22)(C), (24)–(27), 4096(a)(1), Dec. 22, 1987, , 1330–78, 1330–83 to 1330–89, 1330–93, 1330–97, 1330–109, 1330–126, 1330–128, 1330–131, 1330–132, 1330–139, as amended , title IV, § 411(f)(1)(A), (2)(C), (D), (F), (3)(A), (4)(B), (7)(B), (11)(A), (14), (g)(2)(C), (i)(2), (4)(C)(vi), (j)(4)(A), July 1, 1988, , 781, 783, 788, 789, 791; , title II, §§ 201(c),
, (e)(1)–(3)(A), (C), (4)(A), (5), (g), 223(b), (c), title IV, § 411(a)(3)(A), (C)(i), (f)(1)(B), (2)(A), (B), (E), (3)(B), (4)(A), (C), (5), (6)(B), (7)(A), (9), (g)(2)(A), (B), (i)(1)(A), July 1, 1988, , 713, 716–718, 747, 768, 776–780, 783, 787; , title VI, § 608(d)(5)(A)–(D), (F)–(H), (17), (21)(A), (B), (D), (24)(B), Oct. 13, 1988, , 2418, 2420, 2421; , title II, § 201(a), title III, § 301(b)(2), (6), (c)(2), (d)(3), Dec. 13, 1989, , 1985, 1986; , title VI, §§ 6003(g)(3)(D)(ix),
, (e)(2)–(4), (9), 6104, 6106(a), 6107(b), 6108(a)(1), (b)(1), (2), 6114(b), (c), 6202(d)(2), Dec. 19, 1989, , 2184, 2187, 2188, 2208, 2210, 2212, 2213, 2218, 2234; , title IV, §§ 4101(a), (b)(1),
,
, (2), (b)(1),
, (b)(2),
4108
(a),
4110
(a),
4118
(a)(1), (2), (f)(2)(A)–(C), (i)(1), (j)(2), 4155(c), Nov. 5, 1990, , 1388–58 to 1388–63, 1388–66, 1388–67, 1388–69 to 1388–71, 1388–87; , title IV, § 401(c)(2), Nov. 16, 1990, ; , title XIII, §§ 13515(a)(2),
13516
(a)(2),
13517
(b),
13568
(a), (b), Aug. 10, 1993, , 608; , title I, §§ 123(b)(1), (2)(B), (c),
, (b)(1),
126
(a)(1), (c), (e), (g)(9), (h)(2),
,
151
(b)(1)(B), (2)(B), Oct. 31, 1994, , 4423, 4434; , title II, §§ 202(b)(2),
, Aug. 21, 1996, , 2011; , title IV, §§ 4201(c)(1),
4205
(d)(3)(B),
,
4315
(a),
4316
(a),
4317
(a), (b),
, (4),
, (c),
,
4556
(a),
,
4611
(d), Aug. 5, 1997, , 377, 382, 390, 392, 421, 444, 450, 462, 471, 473; , div. B, § 1000(a)(6) [title II, § 223(c), title III, §§ 305(a),
321
(k)(4)], Nov. 29, 1999, , 1501A–353, 1501A–361, 1501A–366; , § 1(a)(6) [title I, §§ 105(d),
, title II, § 222(a), title III, § 313(b)(1), (2), title IV, § 432(b)(2)], Dec. 21, 2000, , 2763A–472, 2763A–473, 2763A–487, 2763A–499, 2763A–526.)
References in Text
Part A of this subchapter, referred to in subsecs. (a) and (b)(2)(E), is classified to section
et seq. of this title.
Section
of this title, referred to in subsec. (b)(2)(A), was repealed by , title IV, § 4022(b)(2)(A), Aug. 5, 1997, .
Section 4611 of the Balanced Budget Act of 1997, referred to in subsec. (b)(2)(E), is section 4611 of , which amended this section and sections
,
and
of this title.
The Omnibus Budget Reconciliation Act of 1990, referred to in subsec. (b)(14)(A)(ii), is , Nov. 5, 1990, . For complete classification of this Act to the Code, see Tables.
Part B of subchapter XI of this chapter, referred to in subsec. (l)(1)(A)(iii), (2), is classified to section
et seq. of this title.
Amendments
2000—Subsec. (b)(6)(C). , § 1(a)(6) [title II, § 222(a)], struck out “for such services provided before January 1, 2003,” before “payment may be made” and substituted comma for semicolon at end.
Subsec. (b)(6)(E). , § 1(a)(6) [title III, § 313(b)(1)], inserted “by, or under arrangements made by, a skilled nursing facility” before “to an individual who” and struck out “or of a part of a facility that includes a skilled nursing facility (as determined under regulations)” before “, payment shall be made” and “(without regard to whether or not the item or service was furnished by the facility, by others under arrangement with them made by the facility, under any other contracting or consulting arrangement, or otherwise)” after “to the facility”.
Subsec. (b)(6)(G). , § 1(a)(6) [title IV, § 432(b)(2)], added subpar. (G).
Subsec. (b)(18)(C)(vi). , § 1(a)(6) [title I, § 105(d)], added cl. (vi).
Subsec. (o)(3). , § 1(a)(6) [title I, § 114(a)], added par. (3).
Subsec. (t). , § 1(a)(6) [title III, § 313(b)(2)], struck out “by a physician” before “to an individual” and “or of a part of a facility that includes a skilled nursing facility (as determined under regulations),” before “for which payment may be made”.
1999—Subsec. (b)(6)(F). , § 1000(a)(6) [title III, § 305(a)], inserted “(including medical supplies described in section
of this title, but excluding durable medical equipment to the extent provided for in such section)” after “home health services”.
Subsec. (b)(8)(A)(i)(I). , § 1000(a)(6) [title II, § 223(c)], substituted “the application of this subchapter to payment under this part” for “the application of this part”.
Subsec. (s)(2)(E). , § 1000(a)(6) [title III, § 321(k)(4)], inserted period at end.
1997—Subsec. (b)(2)(E). , § 4611(d), added subpar. (E).
Subsec. (b)(6). , § 4512(c), inserted at end “For purposes of subparagraph (C) of the first sentence of this paragraph, an employment relationship may include any independent contractor arrangement, and employer status shall be determined in accordance with the law of the State in which the services described in such clause are performed.”
Subsec. (b)(6)(A)(ii). , § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (b)(6)(C). , § 4205(d)(3)(B), amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: “in the case of services described in clauses (i), (ii), or (iv) of section
of this title payment shall be made to the employer of the physician assistant or nurse practitioner involved, and”.
Subsec. (b)(6)(E). , § 4432(b)(2), added subpar. (E).
Subsec. (b)(6)(F). , § 4603(c)(2)(B)(i), added subpar. (F).
Subsec. (b)(8), (9). , § 4316(a), amended pars. (8) and (9) generally. Prior to amendment, par. (8) related to determination of reasonable charges for physician services, including factors to be considered, provision for increase or decrease of charge, consideration of resource costs, accounting for regional differences in prevailing charges, and impact of changes in reasonable charges, and par. (9) related to notice of proposed reasonable charges to be published in Federal Register, provision for comments on proposed changes, and publication of final determinations with respect to change in reasonable charges.
Subsec. (b)(12). , § 4512(b)(2), struck out par. (12) which read as follows:
“(12)(A) With respect to services described in clauses (i), (ii), or (iv) of section
of this title (relating to a physician assistants and nurse practitioners)—
“(i) payment under this part may only be made on an assignment-related basis; and
“(ii) the prevailing charges determined under paragraph (3) shall not exceed—
“(I) in the case of services performed as an assistant at surgery, 65 percent of the amount that would otherwise be recognized if performed by a physician who is serving as an assistant at surgery, or
“(II) in other cases, the applicable percentage (as defined in subparagraph (B)) of the prevailing charge rate determined for such services (or, for services furnished on or after January 1, 1992, the fee schedule amount specified in section
of this title) performed by physicians who are not specialists.
“(B) In subparagraph (A)(ii)(II), the term ‘applicable percentage’ means—
“(i) 75 percent in the case of services performed (other than as an assistant at surgery) in a hospital, and
“(ii) 85 percent in the case of other services.”
Subsec. (b)(19). , § 4531(a)(2), added par. (19).
Subsec. (h)(8). , § 4302(b), added par. (8).
Subsec. (o). , § 4556(a), added subsec. (o).
Subsec. (p)(1), (2). , § 4317(a), inserted “or practitioner specified in subsection (b)(18)(C) of this section” after “by a physician”.
Subsec. (p)(4). , § 4317(b), added par. (4).
Subsec. (s). , § 4315(a), added subsec. (s).
Subsec. (t). , § 4432(b)(4), added subsec. (t).
1996—Subsec. (c)(6). , § 202(b)(2), added par. (6).
Subsec. (r). , § 221(b), inserted at end “Under such system, the Secretary may impose appropriate fees on such physicians to cover the costs of investigation and recertification activities with respect to the issuance of the identifiers.”
1994—Subsec. (b)(2)(A). , § 126(g)(9), made technical amendment to directory language of , § 4118(j)(2). See 1990 Amendment note below.
Subsec. (b)(2)(D). , § 151(b)(2)(B), added subpar. (D).
Subsec. (b)(3)(G). , § 151(b)(1)(B)(i), which directed striking out “and” at end of subpar. (G), could not be executed because “and” did not appear at end of subpar. (G) subsequent to amendment by , § 123(c)(2). See below.
, § 123(c)(2), amended subpar. (G) generally. Prior to amendment, subpar. (G) read as follows: “will provide to each nonparticipating physician, at the beginning of each year, a list of the physician’s limiting charges established under section
of this title for the year for the physicians’ services mostly commonly furnished by that physician; and”.
Subsec. (b)(3)(H). , § 151(b)(1)(B)(ii), which directed striking out “and” at end of subpar. (H), could not be executed because “and” does not appear at end.
Subsec. (b)(3)(I). , § 151(b)(1)(B)(iii), added subpar. (I).
Subsec. (b)(6)(D). , § 125(b)(1), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: “payment may be made to a physician who arranges for visit services (including emergency visits and related services) to be provided to an individual by a second physician on an occasional, reciprocal basis if (i) the first physician is unavailable to provide the visit services, (ii) the individual has arranged or seeks to receive the visit services from the first physician, (iii) the claim form submitted to the carrier includes the second physician’s unique identifier (provided under the system established under subsection (r) of this section) and indicates that the claim is for such a ‘covered visit service (and related services)’, and (iv) the visit services are not provided by the second physician over a continuous period of longer than 60 days.”
Subsec. (b)(12)(C). , § 123(b)(2)(B), struck out subpar. (C). Prior to amendment, subpar. (C) read as follows: “Except for deductible and coinsurance amounts applicable under section
of this title, 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 clauses (i), (ii), or (iv) of section
of this title in violation of subparagraph (A)(i) is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section
of this title (other than subsections (a) and (b)) 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
of this title.”
Subsec. (b)(16)(B)(iii). , § 126(a)(1), struck out “, simple and subcutaneous” after “Partial”, substituted “injections and small joint” for “injections; small joint” and “femoral fracture and” for “femoral fracture treatments;”, struck out “lobectomy;” after “thoracostomy;” and “enterectomy; colectomy; cholecystectomy;” after “aneurysm repair;”, substituted “fulguration and resection” for “fulguration; transurerethral resection”, and struck out “sacral laminectomy;” before “tympanoplasty”.
Subsec. (b)(17). , § 126(e), redesignated par. (18), relating to payment for technical component of diagnostic tests, as (17) and inserted “, tests specified in paragraph (14)(C)(i),” after “diagnostic laboratory tests”.
Subsec. (b)(18). , § 126(e), redesignated par. (18), relating to payment for technical component of diagnostic tests, as (17).
, § 123(b)(1), added par. (18), relating to payment for service furnished by a practitioner described in subpar. (C).
Subsec. (c)(1). , § 126(h)(2), struck out subpar. (A) designation before “Any contract entered” and struck out subpar. (B) which read as follows: “Of the amounts appropriated for administrative activities to carry out this part, the Secretary shall provide payments, totaling 1 percent of the total payments to carriers for claims processing in any fiscal year, to carriers under this section, to reward carriers for their success in increasing the proportion of physicians in the carrier’s service area who are participating physicians or in increasing the proportion of total payments for physicians’ services which are payments for such services rendered by participating physicians.”
Subsec. (c)(4). , § 125(a), added par. (4).
Subsec. (c)(5). , § 135(b)(2), added par. (5).
Subsec. (h)(7)(C). , § 123(c)(1)(B), struck out “shall include” before cl. (i).
Subsec. (h)(7)(D). , § 123(c)(1)(A), (C), (D), added subpar. (D).
Subsec. (q)(1). , § 126(c)(1), made technical amendment to , § 4103(a). See 1990 Amendment note below.
Subsec. (q)(1)(B). , § 126(c)(2)(A), substituted “shall, subject to clause (iv), be reduced to the adjusted prevailing charge conversion factor for the locality determined as follows:” for “shall be determined as follows:” in introductory provisions.
Subsec. (q)(1)(B)(iii). , § 126(c)(2)(B), substituted “The adjusted prevailing charge conversion factor for” for “Subject to clause (iv), the prevailing charge conversion factor to be applied in”.
1993—Subsec. (b)(4)(F). , § 13515(a)(2), struck out subpar. (F) which related to prevailing charge or fee schedule amount in case of professional services of health care practitioner (other than primary care services and other than services furnished in rural area designated as health professional shortage area) furnished during practitioner’s first through fourth years of practice.
Subsec. (b)(13)(A). , § 13516(a)(2)(A), added subpar. (A) and struck out former subpar. (A) which read as follows: “In determining the reasonable charge under paragraph (3) of a physician for medical direction of two or more nurse anesthetists performing, on or after April 1, 1988, and before January 1, 1996, anesthesia services in whole or in part concurrently, the number of base units which may be recognized with respect to such medical direction for each concurrent procedure (other than cataract surgery or an iridectomy) shall be reduced by—
“(i) 10 percent, in the case of medical direction of 2 nurse anesthetists concurrently,
“(ii) 25 percent, in the case of medical direction of 3 nurse anesthetists concurrently, and
“(iii) 40 percent, in the case of medical direction of 4 nurse anesthetists concurrently.”
Subsec. (b)(13)(B), (C). , § 13516(a)(2), redesignated subpar. (C) as (B), substituted “subparagraph (A)” for “subparagraph (A) or (B)”, and struck out former subpar. (B) which read as follows: “In determining the reasonable charge under paragraph (3) of a physician for medical direction of two or more nurse anesthetists performing, on or after January 1, 1989, and before January 1, 1996, anesthesia services in whole or in part concurrently, the number of base units which may be recognized with respect to such medical direction for each concurrent cataract surgery or iridectomy procedure shall be reduced by 10 percent.”
Subsec. (c)(2)(B)(ii). , § 13568(b), substituted “period ending on or before September 30, 1993” for “period” in subcl. (IV) and added subcl. (V).
Subsec. (c)(3)(B). , § 13568(a), added cls. (i) and (ii) and struck out former cls. (i) and (ii) which read as follows:
“(i) with respect to claims received in the 3-month period beginning July 1, 1988, 10 days, and
“(ii) with respect to claims received in the 12-month period beginning October 1, 1988, 14 days.”
Subsec. (i)(2). , § 13517(b), substituted “; the term” for “, and the term” and inserted before period at end “; and the term ‘nonparticipating supplier or other person’ means a supplier or other person (excluding a provider of services) that is not a participating physician or supplier (as defined in subsection (h)(1) of this section)”.
1990—Subsec. (b)(2)(A). , § 4118(j)(2), as amended by , § 126(g)(9), substituted “section
” for “section
”.
Subsec. (b)(3)(G). , § 4118(f)(2)(B), substituted “section
of this title” for “subsection (j)(1)(C) of this section”.
Subsec. (b)(4)(A)(vi). , § 4105(b)(1), substituted “60 percent” for “50 percent”.
Subsec. (b)(4)(B)(iv). , § 4105(a)(2), added cl. (iv).
Subsec. (b)(4)(E)(iv)(I). , § 4118(a)(2), substituted “the list referred to in paragraph (14)(C)(i)” for “Table #2 in the Joint Explanatory Statement of the Committee of Conference submitted with the Conference Report to accompany H.R. (the ‘Omnibus Budget Reconciliation Act of 1989’), 101st Congress”.
Subsec. (b)(4)(E)(v). , § 4105(a)(1), added cl. (v).
Subsec. (b)(4)(F). , § 4106(a)(1), amended subpar. (F) generally. Prior to amendment, subpar. (F) read as follows: “In determining the customary charges for physicians’ services furnished during a calendar year (other than primary care services and other than services furnished in a rural area (as defined in section
of this title) that is designated, under section
of this title, as a health manpower shortage area) for which adequate actual charge data are not available because a physician has not yet been in practice for a sufficient period of time, the Secretary shall set a customary charge at a level no higher than 80 percent of the prevailing charge for a service. For the first calendar year during which the preceding sentence no longer applies, the Secretary shall set the customary charge at a level no higher than 85 percent of the prevailing charge for the service.”
Subsec. (b)(4)(F)(i). substituted “health professional shortage area” for “health manpower shortage area”.
, § 4106(b)(2)(A), (B), substituted “professional services” for “physicians’ services and professional services” and “practitioner’s first” for “physician’s or practitioner’s first”.
Subsec. (b)(4)(F)(ii)(II). , § 4106(b)(2)(C), substituted “practitioner” for “physician or practitioner” in two places.
Subsec. (b)(6)(C). , § 4155(c), substituted “clauses (i), (ii), or (iv) of section
” for “section
”.
Subsec. (b)(6)(D). , § 4110(a), added subpar. (D).
Subsec. (b)(12)(A). , § 4155(c), substituted “clauses (i), (ii), or (iv) of section
” for “section
” in introductory provisions.
Subsec. (b)(12)(A)(ii)(II). , § 4118(f)(2)(C), struck out “, as the case may be” after “section
of this title”.
, § 4118(f)(2)(A), made technical correction to , § 6102(e)(4). See 1989 Amendment note below.
Subsec. (b)(12)(C). , § 4155(c), substituted “clauses (i), (ii), or (iv) of section
” for “section
”.
Subsec. (b)(13)(A), (B). , § 4103(b), substituted “1996” for “1991”.
Subsec. (b)(14)(A). , § 4101(a), designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (b)(14)(B)(iii)(I). , § 4118(a)(1)(A), which directed amendment of subcl. (I) by substituting “practice expense component (percent), divided by 100, specified in appendix A (pages 187 through 194) of the Report of the Medicare and Medicaid Health Budget Reconciliation Amendments of 1989, prepared by the Subcommittee on Health and the Environment of the Committee on Energy and Commerce, House of Representatives, (Committee Print 101–M, 101st Congress, 1st Session) for the service” for “practice expense ratio for the service (specified in table #1 in the Joint Explanatory Statement referred to in subparagraph (C)(i))”, was executed by making the substitution for “practice expense ratio for the service (specified in Table #1 in the Joint Explanatory Statement referred to in subparagraph (C)(i))” to reflect the probable intent of Congress.
Subsec. (b)(14)(B)(iii)(II). , § 4118(a)(1)(B), substituted “practice expense component (percent), divided by 100” for “practice expense ratio”.
Subsec. (b)(14)(C)(i). , § 4118(a)(1)(C), substituted “procedures specified (by code and description) in the Overvalued Procedures List for Finance Committee, Revised September 20, 1989, prepared by the Physician Payment Review Commission” for “physicians’ services specified in Table #2 in the Joint Explanatory Statement of the Committee of Conference submitted with the Conference Report to accompany H.R. (the ‘Omnibus Budget Reconciliation Act of 1989’), 101st Congress,”.
Subsec. (b)(14)(C)(iii). , § 4118(a)(1)(D), which directed amendment of cl. (iii) by substituting “The ‘percentage change’ specified in this clause, for a physicians’ service specified in clause (i), is the percent difference (but expressed as a positive number) specified for the service in the list” for “The ‘percent change’ specified in this clause, for a physicians’ service specified in clause (i), is the percent change specified for the service in table #2 in the Joint Explanatory Statement”, was executed by making the substitution for “The ‘percent change’ specified in this clause, for a physicians’ service specified in clause (i), is the percent change specified for the service in Table #2 in the Joint Explanatory Statement” to reflect the probable intent of Congress.
Subsec. (b)(14)(C)(iv). , § 4118(a)(1)(E), which directed amendment of cl. (iv) by substituting “the Geographic Overhead Costs Index specified for the locality in table 1 of the September 1989 Supplement to the Geographic Medicare Economic Index: Alternative Approaches (prepared by the Urban Institute and the Center for Health Economics Research)” for “such value specified for the locality in table #3 in the Joint Explanatory Statement referred to in clause (i)”, was executed by making the substitution for “such value specified for the locality in Table #3 in the Joint Explanatory Statement referred to in clause (i)” to reflect the probable intent of Congress.
Subsec. (b)(16). , § 4101(b), added par. (16).
Subsec. (b)(18). , § 4108(a), added par. (18).
Subsec. (q)(1). , § 4103(a), as amended by , § 126(c)(1), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (r). , § 4118(i)(1), added subsec. (r).
1989—Subsec. (b)(2)(A). , § 6202(d)(2), inserted at end “The Secretary may not require, as a condition of entering into or renewing a contract under this section or under section
of this title, that a carrier match data obtained other than in its activities under this part with data used in the administration of this part for purposes of identifying situations in which section
of this title may apply.”
, § 201(a), repealed , § 202(e)(3)(C), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (b)(2)(C). , § 6114(c)(2), added subpar. (C).
Subsec. (b)(3)(G). , § 6102(e)(2), substituted “limiting charges established under subsection (j)(1)(C) of this section” for “maximum allowable actual charges (established under subsection (j)(1)(C) of this section)”.
Subsec. (b)(3)(I) to (K). , § 201(a), repealed , §§ 201(c),
, 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. (b)(3)(L). , § 6102(b), added subpar. (L).
Subsec. (b)(4)(A)(iv). , § 6102(e)(3), inserted “and before January 1, 1992,” after “January 1, 1987,”.
Subsec. (b)(4)(E)(iv). , § 6107(b), added cl. (iv).
Subsec. (b)(4)(F). , § 6108(a)(1), inserted “furnished during a calendar year” after “physicians’ services” and inserted at end “For the first calendar year during which the preceding sentence no longer applies, the Secretary shall set the customary charge at a level no higher than 85 percent of the prevailing charge for the service.”
Subsec. (b)(6)(A)(ii). , § 6003(g)(3)(D)(ix), inserted “rural primary care hospital,” after “hospital,”.
Subsec. (b)(6)(C). , § 6114(c)(1), inserted “or nurse practitioner” after “physician assistant”.
Subsec. (b)(12)(A). , § 6114(b), substituted “physician assistants and nurse practitioners” for “physician assistant acting under the supervision of a physician” in introductory provisions.
Subsec. (b)(12)(A)(ii)(II). , § 6102(e)(4), as amended by , § 4118(f)(2)(A), inserted “(or, for services furnished on or after January 1, 1992, the fee schedule amount specified in section
of this title, as the case may be)” after “prevailing charge rate determined for such services”.
Subsec. (b)(14). , § 6104(a), added par. (14).
Subsec. (b)(15). , § 6108(b)(1), added par. (15).
Subsecs. (c)(1)(A), (2)(A), (3)(A), (4), (f)(3), (h)(1), (2), (4). , § 201(a), repealed , § 202(c)(1)(A), (B), (e)(1), (3)(A), (4)(A), (5), 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. (j)(1)(B)(ii). , § 6102(e)(9), substituted “December 31, 1990.” for “the earlier of (I) December 31, 1990, or (II) one-year after the date the Secretary reports to Congress, under section
of this title, on the development of the relative value scale under section
of this title.”
Subsec. (j)(1)(C)(vii). , § 301(b)(2), (c)(2), amended cl. (vii) identically, substituting “according” for “accordingly”.
Subsec. (j)(1)(D)(ii)(II). , § 6104(b)(1), inserted “or (b)(14)(A)” after “(b)(10)(A)”.
Subsec. (j)(1)(D)(ii)(IV). , § 6108(b)(2)(A), inserted “or (b)(15)(A)” after “subsection (b)(11)(C)(i)”.
Subsec. (j)(1)(D)(iii)(II). , § 6108(b)(2)(B), substituted “(b)(14)(A), or (b)(15)(A)” for “or (b)(14)(A)”.
, § 6104(b)(2), substituted “(b)(11)(C)(i), or (b)(14)(A)” for “or (b)(11)(C)(i)”.
Subsec. (j)(1)(D)(v). , § 6102(e)(9), substituted “December 31, 1990.” for “the earlier of (I) December 31, 1990, or (II) one-year after the date the Secretary reports to Congress, under section
of this title, on the development of the relative value scale under section
of this title.”
Subsec. (j)(2). , § 301(b)(6), (d)(3), which directed identical amendments to subsec. (j)(2) by substituting “subsections” for “paragraphs” in subpar. (B) as amended by section 8(c)(2)(A) of the Medicare and Medicaid Fraud and Abuse Patient Protection Act of 1987 [probably meaning section 8(c)(2)(A) of , the Medicare and Medicaid Patient and Program Protection Act of 1987, which amended subpar. (A) of subsec. (j)(2), generally] could not be executed because the word “paragraphs” did not appear.
Subsec. (o). , § 201(a), repealed , § 202(c)(1)(C), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (q). , § 6106(a), added subsec. (q).
1988—Subsec. (b)(2). , § 411(i)(2), amended , § 4082(c), see 1987 Amendment note below.
Subsec. (b)(2)(A). , § 608(d)(5)(G), inserted “, including claims processing functions” after “and related functions” in last sentence.
, § 411(f)(1)(B), inserted reference to section
of this title in third sentence.
, § 202(e)(3)(C), as amended by , § 608(d)(5)(F), inserted at end “With respect to activities relating to implementation and operation (and related functions) of the electronic system established under subsection (o)(4) of this section, the Secretary may enter into contracts with carriers under this section to perform such activities on a regional basis.”
Subsec. (b)(3). , § 411(i)(4)(C)(vi), added , § 4085(i)(24), see 1987 Amendment note below.
, § 411(f)(4)(B)(ii), added , § 4045(c)(2)(D), see 1987 Amendment note below.
, § 411(f)(11)(A), (14), renumbered and amended , § 4053(a), see 1987 Amendment note below.
Subsec. (b)(3)(B)(ii). , § 411(j)(4)(A), made technical correction to directory language of , § 4096(a)(1)(A), see 1987 Amendment note below.
Subsec. (b)(3)(I). , § 201(c), added subpar. (I) requiring notice that an individual has reached the part B catastrophic limit on out-of-pocket cost sharing for the year.
Subsec. (b)(3)(J). , § 202(e)(2), added subpar. (J) relating to requirements for determinations or payments with respect to covered outpatient drugs, to receive information and respond to requests by participating pharmacies.
Subsec. (b)(3)(K). , § 608(d)(5)(C), inserted “, including claims processing functions,” after “and for related functions”.
, § 202(e)(2), added subpar. (K) requiring contracts with organizations described in subsection (f)(3) of this section to implement and operate the electronic system established under subsection (o)(4) of this section for covered outpatient drugs.
Subsec. (b)(4)(A)(iv). , § 411(f)(2)(F)(i), as amended by , § 608(d)(21)(B), redesignated and amended , § 4042(c)(1), see 1987 Amendment note below.
Subsec. (b)(4)(A)(iv)(II). , § 411(f)(2)(E), substituted “before January 1, 1989” for “before January 1, 1988”.
Subsec. (b)(4)(A)(vi). , § 411(f)(3)(A), made technical amendment to directory language of , § 4044(a), see 1987 Amendment note below.
, § 411(f)(3)(B), substituted “subsection (i)(4) of this section” for “subparagraph (E)(iii)” and “the estimated average prevailing charge levels based on the best available data” for “the average of the prevailing charge levels” and struck out “for participating physicians” before “under the third”.
Subsec. (b)(4)(A)(vii). , § 411(f)(2)(D), added , § 4042(b)(2)(A), see 1987 Amendment note below.
, § 411(f)(3)(A), made technical amendment to directory language of , § 4044(a), see 1987 Amendment note below.
Subsec. (b)(4)(E). , § 411(f)(2)(C), added , § 4042(b)(1)(C), (D), see 1987 Amendment notes below.
Subsec. (b)(4)(F). , § 411(f)(2)(C), added , § 4042(b)(1)(D), see 1987 Amendment note below.
Subsec. (b)(4)(F)(ii)(I). , § 411(f)(2)(B), substituted “subsection (i)(4) of this section” for “subparagraph (E)(iii)”.
Subsec. (b)(4)(F)(iii). , § 411(f)(2)(A), substituted “services,” for “services;” in subcl. (I) and “physicians’ ” for “physician’s” in subcl. (II).
Subsec. (b)(4)(G). , § 411(f)(2)(C), added , § 4042(b)(1)(D), see 1987 Amendment note below.
, § 411(f)(6)(B), substituted “other than primary care services” for “other primary care services” and struck out “(as determined under the third and fourth sentences of paragraph (3) and under paragraph (4))” after “the prevailing charge”.
Subsec. (b)(7)(B)(iii). , § 411(i)(4)(C)(vi), added , § 4085(i)(22)(C), see 1987 Amendment note below.
Subsec. (b)(10)(A)(i). , § 411(f)(4)(A)(i), struck out “under paragraph (3)” after “reasonable charge”, substituted “subparagraph (B)” for “subparagraph (C)”, and struck out “for participating and nonparticipating physicians” after “charge for such procedure”.
Subsec. (b)(10)(A)(iii). , § 411(f)(4)(A)(ii), substituted “clause (i)(I)” for “clause (i)(II)”.
Subsec. (b)(10)(B). , § 411(f)(4)(A)(iii), inserted “(including subsequent insertion of an intraocular lens)” after “cataract surgery”.
Subsec. (b)(10)(D). , § 411(f)(4)(A)(iv), substituted “under section
” for “section
”.
Subsec. (b)(11)(B)(i). , § 411(f)(4)(B)(i), amended , § 4045(c)(2)(B), see 1987 Amendment note below.
Subsec. (b)(11)(C)(i). , § 411(f)(5)(A), substituted “insertion” for “implantation”.
Subsec. (b)(11)(C)(ii). , § 411(g)(2)(A), substituted “inserted during or subsequent to” for “implanted during”.
Subsec. (b)(12)(C). , § 411(i)(4)(C)(vi), added , § 4085(i)(25), see 1987 Amendment note below.
Subsec. (b)(13), (14). , § 411(f)(7)(A), redesignated par. (14) as (13).
Subsec. (c)(1)(A). , § 202(e)(3)(A), designated existing provisions as cl. (i), inserted “, except as provided in clause (ii),” after “under this part, and” and added cl. (ii) relating to payment for implementation and operation of the electronic system for covered outpatient drugs.
Subsec. (c)(1)(A)(ii). , § 608(d)(5)(D), inserted “, including claims processing functions” after “and related functions”.
Subsec. (c)(2)(A), (3)(A). , § 202(e)(5)(A), as amended by , § 608(d)(5)(H), substituted “Except as provided in paragraph (4), each” for “Each”.
Subsec. (c)(4). , § 202(e)(5)(B), added par. (4) requiring contracts for the disbursement of funds with respect to claims for payment for covered outpatient drugs to provide for a payment cycle, and requiring interest if such requirements are not met.
Subsec. (f)(3). , § 608(d)(5)(B), inserted “, including claims processing functions” after “and related functions”.
, § 202(e)(1), added par. (3) which read as follows: “with respect to implementation and operation (and related functions) of the electronic system established under subsection (o)(4) of this section, a voluntary association, corporation, partnership, or other nongovernmental organization, which the Secretary determines to be qualified to conduct such activities.”
Subsec. (h)(1). , § 202(c)(1)(A), inserted “, except that, with respect to a supplier of covered outpatient drugs, the term ‘participating supplier’ means a participating pharmacy (as defined in subsection (o)(1) of this section)” after “part during such year”.
Subsec. (h)(2). , § 202(e)(4)(A), inserted “(other than a carrier described in subsection (f)(3) of this section)” after “Each carrier”.
Subsec. (h)(3)(B). , § 411(i)(1)(A), substituted “payment determination” for “claims determination”, “shall include an explanation of benefits and any additional information that the Secretary may determine to be appropriate in order” for “including such information as the Secretary determines is generally provided”, “enter into agreements” for “enter into arrangements”, and “under this subparagraph by a carrier” for “under this subparagraph” and inserted “, and such user fees shall be collected and retained by the carrier”.
Subsec. (h)(4). , § 202(c)(1)(B), inserted at end “In publishing directories under this paragraph, the Secretary shall provide for separate directories (wherever appropriate) for participating pharmacies.”
Subsec. (h)(5). , § 223(b), designated existing provisions as subpar. (A), inserted “through an annual mailing”, struck out at end “The Secretary shall include such notice in the mailing of appropriate benefit checks provided under subchapter II of this chapter.”, and added subpar. (B).
Subsec. (h)(7). , § 411(f)(2)(C), added , § 4042(b)(1)(A), see 1987 Amendment note below.
, § 223(c), in subpar. (A) inserted “prominent” before “reminder” and substituted “and a clear statement of any amounts charged for the particular items or services on the claim involved above the amount recognized under this part),” for “7E), and” and added subpar. (C).
Subsec. (h)(8). , § 411(f)(2)(C), added , § 4042(b)(1)(B), see 1987 Amendment note below.
Subsec. (i). , § 411(f)(2)(C), added , § 4042(b)(1)(B), see 1987 Amendment note below.
Subsec. (i)(2), (3). , § 411(f)(2)(C), added , § 4042(b)(1)(C), see 1987 Amendment note below.
Subsec. (i)(3). , § 608(d)(21)(A), substituted “subsection (b)(3) of this section” for “paragraph (3)”.
Subsec. (i)(4). , § 411(f)(2)(C), added , § 4042(b)(1)(E), see 1987 Amendment note below.
Subsec. (j)(1)(C)(i). , § 411(f)(2)(F)(ii), added , § 4042(c)(2), see 1987 Amendment note below.
Subsec. (j)(1)(C)(viii). , § 411(f)(1)(A), amended , § 4041(a)(1)(B), see 1987 Amendment note below.
Subsec. (j)(1)(C)(ix). , § 411(f)(7)(B), added , § 4048(e), see 1987 Amendment note below.
Subsec. (j)(1)(D)(ii)(IV). , § 411(f)(5)(B), struck out “is” after “limit”.
Subsec. (j)(1)(D)(ii)(V). , § 411(g)(2)(B), redesignated subcl. (IV) as (V) and struck out “is” after “limit”.
Subsec. (j)(1)(D)(iii). , § 411(g)(2)(C), amended , § 4063(a)(2)(B), see 1987 Amendment note below.
Subsec. (j)(1)(D)(iv). , § 411(f)(4)(C), substituted “bills” for “imposes a charge”.
Subsec. (j)(2). , § 411(i)(4)(C)(vi), as amended by , § 608(d)(24)(B), added , § 4085(i)(26), see 1987 Amendment note below.
Subsec. (l)(1)(C)(i). , § 411(i)(4)(C)(vi), added , § 4085(i)(27), see 1987 Amendment note below.
Subsec. (n)(1). , § 411(f)(9)(A), in introductory provisions, struck out “to a patient” after “includes a charge”, inserted “the bill or request for” after “for which”, and substituted “shares a practice” for “shares his practice” and “supervised the performance of the test, the” for “supervised the test, the”.
Subsec. (n)(1)(A). , § 608(d)(17), substituted “the supplier’s” for “the the supplier’s”.
, § 411(f)(9)(B), as amended by , § 608(d)(21)(D), substituted “(or other applicable limit)” for “to individuals enrolled under this part”.
, § 411(a)(3)(A), (C)(i), clarified that illegible matter after “or, if lower, the” was “the supplier’s reasonable charge to individuals enrolled under this part for the test”.
Subsec. (n)(2)(A). , § 411(f)(9)(C), inserted “the payment amount specified in paragraph (1)(A) and” after “other than”.
Subsec. (n)(3). , § 411(f)(9)(D), struck out “or supplier” after “such physician”.
Subsec. (o). , § 202(c)(1)(C), added subsec. (o) relating to “participating pharmacies” as entities authorized under State law to dispense covered outpatient drugs which had entered into agreements with Secretary to participate in catastrophic coverage program.
Subsec. (o)(1)(A)(i). , § 608(d)(5)(A)(i), substituted “paragraph (4)” for “subparagraph (D)(i)”.
Subsec. (o)(1)(B)(ii). , § 608(d)(5)(A)(ii), substituted “an eligible organization” for “eligible organization”.
Subsec. (p). , § 202(g), added subsec. (p).
1987—Subsec. (b)(2). , § 4082(c), as amended by , § 411(i)(2), designated existing provisions as subpar. (A) and added subpar. (B).
, § 4041(a)(3)(A)(i), inserted at end “In establishing such standards and criteria, the Secretary shall provide a system to measure a carrier’s performance of responsibilities described in paragraph (3)(H) and subsection (h) of this section.”
Subsec. (b)(3). , § 4085(i)(24), as added by , § 411(i)(4)(C)(vi), substituted “In the case of physicians’ services” for “In the case of physician services” and “(with respect to physicians’ services” for “(with respect to physicians services” in fourth sentence.
, § 4045(c)(2)(D), as added by , § 411(f)(4)(B)(ii), inserted “(or under any other provision of law affecting the prevailing charge level)” in fourth sentence.
, § 4053(a), formerly § 4052(a), as renumbered and amended by , § 411(f)(11)(A), (14), inserted “, and shall remain at such prevailing charge level until the prevailing charge for a year (as adjusted by economic index data) equals or exceeds such prevailing charge level” before period at end of penultimate sentence.
Subsec. (b)(3)(B)(ii). , § 4096(a)(1)(A), as amended by , § 411(j)(4)(A), added subcl. (II), redesignated former subcl. (II) as (III), and inserted “(and to refund amounts already collected)”.
Subsec. (b)(3)(C). , § 4085(i)(5), substituted “less than $500” for “not more than $500”.
Subsec. (b)(4)(A)(iv). , § 4042(c)(1), formerly § 4042(c), as redesignated and amended by , § 411(f)(2)(F)(i), and by , § 608(d)(21)(B), amended cl. (iv) generally. Prior to amendment, cl. (iv) read as follows: “In determining the prevailing charge level under the third and fourth sentences of paragraph (3) for a physicians’ service furnished on or after January 1, 1987, by a nonparticipating physician, the Secretary shall set the level at 96 percent of the prevailing charge levels established under such sentences with respect to such service furnished by participating physicians.”
Subsec. (b)(4)(A)(v). , § 4041(a)(1)(A)(i), added cl. (v). Former cl. (v) redesignated (vi).
Subsec. (b)(4)(A)(vi). , § 4044(a), as amended by , § 411(f)(3)(A), added cl. (vi). Former cl. (vi) redesignated (vii).
, § 4041(a)(1)(A)(i), redesignated former cl. (v) as (vi).
Subsec. (b)(4)(A)(vii). , § 4042(b)(2)(A), as added by , § 411(f)(2)(D), substituted “subsection (i)(3) of this section” for “subparagraph (E)(ii)”.
, § 4044(a), as amended by , § 411(f)(3)(A), redesignated former cl. (vi) as (vii).
Subsec. (b)(4)(B)(iii). , § 4041(a)(1)(A)(ii), added cl. (iii).
Subsec. (b)(4)(E). , § 4042(b)(1)(D), as added by , § 411(f)(2)(C), redesignated subpar. (F) as (E). Former subpar. (E) transferred to subsec. (i).
, § 4042(b)(1)(C), as added by , § 411(f)(2)(C), struck out “(E) In this section:” before cl. (i), redesignated cls. (i) and (ii) as pars. (2) and (3), respectively, and transferred those pars. to subsec. (i).
Subsec. (b)(4)(F). , § 4042(b)(1)(D), as added by , § 411(f)(2)(C), redesignated subpar. (G) as (F). Former subpar. (F) redesignated (E).
, § 4042(a), added subpar. (F).
Subsec. (b)(4)(G). , § 4042(b)(1)(D), as added by , § 411(f)(2)(C), redesignated subpar. (G) as (F).
, § 4047(a), added subpar. (G).
Subsec. (b)(7)(B)(iii). , § 4085(i)(22)(C), as added by , § 411(i)(4)(C)(vi), substituted “an assignment-related basis” for “the basis of an assignment described in paragraph (3)(B)(ii) or under the procedure described in section
of this title”.
Subsec. (b)(10). , § 4045(a), amended par. (10) generally, revising and restating as subpars. (A) to (D) provisions of former subpars. (A) to (C).
Subsec. (b)(11)(B)(i). , § 4045(c)(2)(B), as amended by , § 411(f)(4)(B)(i), struck out “and shall be further reduced by 2 percent with respect to procedures performed in 1988” after “in 1987” and struck out second sentence which read as follows: “A reduced prevailing charge under this subparagraph shall become the prevailing charge level for subsequent years for purposes of applying the economic index under the fourth sentence of paragraph (3).”
Subsec. (b)(11)(C). , § 4063(a)(1)(A), designated existing provisions as cl. (i) and added cl. (ii).
, § 4046(a)(1)(B), (C), added subpar. (C) and redesignated former subpar. (C) as (D).
, § 4045(c)(1)(A), struck out former cl. (i) designation before “In the case of” and substituted “, the physician’s actual charge is subject to a limit under subsection (j)(1)(D) of this section.” for “(subject to clause (iv)), the physician may not charge the individual more than the limiting charge (as defined in clause (ii)) plus (for services furnished during the 12-month period beginning on the effective date of the reduction) 1/2 of the amount by which the physician’s actual charges for the service for the previous 12-month period exceeds the limiting charge.”, and struck out former cls. (ii) to (iv) which read as follows:
“(ii) In clause (i), 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 clause (i).
“(iii) If a physician knowingly and willfully imposes charges in violation of clause (i), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2) of this section.
“(iv) This subparagraph 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
of this title, on the development of the relative value scale under section
of this title.”
Subsec. (b)(11)(D). , § 4063(a)(1)(B), which directed that subpar. (D) be amended by inserting “or item” after “service” or “services” each place either appears, was executed by inserting “or item” after “service” wherever appearing. The word “services” does not appear because of a prior amendment by section 4045(c)(1)(A) of to subpar. (D), formerly (C), see above.
, § 4046(a)(1)(A), (B), redesignated former subpar. (C) as (D) and substituted “subparagraph (B) or (C)” for “subparagraph (B)”.
Subsec. (b)(12)(C). , § 4085(i)(25), as added by , § 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
of this title with respect to actions described in subsection (a) of that section.”
Subsec. (b)(14). , § 4048(a), added par. (14).
Subsec. (c)(1). , § 4041(a)(3)(A)(ii), designated existing provisions as subpar. (A) and added subpar. (B).
, § 4035(a)(2), inserted at end “The Secretary shall cause to have published in the Federal Register, by not later than September 1 before each fiscal year, data, standards, and methodology to be used to establish budgets for carriers under this section for that fiscal year, and shall cause to be published in the Federal Register for public comment, at least 90 days before such data, standards, and methodology are published, the data, standards, and methodology proposed to be used.”
Subsec. (c)(3). , § 4031(a)(2), added par. (3).
Subsec. (h)(3). , § 4081(a), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (h)(5). , § 4085(i)(6), substituted “the participation program” for “the the participation program”.
Subsec. (h)(7). , § 4042(b)(1)(A), as added by , § 411(f)(2)(C), struck out “, described in paragraph (8)” after “assignment-related basis” in introductory provisions.
Subsec. (h)(8). , § 4042(b)(1)(B), as added by , § 411(f)(2)(C), substituted “(1) A” for “(8) For purposes of this subchapter, a”, indented such par. 2 ems, and inserted subsec. (i) designation and “For purposes of this subchapter:”, effectively transferring former subsec. (h)(8) to subsec. (i).
Subsec. (i). , § 4042(b)(1)(B), as added by , § 411(f)(2)(C), transferred introductory provisions and par. (1) from former subsec. (h)(8).
Subsec. (i)(2), (3). , § 4042(b)(1)(C), as added by , § 411(f)(2)(C), transferred pars. (2) and (3) from subsec. (b)(4)(E).
Subsec. (i)(4). , § 4042(b)(1)(E), as added by , § 411(f)(2)(C), added par. (4).
Subsec. (j)(1)(B)(i). , § 4054(a)(1), (2), formerly § 4053(a)(1), (2), as renumbered by , § 411(f)(14), substituted “the actual charges of each such physician” for “each such physician’s actual charges” and “on a repeated basis for such a service an actual charge” for “for such a service a physician’s actual charge (as defined in subparagraph (C)(vi)”.
Subsec. (j)(1)(C)(i). , § 4085(i)(7)(A), inserted “maximum allowable” after “If the physician’s”.
, § 4042(c)(2), as added by , § 411(f)(2)(F)(ii), substituted “applicable percent (as defined in subsection (b)(4)(A)(iv) of this section) of the prevailing charge for the year and service involved” for “prevailing charge for the year involved for such service furnished by nonparticipating physicians” in subcls. (I) and (II).
Subsec. (j)(1)(C)(v). , § 4085(i)(7)(B), substituted “1986” for “1987”.
Subsec. (j)(1)(C)(vi). , § 4054(a)(3), formerly § 4053(a)(3), as renumbered by , § 411(f)(14), struck out “and subparagraph (B)” after “purposes of this subparagraph”.
Subsec. (j)(1)(C)(vii). , § 4085(i)(7)(C), added cl. (vii).
Subsec. (j)(1)(C)(viii). , § 4041(a)(1)(B), as amended by , § 411(f)(1)(A), added cl. (viii).
Subsec. (j)(1)(C)(ix). , § 4048(e), as added by , § 411(f)(7)(B), added cl. (ix).
Subsec. (j)(1)(D). , § 4045(c)(1)(B), added subpar. (D).
Subsec. (j)(1)(D)(ii)(IV). , § 4063(a)(2)(A), added subcl. (IV) relating to establishment of reasonable charge limit under subsec. (b)(11)(C)(ii) of this section.
, § 4046(a)(2)(A), added subcl. (IV) relating to establishment of prevailing charge limit under subsec. (b)(11)(C)(i) of this section. Former subcl. (IV) redesignated (V).
Subsec. (j)(1)(D)(ii)(V), (VI). , § 4063(a)(2)(A), redesignated former subcl. (V) as (VI).
, § 4046(a)(2)(A), redesignated former subcl. (IV) as (V).
Subsec. (j)(1)(D)(iii). , § 4063(a)(2)(B), as amended by , § 411(g)(2)(C), struck out “or” at end of subcl. (I), substituted “; or” for period at end of subcl. (II), and added subcl. (III).
, § 4046(a)(2)(B), substituted “, (b)(11)(B), or (b)(11)(C)(i)” for “or (b)(11)(B)” in subcl. (II).
Subsec. (j)(2). , § 4085(i)(26), as added by , § 411(i)(4)(C)(vi), and amended by , § 608(d)(24)(B), substituted “chapter” for “subchapter” in subpar. (A), struck out “the imposition of” before “civil monetary penalties” and inserted “and assessments” in subpar. (B), substituted “chapter” for “subchapter” in two places in last sentence, and amended last sentence generally. Prior to amendment, last sentence read as follows: “No payment may be made under this chapter with respect to any item or service furnished by a physician during the period when he is excluded from participation in the programs under this chapter pursuant to this subsection.”
, § 8(c)(2)(A), amended subpar. (A) generally and substituted “excluded from participation in the programs” for “barred from participation in the program” in last sentence. Prior to amendment, subpar. (A) read as follows: “barring a physician from participation under the program under this subchapter for a period not to exceed 5 years, in accordance with the procedures of paragraphs (2) and (3) of section
of this title, or”.
Subsec. (j)(3)(A). , § 8(c)(2)(B), substituted “exclude” for “bar”.
Subsec. (k)(1), (2). , § 4085(g)(1), substituted “subsection (j)(2) of this section in the case of surgery performed on or after March 1, 1987” for “subsection (j)(2) of this section”.
Subsec. (l)(1)(A)(iii). , § 4096(a)(1)(B), designated existing provisions as subcl. (I) and added subcl. (II).
Subsec. (l)(1)(C). , § 4096(a)(1)(C), inserted “in the case described in subparagraph (A)(iii)(I)” after “to an individual” in introductory provisions.
Subsec. (l)(1)(C)(i). , § 4085(i)(27), as added by , § 411(i)(4)(C)(vi), inserted “the physician establishes that” after “(i)”.
Subsec. (n). , § 4051(a), added subsec. (n).
1986—Subsec. (b)(3). , § 9331(c)(3)(A), inserted “or (with respect to physicians services furnished in a year after 1987) the level determined under this sentence for the previous year” after “ending June 30, 1973,” and “year-to-year” before “economic changes” in fourth sentence.
, § 9301(d)(1)(B), (C), substituted “June 30 last preceding the start of the calendar year” for “March 31 last preceding the start of the twelve-month period (beginning October 1 of each year)” in third sentence, and struck out “the twelve-month period beginning on October 1 in” before “any calendar year after 1974” in eighth sentence.
Subsec. (b)(3)(C). , § 9341(a)(2), substituted “at least $100, but not more than $500” for “$100 or more”.
Subsec. (b)(3)(F). , § 9301(d)(1)(A), struck out “(ending on September 30)” after “before the year”.
Subsec. (b)(3)(G). , § 9331(b)(2), added subpar. (G).
Subsec. (b)(3)(H). , § 9332(a)(1), added subpar. (H).
Subsec. (b)(4)(A)(i), (ii). , § 9301(b)(1)(A), designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (b)(4)(A)(iii). , § 9331(a)(1), added cl. (iii) and struck out former cl. (iii) which read as follows: “In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians’ services furnished during a 12-month period beginning on or after January 1, 1987, by a physician who is not a participating physician (as defined in subsection (h)(1) of this section) at the time of furnishing the services, the Secretary shall not set any level higher than the same level as was set for services furnished during the previous calendar year (without regard to clause (ii)(II)) for physicians who were participating physicians during that year.”
, § 9301(b)(1)(A)(ii), added cl. (iii).
Subsec. (b)(4)(A)(iv), (v). , § 9331(a)(1), added cls. (iv) and (v).
Subsec. (b)(4)(B). , § 9301(b)(1)(B), designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (b)(4)(C). , § 9331(a)(2), directed amendment of subpar. (C) by striking out “(i)” after “(C)” and striking out cl. (ii), applicable to services furnished on or after Jan. 1, 1987, which is identical to amendment by , § 1895(b)(14)(A), as amended, effective as if included in enactment of .
, § 1895(b)(14)(A), as amended by , § 9307(c)(2)(A), struck out cl. (i) designation, and struck out cl. (ii) which read as follows: “In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians’ services furnished during the periods beginning after December 31, 1986, by a physician who was not a participating physician on that date, the Secretary shall treat the level as set under subparagraph (A)(ii) as having fully provided for the economic changes which would have been taken into account but for the limitations contained in subparagraph (A)(ii).”
, § 9301(b)(1)(C), designated existing provisions as cl. (i), substituted “subparagraph (A)(i)” for “subparagraph (A)” wherever appearing, and added cl. (ii).
Subsec. (b)(4)(D)(i) to (iii). , § 9301(b)(1)(D), designated existing provisions as cl. (i), substituted “In determining the customary charges for physicians’ services furnished during the 8-month period beginning May 1, 1986, or the 12-month period beginning January 1, 1987, by a physician who was not a participating physician (as defined in subsection (h)(1) of this section) on September 30, 1985” for “In determining the customary charges for physicians’ services furnished during the 12-month period beginning October 1, 1985, or October 1, 1986, by a physician who at no time for any services furnished during the 12-month period beginning October 1, 1984, was a participating physician (as defined in subsection (h)(1) of this section)”, and added cls. (ii) and (iii).
Subsec. (b)(4)(D)(iv). , § 9331(b)(3), added cl. (iv).
Subsec. (b)(4)(E). , § 9331(a)(3), added subpar. (E).
Subsec. (b)(6). , § 9338(c), substituted “except that (A) payment may be made (i)” for “except that payment may be made (A)(i)”, substituted “(B) payment may be made” for “or (B)”, and inserted before the period at end “, and (C) in the case of services described in section
of this title payment shall be made to the employer of the physician assistant involved”.
Subsec. (b)(7)(B)(ii)(III). , § 9219(b)(1)(A), realigned margin of subcl. (III).
Subsec. (b)(7)(B)(iii). , § 9219(b)(2)(A), realigned margin of cl. (iii).
Subsec. (b)(8). , § 9333(a), designated existing provisions as subpar. (A), redesignated former subpars. (A) and (B) as cls. (i) and (ii), respectively, and added subpars. (B) and (C).
, § 9304(a), added par. (8).
Subsec. (b)(9). , § 9333(b), added par. (9). Former par. (9) redesignated (11).
, § 9306(a), added par. (9).
Subsec. (b)(10). , § 9333(b), added par. (10).
Subsec. (b)(11). , § 9334(a), designated existing provisions as subpar. (A), redesignated former subpars. (A) and (B) as cls. (i) and (ii), respectively, and added subpars. (B) and (C).
, § 9333(b), redesignated former par. (9) as (11).
Subsec. (b)(12). , § 9338(b), added par. (12).
Subsec. (c). , § 9311(c), designated existing provisions as par. (1) and added par. (2).
Subsec. (h)(1). , § 9301(d)(2), substituted “before the beginning of any year beginning with 1984” for “before October 1 of any year beginning with 1984”, “on an assignment-related basis” for “on the basis of an assignment described in subsection (b)(3)(B)(ii) of this section, in accordance with subsection (b)(6)(B) of this section, or under the procedure described in section
of this title”, “during such year” for “during the 12-month period beginning on October 1 of such year”, “after the beginning of a year” for “after October 1 of a year”, and “during the remainder of the year” for “during the remainder of the 12-month period beginning on such October 1”.
Subsec. (h)(2). , § 9332(b)(1)(A), struck out period at end and substituted “and may request a copy of an appropriate directory published under paragraph (4). Each such carrier shall, without charge, mail a copy of such directory upon such a request.”
Subsec. (h)(4). , § 9332(b)(2), inserted at end “Each participating physician directory for an area shall provide an alphabetical listing of all participating physicians practicing in the area and an alphabetical listing by locality and specialty of such physicians.”
, § 9301(c)(3)(D), redesignated par. (2) of subsec. (i) as par. (4) of this subsection.
Subsec. (h)(5). , § 9332(b)(1)(B), substituted “the participation program under this subsection and the publication and availability of the directories” for “publication of the directories” and inserted at end “The Secretary shall include such notice in the mailing of appropriate benefit checks provided under subchapter II of this chapter.”
, § 1895(b)(15)(A), struck out “such” before “the directories” and before “the appropriate area directory”.
, § 9301(c)(3)(D), redesignated par. (3) of subsec. (i) as par. (5) of this subsection.
Subsec. (h)(6). , § 9332(b)(1)(C), inserted before period at end of second sentence “and that an appropriate number of copies of each such directory is sent to hospitals located in the area” and inserted at end “Such copies shall be sent free of charge.”
, § 1895(b)(15)(B), substituted “the” for “the the” before “directories”.
, § 9301(c)(3)(D), redesignated par. (4) of subsec. (i) as par. (6) of this subsection.
Subsec. (h)(7), (8). , § 9301(c)(4), added pars. (7) and (8).
Subsec. (i)(1). , § 9301(c)(3)(A), struck out par. (1) which required the Secretary to publish a list containing the name, address, specialty, and percent of claims submitted with respect to each physician and supplier during preceding year that were paid on the basis of an assignment described in subsec. (b)(3)(B)(ii) of this section, in accordance with subsec. (b)(6)(B) of this section, or under procedure described in section
of this title.
Subsec. (i)(2). , § 9301(c)(3)(D), redesignated par. (2) of this subsection as par. (4) of subsec. (h).
, § 9301(d)(3), substituted “year” for “fiscal year”, wherever appearing.
, § 9301(c)(2)(A), (B), (3)(B), substituted “shall publish directories (for appropriate local geographic areas)” for “shall publish a directory”, inserted “for that area” before “for that fiscal year”, substituted “Each directory shall” for “The directory shall”, and substituted “paragraph (1)” for “subsection (h)(1) of this section”.
Subsec. (i)(3). , § 9301(c)(3)(D), redesignated par. (3) of this subsection as par. (5) of subsec. (h).
, § 9301(c)(2)(C), (3)(C), struck out “directory” first place it appeared and inserted in lieu “the directories”, struck out “directory” second place it appeared and inserted in lieu “the appropriate area directory or directories”, and struck out “list and” wherever appearing.
Subsec. (i)(4). , § 9301(c)(3)(D), redesignated par. (4) of this subsection as par. (6) of subsec. (h).
, § 9301(c)(2)(D), (3)(C), struck out “list and” after “The Secretary shall provide that the” in first sentence, substituted “the directories shall” for “directory shall”, and inserted provision requiring the Secretary to provide that each appropriate area directory be sent to each participating physician located in that area.
Subsec. (j)(1). , § 9331(b)(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).
, § 9301(b)(2), amended first sentence generally. Prior to amendment, first sentence read as follows: “In the case of a physician who is not a participating physician, the Secretary shall monitor each such physician’s actual charges to individuals enrolled under this part for physicians’ services furnished during the 15-month period beginning July 1, 1984.”
Subsec. (j)(2). , § 9320(e)(3), substituted “this paragraph” for “paragraph (1) or subsection (k) of this section” in introductory text.
, § 9307(c)(1), inserted reference to subsec. (k) of this section in introductory text.
Subsec. (k). , § 1895(b)(16)(A), inserted “presents or causes to be presented a claim or” in pars. (1) and (2).
, § 9307(c)(2), added subsec. (k).
Subsec. (l). , § 9332(c)(1), added subsec. (l).
Subsec. (m). , § 9332(d)(1), added subsec. (m).
1984—Subsec. (b)(2). , § 2326(c)(2), inserted at end provision that the Secretary publish in the Federal Register standards and criteria for efficient and effective performance of contract obligations under this section and provide an opportunity for public comment prior to implementation.
Subsec. (b)(3). , § 2306(b)(1)(B), (C), substituted “during the 12-month period ending on the March 31 last preceding” for “during the last preceding calendar year elapsing prior to” in third sentence and substituted “October 1” for “July 1” wherever appearing in third and eighth sentences.
, § 2354(b)(14), substituted “(I)” and “(II)” for “(i)” and “(ii)”, respectively in concluding provisions.
, § 2663(j)(2)(F)(iv), substituted “Health and Human Services” for “Health, Education, and Welfare” in concluding provisions.
Subsec. (b)(3)(B)(ii)(II). , § 2354(b)(13), struck out the period after “subchapter”.
Subsec. (b)(3)(F). , § 2306(b)(1)(A), substituted “September 30” for “June 30”.
Subsec. (b)(4), (5). , § 2306(a), added par. (4) and redesignated former pars. (4) and (5) as (5) and (6), respectively.
Subsec. (b)(6). , § 2339, redesignated cl. (A) as cl. (A)(i) and former cl. (B) as cl. (A)(ii), added a new cl. (B), and in the provisions after cl. (B), substituted “clause (A) of such sentence” for “clause (A) or (B) of such sentence”.
, § 2306(a), redesignated par. (5) as (6). Former par. (6) redesignated (7).
Subsec. (b)(7). , § 2306(a), redesignated par. (6) as (7).
Subsec. (b)(7)(A). , § 3(b)(5)(B), struck out at end “If all the teaching physicians in a hospital agree to have payment made for all of their physicians’ services under this part furnished patients in the hospital on the basis of an assignment described in paragraph (3)(B)(ii) or under the procedure described in section
of this title, notwithstanding clause (ii) of this subparagraph, the carrier shall provide for payment in an amount equal to 90 percent of the prevailing charges paid for similar services in the same locality.”
, § 2307(a)(1), as amended by , § 3(a)(1), inserted “If all the teaching physicians in a hospital agree to have payment made for all of their physicians’ services under this part furnished patients in the hospital on the basis of an assignment described in paragraph (3)(B)(ii) or under the procedure described in section
of this title, notwithstanding clause (ii) of this subparagraph, the carrier shall provide for payment in an amount equal to 90 percent of the prevailing charges paid for similar services in the same locality.” at the end.
Subsec. (b)(7)(A)(ii). , § 3(b)(5)(A), substituted “the payment is based upon a reasonable charge for the services in excess of the customary charge as determined in accordance with subparagraph (B)” for “the amount of the payment exceeds the reasonable charge for the services (with the customary charge determined consistent with subparagraph (B))”.
Subsec. (b)(7)(B)(i). , § 2307(a)(2)(A), (B), substituted “physician who is not a teaching physician (as defined by the Secretary)” for “physician who has a substantial practice outside the teaching setting” and “practice outside the teaching setting” for “outside practice”.
Subsec. (b)(7)(B)(ii). , § 2307(a)(2)(C), (D), substituted “In the case of a teaching physician” for “In the case of a physician who does not have a practice described in clause (i)” and “greatest” for “greater”.
Subsec. (b)(7)(B)(ii)(III). , § 2307(a)(2)(E)–(G), added subcl. (III).
Subsec. (b)(7)(B)(iii). , § 3(b)(6), added cl. (iii).
Subsec. (c). , § 2326(d)(2), inserted provision that the Secretary, in determining a carrier’s necessary and proper cost of administration with respect to each contract, take into account the amount that is reasonable and adequate to meet the costs which must be incurred by an efficiently and economically operated carrier in carrying out the terms of its contract.
Subsec. (h). , § 2306(c), added subsec. (h).
, § 2303(e), struck out subsec. (h) providing for payment for laboratory tests.
Subsecs. (i), (j). , § 2306(c), added subsecs. (i) and (j).
1982—Subsec. (b)(3)(B)(ii)(II). , § 128(d)(1), substituted “section
” for “section
”.
Subsec. (b)(3). , § 104(a), in provisions following subpar. (F), inserted provisions that in determining the reasonable charge for outpatient services, the Secretary may limit such reasonable charge to a percentage of the amount of the prevailing charge for similar services furnished in a physician’s office, taking into account the extent to which overhead costs associated with such outpatient services have been included in the reasonable cost or charge of the facility.
Subsec. (b)(6)(D). , § 113(a), added subpar. (D).
1981—Subsec. (b)(3). inserted provision that the amount of any charges for outpatient services which shall be considered reasonable shall be subject to the limitations established by regulations issued by the Secretary pursuant to section
of this title.
1980—Subsec. (b)(3). , § 946(a), in provisions following subpar. (F), substituted “service is rendered” for “bill is submitted or the request for payment is made”.
Subsec. (b)(3)(F). , § 946(b), added subpar. (F).
Subsec. (b)(6). , § 948(b), added par. (6).
Subsec. (h). , § 918(a)(1), added subsec. (h).
1977—Subsec. (b)(3). provided that, with respect to power-operated wheelchairs for which payment may be made in accordance with section
of this title, charges determined to be reasonable may not exceed the lowest charge at which power-operated wheelchairs are available in the locality.
Subsec. (b)(5). inserted provisions relating to payments under a reassignment or power of attorney in cases other than direct payments to physicians or service providers.
1976—Subsec. (b)(3). substituted “for the twelve-month period beginning on July 1 in any calendar year after 1974” for “for the fiscal year beginning July 1, 1975,”, “prior to the start of the twelve-month period (beginning July 1, of each year) in which the bill is submitted or the request for payment is made” for “prior to the start of the fiscal year in which the bill is submitted or the request for payment is made”, and “for any twelve-month period (beginning after June 30, 1973) specified in clause (ii) of such sentence” for “for any fiscal year beginning after June 30, 1973,”.
1975—Subsec. (b)(3). inserted provisions relating to raising for fiscal year beginning July 1, 1975 inadequate prevailing charge levels for services of physicians in certain localities.
1974—Subsec. (g). substituted “section
of title
” for “section
of title
”.
1972—Subsec. (a). , § 227(e)(3), substituted “which involve payments for physicians’ services on a reasonable charge basis” for “which involve payments for physicians’ services”.
Subsec. (b)(3). , §§ 244(a),
, inserted provisions relating to determination of reasonableness of physician charges, medical services, supplies, and equipment and for the extension of time for filing claims for supplementary medical insurance benefits where the delay is due to administrative error, at end thereof.
Subsec. (b)(3)(B)(ii). , §§ 211(c)(3),
, designated existing provisions as subcl. (I), added subcl. II, inserted exception in the case of services furnished as described in section
of this title, other than for purposes of section
of this title.
Subsec. (b)(3)(C). , § 262(a), inserted provisions setting a $100 minimum amount on claims to establish entitlement to a hearing.
Subsec. (b)(5). , § 236(a), added par. (5).
Subsec. (g). , § 263(d)(5), added subsec. (g).
1968—Subsec. (b)(3)(B). provided that payment be made on the basis of an itemized bill instead of a receipted bill as formerly required, and established a time limit within which payment may be requested, and inserted “(except as otherwise provided in section
of this title)” after “payment will”.
Change of Name
Committee on Energy and Commerce of House of Representatives treated as referring to Committee on Commerce of House of Representatives by section 1(a) of , set out as a note preceding section
of Title
, The Congress. Committee on Commerce of House of Representatives changed to Committee on Energy and Commerce of House of Representatives, and jurisdiction over matters relating to securities and exchanges and insurance generally transferred to Committee on Financial Services of House of Representatives by House Resolution No. 5, One Hundred Seventh Congress, Jan. 3, 2001.
Effective Date of 2000 Amendment
Amendment by section
[title I, § 105(d)] of applicable to services furnished on or after Jan. 1, 2002, see section
[title I, § 105(e)] of , set out as a note under section
of this title.
, § 1(a)(6) [title I, § 114(b)], Dec. 21, 2000, , 2763A–474, provided that: “The amendment made by subsection (a) [amending this section] shall apply to items furnished on or after January 1, 2001.”
, § 1(a)(6) [title II, § 222(b)], Dec. 21, 2000, , 2763A–487, provided that: “The amendments made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Dec. 21, 2000].”
, § 1(a)(6) [title III, § 313(c)], Dec. 21, 2000, , 2763A–499, provided that: “The amendments made by subsections (a) and (b) [amending this section and sections
and
of this title] shall apply to services furnished on or after January 1, 2001.”
, § 1(a)(6) [title IV, § 432(c)], Dec. 21, 2000, , 2763A–526, provided that: “The amendments made by this section [amending this section and sections
and
of this title] shall apply to services furnished on or after July 1, 2001.”
Effective Date of 1999 Amendment
, div. B, § 1000(a)(6) [title III, § 305(c)], Nov. 29, 1999, , 1501A–362, provided that: “The amendments made by this section [amending this section and section
of this title] shall apply to payments for services provided on or after the date of enactment of this Act [Nov. 29, 1999].”
Amendment by section
1000
(a)(6) [title III, § 321(k)(4)] of effective as if included in the enactment of the Balanced Budget Act of 1997, , except as otherwise provided, see section
1000
(a)(6) [title III, § 321(m)] of , set out as a note under section
of this title.
Effective Date of 1997 Amendment
Amendment by section 4201(c)(1) of applicable to services furnished on or after Oct. 1, 1997, see section 4201(d) of , set out as a note under section
of this title.
Amendment by section 4205(d)(3)(B) of effective Aug. 5, 1997, see section 4205(d)(4) of , set out as a note under section
of this title.
Section 4302(c) of provided that: “The amendments made by this section [amending this section and section
of this title] shall take effect on the date of the enactment of this Act [Aug. 5, 1997] and apply to the entry and renewal of contracts on or after such date.”
Amendment by section 4315(a) of , to the extent such amendment substitutes fee schedules for reasonable charges, applicable to particular services as of date specified by the Secretary of Health and Human Services, see section 4315(c) of , set out as a note under section
of this title.
Amendment by section 4316(a) of effective Aug. 5, 1997, see section 4316(c) of , set out as a note under section
of this title.
Section 4317(c) of provided that: “The amendments made by this section [amending this section] shall apply to items and services furnished on or after January 1, 1998.”
Amendment by section 4432(b)(2), (4) of applicable to items and services furnished on or after July 1, 1998, see section 4432(d) of , set out as a note under section
of this title.
Amendment by section 4512(b)(2), (c) of applicable with respect to services furnished and supplies provided on and after Jan. 1, 1998, see section 4512(d) of , set out as a note under section
of this title.
Amendment by section 4556(a) of applicable to drugs and biologicals furnished on or after Jan. 1, 1998, see section 4556(d) of , set out as a note under section
of this title.
Amendment by section 4603(c)(2)(B)(i) of applicable to cost reporting periods beginning on or after Oct. 1, 1999, except as otherwise provided, see section 4603(d) of , set out as an Effective Date note under section
of this title.
Amendment by section 4611(d) of applicable to services furnished on or after Jan. 1, 1998, and for purposes of applying such amendment, any home health spell of illness that began, but did not end, before such date, to be considered to have begun as of such date, see section 4611(f) of , set out as a note under section
of this title.
Effective Date of 1994 Amendment
Amendment by section 123(b)(1), (2)(B) of applicable to services furnished on or after Jan. 1, 1995, see section 123(f)(2) of , set out as a note under section
of this title.
Section 123(f)(3), (4) of provided that:
“(3) EOMBs.—The amendments made by subsection (c)(1) [amending this section] shall apply to explanations of benefits provided on or after July 1, 1995.
“(4) Carrier determinations.—The amendments made by subsection (c)(2) [amending this section] shall apply to contracts as of January 1, 1995.”
Section 125(b)(2) of provided that: “The amendment made by paragraph (1) [amending this section] shall apply to services furnished on or after the first day of the first month beginning more than 60 days after the date of the enactment of this Act [Oct. 31, 1994].”
Amendment by section 126(a)(1), (c), (e), (g)(9) of effective as if included in the enactment of , see section 126(i) of , set out as a note under section
of this title.
Section 126(h)(2) of provided that the amendment made by that section is effective for payments for fiscal years beginning with fiscal year 1994.
Section 135(b)(2) of provided that the amendment made by that section is effective for standards applied for contract years beginning after Oct. 31, 1994.
Amendment by section 151(b)(1)(B), (2)(B) of applicable to contracts with fiscal intermediaries and carriers under this subchapter for contract years beginning with 1995, see section 151(b)(4) of , set out as a note under section
of this title.
Effective Date of 1993 Amendment
Section 13515(d) of provided that: “The amendments made by subsection (a) [amending this section and section
of this title] shall apply to services furnished on or after January 1, 1994.”
Amendment by section 13568(a), (b) of applicable to claims received on or after Oct. 1, 1993, see section 13568(c) of , set out as a note under section
of this title.
Effective Date of 1990 Amendment
Section 4105(b)(3) of , as amended by , title I, § 126(g)(2)(A)(ii), Oct. 31, 1994, , provided that: “The amendment made by paragraph (1) [amending this section] shall apply to services furnished on or after January 1, 1991.”
Section 4106(d) of provided that:
“(1) The amendments made by subsection (a) [amending this section and provisions set out below] apply to services furnished after 1990, except that—
“(A) the provisions concerning the third and fourth years of practice apply only to physicians’ services furnished after 1990 and 1991, respectively, and
“(B) the provisions concerning the second, third, and fourth years of practice apply only to services of a health care practitioner furnished after 1991, 1992, and 1993, respectively.
“(2) The amendments made by subsection (b) [amending this section and section
of this title] shall apply to services furnished after 1991.”
Section 4108(b) of provided that: “The amendment made by subsection (a) [amending this section] shall apply to tests and services furnished on or after January 1, 1991.”
Section 4110(b) of provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after the first day of the first month beginning more than 60 days after the date of the enactment of this Act [Nov. 5, 1990].”
Section 4118(a)(3) of provided that: “The amendments made by paragraphs (1) and (2) [amending this section] apply to services furnished after March 1990.”
Section 4118(f)(2)(A) of provided that the amendment by that section is effective as if included in the Omnibus Budget Reconciliation Act of 1989, .
Section 4118(f)(2)(B) of provided that the amendment by that section is effective Jan. 1, 1991.
Amendment by section 4155(c) of applicable to services furnished on or after Jan. 1, 1991, see section 4155(e) of , set out as a note under section
of this title.
Effective Date of 1989 Amendments
Section 6102(e)(3) of provided that the amendment made by that section is effective for physicians’ services furnished on or after Jan. 1, 1992.
Section 6106(b) of provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after April 1, 1990.”
Section 6108(a)(2) of , as amended by , title IV, § 4106(a)(2), Nov. 5, 1990, , provided that:
“(A) Subject to subparagraph (B), the amendments made by paragraph (1) [amending this section] apply to services furnished in 1990 or 1991 which were subject to the first sentence of section 1842(b)(4)(F) of the Social Security Act [subsec. (b)(4)(F) of this section] in 1989 or 1990.
“(B) The amendments made by paragraph (1) shall not apply to services furnished in 1990 before April 1, 1990. With respect to physicians’ services furnished during 1990 on and after April 1, such amendments shall be applied as though any reference, in the matter inserted by such amendments, to the ‘first calendar year during which the preceding sentence no longer applies’ were deemed a reference to the remainder of 1990.”
Section 6108(b)(3) of provided that: “The amendments made by this subsection [amending this section] apply to procedures performed after March 31, 1990.”
Section 6114(f) of provided that: “The amendments made by this section [amending this section and section
of this title] shall apply to services furnished on or after April 1, 1990.”
Amendment by section 6202(d)(2) of applicable to agreements and contracts entered into or renewed on or after Dec. 19, 1989, see section 6202(d)(3) of , set out as a note under section
of this title.
Amendment by section 201(a) of effective Jan. 1, 1990, see section 201(c) of , set out as a note under section
of this title.
Section 301(e) of provided that: “The provisions of this section [amending this section and sections
,
,
, and
of this title, enacting provisions set out as notes under section
of this title, and repealing provisions set out as notes under sections
,
,
, and
of this title and section
of Title
, Government Organization and Employees] (other than subsections (c) and (d) [amending this section and sections
,
,
, and
of this title and enacting provisions set out as a note under section
of this title]) shall take effect January 1, 1990, except that—
“(1) the repeal of section 421 of MCCA [, set out as a note under section
of this title] shall not apply to duplicative part A benefits for periods before January 1, 1990, and
“(2) the amendments made by subsection (b) [amending this section and sections
,
,
, and
of this title] shall take effect on the date of the enactment of this Act [Dec. 13, 1989].”
Effective Date of 1988 Amendments
Amendment by effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, , see section 608(g)(1) of , set out as a note under section
of this title.
Section 202(m) of , as amended by , title II, § 201(a), Dec. 13, 1989, , provided that:
“(1) [Repealed. Prior to repeal by , par. (1) read as follows: ‘In general.—Except as otherwise provided in this subsection, the amendments made by this section [enacting section
of this title and amending this section and sections
,
,
,
,
,
,
, and
of this title] shall apply to items dispensed on or after January 1, 1990.’]
“(2) [Repealed. Prior to repeal by , par. (2) read as follows: ‘Carriers.—The amendments made by subsection (e) [amending this section] shall take effect on the date of the enactment of this Act [July 1, 1988]; except that the amendments made by subsection (e)(5) [amending this section] shall take effect on January 1, 1991, but shall not be construed as requiring payment before February 1, 1991.’]
“(3) [Repealed. Prior to repeal by , par. (3) read as follows: ‘HMO/CMP enrollments.—The amendment made by subsection (f) [amending section
of this title] shall apply to enrollments effected on or after January 1, 1990.’]
“(4) Diagnostic coding.—The amendment made by subsection (g) [amending this section] shall apply to services furnished after March 31, 1989.
“(5) [Repealed. Prior to repeal by , par. (5) read as follows: ‘Transition.—With respect to administrative expenses (and costs of the Prescription Drug Payment Review Commission) for periods before January 1, 1990, amounts otherwise payable from the Federal Catastrophic Drug Insurance Trust Fund shall be payable from the Federal Supplementary Medical Insurance Trust Fund and shall also be treated as a debit to the Medicare Catastrophic Coverage Account.’].”
[Amendment of section 202(m) of , set out above, effective Jan. 1, 1990, see section 201(c) of , set out as an Effective Date of 1989 Amendment note under section
of this title.]
Section 223(d)(2), (3) of provided that:
“(2) The amendments made by subsection (b) [amending this section] shall apply to annual notices beginning with 1989.
“(3) The amendments made by subsection (c) [amending this section] shall first apply to explanations of benefits provided for items and services furnished on or after January 1, 1989.”
Except as specifically provided in section 411 of , amendment by section
, (C)(i), (f)(1)(A), (B), (2)–(4)(C), (5), (6)(B), (7), (9), (11)(A), (14), (g)(2)(A)–(C), (i)(1)(A), (2), (4)(C)(vi), and (j)(4)(A) of , as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, , effective as if included in the enactment of that provision in , see section 411(a) of , set out as a Reference to OBRA; Effective Date note under section
of Title
, General Provisions.
Effective Date of 1987 Amendments
Amendment by section 4031(a)(2) of applicable to claims received on or after July 1, 1988, see section 4031(a)(3)(A) of , set out as a note under section
of this title.
Amendment by section 4035(a)(2) of effective Dec. 22, 1987, and applicable to budgets for fiscal years beginning with fiscal year 1989, see section 4035(a)(3) of , set out as a note under section
of this title.
Section 4044(b) of provided that: “The amendments made by subsection (a) [amending this section] shall apply to payment for physicians’ services furnished on or after January 1, 1989.”
Section 4045(d) of provided that: “The amendments made by this section [amending this section and sections
and
of this title and amending provisions set out below] shall apply to items and services furnished on or after April 1, 1988, except the amendment made by subsection (c)(2)(B) [amending this section] shall apply to services furnished on or after January 1, 1988.”
Section 4046(b) of provided that: “The amendments made by subsection (a) [amending this section] shall apply to services furnished on or after April 1, 1988.”
Section 4047(b) of , as amended by , title IV, § 411(f)(6)(C), July 1, 1988, , provided that: “The amendment made by subsection (a) [amending this section] shall apply to physicians who first furnish services to medicare beneficiaries on or after April 1, 1988.”
Section 4051(c) of provided that:
“(1) The amendment made by subsection (a) [amending this section] shall apply to diagnostic tests performed on or after April 1, 1988.
“(2) The Secretary of Health and Human Services shall complete the review and make an appropriate adjustment of prevailing charge levels under subsection (b) [set out below] for items and services furnished no later than January 1, 1989.”
Section
, formerly § 4052(b), of , as renumbered and amended by , title IV, § 411(f)(11)(B), (14), July 1, 1988, , provided that: “The amendment made by subsection (a) [amending this section] shall apply to payment for services furnished on or after April 1, 1988.”
Section
, formerly § 4053(c), of , as renumbered by , title IV, § 411(f)(14), July 1, 1988, , provided that: “The amendment made by subsection (a) [amending this section] shall apply to charges imposed for services furnished on or after April 1, 1988.”
Amendment by section 4063(a) of applicable to items furnished on or after July 1, 1988, see section 4063(c) of , set out as a note under section
of this title.
Section 4081(c)(1) of provided that: “The amendment made by subsection (a) [amending this section] shall apply to contracts with carriers for claims for items and services furnished by participating physicians and suppliers on or after January 1, 1989.”
Section 4082(e)(3) of provided that: “The amendments made by subsection (c) [amending this section] shall apply to evaluation of performance of carriers under contracts entered into or renewed on or after October 1, 1988.”
Section 4085(g)(2) of provided that: “The amendment made by paragraph (1) [amending this section] shall be effective as if included in section 9307(c) of the Consolidated Omnibus Budget Reconciliation Act of 1985 [].”
Section 4085(i)(7) of provided that the amendment made by that section is effective as if included in the enactment of .
Amendment by section 4096(a)(1) of applicable to services furnished on or after Jan. 1, 1988, see section 4096(d) of , set out as a note under section
of this title.
Amendment by effective at end of fourteen-day period beginning Aug. 18, 1987, and inapplicable to administrative proceedings commenced before end of such period, see section 15(a) of , set out as a note under section
of this title.
Effective Date of 1986 Amendments
Section 1895(b)(16)(B) of provided that: “The amendment made by subparagraph (A) [amending this section] shall apply to claims presented after the date of the enactment of this Act [Oct. 22, 1986].”
Amendment by section 1895(b)(14)(A), (15) of effective, except as otherwise provided, as if included in enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985, , see section 1895(e) of , set out as a note under section
of Title
, Internal Revenue Code.
Section 9307(c)(2) of provided that the amendment made by section 9307(c)(2)(A) of [amending directory language of section 1895(b)(14)(A)(ii) of which amended this section] is effective as if included in the enactment of the Tax Reform Act of 1986, .
Amendment by section 9311(c) of applicable to claims received on or after Nov. 1, 1986, with subsec. (c)(2)(C) of this section applicable to claims received on or after Apr. 1, 1987, see section 9311(d) of , set out as a note under section
of this title.
Amendment by section 9320(e)(3) of 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 , as amended, set out as notes under section
of this title.
Section 9331(a)(4) of provided that: “The amendments made by this subsection [amending this section] shall apply to services furnished on or after January 1, 1987.”
Section 9331(b)(4) of provided that: “The amendments made by this subsection [amending this section] shall apply to services furnished on or after January 1, 1987.”
Section 9331(c)(3)(B) of provided that: “The amendments made by subparagraph (A) [amending this section] shall apply to physicians’ services furnished on or after January 1, 1988.”
Section 9332(a)(4)(A) of provided that: “The amendment made by paragraph (1) [amending this section] shall be effective for contracts under section 1842 of the Social Security Act [this section] as of October 1, 1987.”
Section 9332(b)(3) of provided that: “The amendments made by this paragraph [probably means ‘this subsection’ which amended this section] shall first apply to directories for 1987.”
Section 9332(c)(2) of provided that: “The amendment made by paragraph (1) [amending this section] shall apply to services furnished on or after October 1, 1987.”
Section 9332(d)(2) of provided that: “The amendment made by paragraph (1) [amending this section] shall apply to surgical procedures performed on or after October 1, 1987.”
Section 9333(d) of provided that: “The amendments made by this section [amending this section] shall take effect on the date of the enactment of this Act [Oct. 21, 1986].”
Section 9334(c) of provided that: “The amendments made by this section [amending this section] shall apply to services furnished on or after January 1, 1987.”
Amendment by section 9338(b), (c) of applicable to services furnished on or after Jan. 1, 1987, see section 9338(f) of set out as a note under section
of this title.
Amendment by section 9341(a)(2) of applicable to items and services furnished on or after Jan. 1, 1987, see section 9341(b) of , set out as a note under section
of this title.
Section 9219(b)(1)(D) of provided that: “The amendments made by this paragraph [amending this section and sections
and
of this title] shall be effective as if they had been originally included in the Deficit Reduction Act of 1984 [].”
Section 9219(b)(2)(B) of provided that: “The amendment made by subparagraph (A) [amending this section] shall be effective as if it had been originally included in Public Law 98–617.”
Section 9301(b)(4) of provided that: “The amendments made by this subsection [amending this section and enacting provisions set out as a note under this section] shall apply to services furnished on or after May 1, 1986.”
Section 9301(c)(5) of , as amended by , title XVIII, § 1895(b)(14)(B), Oct. 22, 1986, , provided that: “Section 1842(h)(7) of the Social Security Act [subsec. (h)(7) of this section], as added by paragraph (4) of this subsection, shall apply to explanations of benefits provided on or after such date (not later than October 1, 1986) as the Secretary of Health and Human Services shall specify.”
Section 9301(d)(4) of provided that: “The amendments made by this subsection [amending this section and enacting provisions set out as a note under this section] shall apply to items and services furnished on or after October 1, 1986.”
Section 9306(b) of provided that: “The amendments made by this section [amending this section] shall apply to items and services furnished on or after April 1, 1986.”
Amendment by section 9307(c) of applicable to services performed on or after April 1, 1986, see section 9307(e) of , set out as a note under section
of this title.
Effective Date of 1984 Amendments
Amendment by effective as if originally included in the Deficit Reduction Act of 1984, , see section 3(c) of , set out as a note under section
of this title.
Amendment by section 2303(e) of applicable to clinical diagnostic laboratory tests furnished on or after July 1, 1984, but not applicable to clinical diagnostic laboratory tests furnished to inpatients of a provider operating under a waiver granted pursuant to section 602(k) of , set out as a note under section
of this title, see section 2303(j)(1), (3) of , set out as a note under section
of this title.
Section 2306(b)(2) of provided that: “The amendments made by paragraph (1) [amending this section] shall apply to items and services furnished on or after October 1, 1985.”
Section 2307(a)(3) of provided that: “The amendments made by this subsection [amending this section] shall apply to services furnished on or after July 1, 1984.”
Amendment by section 2326(d)(2) of applicable to agreements and contracts entered into or renewed after Sept. 30, 1984, see section 2326(d)(3) of , set out as a note under section
of this title.
Amendment by section 2354(b)(13), (14) of 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 , set out as a note under section
of this title.
Amendment by section 2663(j)(2)(F)(iv) of 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 2664(b) of , set out as a note under section
of this title.
Effective Date of 1982 Amendment
Section 104(b) of , as amended by , title III, § 309(a)(2), Jan. 12, 1983, , provided that: “The amendment made by subsection (a) [amending this section] shall be effective with respect to services furnished on or after October 1, 1982.”
Section 113(b)(1) of provided that: “The amendment made by subsection (a) [amending this section] is effective with respect to services performed on or after October 1, 1982.”
Amendment by section 128(d)(1) of effective Sept. 3, 1982, see section 128(e)(3) of , set out as a note under section
of this title.
Effective Date of 1980 Amendment
Section 918(a)(2) of provided that: “The amendment made by paragraph (1) [amending this section] shall apply to bills submitted and requests for payment made on or after such date (not later than April 1, 1981) as the Secretary of Health and Human Services prescribes by a notice published in the Federal Register.”
Section 946(c) of provided that: “The amendments made by subsections (a) and (b) [amending this section] shall become effective with respect to bills submitted or requests for payment made on or after July 1, 1981.”
Section 948(c)(2) of provided that: “The amendment made by subsection (b) [amending this section] shall apply with respect to cost accounting periods beginning on or after January 1, 1981.”
Effective Date of 1977 Amendments
Amendment by effective in the case of items and services furnished after Dec. 20, 1977, see section 501(c) of , set out as a note under section
of this title.
Amendment by applicable with respect to care and services furnished on or after Oct. 25, 1977, see section 2(a)(4) of , set out as a note under section
of this title.
Effective Date of 1976 Amendment
Section 4 of provided that: “The amendments made by sections 2 and 3 of this Act [amending this section and provisions set out as a note under section
390e of Title
, Agriculture] shall be effective with respect to periods beginning after June 30, 1976; except that, for the twelve-month period beginning July 1, 1976, the amendments made by section
[amending this section and provisions set out as a note under section
390e of Title
, Agriculture] shall be applicable with respect to claims filed under part B of title XVIII of the Social Security Act [this part] (after June 30, 1976, and before July 1, 1977) with a carrier designated pursuant to section 1842 of such Act [this section], and processed by such carrier after the appropriate changes were made pursuant to such section
in the prevailing charge levels for such twelve-month period under the third and fourth sentences of section 1842(b)(3) of the Social Security Act [subsec. (b)(3) of this section].”
Effective Date of 1974 Amendment
Amendment by effective Jan. 1, 1975, see section 603 of , set out as a note under section
of this title.
Effective Date of 1972 Amendment
Amendment by section 211(c)(3) of applicable to services furnished with respect to admissions occurring after Dec. 31, 1972, see section 211(d) of , set out as a note under section
of this title.
Amendment by section 227(e)(3) of applicable with respect to accounting periods beginning after June 30, 1973, see section 227(g) of , set out as a note under section
of this title.
Section 236(c) of provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to bills submitted and requests for payments made after the date of the enactment of this Act [Oct. 30, 1972]. The amendments made by subsection (b) [amending section
of this title] shall be effective January 1, 1973 (or earlier if the State plan so provides).”
Section 258(b) of provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to bills submitted and requests for payment made after March 1968.”
Section 262(b) of provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to hearings requested (under the procedures established under section 1842(b)(3)(C) of the Social Security Act [subsec. (b)(3)(C) of this section]) after the date of the enactment of this Act [Oct. 30, 1972].”
Amendment by section 263(d)(5) of with respect to collection of premiums applicable to premiums becoming due and payable after the fourth month following the month of enactment of which was approved on Oct. 30, 1972, see section 263(f) of , set out as a note under section
of this title.
Amendment by section 281(d) of to apply in the case of notices sent to individuals after 1968, see section 281(g) of , set out as a note under section
of this title.
Effective Date of 1968 Amendment
Section 125(b) of provided that: “The amendments made by subsection (a) [amending this section] shall apply with respect to claims on which a final determination has not been made on or before the date of enactment of this Act [Jan. 2, 1968].”
Transfer of Functions
Physician Payment Review Commission (PPRC) was terminated and its assets and staff transferred to the Medicare Payment Advisory Commission (MedPAC) by section 4022(c)(2), (3) of , set out as a note under section
of this title. Section
, (3) further provided that MedPAC was to be responsible for preparation and submission of reports required by law to be submitted by PPRC, and that, for that purpose, any reference in law to PPRC was to be deemed, after the appointment of MedPAC, to refer to MedPAC.
Revised Part B Payment for Drugs and Biologicals and Related Services
, § 1(a)(6) [title IV, § 429], Dec. 21, 2000, , 2763A–522, provided that:
“(a) Recommendations for Revised Payment Methodology for Drugs and Biologicals.—
“(1) Study.—
“(A) In general.—The Comptroller General of the United States shall conduct a study on the reimbursement for drugs and biologicals under the current medicare payment methodology (provided under section 1842(o) of the Social Security Act ( U.S.C.
)) and for related services under part B of title XVIII of such Act [this part]. In the study, the Comptroller General shall—
“(i) identify the average prices at which such drugs and biologicals are acquired by physicians and other suppliers;
“(ii) quantify the difference between such average prices and the reimbursement amount under such section; and
“(iii) determine the extent to which (if any) payment under such part is adequate to compensate physicians, providers of services, or other suppliers of such drugs and biologicals for costs incurred in the administration, handling, or storage of such drugs or biologicals.
“(B) Consultation.—In conducting the study under subparagraph (A), the Comptroller General shall consult with physicians, providers of services, and suppliers of drugs and biologicals under the medicare program under title XVIII of such Act [this subchapter], as well as other organizations involved in the distribution of such drugs and biologicals to such physicians, providers of services, and suppliers.
“(2) Report.—Not later than 9 months after the date of the enactment of this Act [Dec. 21, 2000], the Comptroller General shall submit to Congress and to the Secretary of Health and Human Services a report on the study conducted under this subsection, and shall include in such report recommendations for revised payment methodologies described in paragraph (3).
“(3) Recommendations for revised payment methodologies.—
“(A) In general.—The Comptroller General shall provide specific recommendations for revised payment methodologies for reimbursement for drugs and biologicals and for related services under the medicare program. The Comptroller General may include in the recommendations—
“(i) proposals to make adjustments under subsection (c) of section
1848 of the Social Security Act ( U.S.C. ) for the practice expense component of the physician fee schedule under such section for the costs incurred in the administration, handling, or storage of certain categories of such drugs and biologicals, if appropriate; and
“(ii) proposals for new payments to providers of services or suppliers for such costs, if appropriate.
“(B) Ensuring patient access to care.—In making recommendations under this paragraph, the Comptroller General shall ensure that any proposed revised payment methodology is designed to ensure that medicare beneficiaries continue to have appropriate access to health care services under the medicare program.
“(C) Matters considered.—In making recommendations under this paragraph, the Comptroller General shall consider—
“(i) the method and amount of reimbursement for similar drugs and biologicals made by large group health plans;
“(ii) as a result of any revised payment methodology, the potential for patients to receive inpatient or outpatient hospital services in lieu of services in a physician’s office; and
“(iii) the effect of any revised payment methodology on the delivery of drug therapies by hospital outpatient departments.
“(D) Coordination with bbra study.—In making recommendations under this paragraph, the Comptroller General shall conclude and take into account the results of the study provided for under section 213(a) of BBRA [, § 1000(a)(6) [title II, § 213(a)], set out as a note under section
of this title] (A–350).
“(b) Implementation of New Payment Methodology.—
“(1) In general.—Notwithstanding any other provision of law, based on the recommendations contained in the report under subsection (a), the Secretary of Health and Human Services, subject to paragraph (2), shall revise the payment methodology under section 1842(o) of the Social Security Act ( U.S.C.
) for drugs and biologicals furnished under part B of the medicare program [this part]. To the extent the Secretary determines appropriate, the Secretary may provide for the adjustments to payments amounts referred to in subsection (a)(3)(A)(i) or additional payments referred to in subsection (a)(2)(A)(ii).
“(2) Limitation.—In revising the payment methodology under paragraph (1), in no case may the estimated aggregate payments for drugs and biologicals under the revised system (including additional payments referred to in subsection (a)(3)(A)(ii)) exceed the aggregate amount of payment for such drugs and biologicals, as projected by the Secretary, that would have been made under the payment methodology in effect under such section
1842
(o).
“(c) Moratorium on Decreases in Payment Rates.—Notwithstanding any other provision of law, effective for drugs and biologicals furnished on or after January 1, 2001, the Secretary may not directly or indirectly decrease the rates of reimbursement (in effect as of such date) for drugs and biologicals under the current medicare payment methodology (provided under section 1842(o) of the Social Security Act ( U.S.C.
)) until such time as the Secretary has reviewed the report submitted under subsection (a)(2).”
Implementation of Inherent Reasonableness (IR) Authority
, div. B, § 1000(a)(6) [title II, § 223(a), (b)], Nov. 29, 1999, , 1501A–352, 1501A–353, provided that:
“(a) Limitation on Use.—The Secretary of Health and Human Services may not use, or permit fiscal intermediaries or carriers to use, the inherent reasonableness authority provided under section 1842(b)(8) of the Social Security Act ( U.S.C.
) until after—
“(1) the Comptroller General of the United States releases a report pursuant to the request for such a report made on March 1, 1999, regarding the impact of the Secretary’s, fiscal intermediaries’, and carriers’ use of such authority; and
“(2) the Secretary has published a notice of final rulemaking in the Federal Register that relates to such authority and that responds to such report and to comments received in response to the Secretary’s interim final regulation relating to such authority that was published in the Federal Register on January 7, 1998.
“(b) Reevaluation of IR Criteria.—In promulgating the final regulation under subsection (a)(2), the Secretary shall—
“(1) reevaluate the appropriateness of the criteria included in such interim final regulation for identifying payments which are excessive or deficient; and
“(2) take appropriate steps to ensure the use of valid and reliable data when exercising such authority.”
Initial Budget Neutrality
Section 4315(d) of provided that: “The Secretary, in developing a fee schedule for particular services (under the amendments made by this section [amending this section and section
of this title]), shall set amounts for the first year period to which the fee schedule applies at a level so that the total payments under title XVIII of the Social Security Act ( U.S.C. et seq.) for those services for that year period shall be approximately equal to the estimated total payments if such fee schedule had not been implemented.”
Improvements in Administration of Laboratory Tests Benefit
Section 4554 of provided that:
“(a) Selection of Regional Carriers.—
“(1) In general.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall—
“(A) divide the United States into no more than 5 regions, and
“(B) designate a single carrier for each such region, for the purpose of payment of claims under part B of title XVIII of the Social Security Act [this part] with respect to clinical diagnostic laboratory tests furnished on or after such date (not later than July 1, 1999) as the Secretary specifies.
“(2) Designation.—In designating such carriers, the Secretary shall consider, among other criteria—
“(A) a carrier’s timeliness, quality, and experience in claims processing, and
“(B) a carrier’s capacity to conduct electronic data interchange with laboratories and data matches with other carriers.
“(3) Single data resource.—The Secretary shall select one of the designated carriers to serve as a central statistical resource for all claims information relating to such clinical diagnostic laboratory tests handled by all the designated carriers under such part.
“(4) Allocation of claims.—The allocation of claims for clinical diagnostic laboratory tests to particular designated carriers shall be based on whether a carrier serves the geographic area where the laboratory specimen was collected or other method specified by the Secretary.
“(5) Secretarial exclusion.—Paragraph (1) shall not apply with respect to clinical diagnostic laboratory tests furnished by physician office laboratories if the Secretary determines that such offices would be unduly burdened by the application of billing responsibilities with respect to more than one carrier.
“(b) Adoption of National Policies for Clinical Laboratory Tests Benefit.—
“(1) In general.—Not later than January 1, 1999, the Secretary shall first adopt, consistent with paragraph (2), national coverage and administrative policies for clinical diagnostic laboratory tests under part B of title XVIII of the Social Security Act [this part], using a negotiated rulemaking process under subchapter
of chapter
of title
, United States Code.
“(2) Considerations in design of national policies.—The policies under paragraph (1) shall be designed to promote program integrity and national uniformity and simplify administrative requirements with respect to clinical diagnostic laboratory tests payable under such part in connection with the following:
“(A) Beneficiary information required to be submitted with each claim or order for laboratory tests.
“(B) The medical conditions for which a laboratory test is reasonable and necessary (within the meaning of section 1862(a)(1)(A) of the Social Security Act [section
of this title]).
“(C) The appropriate use of procedure codes in billing for a laboratory test, including the unbundling of laboratory services.
“(D) The medical documentation that is required by a medicare contractor at the time a claim is submitted for a laboratory test in accordance with section 1833(e) of the Social Security Act [section
of this title].
“(E) Recordkeeping requirements in addition to any information required to be submitted with a claim, including physicians’ obligations regarding such requirements.
“(F) Procedures for filing claims and for providing remittances by electronic media.
“(G) Limitation on frequency of coverage for the same tests performed on the same individual.
“(3) Changes in laboratory policies pending adoption of national policy.—During the period that begins on the date of the enactment of this Act [Aug. 5, 1997] and ends on the date the Secretary first implements national policies pursuant to regulations promulgated under this subsection, a carrier under such part may implement changes relating to requirements for the submission of a claim for clinical diagnostic laboratory tests.
“(4) Use of interim policies.—After the date the Secretary first implements such national policies, the Secretary shall permit any carrier to develop and implement interim policies of the type described in paragraph (1), in accordance with guidelines established by the Secretary, in cases in which a uniform national policy has not been established under this subsection and there is a demonstrated need for a policy to respond to aberrant utilization or provision of unnecessary tests. Except as the Secretary specifically permits, no policy shall be implemented under this paragraph for a period of longer than 2 years.
“(5) Interim national policies.—After the date the Secretary first designates regional carriers under subsection (a), the Secretary shall establish a process under which designated carriers can collectively develop and implement interim national policies of the type described in paragraph (1). No such policy shall be implemented under this paragraph for a period of longer than 2 years.
“(6) Biennial review process.—Not less often than once every 2 years, the Secretary shall solicit and review comments regarding changes in the national policies established under this subsection. As part of such biennial review process, the Secretary shall specifically review and consider whether to incorporat