Medicare Secondary Payer Statute and Workers Compensation Settlements

From the U.S. Code Online via GPO Access
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[Laws in effect as of January 3, 2006]
[CITE: 42USC1395y]

TITLE 42--THE PUBLIC HEALTH AND WELFARE

CHAPTER 7--SOCIAL SECURITY

SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED

Part E--Miscellaneous Provisions

Sec. 1395y. Exclusions from coverage and medicare as secondary
payer

(a) Items or services specifically excluded

Notwithstanding any other provision of this subchapter, no payment
may be made under part A or part B of this subchapter for any expenses
incurred for items or services--
(1)(A) which, except for items and services described in a
succeeding subparagraph, are not reasonable and necessary for the
diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member,
(B) in the case of items and services described in section
1395x(s)(10) of this title, which are not reasonable and necessary
for the prevention of illness,
(C) in the case of hospice care, which are not reasonable and
necessary for the palliation or management of terminal illness,
(D) in the case of clinical care items and services provided
with the concurrence of the Secretary and with respect to research
and experimentation conducted by, or under contract with, the
Medicare Payment Advisory Commission or the Secretary, which are not
reasonable and necessary to carry out the purposes of section
1395ww(e)(6) of this title,\1\
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\1\ See References in Text note below.
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(E) in the case of research conducted pursuant to section 1320b-
12 of this title, which is not reasonable and necessary to carry out
the purposes of that section,
(F) in the case of screening mammography, which is performed
more frequently than is covered under section 1395m(c)(2) of this
title or which is not conducted by a facility described in section
1395m(c)(1)(B) of this title, in the case of screening pap smear and
screening pelvic exam, which is performed more frequently than is
provided under section 1395x(nn) of this title, and, in the case of
screening for glaucoma, which is performed more frequently than is
provided under section 1395x(uu) of this title,
(G) in the case of prostate cancer screening tests (as defined
in section 1395x(oo) of this title), which are performed more
frequently than is covered under such section,
(H) in the case of colorectal cancer screening tests, which are
performed more frequently than is covered under section 1395m(d) of
this title,
(I) the frequency and duration of home health services which are
in excess of normative guidelines that the Secretary shall establish
by regulation,
(J) in the case of a drug or biological specified in section
1395w-3a(c)(6)(C) of this title for which payment is made under part
B of this subchapter that is furnished in a competitive area under
section 1395w-3b of this title, that is not furnished by an entity
under a contract under such section,
(K) in the case of an initial preventive physical examination,
which is performed not later than 6 months after the date the
individual's first coverage period begins under part B of this
subchapter,
(L) in the case of cardiovascular screening blood tests (as
defined in section 1395x(xx)(1) of this title), which are performed
more frequently than is covered under section 1395x(xx)(2) of this
title, and
(M) in the case of a diabetes screening test (as defined in
section 1395x(yy)(1) of this title), which is performed more
frequently than is covered under section 1395x(yy)(3) of this title;
(2) for which the individual furnished such items or services
has no legal obligation to pay, and which no other person (by reason
of such individual's membership in a prepayment plan or otherwise)
has a legal obligation to provide or pay for, except in the case of
Federally qualified health center services;
(3) which are paid for directly or indirectly by a governmental
entity (other than under this chapter and other than under a health
benefits or insurance plan established for employees of such an
entity), except in the case of rural health clinic services, as
defined in section 1395x(aa)(1) of this title, in the case of
Federally qualified health center services, as defined in section
1395x(aa)(3) of this title, in the case of services for which
payment may be made under section 1395qq(e) of this title, and in
such other cases as the Secretary may specify;
(4) which are not provided within the United States (except for
inpatient hospital services furnished outside the United States
under the conditions described in section 1395f(f) of this title
and, subject to such conditions, limitations, and requirements as
are provided under or pursuant to this subchapter, physicians'
services and ambulance services furnished an individual in
conjunction with such inpatient hospital services but only for the
period during which such inpatient hospital services were
furnished);
(5) which are required as a result of war, or of an act of war,
occurring after the effective date of such individual's current
coverage under such part;
(6) which constitute personal comfort items (except, in the case
of hospice care, as is otherwise permitted under paragraph (1)(C));
(7) where such expenses are for routine physical checkups,
eyeglasses (other than eyewear described in section 1395x(s)(8) of
this title) or eye examinations for the purpose of prescribing,
fitting, or changing eyeglasses, procedures performed (during the
course of any eye examination) to determine the refractive state of
the eyes, hearing aids or examinations therefor, or immunizations
(except as otherwise allowed under section 1395x(s)(10) of this
title and subparagraph (B), (F), (G), (H), or (K) of paragraph (1));
(8) where such expenses are for orthopedic shoes or other
supportive devices for the feet, other than shoes furnished pursuant
to section 1395x(s)(12) of this title;
(9) where such expenses are for custodial care (except, in the
case of hospice care, as is otherwise permitted under paragraph
(1)(C));
(10) where such expenses are for cosmetic surgery or are
incurred in connection therewith, except as required for the prompt
repair of accidental injury or for improvement of the functioning of
a malformed body member;
(11) where such expenses constitute charges imposed by immediate
relatives of such individual or members of his household;
(12) where such expenses are for services in connection with the
care, treatment, filling, removal, or replacement of teeth or
structures directly supporting teeth, except that payment may be
made under part A of this subchapter in the case of inpatient
hospital services in connection with the provision of such dental
services if the individual, because of his underlying medical
condition and clinical status or because of the severity of the
dental procedure, requires hospitalization in connection with the
provision of such services;
(13) where such expenses are for--
(A) the treatment of flat foot conditions and the
prescription of supportive devices therefor,
(B) the treatment of subluxations of the foot, or
(C) routine foot care (including the cutting or removal of
corns or calluses, the trimming of nails, and other routine
hygienic care);

(14) which are other than physicians' services (as defined in
regulations promulgated specifically for purposes of this
paragraph), services described by section 1395x(s)(2)(K) of this
title, certified nurse-midwife services, qualified psychologist
services, and services of a certified registered nurse anesthetist,
and which are furnished to an individual who is a patient of a
hospital or critical access hospital by an entity other than the
hospital or critical access hospital, unless the services are
furnished under arrangements (as defined in section 1395x(w)(1) of
this title) with the entity made by the hospital or critical access
hospital;
(15)(A) which are for services of an assistant at surgery in a
cataract operation (including subsequent insertion of an intraocular
lens) unless, before the surgery is performed, the appropriate
utilization and quality control peer review organization (under part
B of subchapter XI of this chapter) or a carrier under section 1395u
of this title has approved of the use of such an assistant in the
surgical procedure based on the existence of a complicating medical
condition, or
(B) which are for services of an assistant at surgery to which
section 1395w-4(i)(2)(B) of this title applies;
(16) in the case in which funds may not be used for such items
and services under the Assisted Suicide Funding Restriction Act of
1997 [42 U.S.C. 14401 et seq.];
(17) where the expenses are for an item or service furnished in
a competitive acquisition area (as established by the Secretary
under section 1395w-3(a) of this title) by an entity other than an
entity with which the Secretary has entered into a contract under
section 1395w-3(b) of this title for the furnishing of such an item
or service in that area, unless the Secretary finds that the
expenses were incurred in a case of urgent need, or in other
circumstances specified by the Secretary;
(18) which are covered skilled nursing facility services
described in section 1395yy(e)(2)(A)(i) of this title and which are
furnished to an individual who is a resident of a skilled nursing
facility during a period in which the resident is provided covered
post-hospital extended care services (or, for services described in
section 1395x(s)(2)(D) of this title, which are furnished to such an
individual without regard to such period), by an entity other than
the skilled nursing facility, unless the services are furnished
under arrangements (as defined in section 1395x(w)(1) of this title)
with the entity made by the skilled nursing facility;
(19) which are for items or services which are furnished
pursuant to a private contract described in section 1395a(b) of this
title;
(20) in the case of outpatient occupational therapy services or
outpatient physical therapy services furnished as an incident to a
physician's professional services (as described in section
1395x(s)(2)(A) of this title), that do not meet the standards and
conditions (other than any licensing requirement specified by the
Secretary) under the second sentence of section 1395x(p) of this
title (or under such sentence through the operation of section
1395x(g) of this title) as such standards and conditions would apply
to such therapy services if furnished by a therapist;
(21) where such expenses are for home health services (including
medical supplies described in section 1395x(m)(5) of this title, but
excluding durable medical equipment to the extent provided for in
such section) furnished to an individual who is under a plan of care
of the home health agency if the claim for payment for such services
is not submitted by the agency; or
(22) subject to subsection (h) of this section, for which a
claim is submitted other than in an electronic form specified by the
Secretary.

Paragraph (7) shall not apply to Federally qualified health center
services described in section 1395x(aa)(3)(B) of this title. In making a
national coverage determination (as defined in paragraph (1)(B) of
section 1395ff(f) of this title) the Secretary shall ensure consistent
with subsection (l) of this section that the public is afforded notice
and opportunity to comment prior to implementation by the Secretary of
the determination; meetings of advisory committees with respect to the
determination are made on the record; in making the determination, the
Secretary has considered applicable information (including clinical
experience and medical, technical, and scientific evidence) with respect
to the subject matter of the determination; and in the determination,
provide a clear statement of the basis for the determination (including
responses to comments received from the public), the assumptions
underlying that basis, and make available to the public the data (other
than proprietary data) considered in making the determination.

(b) Medicare as secondary payer

(1) Requirements of group health plans

(A) Working aged under group health plans

(i) In general

A group health plan--
(I) may not take into account that an individual (or
the individual's spouse) who is covered under the plan
by virtue of the individual's current employment status
with an employer is entitled to benefits under this
subchapter under section 426(a) of this title, and
(II) shall provide that any individual age 65 or
older (and the spouse age 65 or older of any individual)
who has current employment status with an employer shall
be entitled to the same benefits under the plan under
the same conditions as any such individual (or spouse)
under age 65.
(ii) Exclusion of group health plan of a small
employer

Clause (i) shall not apply to a group health plan unless
the plan is a plan of, or contributed to by, an employer
that has 20 or more employees for each working day in each
of 20 or more calendar weeks in the current calendar year or
the preceding calendar year.
(iii) Exception for small employers in multiemployer
or multiple employer group health plans

Clause (i) also shall not apply with respect to
individuals enrolled in a multiemployer or multiple employer
group health plan if the coverage of the individuals under
the plan is by virtue of current employment status with an
employer that does not have 20 or more individuals in
current employment status for each working day in each of 20
or more calendar weeks in the current calendar year and the
preceding calendar year; except that the exception provided
in this clause shall only apply if the plan elects treatment
under this clause.
(iv) Exception for individuals with end stage renal
disease

Subparagraph (C) shall apply instead of clause (i) to an
item or service furnished in a month to an individual if for
the month the individual is, or (without regard to
entitlement under section 426 of this title) would upon
application be, entitled to benefits under section 426-1 of
this title.
(v) ``Group health plan'' defined

In this subparagraph, and subparagraph (C), the term
``group health plan'' has the meaning given such term in
section 5000(b)(1) of the Internal Revenue Code of 1986,
without regard to section 5000(d) of such Code.

(B) Disabled individuals in large group health plans

(i) In general

A large group health plan (as defined in clause (iii))
may not take into account that an individual (or a member of
the individual's family) who is covered under the plan by
virtue of the individual's current employment status with an
employer is entitled to benefits under this subchapter under
section 426(b) of this title.
(ii) Exception for individuals with end stage renal
disease

In this subparagraph, the term ``large group health
plan'' has the meaning given such term in section 5000(b)(2)
of the Internal Revenue Code of 1986, without regard to
section 5000(d) of such Code.

A group health plan (as defined in subparagraph (A)(v))--
(i) may not take into account that an individual is
entitled to or eligible for benefits under this subchapter
under section 426-1 of this title during the 12-month period
which begins with the first month in which the individual
becomes entitled to benefits under part A of this subchapter
under the provisions of section 426-1 of this title, or, if
earlier, the first month in which the individual would have
been entitled to benefits under such part under the
provisions of section 426-1 of this title if the individual
had filed an application for such benefits; and
(ii) may not differentiate in the benefits it provides
between individuals having end stage renal disease and other
individuals covered by such plan on the basis of the
existence of end stage renal disease, the need for renal
dialysis, or in any other manner;

except that clause (ii) shall not prohibit a plan from paying
benefits secondary to this subchapter when an individual is
entitled to or eligible for benefits under this subchapter under
section 426-1 of this title after the end of the 12-month period
described in clause (i). Effective for items and services
furnished on or after February 1, 1991, and before August 5,
1997,\2\ (with respect to periods beginning on or after February
1, 1990), this subparagraph shall be applied by substituting
``18-month'' for ``12-month'' each place it appears. Effective
for items and services furnished on or after August 5, 1997,\2\
(with respect to periods beginning on or after the date that is
18 months prior to August 5, 1997), clauses (i) and (ii) shall
be applied by substituting ``30-month'' for ``12-month'' each
place it appears.
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\2\ So in original. The comma probably should not appear.
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(D) Treatment of certain members of religious orders

In this subsection, an individual shall not be considered to
be employed, or an employee, with respect to the performance of
services as a member of a religious order which are considered
employment only by virtue of an election made by the religious
order under section 3121(r) of the Internal Revenue Code of
1986.

(E) General provisions

For purposes of this subsection:
(i) Aggregation rules

(I) All employers treated as a single employer under
subsection (a) or (b) of section 52 of the Internal
Revenue Code of 1986 shall be treated as a single
employer.
(II) All employees of the members of an affiliated
service group (as defined in section 414(m) of such
Code) shall be treated as employed by a single employer.
(III) Leased employees (as defined in section
414(n)(2) of such Code) shall be treated as employees of
the person for whom they perform services to the extent
they are so treated under section 414(n) of such Code.

In applying sections of the Internal Revenue Code of 1986
under this clause, the Secretary shall rely upon regulations
and decisions of the Secretary of the Treasury respecting
such sections.
(ii) ``Current employment status'' defined

An individual has ``current employment status'' with an
employer if the individual is an employee, is the employer,
or is associated with the employer in a business
relationship.
(iii) Treatment of self-employed persons as
employers

The term ``employer'' includes a self-employed person.

(F) Limitation on beneficiary liability

An individual who is entitled to benefits under this
subchapter and is furnished an item or service for which such
benefits are incorrectly paid is not liable for repayment of
such benefits under this paragraph unless payment of such
benefits was made to the individual.

(2) Medicare secondary payer

(A) In general

Payment under this subchapter may not be made, except as
provided in subparagraph (B), with respect to any item or
service to the extent that--
(i) payment has been made, or can reasonably be expected
to be made, with respect to the item or service as required
under paragraph (1), or
(ii) payment has been made, or can reasonably be
expected to be made under a workmen's compensation law or
plan of the United States or a State or under an automobile
or liability insurance policy or plan (including a self-
insured plan) or under no fault insurance.

In this subsection, the term ``primary plan'' means a group
health plan or large group health plan, to the extent that
clause (i) applies, and a workmen's compensation law or plan, an
automobile or liability insurance policy or plan (including a
self-insured plan) or no fault insurance, to the extent that
clause (ii) applies. An entity that engages in a business,
trade, or profession shall be deemed to have a self-insured plan
if it carries its own risk (whether by a failure to obtain
insurance, or otherwise) in whole or in part.

(B) Conditional payment

(i) Authority to make conditional payment

The Secretary may make payment under this subchapter
with respect to an item or service if a primary plan
described in subparagraph (A)(ii) has not made or cannot
reasonably be expected to make payment with respect to such
item or service promptly (as determined in accordance with
regulations). Any such payment by the Secretary shall be
conditioned on reimbursement to the appropriate Trust Fund
in accordance with the succeeding provisions of this
subsection.
(ii) Repayment required

A primary plan, and an entity that receives payment from
a primary plan, shall reimburse the appropriate Trust Fund
for any payment made by the Secretary under this subchapter
with respect to an item or service if it is demonstrated
that such primary plan has or had a responsibility to make
payment with respect to such item or service. A primary
plan's responsibility for such payment may be demonstrated
by a judgment, a payment conditioned upon the recipient's
compromise, waiver, or release (whether or not there is a
determination or admission of liability) of payment for
items or services included in a claim against the primary
plan or the primary plan's insured, or by other means. If
reimbursement is not made to the appropriate Trust Fund
before the expiration of the 60-day period that begins on
the date notice of, or information related to, a primary
plan's responsibility for such payment or other information
is received, the Secretary may charge interest (beginning
with the date on which the notice or other information is
received) on the amount of the reimbursement until
reimbursement is made (at a rate determined by the Secretary
in accordance with regulations of the Secretary of the
Treasury applicable to charges for late payments).
(iii) Action by United States

In order to recover payment made under this subchapter
for an item or service, the United States may bring an
action against any or all entities that are or were required
or responsible (directly, as an insurer or self-insurer, as
a third-party administrator, as an employer that sponsors or
contributes to a group health plan, or large group health
plan, or otherwise) to make payment with respect to the same
item or service (or any portion thereof) under a primary
plan. The United States may, in accordance with paragraph
(3)(A) collect double damages against any such entity. In
addition, the United States may recover under this clause
from any entity that has received payment from a primary
plan or from the proceeds of a primary plan's payment to any
entity. The United States may not recover from a third-party
administrator under this clause in cases where the third-
party administrator would not be able to recover the amount
at issue from the employer or group health plan and is not
employed by or under contract with the employer or group
health plan at the time the action for recovery is initiated
by the United States or for whom it provides administrative
services due to the insolvency or bankruptcy of the employer
or plan.
(iv) Subrogation rights

The United States shall be subrogated (to the extent of
payment made under this subchapter for such an item or
service) to any right under this subsection of an individual
or any other entity to payment with respect to such item or
service under a primary plan.
(v) Waiver of rights

The Secretary may waive (in whole or in part) the
provisions of this subparagraph in the case of an individual
claim if the Secretary determines that the waiver is in the
best interests of the program established under this
subchapter.
(vi) Claims-filing period

Notwithstanding any other time limits that may exist for
filing a claim under an employer group health plan, the
United States may seek to recover conditional payments in
accordance with this subparagraph where the request for
payment is submitted to the entity required or responsible
under this subsection to pay with respect to the item or
service (or any portion thereof) under a primary plan within
the 3-year period beginning on the date on which the item or
service was furnished.

The Secretary may not fail to make payment under
subparagraph (A) solely on the ground that an individual failed
to complete a questionnaire concerning the existence of a
primary plan.

(3) Enforcement

(A) Private cause of action

There is established a private cause of action for damages
(which shall be in an amount double the amount otherwise
provided) in the case of a primary plan which fails to provide
for primary payment (or appropriate reimbursement) in accordance
with paragraphs (1) and (2)(A).

(B) Reference to excise tax with respect to nonconforming group
health plans

For provision imposing an excise tax with respect to
nonconforming group health plans, see section 5000 of the
Internal Revenue Code of 1986.

It is unlawful for an employer or other entity to offer any
financial or other incentive for an individual entitled to
benefits under this subchapter not to enroll (or to terminate
enrollment) under a group health plan or a large group health
plan which would (in the case of such enrollment) be a primary
plan (as defined in paragraph (2)(A)). Any entity that violates
the previous sentence is subject to a civil money penalty of not
to exceed $5,000 for each such violation. The provisions of
section 1320a-7a 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 1320a-7a(a) of this title.

(4) Coordination of benefits

Where payment for an item or service by a primary plan is less
than the amount of the charge for such item or service and is not
payment in full, payment may be made under this subchapter (without
regard to deductibles and coinsurance under this subchapter) for the
remainder of such charge, but--
(A) payment under this subchapter may not exceed an amount
which would be payable under this subchapter for such item or
service if paragraph (2)(A) did not apply; and
(B) payment under this subchapter, when combined with the
amount payable under the primary plan, may not exceed--
(i) in the case of an item or service payment for which
is determined under this subchapter on the basis of
reasonable cost (or other cost-related basis) or under
section 1395ww of this title, the amount which would be
payable under this subchapter on such basis, and
(ii) in the case of an item or service for which payment
is authorized under this subchapter on another basis--
(I) the amount which would be payable under the
primary plan (without regard to deductibles and
coinsurance under such plan), or
(II) the reasonable charge or other amount which
would be payable under this subchapter (without regard
to deductibles and coinsurance under this subchapter),

whichever is greater.

(5) Identification of secondary payer situations

(A) Requesting matching information

(i) Commissioner of Social Security

The Commissioner of Social Security shall, not less
often than annually, transmit to the Secretary of the
Treasury a list of the names and TINs of medicare
beneficiaries (as defined in section 6103(l)(12) of the
Internal Revenue Code of 1986) and request that the
Secretary disclose to the Commissioner the information
described in subparagraph (A) of such section.
(ii) Administrator

The Administrator of the Centers for Medicare & Medicaid
Services shall request, not less often than annually, the
Commissioner of the Social Security Administration to
disclose to the Administrator the information described in
subparagraph (B) of section 6103(l)(12) of the Internal
Revenue Code of 1986.

(B) Disclosure to fiscal intermediaries and carriers

In addition to any other information provided under this
subchapter to fiscal intermediaries and carriers, the
Administrator shall disclose to such intermediaries and carriers
(or to such a single intermediary or carrier as the Secretary
may designate) the information received under subparagraph (A)
for purposes of carrying out this subsection.

(i) In general

With respect to each individual (in this subparagraph
referred to as an ``employee'') who was furnished a written
statement under section 6051 of the Internal Revenue Code of
1986 by a qualified employer (as defined in section
6103(l)(12)(E)(iii) of such Code), as disclosed under
subparagraph (B), the appropriate fiscal intermediary or
carrier shall contact the employer in order to determine
during what period the employee or employee's spouse may be
(or have been) covered under a group health plan of the
employer and the nature of the coverage that is or was
provided under the plan (including the name, address, and
identifying number of the plan).
(ii) Employer response

Within 30 days of the date of receipt of the inquiry,
the employer shall notify the intermediary or carrier making
the inquiry as to the determinations described in clause
(i). An employer (other than a Federal or other governmental
entity) who willfully or repeatedly fails to provide timely
and accurate notice in accordance with the previous sentence
shall be subject to a civil money penalty of not to exceed
$1,000 for each individual with respect to which such an
inquiry is made. The provisions of section 1320a-7a 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 1320a-7a(a) of this title.

(D) Obtaining information from beneficiaries

Before an individual applies for benefits under part A of
this subchapter or enrolls under part B of this subchapter, the
Administrator shall mail the individual a questionnaire to
obtain information on whether the individual is covered under a
primary plan and the nature of the coverage provided under the
plan, including the name, address, and identifying number of the
plan.

(6) Screening requirements for providers and suppliers

(A) In general

Notwithstanding any other provision of this subchapter, no
payment may be made for any item or service furnished under part
B of this subchapter unless the entity furnishing such item or
service completes (to the best of its knowledge and on the basis
of information obtained from the individual to whom the item or
service is furnished) the portion of the claim form relating to
the availability of other health benefit plans.

(B) Penalties

An entity that knowingly, willfully, and repeatedly fails to
complete a claim form in accordance with subparagraph (A) or
provides inaccurate information relating to the availability of
other health benefit plans on a claim form under such
subparagraph shall be subject to a civil money penalty of not to
exceed $2,000 for each such incident. The provisions of section
1320a-7a 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 1320a-7a(a) of this title.

No payment may be made under part B of this subchapter for any
expenses incurred for--
(1) a drug product--
(A) which is described in section 107(c)(3) of the Drug
Amendments of 1962,
(B) which may be dispensed only upon prescription,
(C) for which the Secretary has issued a notice of an
opportunity for a hearing under subsection (e) of section 355 of
title 21 on a proposed order of the Secretary to withdraw
approval of an application for such drug product under such
section because the Secretary has determined that the drug is
less than effective for all conditions of use prescribed,
recommended, or suggested in its labeling, and
(D) for which the Secretary has not determined there is a
compelling justification for its medical need; and

(2) any other drug product--
(A) which is identical, related, or similar (as determined
in accordance with section 310.6 of title 21 of the Code of
Federal Regulations) to a drug product described in paragraph
(1), and
(B) for which the Secretary has not determined there is a
compelling justification for its medical need,

until such time as the Secretary withdraws such proposed order.

(d) Items or services provided for emergency medical conditions

For purposes of subsection (a)(1)(A) of this section, in the case of
any item or service that is required to be provided pursuant to section
1395dd of this title to an individual who is entitled to benefits under
this subchapter, determinations as to whether the item or service is
reasonable and necessary shall be made on the basis of the information
available to the treating physician or practitioner (including the
patient's presenting symptoms or complaint) at the time the item or
service was ordered or furnished by the physician or practitioner (and
not on the patient's principal diagnosis). When making such
determinations with respect to such an item or service, the Secretary
shall not consider the frequency with which the item or service was
provided to the patient before or after the time of the admission or
visit.

(e) Item or service by excluded individual or entity or at direction of
excluded physician; limitation of liability of beneficiaries
with respect to services furnished by excluded individuals and
entities

(1) No payment may be made under this subchapter with respect to any
item or service (other than an emergency item or service, not including
items or services furnished in an emergency room of a hospital)
furnished--
(A) by an individual or entity during the period when such
individual or entity is excluded pursuant to section 1320a-7, 1320a-
7a, 1320c-5 or 1395u(j)(2) of this title from participation in the
program under this subchapter; or
(B) at the medical direction or on the prescription of a
physician during the period when he is excluded pursuant to section
1320a-7, 1320a-7a, 1320c-5 or 1395u(j)(2) of this title from
participation in the program under this subchapter and when the
person furnishing such item or service knew or had reason to know of
the exclusion (after a reasonable time period after reasonable
notice has been furnished to the person).

(2) Where an individual eligible for benefits under this subchapter
submits a claim for payment for items or services furnished by an
individual or entity excluded from participation in the programs under
this subchapter, pursuant to section 1320a-7, 1320a-7a, 1320c-5, 1320c-9
(as in effect on September 2, 1982), 1395u(j)(2), 1395y(d) (as in effect
on August 18, 1987), or 1395cc of this title, and such beneficiary did
not know or have reason to know that such individual or entity was so
excluded, then, to the extent permitted by this subchapter, and
notwithstanding such exclusion, payment shall be made for such items or
services. In each such case the Secretary shall notify the beneficiary
of the exclusion of the individual or entity furnishing the items or
services. Payment shall not be made for items or services furnished by
an excluded individual or entity to a beneficiary after a reasonable
time (as determined by the Secretary in regulations) after the Secretary
has notified the beneficiary of the exclusion of that individual or
entity.

(f) Utilization guidelines for provision of home health services

The Secretary shall establish utilization guidelines for the
determination of whether or not payment may be made, consistent with
paragraph (1)(A) of subsection (a) of this section, under part A or part
B of this subchapter for expenses incurred with respect to the provision
of home health services, and shall provide for the implementation of
such guidelines through a process of selective postpayment coverage
review by intermediaries or otherwise.

(g) Contracts with utilization and quality control peer review
organizations

The Secretary shall, in making the determinations under paragraphs
(1) and (9) of subsection (a) of this section, and for the purposes of
promoting the effective, efficient, and economical delivery of health
care services, and of promoting the quality of services of the type for
which payment may be made under this subchapter, enter into contracts
with utilization and quality control peer review organizations pursuant
to part B of subchapter XI of this chapter.

(h) Waiver of electronic form requirement

(1) The Secretary--
(A) shall waive the application of subsection (a)(22) of this
section in cases in which--
(i) there is no method available for the submission of
claims in an electronic form; or
(ii) the entity submitting the claim is a small provider of
services or supplier; and

(B) may waive the application of such subsection in such unusual
cases as the Secretary finds appropriate.

(2) For purposes of this subsection, the term ``small provider of
services or supplier'' means--
(A) a provider of services with fewer than 25 full-time
equivalent employees; or
(B) a physician, practitioner, facility, or supplier (other than
provider of services) with fewer than 10 full-time equivalent
employees.

(i) Awards and contracts for original research and experimentation of
new and existing medical procedures; conditions

In order to supplement the activities of the Medicare Payment
Advisory Commission under section 1395ww(e) of this title in assessing
the safety, efficacy, and cost-effectiveness of new and existing medical
procedures, the Secretary may carry out, or award grants or contracts
for, original research and experimentation of the type described in
clause (ii) of section 1395ww(e)(6)(E) of this title with respect to
such a procedure if the Secretary finds that--
(1) such procedure is not of sufficient commercial value to
justify research and experimentation by a commercial organization;
(2) research and experimentation with respect to such procedure
is not of a type that may appropriately be carried out by an
institute, division, or bureau of the National Institutes of Health;
and
(3) such procedure has the potential to be more cost-effective
in the treatment of a condition than procedures currently in use
with respect to such condition.

(j) Nonvoting members and experts

(1) Any advisory committee appointed to advise the Secretary on
matters relating to the interpretation, application, or implementation
of subsection (a)(1) of this section shall assure the full participation
of a nonvoting member in the deliberations of the advisory committee,
and shall provide such nonvoting member access to all information and
data made available to voting members of the advisory committee, other
than information that--
(A) is exempt from disclosure pursuant to subsection (a) of
section 552 of title 5 by reason of subsection (b)(4) of such
section (relating to trade secrets); or
(B) the Secretary determines would present a conflict of
interest relating to such nonvoting member.

(2) If an advisory committee described in paragraph (1) organizes
into panels of experts according to types of items or services
considered by the advisory committee, any such panel of experts may
report any recommendation with respect to such items or services
directly to the Secretary without the prior approval of the advisory
committee or an executive committee thereof.

(k) Dental benefits under group health plans

(1) Subject to paragraph (2), a group health plan (as defined in
subsection (a)(1)(A)(v) \3\ of this section) providing supplemental or
secondary coverage to individuals also entitled to services under this
subchapter shall not require a medicare claims determination under this
subchapter for dental benefits specifically excluded under subsection
(a)(12) of this section as a condition of making a claims determination
for such benefits under the group health plan.
---------------------------------------------------------------------------
\3\ So in original. Probably should be ``(b)(1)(A)(v)''.
---------------------------------------------------------------------------
(2) A group health plan may require a claims determination under
this subchapter in cases involving or appearing to involve inpatient
dental hospital services or dental services expressly covered under this
subchapter pursuant to actions taken by the Secretary.

(l) National and local coverage determination process

(1) Factors and evidence used in making national coverage
determinations

The Secretary shall make available to the public the factors
considered in making national coverage determinations of whether an
item or service is reasonable and necessary. The Secretary shall
develop guidance documents to carry out this paragraph in a manner
similar to the development of guidance documents under section
371(h) of title 21.

(2) Timeframe for decisions on requests for national
coverage determinations

In the case of a request for a national coverage determination
that--
(A) does not require a technology assessment from an outside
entity or deliberation from the Medicare Coverage Advisory
Committee, the decision on the request shall be made not later
than 6 months after the date of the request; or
(B) requires such an assessment or deliberation and in which
a clinical trial is not requested, the decision on the request
shall be made not later than 9 months after the date of the
request.

(3) Process for public comment in national coverage
determinations

(A) Period for proposed decision

Not later than the end of the 6-month period (or 9-month
period for requests described in paragraph (2)(B)) that begins
on the date a request for a national coverage determination is
made, the Secretary shall make a draft of proposed decision on
the request available to the public through the Internet website
of the Centers for Medicare & Medicaid Services or other
appropriate means.

(B) 30-day period for public comment

Beginning on the date the Secretary makes a draft of the
proposed decision available under subparagraph (A), the
Secretary shall provide a 30-day period for public comment on
such draft.

Not later than 60 days after the conclusion of the 30-day
period referred to under subparagraph (B), the Secretary shall--
(i) make a final decision on the request;
(ii) include in such final decision summaries of the
public comments received and responses to such comments;
(iii) make available to the public the clinical evidence
and other data used in making such a decision when the
decision differs from the recommendations of the Medicare
Coverage Advisory Committee; and
(iv) in the case of a final decision under clause (i) to
grant the request for the national coverage determination,
the Secretary shall assign a temporary or permanent code
(whether existing or unclassified) and implement the coding
change.

(4) Consultation with outside experts in certain national
coverage determinations

With respect to a request for a national coverage determination
for which there is not a review by the Medicare Coverage Advisory
Committee, the Secretary shall consult with appropriate outside
clinical experts.

(5) Local coverage determination process

(A) Plan to promote consistency of coverage determinations

The Secretary shall develop a plan to evaluate new local
coverage determinations to determine which determinations should
be adopted nationally and to what extent greater consistency can
be achieved among local coverage determinations.

(B) Consultation

The Secretary shall require the fiscal intermediaries or
carriers providing services within the same area to consult on
all new local coverage determinations within the area.

The Secretary should serve as a center to disseminate
information on local coverage determinations among fiscal
intermediaries and carriers to reduce duplication of effort.

(6) National and local coverage determination defined

For purposes of this subsection--

(A) National coverage determination

The term ``national coverage determination'' means a
determination by the Secretary with respect to whether or not a
particular item or service is covered nationally under this
subchapter.

(B) Local coverage determination

The term ``local coverage determination'' has the meaning
given that in section 1395ff(f)(2)(B) of this title.

(m) Coverage of routine costs associated with certain clinical trials of
category A devices

(1) In general

In the case of an individual entitled to benefits under part A
of this subchapter, or enrolled under part B of this subchapter, or
both who participates in a category A clinical trial, the Secretary
shall not exclude under subsection (a)(1) of this section payment
for coverage of routine costs of care (as defined by the Secretary)
furnished to such individual in the trial.

(2) Category A clinical trial

For purposes of paragraph (1), a ``category A clinical trial''
means a trial of a medical device if--
(A) the trial is of an experimental/investigational
(category A) medical device (as defined in regulations under
section 405.201(b) of title 42, Code of Federal Regulations (as
in effect as of September 1, 2003));
(B) the trial meets criteria established by the Secretary to
ensure that the trial conforms to appropriate scientific and
ethical standards; and
(C) in the case of a trial initiated before January 1, 2010,
the device involved in the trial has been determined by the
Secretary to be intended for use in the diagnosis, monitoring,
or treatment of an immediately life-threatening disease or
condition.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1862, as added Pub. L. 89-97,
title I, Sec. 102(a), July 30, 1965, 79 Stat. 325; amended Pub. L. 90-
248, title I, Secs. 127(b), 128, Jan. 2, 1968, 81 Stat. 846, 847; Pub.
L. 92-603, title II, Secs. 210, 211(c)(1), 229(a), 256(c), Oct. 30,
1972, 86 Stat. 1382, 1384, 1408, 1447; Pub. L. 93-233, Sec. 18(k)(3),
Dec. 31, 1973, 87 Stat. 970; Pub. L. 93-480, Sec. 4(a), Oct. 26, 1974,
88 Stat. 1454; Pub. L. 94-182, title I, Sec. 103, Dec. 31, 1975, 89
Stat. 1051; Pub. L. 95-142, Secs. 7(a), 13(a), (b)(1), (2), Oct. 25,
1977, 91 Stat. 1192, 1197, 1198; Pub. L. 95-210, Sec. 1(f), Dec. 13,
1977, 91 Stat. 1487; Pub. L. 96-272, title III, Sec. 308(a), June 17,
1980, 94 Stat. 531; Pub. L. 96-499, title IX, Secs. 913(b), 936(c),
939(a), 953, Dec. 5, 1980, 94 Stat. 2620, 2640, 2647; Pub. L. 96-611,
Sec. 1(a)(3), Dec. 28, 1980, 94 Stat. 3566; Pub. L. 97-35, title XXI,
Secs. 2103(a)(1), 2146(a), 2152(a), Aug. 13, 1981, 95 Stat. 787, 800,
802; Pub. L. 97-248, title I, Secs. 116(b), 122(f), (g)(1), 128(a)(2)-
(4), 142, 148(a), Sept. 3, 1982, 96 Stat. 353, 362, 366, 381, 394; Pub.
L. 97-448, title III, Sec. 309(b)(10), Jan. 12, 1983, 96 Stat. 2409;
Pub. L. 98-21, title VI, Secs. 601(f), 602(e), Apr. 20, 1983, 97 Stat.
162, 163; Pub. L. 98-369, div. B, title III, Secs. 2301(a), 2304(c),
2313(c), 2344(a)-(c), 2354(b)(30), (31), July 18, 1984, 98 Stat. 1063,
1068, 1078, 1095, 1101, 1102; Pub. L. 99-272, title IX, Secs. 9201(a),
9307(a), 9401(c)(1), Apr. 7, 1986, 100 Stat. 170, 193, 199; Pub. L. 99-
509, title IX, Secs. 9316(b), 9319(a), (b), 9320(h)(1), 9343(c)(1), Oct.
21, 1986, 100 Stat. 2007, 2010, 2011, 2016, 2040; Pub. L. 99-514,
Sec. 2, Oct. 22, 1986, 100 Stat. 2095; Pub. L. 100-93, Secs. 8(c)(1),
(3), 10, Aug. 18, 1987, 101 Stat. 692, 693, 696; Pub. L. 100-203, title
IV, Secs. 4009(j)(6)(C), 4034(a), 4036(a)(1), 4039(c)(1), 4072(c),
4085(i)(15), (16), Dec. 22, 1987, 101 Stat. 1330-59, 1330-77, 1330-79,
1330-82, 1330-117, 1330-133; Pub. L. 100-360, title II, Secs. 202(d),
204(d)(2), 205(e)(1), title IV, Sec. 411(f)(4)(D)(i), (i)(4)(D), July 1,
1988, 102 Stat. 715, 729, 731, 778, 790; Pub. L. 100-485, title VI,
Sec. 608(d)(7), (24)(C), Oct. 13, 1988, 102 Stat. 2415, 2421; Pub. L.
101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L.
101-239, title VI, Secs. 6003(g)(3)(D)(xi), 6103(b)(3)(B), 6115(b),
6202(a)(2)(A), (b)(1), (e)(1), 6411(d)(2), Dec. 19, 1989, 103 Stat.
2154, 2199, 2219, 2228, 2229, 2234, 2271; Pub. L. 101-508, title IV,
Secs. 4107(b), 4153(b)(2)(B), 4157(c)(1), 4161(a)(3)(C), 4163(d)(2),
4203(a)(1), (b), (c)(1), 4204(g)(1), Nov. 5, 1990, 104 Stat. 1388-62,
1388-84, 1388-89, 1388-94, 1388-100, 1388-107, 1388-112; Pub. L. 103-66,
title XIII, Secs. 13561(a)(1), (b)-(d)(1), (e)(1), 13581(b)(1), Aug. 10,
1993, 107 Stat. 593, 594, 611; Pub. L. 103-432, title I,
Secs. 145(c)(1), 147(e)(6), 151(a)(1)(A), (C), (2)(A), (b)(3)(A), (B),
(c)(1), (4)-(6), (9)(B), 156(a)(2)(D), 157(b)(7), Oct. 31, 1994, 108
Stat. 4427, 4430, 4432-4436, 4441, 4442; Pub. L. 104-224, Sec. 1, Oct.
2, 1996, 110 Stat. 3031; Pub. L. 104-226, Sec. 1(b)(1), Oct. 2, 1996,
110 Stat. 3033; Pub. L. 105-12, Sec. 9(a)(1), Apr. 30, 1997, 111 Stat.
26; Pub. L. 105-33, title IV, Secs. 4022(b)(1)(B), 4102(c), 4103(c),
4104(c)(3), 4201(c)(1), 4319(b), 4432(b)(1), 4507(a)(2)(B),
4511(a)(2)(C), 4541(b), 4603(c)(2)(C), 4614(a), 4631(a)(1), (b), (c)(1),
4632(a), 4633(a), (b), Aug. 5, 1997, 111 Stat. 354, 361, 362, 365, 373,
394, 420, 441, 442, 456, 471, 474, 486, 487; Pub. L. 106-113, div. B,
Sec. 1000(a)(6) [title III, Secs. 305(b), 321(k)(10)], Nov. 29, 1999,
113 Stat. 1536, 1501A-362, 1501A-367; Pub. L. 106-554, Sec. 1(a)(6)
[title I, Sec. 102(c), title III, Sec. 313(a), title IV, Sec. 432(b)(1),
title V, Sec. 522(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A-468, 2763A-
499, 2763A-526, 2763A-546; Pub. L. 107-105, Sec. 3(a), Dec. 27, 2001,
115 Stat. 1006; Pub. L. 108-173, title III, Secs. 301(a)-(c),
303(i)(3)(B), title VI, Secs. 611(d)(1), 612(c), 613(c), title VII,
Sec. 731(a)(1), (b)(1), title IX, Secs. 900(e)(1)(J), 944(a)(1), 948(a),
950(a), Dec. 8, 2003, 117 Stat. 2221, 2222, 2254, 2304-2306, 2349, 2351,
2372, 2422, 2425, 2426.)

References in Text

Parts A and B of this subchapter, referred to in text, are
classified to sections 1395c et seq. and 1395j et seq., respectively, of
this title.
Section 1395ww(e)(6) of this title, referred to in subsec.
(a)(1)(D), was repealed by Pub. L. 105-33, title IV,
Sec. 4022(b)(1)(A)(i), Aug. 5, 1997, 111 Stat. 354.
Part B of subchapter XI of this chapter, referred to in subsecs.
(a)(15) and (g), is classified to section 1320c et seq. of this title.
The Assisted Suicide Funding Restriction Act of 1997, referred to in
subsec. (a)(16), is Pub. L. 105-12, Apr. 30, 1997, 111 Stat. 23, which
is classified principally to chapter 138 (Sec. 14401 et seq.) of this
title. For complete classification of this Act to the Code, see Short
Title note set out under section 14401 of this title and Tables.
The Internal Revenue Code of 1986, referred to in subsec. (b), is
classified generally to Title 26, Internal Revenue Code.
Section 107(c)(3) of the Drug Amendments of 1962, referred to in
subsec. (c)(1)(A), is section 107(c)(3) of Pub. L. 87-781, title I, Oct.
10, 1962, 76 Stat. 788, which is set out as an Effective Date of 1962
Amendment note under section 321 of Title 21, Food and Drugs.

Codification

Section 1314(i) of this title, which was transferred and
redesignated as subsec. (j) of this section by Pub. L. 108-173, was
based on act Aug. 14, 1935, ch. 531, title XI, Sec. 1114(i), as added
Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 522(c)], Dec. 21, 2000, 114
Stat. 2763, 2763A-546.
Amendments by section 301(a) to (c) of Pub. L. 108-173 were executed
to this section as it read on the date of enactment of Pub. L. 108-173
to reflect the probable intent of Congress, notwithstanding section
301(d) of Pub. L. 108-173, set out as an Effective Date of 2003
Amendment note below, which provided that the amendments by section
301(a) of Pub. L. 108-173 be effective as if included in the enactment
of title III of Pub. L. 98-369 and that the amendments by section
301(b), (c) of Pub. L. 108-173 be effective as if included in the
enactment of section 953 of Pub. L. 96-499. The amendments by section
301(a) are incapable of being executed to this section as it read on the
effective date of title III of Pub. L. 98-369, and the amendments by
section 301(b), (c) are incapable of being executed to this section as
it read on the effective date of section 953 of Pub. L. 96-499. See 2003
Amendment notes below.

Amendments

2003--Subsec. (a). Pub. L. 108-173, Sec. 948(a)(2)(A), struck out
``established under section 1314(f) of this title'' after ``meetings of
advisory committees'' in concluding provisions.
Pub. L. 108-173, Sec. 731(a)(1)(A), inserted ``consistent with
subsection (l) of this section'' after ``the Secretary shall ensure'' in
concluding provisions.
Subsec. (a)(1)(J). Pub. L. 108-173, Sec. 303(i)(3)(B), added subpar.
(J).
Subsec. (a)(1)(K). Pub. L. 108-173, Sec. 611(d)(1)(A), added subpar.
(K).
Subsec. (a)(1)(L). Pub. L. 108-173, Sec. 612(c), added subpar. (L).
Subsec. (a)(1)(M). Pub. L. 108-173, Sec. 613(c), added subpar. (M).
Subsec. (a)(7). Pub. L. 108-173, Sec. 611(d)(1)(B), substituted
``(H), or (K)'' for ``or (H)''.
Subsec. (b)(1)(A). Pub. L. 108-173, Sec. 301(c)(1), realigned
margins.
Subsec. (b)(2)(A). Pub. L. 108-173, Sec. 301(b)(1), inserted at end
of concluding provisions ``An entity that engages in a business, trade,
or profession shall be deemed to have a self-insured plan if it carries
its own risk (whether by a failure to obtain insurance, or otherwise) in
whole or in part.''
Subsec. (b)(2)(A)(ii). Pub. L. 108-173, Sec. 301(a)(1), struck out
``promptly (as determined in accordance with regulations)'' after ``be
expected to be made''.
Subsec. (b)(2)(B)(i). Pub. L. 108-173, Sec. 301(a)(2)(B), added cl.
(i). Former cl. (i) redesignated (ii).
Subsec. (b)(2)(B)(ii). Pub. L. 108-173, Sec. 301(b)(2), substituted
``A primary plan, and an entity that receives payment from a primary
plan, shall reimburse the appropriate Trust Fund for any payment made by
the Secretary under this subchapter with respect to an item or service
if it is demonstrated that such primary plan has or had a responsibility
to make payment with respect to such item or service. A primary plan's
responsibility for such payment may be demonstrated by a judgment, a
payment conditioned upon the recipient's compromise, waiver, or release
(whether or not there is a determination or admission of liability) of
payment for items or services included in a claim against the primary
plan or the primary plan's insured, or by other means.'' for ``Any
payment under this subchapter with respect to any item or service to
which subparagraph (A) applies shall be conditioned on reimbursement to
the appropriate Trust Fund established by this subchapter when notice or
other information is received that payment for such item or service has
been or could be made under such subparagraph.'' and ``on the date
notice of, or information related to, a primary plan's responsibility
for such payment or other information is received'' for ``on the date
such notice or other information is received''.
Pub. L. 108-173, Sec. 301(a)(2)(A), redesignated cl. (i) as (ii).
Former cl. (ii) redesignated (iii).
Subsec. (b)(2)(B)(iii). Pub. L. 108-173, Sec. 301(b)(3), substituted
``In order to recover payment made under this subchapter for an item or
service, the United States may bring an action against any or all
entities that are or were required or responsible (directly, as an
insurer or self-insurer, as a third-party administrator, as an employer
that sponsors or contributes to a group health plan, or large group
health plan, or otherwise) to make payment with respect to the same item
or service (or any portion thereof) under a primary plan. The United
States may, in accordance with paragraph (3)(A) collect double damages
against any such entity. In addition, the United States may recover
under this clause from any entity that has received payment from a
primary plan or from the proceeds of a primary plan's payment to any
entity.'' for ``In order to recover payment under this subchapter for
such an item or service, the United States may bring an action against
any entity which is required or responsible (directly, as a third-party
administrator, or otherwise) to make payment with respect to such item
or service (or any portion thereof) under a primary plan (and may, in
accordance with paragraph (3)(A) collect double damages against that
entity), or against any other entity (including any physician or
provider) that has received payment from that entity with respect to the
item or service, and may join or intervene in any action related to the
events that gave rise to the need for the item or service.''
Pub. L. 108-173, Sec. 301(a)(2)(A), redesignated cl. (ii) as (iii).
Former cl. (iii) redesignated (iv).
Subsec. (b)(2)(B)(iv) to (vi). Pub. L. 108-173, Sec. 301(a)(2)(A),
redesignated cls. (iii) to (v) as (iv) to (vi), respectively.
Subsec. (b)(3)(A). Pub. L. 108-173, Sec. 301(c)(2), struck out
``such'' before ``paragraphs''.
Subsec. (b)(5)(A)(ii). Pub. L. 108-173, Sec. 900(e)(1)(J),
substituted ``Centers for Medicare & Medicaid Services'' for ``Health
Care Financing Administration''.
Subsec. (d). Pub. L. 108-173, Sec. 944(a)(1), added subsec. (d).
Subsec. (j). Pub. L. 108-173, Sec. 948(a)(1), transferred subsec.
(i) of section 1314 of this title and redesignated it as subsec. (j) of
this section. See Codification note above.
Subsec. (j)(1). Pub. L. 108-173, Sec. 948(a)(2)(B), in introductory
provisions, struck out ``under subsection (f) of this section'' after
``appointed'' and substituted ``subsection (a)(1) of this section'' for
``section 1395y(a)(1) of this title''.
Subsec. (k). Pub. L. 108-173, Sec. 950(a), added subsec. (k).
Subsec. (l). Pub. L. 108-173, Sec. 731(a)(1)(B), added subsec. (l).
Subsec. (m). Pub. L. 108-173, Sec. 731(b)(1), added subsec. (m).
2001--Subsec. (a)(22). Pub. L. 107-105, Sec. 3(a)(1), added par.
(22).
Subsec. (h). Pub. L. 107-105, Sec. 3(a)(2), added subsec. (h).
2000--Subsec. (a). Pub. L. 106-554, Sec. 1(a)(6) [title V,
Sec. 522(b)], inserted at end ``In making a national coverage
determination (as defined in paragraph (1)(B) of section 1395ff(f) of
this title) the Secretary shall ensure that the public is afforded
notice and opportunity to comment prior to implementation by the
Secretary of the determination; meetings of advisory committees
established under section 1314(f) of this title with respect to the
determination are made on the record; in making the determination, the
Secretary has considered applicable information (including clinical
experience and medical, technical, and scientific evidence) with respect
to the subject matter of the determination; and in the determination,
provide a clear statement of the basis for the determination (including
responses to comments received from the public), the assumptions
underlying that basis, and make available to the public the data (other
than proprietary data) considered in making the determination.''
Subsec. (a)(1)(F). Pub. L. 106-554, Sec. 1(a)(6) [title I,
Sec. 102(c)], struck out ``and,'' after ``section 1395m(c)(1)(B) of this
title,'' and inserted at end ``and, in the case of screening for
glaucoma, which is performed more frequently than is provided under
section 1395x(uu) of this title,''.
Subsec. (a)(3). Pub. L. 106-554, Sec. 1(a)(6) [title IV,
Sec. 432(b)(1)], struck out second comma after ``section 1395x(aa)(1) of
this title'' and inserted ``in the case of services for which payment
may be made under section 1395qq(e) of this title,'' after ``section
1395x(aa)(3) of this title,''.
Subsec. (a)(18). Pub. L. 106-554, Sec. 1(a)(6) [title III,
Sec. 313(a)], substituted ``during a period in which the resident is
provided covered post-hospital extended care services (or, for services
described in section 1395x(s)(2)(D) of this title, which are furnished
to such an individual without regard to such period),'' for ``or of a
part of a facility that includes a skilled nursing facility (as
determined under regulations),''.
1999--Subsec. (a)(7). Pub. L. 106-113, Sec. 1000(a)(6) [title III,
Sec. 321(k)(10)], substituted ``subparagraph'' for ``subparagraphs''.
Subsec. (a)(21). Pub. L. 106-113, Sec. 1000(a)(6) [title III,
Sec. 305(b)], inserted ``(including medical supplies described in
section 1395x(m)(5) of this title, but excluding durable medical
equipment to the extent provided for in such section)'' after ``home
health services''.
1997--Subsec. (a)(1)(D). Pub. L. 105-33, Sec. 4022(b)(1)(B),
substituted ``Medicare Payment Advisory Commission'' for ``Prospective
Payment Assessment Commission''.
Subsec. (a)(1)(F). Pub. L. 105-33, Sec. 4102(c), inserted ``and
screening pelvic exam'' after ``screening pap smear''.
Subsec. (a)(1)(G). Pub. L. 105-33, Sec. 4103(c)(1), added subpar.
(G).
Subsec. (a)(1)(H). Pub. L. 105-33, Sec. 4104(c)(3)(A), added subpar.
(H).
Subsec. (a)(1)(I). Pub. L. 105-33, Sec. 4614(a), added subpar. (I).
Subsec. (a)(7). Pub. L. 105-33, Sec. 4104(c)(3)(B), substituted
``(G), or (H)'' for ``or (G)''.
Pub. L. 105-33, Sec. 4103(c)(2), substituted ``subparagraphs (B),
(F), or (G) of paragraph (1)'' for ``paragraph (1)(B) or under paragraph
(1)(F)''.
Subsec. (a)(14). Pub. L. 105-33, Sec. 4511(a)(2)(C), substituted
``section 1395x(s)(2)(K) of this title'' for ``section 1395x(s)(2)(K)(i)
or 1395x(s)(2)(K)(iii) of this title''.
Pub. L. 105-33, Sec. 4201(c)(1), substituted ``critical access'' for
``rural primary care'' wherever appearing.
Subsec. (a)(16). Pub. L. 105-12 added par. (16).
Subsec. (a)(17). Pub. L. 105-33, Sec. 4319(b), added par. (17).
Subsec. (a)(18). Pub. L. 105-33, Sec. 4432(b)(1), added par. (18).
Subsec. (a)(19). Pub. L. 105-33, Sec. 4507(a)(2)(B), added par.
(19).
Subsec. (a)(20). Pub. L. 105-33, Sec. 4541(b), added par. (20).
Subsec. (a)(21). Pub. L. 105-33, Sec. 4603(c)(2)(C), added par.
(21).
Subsec. (b)(1)(B)(i). Pub. L. 105-33, Sec. 4631(a)(1)(A),
substituted ``in clause (iii))'' for ``in clause (iv))''.
Subsec. (b)(1)(B)(iii), (iv). Pub. L. 105-33, Sec. 4631(a)(1)(B),
(C), redesignated cl. (iv) as (iii) and struck out heading and text of
former cl. (iii). Text read as follows: ``Clause (i) shall only apply to
items and services furnished on or after January 1, 1987, and before
October 1, 1998.''
Subsec. (b)(1)(C). Pub. L. 105-33, Sec. 4631(b), in concluding
provisions, substituted ``August 5, 1997'' for ``October 1, 1998'' and
inserted at end ``Effective for items and services furnished on or after
August 5, 1997, (with respect to periods beginning on or after the date
that is 18 months prior to August 5, 1997), clauses (i) and (ii) shall
be applied by substituting `30-month' for `12-month' each place it
appears.''
Subsec. (b)(1)(F). Pub. L. 105-33, Sec. 4633(b), added subpar. (F).
Subsec. (b)(2)(B)(ii). Pub. L. 105-33, Sec. 4633(a), substituted
``(directly, as a third-party administrator, or otherwise) to make
payment'' for ``under this subsection to pay'' and inserted at end ``The
United States may not recover from a third-party administrator under
this clause in cases where the third-party administrator would not be
able to recover the amount at issue from the employer or group health
plan and is not employed by or under contract with the employer or group
health plan at the time the action for recovery is initiated by the
United States or for whom it provides administrative services due to the
insolvency or bankruptcy of the employer or plan.''
Subsec. (b)(2)(B)(v). Pub. L. 105-33, Sec. 4632(a), added cl. (v).
Subsec. (b)(5)(C)(iii). Pub. L. 105-33, Sec. 4631(c)(1), struck out
heading and text of cl. (iii). Text read as follows: ``Clause (ii) shall
not apply to inquiries made after September 30, 1998.''
Subsec. (i). Pub. L. 105-33, Sec. 4022(b)(1)(B), substituted
``Medicare Payment Advisory Commission'' for ``Prospective Payment
Assessment Commission'' in introductory provisions.
1996--Subsec. (b)(5)(B). Pub. L. 104-226, Sec. 1(b)(1)(A),
substituted ``under subparagraph (A) for purposes of carrying out this
subsection'' for ``under--
``(i) subparagraph (A), and
``(ii) section 1320b-14 of this title,
for purposes of carrying out this subsection''.
Subsec. (b)(5)(C)(i). Pub. L. 104-226, Sec. 1(b)(1)(B), substituted
``disclosed under subparagraph (B)'' for ``disclosed under subparagraph
(B)(i)''.
Subsec. (h). Pub. L. 104-224 struck out subsec. (h) which required
Secretary to provide registry of all cardiac pacemaker devices and
pacemaker leads for which payment was made under this chapter.
1994--Subsec. (a)(1)(F). Pub. L. 103-432, Sec. 145(c)(1),
substituted ``is not conducted by a facility described in section
1395m(c)(1)(B) of this title'' for ``or which does not meet the
standards established under section 1395m(c)(3) of this title''.
Subsec. (a)(14). Pub. L. 103-432, Sec. 156(a)(2)(D)(i), inserted
``or'' at end.
Pub. L. 103-432, Sec. 147(e)(6), substituted ``section
1395x(s)(2)(K)(i) or 1395x(s)(2)(K)(iii) of this title'' for ``section
1395x(s)(2)(K)(i) of this title''.
Subsec. (a)(15). Pub. L. 103-432, Sec. 156(a)(2)(D)(ii), substituted
period for ``; or'' at end.
Subsec. (a)(16). Pub. L. 103-432, Sec. 156(a)(2)(D)(iii), struck out
par. (16) which read as follows: ``furnished in connection with a
surgical procedure for which a second opinion is required under section
1320c-13(c)(2) of this title and has not been obtained.''
Subsec. (b)(1)(A)(i)(II). Pub. L. 103-432, Sec. 151(c)(1)(A),
substituted ``older (and the spouse age 65 or older of any individual)
who has current employment status with an employer'' for ``over (and the
individual's spouse age 65 or older) who is covered under the plan by
virtue of the individual's current employment status with an employer''.
Subsec. (b)(1)(A)(ii). Pub. L. 103-432, Sec. 151(c)(1)(B),
substituted ``employer that has 20 or more employees'' for ``employer or
employee organization that has 20 or more individuals in current
employment status''.
Subsec. (b)(1)(A)(v). Pub. L. 103-432, Sec. 151(c)(9)(B), made
technical amendment to directory language of Pub. L. 103-66,
Sec. 13561(e)(1)(D). See 1993 Amendment note below.
Subsec. (b)(1)(C). Pub. L. 103-432, Sec. 151(c)(5), substituted
``paying benefits secondary to this subchapter when'' for ``taking into
account that'' in closing provisions.
Pub. L. 103-432, Sec. 151(c)(4), substituted ``this subparagraph''
for ``clauses (i) and (ii)'' after ``February 1, 1990),'' in last
sentence.
Subsec. (b)(2)(B)(i). Pub. L. 103-432, Sec. 151(b)(3)(A), (B),
substituted ``Repayment required'' for ``Primary plans'' in heading and
inserted at end ``If reimbursement is not made to the appropriate Trust
Fund before the expiration of the 60-day period that begins on the date
such notice or other information is received, the Secretary may charge
interest (beginning with the date on which the notice or other
information is received) on the amount of the reimbursement until
reimbursement is made (at a rate determined by the Secretary in
accordance with regulations of the Secretary of the Treasury applicable
to charges for late payments).''
Subsec. (b)(2)(C). Pub. L. 103-432, Sec. 151(a)(1)(C), added subpar.
(C).
Subsec. (b)(3)(C). Pub. L. 103-432, Sec. 157(b)(7), substituted
``group health plan or a large group health plan'' for ``group health
plan'' in heading and text, struck out ``, unless such incentive is also
offered to all individuals who are eligible for coverage under the
plan'' after ``(as defined in paragraph (2)(A))'', and substituted
``(other than subsections (a) and (b))'' for ``(other than the first
sentence of subsection (a) and other than subsection (b))''.
Subsec. (b)(5)(C)(i). Pub. L. 103-432, Sec. 151(c)(6), substituted
``section 6103(l)(12)(E)(iii) of such Code'' for ``section
6103(l)(12)(D)(iii) of such Code''.
Subsec. (b)(5)(D). Pub. L. 103-432, Sec. 151(a)(1)(A), added subpar.
(D).
Subsec. (b)(6). Pub. L. 103-432, Sec. 151(a)(2)(A), added par. (6).
1993--Subsec. (b)(1)(A)(i). Pub. L. 103-66, Sec. 13561(e)(1)(A),
amended subcls. (I) and (II) generally. Prior to amendment, subcls. (I)
and (II) read as follows:
``(I) may not take into account, for any item or service furnished
to an individual 65 years of age or older at the time the individual is
covered under the plan by reason of the current employment of the
individual (or the individual's spouse), that the individual is entitled
to benefits under this subchapter under section 426(a) of this title,
and
``(II) shall provide that any employee age 65 or older, and any
employee's spouse age 65 or older, shall be entitled to the same
benefits under the plan under the same conditions as any employee, and
the spouse of such employee, under age 65.''
Subsec. (b)(1)(A)(ii). Pub. L. 103-66, Sec. 13561(e)(1)(B),
substituted ``unless the plan is a plan of, or contributed to by, an
employer or employee organization that has 20 or more individuals in
current employment status'' for ``unless the plan is sponsored by or
contributed to by an employer that has 20 or more employees''.
Subsec. (b)(1)(A)(iii). Pub. L. 103-66, Sec. 13561(e)(1)(C),
substituted ``by virtue of current employment status with an employer
that does not have 20 or more individuals in current employment status
for each working day in each of 20 or more calendar weeks in the current
calendar year and'' for ``by virtue of employment with an employer that
does not have 20 or more employees for each working day in each of 20 or
more calendar weeks in the current calendar year or''.
Subsec. (b)(1)(A)(iv). Pub. L. 103-66, Sec. 13561(c)(2), substituted
``Subparagraph (C) shall apply instead of clause (i)'' for ``Clause (i)
shall not apply'' and inserted ``(without regard to entitlement under
section 426 of this title)'' after ``individual is, or''.
Subsec. (b)(1)(A)(v). Pub. L. 103-66, Sec. 13561(e)(1)(D), as
amended by Pub. L. 103-432, Sec. 151(c)(9)(B), inserted before period at
end ``, without regard to section 5000(d) of such Code''.
Subsec. (b)(1)(B). Pub. L. 103-66, Sec. 13561(e)(1)(E), substituted
``individuals'' for ``active individuals'' in heading.
Subsec. (b)(1)(B)(i). Pub. L. 103-66, Sec. 13561(e)(1)(F),
substituted ``clause (iv)) may not take into account that an individual
(or a member of the individual's family) who is covered under the plan
by virtue of the individual's current employment status with an
employer'' for ``clause (iv)(II)) may not take into account that an
active individual (as defined in clause (iv)(I))''.
Subsec. (b)(1)(B)(ii). Pub. L. 103-66, Sec. 13561(c)(2), substituted
``Subparagraph (C) shall apply instead of clause (i)'' for ``Clause (i)
shall not apply'' and inserted ``(without regard to entitlement under
section 426 of this title)'' after ``individual is, or''.
Subsec. (b)(1)(B)(iii). Pub. L. 103-66, Sec. 13561(b), substituted
``1998'' for ``1995''.
Subsec. (b)(1)(B)(iv). Pub. L. 103-66, Sec. 13561(e)(1)(G), amended
heading and text generally. Prior to amendment, text defined ``active
individual'' and ``large group health plan''.
Subsec. (b)(1)(C). Pub. L. 103-66, Sec. 13561(c)(1), (3),
substituted ``or eligible for benefits under this subchapter under'' for
``benefits under this subchapter solely by reason of'' in cl. (i) and
concluding provisions and substituted ``before October 1, 1998'' for
``on or before January 1, 1996'' in concluding provisions.
Subsec. (b)(1)(E). Pub. L. 103-66, Sec. 13561(e)(1)(H), added cls.
(ii) and (iii).
Pub. L. 103-66, Sec. 13561(d)(1), added subpar. (E).
Subsec. (b)(5)(B). Pub. L. 103-66, Sec. 13581(b)(1)(A), substituted
``under--'' for ``under subparagraph (A) for the purposes of carrying
out this subsection.'' and added cls. (i) and (ii) and concluding
provisions.
Subsec. (b)(5)(C)(i). Pub. L. 103-66, Sec. 13581(b)(1)(B),
substituted ``subparagraph (B)(i)'' for ``subparagraph (B)''.
Subsec. (b)(5)(C)(iii). Pub. L. 103-66, Sec. 13561(a)(1),
substituted ``1998'' for ``1995''.
1990--Subsec. (a). Pub. L. 101-508, Sec. 4161(a)(3)(C)(iii),
inserted at end ``Paragraph (7) shall not apply to Federally qualified
health center services described in section 1395x(aa)(3)(B) of this
title.''
Subsec. (a)(1)(A). Pub. L. 101-508, Sec. 4163(d)(2)(A)(i),
substituted ``a succeeding subparagraph'' for ``subparagraph (B), (C),
(D), or (E)''.
Subsec. (a)(1)(F). Pub. L. 101-508, Sec. 4163(d)(2)(A)(ii)-(iv),
added subpar. (F).
Subsec. (a)(2). Pub. L. 101-508, Sec. 4161(a)(3)(C)(i), inserted
before semicolon at end ``, except in the case of Federally qualified
health center services''.
Subsec. (a)(3). Pub. L. 101-508, Sec. 4161(a)(3)(C)(ii), inserted
``, in the case of Federally qualified health center services, as
defined in section 1395x(aa)(3) of this title,'' after ``section
1395x(aa)(1) of this title,''.
Subsec. (a)(7). Pub. L. 101-508, Sec. 4163(d)(2)(B), inserted ``or
under paragraph (1)(F)'' after ``paragraph (1)(B)''.
Pub. L. 101-508, Sec. 4153(b)(2)(B), inserted ``(other than eyewear
described in section 1395x(s)(8) of this title)'' after first reference
to ``eyeglasses''.
Subsec. (a)(14). Pub. L. 101-508, Sec. 4157(c)(1), inserted ``,
services described by section 1395x(s)(2)(K)(i) of this title, certified
nurse-midwife services, qualified psychologist services, and services of
a certified registered nurse anesthetist,'' after ``this paragraph)''
and struck out before semicolon at end ``or are services of a certified
registered nurse anesthetist''.
Subsec. (a)(15). Pub. L. 101-508, Sec. 4107(b), designated existing
provisions as par. (A), substituted ``, or'' for ``; or'' at end, and
added par. (B).
Subsec. (b)(1)(B)(iii). Pub. L. 101-508, Sec. 4203(b), substituted
``October 1, 1995'' for ``January 1, 1992''.
Subsec. (b)(1)(C). Pub. L. 101-508, Sec. 4203(c)(1)(B), inserted at
end ``Effective for items and services furnished on or after February 1,
1991, and on or before January 1, 1996, (with respect to periods
beginning on or after February 1, 1990), clauses (i) and (ii) shall be
applied by substituting `18-month' for `12-month' each place it
appears.''
Subsec. (b)(1)(C)(i). Pub. L. 101-508, Sec. 4203(c)(1)(A),
substituted ``during the 12-month period which begins with the first
month in which the individual becomes entitled to benefits under part A
of this subchapter under the provisions of section 426-1 of this title,
or, if earlier, the first month in which the individual would have been
entitled to benefits under such part under the provisions of section
426-1 of this title if the individual had filed an application for such
benefits; and'' for ``during the 12-month period which begins with the
earlier of--
``(I) the month in which a regular course of renal dialysis is
initiated, or
``(II) in the case of an individual who receives a kidney
transplant, the first month in which he would be eligible for
benefits under part A of this subchapter (if he had filed an
application for such benefits) under the provisions of section 426-
1(b)(1)(B) of this title; and''.
Subsec. (b)(3)(C). Pub. L. 101-508, Sec. 4204(g)(1), added subpar.
(C).
Subsec. (b)(5)(C)(iii). Pub. L. 101-508, Sec. 4203(a)(1),
substituted ``September 30, 1995'' for ``September 30, 1991''.
1989--Pub. L. 101-239, Sec. 6202(b)(1)(A), inserted ``and medicare
as secondary payer'' in section catchline.
Subsec. (a)(1)(A). Pub. L. 101-234 repealed Pub. L. 100-360,
Sec. 204(d)(2)(A)(i), and provided that the provisions of law amended or
repealed by such section are restored or revived as if such section had
not been enacted, see 1988 Amendment note below.
Subsec. (a)(1)(E). Pub. L. 101-239, Sec. 6103(b)(3)(B), substituted
``section 1320b-12'' for ``section 1395ll(c)''.
Subsec. (a)(1)(F). Pub. L. 101-239, Sec. 6115(b), inserted before
semicolon at end ``, and, in the case of screening pap smear, which is
performed more frequently than is provided under 1395x(nn) of this
title''.
Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 204(d)(2)(A)(ii)-
(iv), and provided that the provisions of law amended or repealed by
such section are restored or revived as if such section had not been
enacted, see 1988 Amendment note below.
Subsec. (a)(1)(G), (6), (7). Pub. L. 101-234 repealed Pub. L. 100-
360, Secs. 204(d)(2)(B), 205(e)(1), and provided that the provisions of
law amended or repealed by such sections are restored or revived as if
such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(14). Pub. L. 101-239, Sec. 6003(g)(3)(D)(xi),
substituted ``hospital or rural primary care hospital'' for ``hospital''
in three places.
Subsec. (b). Pub. L. 101-239, Sec. 6202(b)(1)(B), amended heading
and text generally, substituting pars. (1) to (4) relating to medicare
as secondary payer for former pars. (1) to (5) relating to items or
services paid under workmen's compensation laws and end stage renal
disease program.
Subsec. (b)(1)(D). Pub. L. 101-239, Sec. 6202(e)(1), added subpar.
(D).
Subsec. (b)(5). Pub. L. 101-239, Sec. 6202(a)(2)(A), added par. (5).
Subsec. (c). Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 202(d),
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. (e)(1). Pub. L. 101-239, Sec. 6411(d)(2), inserted ``, not
including items or services furnished in an emergency room of a
hospital'' after ``(other than an emergency item or service''.
1988--Subsec. (a)(1)(A). Pub. L. 100-360, Sec. 204(d)(2)(A)(i),
substituted ``a succeeding subparagraph'' for ``subparagraph (B), (C),
(D), or (E)''.
Subsec. (a)(1)(F). Pub. L. 100-360, Sec. 204(d)(2)(A)(ii)-(iv),
added subpar. (F) relating to screening mammography.
Subsec. (a)(1)(G). Pub. L. 100-360, Sec. 205(e)(1)(A), as amended by
Pub. L. 100-485, Sec. 608(d)(7), added subpar. (G) relating to in-home
care for chronically dependent individuals.
Subsec. (a)(6). Pub. L. 100-360, Sec. 205(e)(1)(B), inserted ``and
except, in the case of in-home care, as is otherwise permitted under
paragraph (1)(G)'' after ``paragraph (1)(C)''.
Subsec. (a)(7). Pub. L. 100-360, Sec. 204(d)(2)(B), inserted ``or
under paragraph (1)(F)'' after ``(1)(B)''.
Subsec. (a)(15). Pub. L. 100-360, Sec. 411(f)(4)(D)(i), inserted
``(including subsequent insertion of an intraocular lens)'' after
``operation''.
Subsec. (c). Pub. L. 100-360, Sec. 202(d), designated existing
provisions as par. (1), redesignated former par. (1) as subpar. (A),
redesignated former subpars. (A) to (D) as cls. (i) to (iv),
redesignated former par. (2) as subpar. (B), redesignated former subpar.
(A) as cl. (i) and substituted ``subparagraph (A)'' for ``paragraph
(1)'', redesignated former subpar. (B) as cl. (ii), and added par. (2)
prohibiting payment for expenses incurred for a covered outpatient drug
if the drug is dispensed in a quantity exceeding a supply of 30 days
with an exception.
Subsec. (e)(1). Pub. L. 100-360, Sec. 411(i)(4)(D)(i), as amended by
Pub. L. 100-485, Sec. 608(d)(24)(C)(i), designated existing provisions
of subsec. (e) as par. (1), redesignated former par. (1) as subpar. (A),
substituted ``, 1320a-7a, 1320c-5 or 1395u(j)(2)'' for ``or section
1320a-7a'', redesignated former par. (2) as subpar. (B), and substituted
``, 1320a-7a, 1320c-5 or 1395u(j)(2)'' for ``or section 1320a-7a''.
Subsec. (e)(2). Pub. L. 100-360, Sec. 411(i)(4)(D)(ii), as amended
by Pub. L. 100-485, Sec. 608(d)(24)(C)(ii), amended former section
1395aaa of this title by striking out the catchline ``Limitation of
liability of beneficiaries with respect to services furnished by
excluded individuals and entities'', substituting ``(2)'' for the
section designation, inserting ``1395u(j)(2),'' in text, and
transferring the text to par. (2) of subsec. (e) of this section.
1987--Subsec. (a)(1)(A). Pub. L. 100-203, Sec. 4085(i)(15),
substituted ``(D), or (E)'' for ``or (D)''.
Subsec. (a)(8). Pub. L. 100-203, Sec. 4072(c), inserted ``, other
than shoes furnished pursuant to section 1395x(s)(12) of this title''
before semicolon.
Subsec. (a)(14). Pub. L. 100-203, Sec. 4085(i)(16), substituted ``a
patient'' for ``an patient''.
Pub. L. 100-203, Sec. 4009(j)(6)(C), made technical amendment to
Pub. L. 99-509, Sec. 9320(h)(1). See 1986 Amendment note below.
Subsec. (b)(2)(A)(ii). Pub. L. 100-203, Sec. 4036(a)(1), substituted
``can reasonably be expected to be made under such a plan'' for ``the
Secretary determines will be made under such a plan as promptly as would
otherwise be the case if payment were made by the Secretary under this
subchapter''.
Subsec. (b)(4)(B)(i). Pub. L. 100-203, Sec. 4034(a), substituted
``subsection (b) of section 5000 of the Internal Revenue Code of 1986
without regard to subsection (d) of such section'' for ``section 5000(b)
of the Internal Revenue Code of 1986''.
Subsec. (d). Pub. L. 100-93, Sec. 8(c)(1)(A), struck out subsec.
(d), which provided that no payment be made under this subchapter for
any item or services to an individual by a person where Secretary
determines such person knowingly and willfully made any false statement
or representation of a material fact, submitted excessive bills or
requests, or furnished excessive services or supplies, and provided a
dissatisfied person with a hearing on determination of the Secretary.
Subsec. (e) [formerly Sec. 1395aaa]. Pub. L. 100-93, Sec. 10, added
par. (2). See 1988 Amendment note above.
Pub. L. 100-93, Sec. 8(c)(1)(B), amended subsec. (e) generally.
Prior to amendment, subsec. (e) read as follows: ``No payment may be
made under this subchapter with respect to any item or service furnished
by a physician or other individual during the period when he is barred
pursuant to section 1320a-7 of this title from participation in the
program under this subchapter.''
Subsec. (h)(1)(B). Pub. L. 100-203, Sec. 4039(c)(1)(A), substituted
``law (and any amount paid to a provider under any such warranty),'' for
``law,''.
Subsec. (h)(1)(D). Pub. L. 100-203, Sec. 4039(c)(1)(B), inserted
``in determining the amount subject to repayment under paragraph
(2)(C),'' after ``(3),''.
Subsec. (h)(2)(C). Pub. L. 100-203, Sec. 4039(c)(1)(C), added
subpar. (C).
Subsec. (h)(4). Pub. L. 100-93, Sec. 8(c)(3), substituted
``subsections (c), (f), and (g) of section 1320a-7 of this title'' for
``paragraphs (2) and (3) of subsection (d) of this section''.
Subsec. (h)(4)(B). Pub. L. 100-203, Sec. 4039(c)(1)(D), substituted
``, has improperly'' for ``or has improperly'' and inserted ``or has
failed to make repayment to the Secretary as required under paragraph
(2)(C),'' after ``(2)(B),''.
1986--Subsec. (a)(1)(E). Pub. L. 99-509, Sec. 9316(b), added subpar.
(E).
Subsec. (a)(14). Pub. L. 99-509, Sec. 9343(c)(1), substituted
``patient'' for ``inpatient''.
Pub. L. 99-509, Sec. 9320(h)(1), as amended by Pub. L. 100-203,
Sec. 4009(j)(6)(C), inserted ``or are services of a certified registered
nurse anesthetist'' after ``hospital'' at end.
Subsec. (a)(15). Pub. L. 99-272, Sec. 9307(a), added par. (15).
Subsec. (a)(16). Pub. L. 99-272, Sec. 9401(c)(1), added par. (16).
Subsec. (b)(2)(A). Pub. L. 99-514 substituted ``Internal Revenue
Code of 1986'' for ``Internal Revenue Code of 1954''.
Subsec. (b)(3)(A)(i). Pub. L. 99-272, Sec. 9201(a)(1), substituted
``(or to the spouse of such individual)'' for ``who is under 70 years of
age during any part of such month (or to the spouse of such individual,
if the spouse is under 70 years of age during any part of such month)''.
Subsec. (b)(3)(A)(iii). Pub. L. 99-272, Sec. 9201(a)(2), struck out
``and ending with the month before the month in which such individual
attains the age of 70'' after ``section 426(a) of this title''.
Subsec. (b)(3)(A)(iv). Pub. L. 99-514 substituted ``Internal Revenue
Code of 1986'' for ``Internal Revenue Code of 1954''.
Subsec. (b)(4). Pub. L. 99-509, Sec. 9319(a), added par. (4).
Subsec. (b)(5). Pub. L. 99-509, Sec. 9319(b), added par. (5).
1984--Subsec. (a)(12). Pub. L. 98-369, Sec. 2354(b)(30), struck out
second comma after ``dental procedure''.
Subsec. (b)(1). Pub. L. 98-369, Sec. 2344(a), substituted ``to be
made promptly'' for ``to be made'' and ``has been or could be made under
such a law'' for ``has been made under such a law'', and inserted ``In
order to recover payment made under this subchapter for an item or
service, the United States may bring an action against any entity which
would be responsible for payment with respect to such item or service
(or any portion thereof) under such a law, policy, plan, or insurance,
or against any entity (including any physician or provider) which has
been paid with respect to such item or service under such law, policy,
plan, or insurance, and may join or intervene in any action related to
the events that gave rise to the need for such item or service. The
United States shall be subrogated (to the extent of payment made under
this subchapter for an item or service) to any right of an individual or
any other entity to payment with respect to such item or service under
such a law, policy, plan, or insurance.''
Subsec. (b)(2)(B). Pub. L. 98-369, Sec. 2344(b), substituted ``has
been or could be made under a plan'' for ``has been made under a plan'',
and inserted ``In order to recover payment made under this subchapter
for an item or service, the United States may bring an action against
any entity which would be responsible for payment with respect to such
item or service (or any portion thereof) under such a plan, or against
any entity (including any physician or provider) which has been paid
with respect to such item or service under such plan, and may join or
intervene in any action related to the events that gave rise to the need
for such item or service. The United States shall be subrogated (to the
extent of payment made under this subchapter for an item or service) to
any right of an individual or any other entity to payment with respect
to such item or service under such a plan.''
Subsec. (b)(3)(A)(i). Pub. L. 98-369, Sec. 2301(a), struck out
``over 64 but'' before ``under 70 years'' in two places.
Subsec. (b)(3)(A)(ii). Pub. L. 98-369, Sec. 2344(c), substituted
``has been or could be made under a group health plan'' for ``has been
made under a group health plan'', and inserted ``In order to recover
payment made under this title for an item or service, the United States
may bring an action against any entity which would be responsible for
payment with respect to such item or service (or any portion thereof)
under such a plan, or against any entity (including any physician or
provider) which has been paid with respect to such item or service under
such plan, and may join or intervene in any action related to the events
that gave rise to the need for such item or service. The United States
shall be subrogated (to the extent of payment made under this title for
an item or service) to any right of an individual or any other entity to
payment with respect to such item or service under such a plan.''
Subsec. (b)(3)(A)(iii). Pub. L. 98-369, Sec. 2354(b)(31), inserted
``before the month'' after ``ending with the month''.
Subsec. (h). Pub. L. 98-369, Sec. 2304(c), added subsec. (h).
Subsec. (i). Pub. L. 98-369, Sec. 2313(c), added subsec. (i).
1983--Subsec. (a)(1)(A). Pub. L. 98-21, Sec. 601(f)(1), inserted
reference to subpar. (D).
Subsec. (a)(1)(D). Pub. L. 98-21, Sec. 601(f)(2)-(4), added subpar.
(D).
Subsec. (a)(14). Pub. L. 98-21, Sec. 602(e), added par. (14).
Subsec. (b)(3)(A)(i). Pub. L. 97-448 inserted ``in any month'' after
``service furnished'', and ``during any part of such month'' after ``70
years of age'' wherever appearing.
1982--Subsec. (a)(1). Pub. L. 97-248, Sec. 122(f)(1), designated
existing provisions as subpars. (A) and (B), in subpar. (A) as so
designated inserted exception to provisions for items and services
described in subpar. (B) or (C), substituted ``and'' for ``or'' as the
connector between provisions, and added subpar. (C).
Subsec. (a)(6). Pub. L. 97-248, Sec. 122(f)(2), inserted ``(except,
in the case of hospice care, as is otherwise permitted under paragraph
(1)(C))''.
Subsec. (a)(7). Pub. L. 97-248, Sec. 122(f)(3), substituted
``paragraph (1)(B)'' for ``paragraph (1)''.
Subsec. (a)(9). Pub. L. 97-248, Sec. 122(f)(4), inserted ``(except,
in the case of hospice care, as is otherwise permitted under paragraph
(1)(C))''.
Subsec. (b)(1). Pub. L. 97-248, Sec. 128(a)(2), struck out ``or
plan'' after ``service has been made under such a law''.
Subsec. (b)(2)(A). Pub. L. 97-248, Sec. 128(a)(3), substituted
``section 162(i)(2)'' for ``section 162(h)(2)''.
Subsec. (b)(2)(B). Pub. L. 97-248, Sec. 128(a)(4), inserted
``furnished'' before ``to an individual''.
Subsec. (b)(3). Pub. L. 97-248, Sec. 116(b), added par. (3).
Subsec. (d)(1)(C). Pub. L. 97-248, Sec. 148(a), substituted ``on the
basis of information acquired by the Secretary in the administration of
this subchapter'' for ``, on the basis of reports transmitted to him in
accordance with section 1320c-6 of this title (or, in the absence of any
such report, on the basis of such data as he acquires in the
administration of the program under this subchapter),''.
Subsec. (f). Pub. L. 97-248, Sec. 122(g)(1), substituted ``paragraph
(1)(A)'' for ``paragraph (1)''.
Subsec. (g). Pub. L. 97-248, Sec. 142, added subsec. (g).
1981--Subsec. (b). Pub. L. 97-35, Sec. 2146(a), designated existing
provisions as par. (1) and added par. (2).
Subsec. (c). Pub. L. 97-35, Sec. 2103(a)(1), added subsec. (c).
Subsec. (f). Pub. L. 97-35, Sec. 2152(a), added subsec. (f).
1980--Subsec. (a)(1). Pub. L. 96-611, Sec. 1(a)(3)(A), inserted ``,
or, in the case of items and services described in section 1395x(s)(10)
of this title, which are not reasonable and necessary for the prevention
of illness'' after ``of a malformed body member''.
Subsec. (a)(7). Pub. L. 96-611, Sec. 1(a)(3)(B), inserted ``(except
as otherwise allowed under section 1395x(s)(10) of this title and
paragraph (1))'' after ``immunizations''.
Subsec. (a)(12). Pub. L. 96-499, Sec. 936(c), inserted ``or because
of the severity of the dental procedure,'' after ``and clinical
status''.
Subsec. (a)(13)(C). Pub. L. 96-499, Sec. 939(a), struck out ``,
warts,'' after ``corns''.
Subsec. (b). Pub. L. 96-499, Sec. 953, inserted ``or under an
automobile or liability insurance policy or plan (including a self-
insured plan) or under no fault insurance'' and ``, policy, plan, or
insurance'' after ``or a State'' and ``, policy, plan, or insurance''
after ``law or plan'' and inserted provision authorizing the Secretary
to waive the provisions of this subsection in the case of an individual
claim if he determined that the probability of recovery or amount
involved did not warrant the pursuit of the claim.
Subsec. (d)(4). Pub. L. 96-272 added par. (4).
Subsec. (e). Pub. L. 96-499, Sec. 913(b), substituted provisions
barring payment under this subchapter with respect to items or services
furnished by a physician or other individual during a period when such
physician or other individual was barred pursuant to section 1320a-7 of
this title from participation under this subchapter for provisions
authorizing the Secretary to suspend a physician or individual
practitioner from participation under this subchapter upon determining
that such physician or practitioner had been convicted of a criminal
offense related to such physician's or practitioner's involvement in the
programs under this subchapter or the program under subchapter XIX of
this chapter.
1977--Subsec. (a)(3). Pub. L. 95-210 substituted ``except in the
case of rural health clinic services, as defined in section 1395x(aa)(1)
of this title, and in such other cases as the Secretary may specify''
for ``except in such cases as the Secretary may specify''.
Subsec. (d)(1)(B). Pub. L. 95-142, Sec. 13(b)(1), struck out
requirement for concurrence of appropriate program review team for
finding of Secretary under this paragraph.
Subsec. (d)(1)(C). Pub. L. 95-142, Sec. 13(b)(2), substituted
provisions relating to determinations by the Secretary on the basis of
reports transmitted to him in accordance with section 1320c-6 of this
title or other data acquired in the administration of this subchapter,
for provisions relating to determinations by the Secretary with the
concurrence of appropriate review team members.
Subsec. (d)(4). Pub. L. 95-142, Sec. 13(a), struck out par. (4)
which set forth provisions relating to appointment and functions of
program review teams.
Subsec. (e). Pub. L. 95-142, Sec. 7(a), added subsec. (e).
1975--Subsec. (c). Pub. L. 94-182 struck out subsec. (c) prohibiting
payments to Federal employees under this subchapter unless a
determination and certification by the Secretary of a modification of
any health benefits plan under chapter 89 of Title 5 was made which
would allow a Federal employee benefits under part A or B of this
subchapter.
1974--Subsec. (c). Pub. L. 93-480 substituted ``January 1, 1976''
for ``January 1, 1975''.
1973--Subsec. (a)(12). Pub. L. 93-233 substituted ``the provision of
such dental services if the individual, because of his underlying
medical condition and clinical status, requires hospitalization in
connection with the provision of such services'' for ``a dental
procedure where the individual suffers from impairments of such severity
as to require hospitalization''.
1972--Subsec. (a)(4). Pub. L. 92-603, Sec. 211(c)(1), inserted
reference to physicians' services and ambulance services furnished an
individual in conjunction with emergency inpatient hospital services.
Subsec. (a)(12). Pub. L. 92-603, Sec. 256(c), authorized payment
under part A in the case of inpatient hospital services in connection
with a dental procedure where the individual suffers from impairments of
such severity as to require hospitalization.
Subsec. (c). Pub. L. 92-603, Sec. 210, added subsec. (c).
Subsec. (d). Pub. L. 92-603, Sec. 229(a), added subsec. (d).
1968--Subsec. (a)(7). Pub. L. 90-248, Sec. 128, prohibited payment
for procedures performed (during the course of any eye examination) to
determine the refractive state of the eyes.
Subsec. (a)(13). Pub. L. 90-248, Sec. 127(b), added par. (13).

Effective Date of 2003 Amendment

Pub. L. 108-173, title III, Sec. 301(d), Dec. 8, 2003, 117 Stat.
2222, provided that: ``The amendments made by this section [amending
this section] shall be effective--
``(1) in the case of subsection (a), as if included in the
enactment of title III [sic] of the Medicare and Medicaid Budget
Reconciliation Amendments of 1984 (Public Law 98-369); and
``(2) in the case of subsections (b) and (c), as if included in
the enactment of section 953 of the Omnibus Reconciliation Act of
1980 (Public Law 96-499; 94 Stat. 2647).''
Amendment by section 611(d)(1) of Pub. L. 108-173 applicable to
services furnished on or after Jan. 1, 2005, but only for individuals
whose coverage period under this part begins on or after such date, see
section 611(e) of Pub. L. 108-173, set out as a note under section
1395w-4 of this title.
Amendment by section 612(c) of Pub. L. 108-173 applicable to tests
furnished on or after Jan. 1, 2005, see section 612(d) of Pub. L. 108-
173, set out as a note under section 1395x of this title.
Amendment by section 613(c) of Pub. L. 108-173 applicable to tests
furnished on or after Jan. 1, 2005, see section 613(d) of Pub. L. 108-
173, set out as a note under section 1395x of this title.
Pub. L. 108-173, title VII, Sec. 731(a)(2), Dec. 8, 2003, 117 Stat.
2351, provided that: ``The amendments made by paragraph (1) [amending
this section] shall apply to national coverage determinations as of
January 1, 2004, and section 1862(l)(5) of the Social Security Act
[subsec. (l)(5) of this section], as added by such paragraph, shall
apply to local coverage determinations made on or after July 1, 2004.''
Pub. L. 108-173, title VII, Sec. 731(b)(2), Dec. 8, 2003, 117 Stat.
2351, provided that: ``The amendment made by paragraph (1) [amending
this section] shall apply to routine costs incurred on and after January
1, 2005, and, as of such date, section 411.15(o) of title 42, Code of
Federal Regulations, is superseded to the extent inconsistent with
section 1862(m) of the Social Security Act [subsec. (m) of this
section], as added by such paragraph.''
Pub. L. 108-173, title IX, Sec. 944(a)(2), Dec. 8, 2003, 117 Stat.
2423, provided that: ``The amendment made by paragraph (1) [amending
this section] shall apply to items and services furnished on or after
January 1, 2004.''
Amendment by section 948(a) of Pub. L. 108-173 effective, except as
otherwise provided, as if included in the enactment of BIPA [the
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of
2000, H.R. 5661, as enacted by section 1(a)(6) of Public Law 106-554],
see section 948(e) of Pub. L. 108-173, set out as a note under section
1314 of this title.
Pub. L. 108-173, title IX, Sec. 950(b), Dec. 8, 2003, 117 Stat.
2427, provided that: ``The amendment made by subsection (a) [amending
this section] shall take effect on the date that is 60 days after the
date of the enactment of this Act [Dec. 8, 2003].''

Effective Date of 2001 Amendment

Pub. L. 107-105, Sec. 3(b), Dec. 27, 2001, 115 Stat. 1007, provided
that: ``The amendments made by subsection (a) [amending this section]
shall apply to claims submitted on or after October 16, 2003.''

Effective Date of 2000 Amendment

Amendment by section 1(a)(6) [title I, Sec. 102(c)] of Pub. L. 106-
554 applicable to services furnished on or after Jan. 1, 2002, see
section 1(a)(6) [title I, Sec. 102(d)] of Pub. L. 106-554, set out as a
note under section 1395x of this title.
Amendment by section 1(a)(6) [title III, Sec. 313(a)] of Pub. L.
106-554 applicable to services furnished on or after Jan. 1, 2001, see
section 1(a)(6) [title III, Sec. 313(c)] of Pub. L. 106-554, set out as
a note under section 1395u of this title.
Amendment by section 1(a)(6) [title IV, Sec. 432(b)(1)] of Pub. L.
106-554 applicable to services furnished on or after July 1, 2001 see
section 1(a)(6) [title IV, Sec. 432(c)] of Pub. L. 106-554, set out as a
note under section 1395u of this title.
Amendment by section 1(a)(6) [title V, Sec. 522(b)] of Pub. L. 106-
554 applicable with respect to a review of any national or local
coverage determination filed, a request to make such a determination
made, and a national coverage determination made, on or after Oct. 1,
2001, see section 1(a)(6) [title V, Sec. 522(d)] of Pub. L. 106-554, set
out as a note under section 1314 of this title.

Effective Date of 1999 Amendment

Amendment by section 1000(a)(6) [title III, Sec. 305(b)] of Pub. L.
106-113 applicable to payments for services provided on or after Nov.
29, 1999, see Sec. 1000(a)(6) [title III, Sec. 305(c)] of Pub. L. 106-
113, set out as a note under section 1395u of this title.
Amendment by section 1000(a)(6) [title III, Sec. 321(k)(10)] of Pub.
L. 106-113 effective as if included in the enactment of the Balanced
Budget Act of 1997, Pub. L. 105-33, except as otherwise provided, see
section 1000(a)(6) [title III, Sec. 321(m)] of Pub. L. 106-113, set out
as a note under section 1395d of this title.

Effective Date of 1997 Amendments

Amendment by Pub. L. 105-12 effective Apr. 30, 1997, and applicable
to Federal payments made pursuant to obligations incurred after Apr. 30,
1997, for items and services provided on or after such date, subject to
also being applicable with respect to contracts entered into, renewed,
or extended after Apr. 30, 1997, as well as contracts entered into
before Apr. 30, 1997, to the extent permitted under such contracts, see
section 11 of Pub. L. 105-12, set out as an Effective Date note under
section 14401 of this title.
Amendment by section 4022(b)(1)(B) of Pub. L. 105-33 effective Nov.
1, 1997, the date of termination of the Prospective Payment Assessment
Commission and the Physician Payment Review Commission, see section
4022(c)(2) of Pub. L. 105-33, set out as an Effective Date; Transition;
Transfer of Functions note under section 1395b-6 of this title.
Amendment by section 4102(c) of Pub. L. 105-33 applicable to items
and services furnished on or after Jan. 1, 1998, see section 4102(e) of
Pub. L. 105-33, set out as a note under section 1395l of this title.
Amendment by section 4103(c) of Pub. L. 105-33 applicable to items
and services furnished on or after Jan. 1, 2000, see section 4103(e) of
Pub. L. 105-33, set out as a note under section 1395l of this title.
Amendment by section 4104(c)(3) of Pub. L. 105-33 applicable to
items and services furnished on or after Jan. 1, 1998, see section
4104(e) of Pub. L. 105-33, set out as a note under section 1395l of this
title.
Amendment by section 4201(c)(1) of Pub. L. 105-33 applicable to
services furnished on or after Oct. 1, 1997, see section 4201(d) of Pub.
L. 105-33, set out as a note under section 1395f of this title.
Amendment by section 4432(b)(1) of Pub. L. 105-33 applicable to
items and services furnished on or after July 1, 1998, see section
4432(d) of Pub. L. 105-33, set out as a note under section 1395i-3 of
this title.
Amendment by section 4507(a)(2)(B) of Pub. L. 105-33 applicable with
respect to contracts entered into on and after Jan. 1, 1998, see section
4507(c) of Pub. L. 105-33, set out as a note under section 1395a of this
title.
Amendment by section 4511(a)(2)(C) of Pub. L. 105-33 applicable with
respect to services furnished and supplies provided on and after Jan. 1,
1998, see section 4511(e) of Pub. L. 105-33, set out as a note under
section 1395k of this title.
Amendment by section 4541(b) of Pub. L. 105-33 applicable to
services furnished on or after Jan. 1, 1998, including portions of cost
reporting periods occurring on or after such date, see section 4541(e)
of Pub. L. 105-33, set out as a note under section 1395l of this title.
Amendment by section 4603(c)(2)(C) of Pub. L. 105-33 applicable to
cost reporting periods beginning on or after Oct. 1, 1999, except as
otherwise provided, see section 4603(d) of Pub. L. 105-33, set out as an
Effective Date note under section 1395fff of this title.
Section 4614(c) of Pub. L. 105-33 provided that: ``The amendments
made by this section [amending this section] apply to services furnished
on or after October 1, 1997.''
Section 4632(b) of Pub. L. 105-33 provided that: ``The amendments
made by this section [amending this section] apply to items and services
furnished on or after the date of the enactment of this Act [Aug. 5,
1997].''
Section 4633(c) of Pub. L. 105-33 provided that: ``The amendments
made by this section [amending this section] apply to items and services
furnished on or after the date of the enactment of this Act [Aug. 5,
1997].''

Effective Date of 1994 Amendment

Amendment by section 145(c)(1) of Pub. L. 103-432 applicable to
mammography furnished by a facility on and after the first date that the
certificate requirements of section 263b(b) of this title apply to such
mammography conducted by such facility, see section 145(d) of Pub. L.
103-432, set out as a note under section 1395m of this title.
Amendment by section 147(e)(6) of Pub. L. 103-432 effective as if
included in the enactment of Pub. L. 101-508, see section 147(g) of Pub.
L. 103-432, set out as a note under section 1320a-3a of this title.
Section 151(a)(2)(B) of Pub. L. 103-432 provided that: ``The
amendment made by subparagraph (A) [amending this section] shall apply
with respect to items and services furnished on or after the expiration
of the 120-day period beginning on the date of the enactment of this Act
[Oct. 31, 1994].''
Section 151(b)(3)(C) of Pub. L. 103-432 provided that: ``The
amendments made by this paragraph [amending this section] shall apply to
payments for items and services furnished on or after the date of the
enactment of this Act [Oct. 31, 1994].''
Section 151(c)(1), (9) of Pub. L. 103-432 provided that the
amendment made by that section is effective as if included in the
enactment of Pub. L. 103-66.
Section 151(c)(4) of Pub. L. 103-432 provided that the amendment
made by that section is effective as if included in the enactment of
Pub. L. 101-508.
Section 151(c)(5), (6) of Pub. L. 103-432 provided that the
amendment made by that section is effective as if included in the
enactment of Pub. L. 101-239.
Amendment by section 156(a)(2)(D) of Pub. L. 103-432 applicable to
services provided on or after Oct. 31, 1994, see section 156(a)(3) of
Pub. L. 103-432, set out as a note under section 1320c-3 of this title.
Section 157(b)(8) of Pub. L. 103-432 provided that: ``The amendments
made by this subsection [amending this section, section 1395mm of this
title, and provisions set out as notes under section 1395mm of this
title] shall take effect as if included in the enactment of OBRA-1990
[Pub. L. 101-508].''

Effective Date of 1993 Amendment

Section 151(c)(10) of Pub. L. 103-432 provided that: ``The amendment
made by section 13561(e)(1)(G) of OBRA-1993 [Pub. L. 103-66, amending
this section], to the extent it relates to the definition of large group
health plan, shall be effective as if included in the enactment of OBRA-
1989 [Pub. L. 101-239].''
Amendment by section 13561(d)(1) of Pub. L. 103-66 effective 90 days
after Aug. 10, 1993, see section 13561(d)(3) of Pub. L. 103-66, set out
as a note under section 5000 of Title 26, Internal Revenue Code.
Section 13561(e)(1)(D) of Pub. L. 103-66, as amended by Pub. L. 103-
432, title I, Sec. 151(c)(9)(A), Oct. 31, 1994, 108 Stat. 4436, provided
that the amendment made by that section is effective as if included in
the enactment of Pub. L. 101-239.
Section 13581(d) of Pub. L. 103-66 provided that: ``The amendments
made by this section [enacting section 1320b-14 of this title and
amending this section, section 1396a of this title, and section 552a of
Title 5, Government Organization and Employees] shall take effect on
January 1, 1994.''

Effective Date of 1990 Amendment

Amendment by section 4153(b)(2)(B) of Pub. L. 101-508 applicable to
items furnished on or after Jan. 1, 1991, see section 4153(b)(2)(C) of
Pub. L. 101-508, set out as a note under section 1395x of this title.
Amendment by section 4157(c)(1) of Pub. L. 101-508 applicable to
services furnished on or after Jan. 1, 1991, see section 4157(d) of Pub.
L. 101-508, set out as a note under section 1395k of this title.
Amendment by section 4161(a)(3)(C) of Pub. L. 101-508 applicable to
services furnished on or after Oct. 1, 1991, see section 4161(a)(8) of
Pub. L. 101-508, set out as a note under section 1395k of this title.
Amendment by section 4163(d)(2)(A)(i)-(iii), (B) of Pub. L. 101-508
applicable to screening mammography performed on or after Jan. 1, 1991,
see section 4163(e) of Pub. L. 101-508, as amended, set out as a note
under section 1395l of this title.
Section 4163(d)(3) of Pub. L. 101-508, as added by Pub. L. 103-432,
title I, Sec. 147(f)(5)(A), Oct. 31, 1994, 108 Stat. 4431, provided
that: ``The amendment made by paragraph (2)(A)(iv) [amending this
section] shall apply to screening pap smears performed on or after July
1, 1990.''
Section 4204(g)(2) of Pub. L. 101-508 provided that: ``The amendment
made by paragraph (1) [amending this section] shall apply to incentives
offered on or after the date of the enactment of this Act [Nov. 5,
1990].''

Effective Date of 1989 Amendments

Amendment by section 6115(b) of Pub. L. 101-239 applicable to
screening pap smears performed on or after July 1, 1990, see section
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of
this title.
Amendment by section 6202(b)(1) of Pub. L. 101-239 applicable to
items and services furnished after Dec. 19, 1989, see section 6202(b)(5)
of Pub. L. 101-239, set out as a note under section 162 of Title 26,
Internal Revenue Code.
Section 6202(e)(2) of Pub. L. 101-239 provided that: ``The amendment
made by paragraph (1) [amending this section] shall apply to items and
services furnished on or after October 1, 1989.''
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a of
this title.

Effective Date of 1988 Amendments

Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 202(d) of Pub. L. 100-360 applicable to items
dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub. L.
100-360, set out as a note under section 1395u of this title.
Amendment by section 204(d)(2) of Pub. L. 100-360 applicable to
screening mammography performed on or after Jan. 1, 1990, see section
204(e) of Pub. L. 100-360, set out as a note under section 1395m of this
title.
Amendment by section 205(e)(1) of Pub. L. 100-360 applicable to
items and services furnished on or after Jan. 1, 1990, see section
205(f) of Pub. L. 100-360, set out as a note under section 1395k of this
title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(i)(4)(D) of Pub. L. 100-360, as it relates to a
provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-
203, effective as if included in the enactment of that provision in Pub.
L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a
Reference to OBRA; Effective Date note under section 106 of Title 1,
General Provisions.
Section 411(f)(4)(D)(ii) of Pub. L. 100-360 provided that: ``The
amendment made by clause (i) [amending this section] shall apply to
operations performed on or after 60 days after the date of the enactment
of this Act [July 1, 1988].''

Effective Date of 1987 Amendments

Section 4009(j)(6) of Pub. L. 100-203, provided that the amendment
made by that section is effective as if included in the enactment of
Pub. L. 99-509.
Section 4034(b) of Pub. L. 100-203 provided that: ``The amendment
made by subsection (a) [amending this section] shall be effective as if
included in the enactment of section 9319(a) of the Omnibus Budget
Reconciliation Act of 1986 [Pub. L. 99-509].''
Section 4036(a)(2) of Pub. L. 100-203 provided that: ``The amendment
made by paragraph (1) [amending this section] shall apply with respect
to items and services furnished on or after 30 days after the date of
the enactment of this Act [Dec. 22, 1987].''
Section 4039(c)(2) of Pub. L. 100-203 provided that: ``The
amendments made by paragraph (1) [amending this section] shall become
effective on January 1, 1988.''
For effective date of amendment by section 4072(c) of Pub. L. 100-
203, see section 4072(e) of Pub. L. 100-203, set out as a note under
section 1395x of this title.
Amendment by Pub. L. 100-93 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 Pub. L. 100-
93, set out as a note under section 1320a-7 of this title.

Effective Date of 1986 Amendments

Section 9319(f) of Pub. L. 99-509 provided that:
``(1) Except as provided in paragraph (2), the amendments made by
this section [enacting section 5000 of Title 26, Internal Revenue Code,
and amending this section and sections 1395p and 1395r of this title]
shall apply to items and services furnished on or after January 1, 1987.
``(2) The amendments made by subsection (c) [amending sections 1395p
and 1395r of this title] shall apply to enrollments occurring on or
after January 1, 1987.''
Amendment by section 9320(h)(1) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of this
title.
Amendment by section 9343(c)(1) of Pub. L. 99-509 applicable to
services furnished after June 30, 1987, see section 9343(h)(2) of Pub.
L. 99-509, as amended, set out as a note under section 1395l of this
title.
Section 9201(d)(1) of Pub. L. 99-272 provided that: ``The amendments
made by subsection (a) [amending this section] shall apply with respect
to items and services furnished on or after May 1, 1986.