TITLE XVIII—HEALTH INSURANCE FOR THE AGED AND DISABLED[1]
TABLE OF CONTENTS OF TITLE[2]
Part A—Hospital Insurance Benefits for the Aged and Disabled
Part B—Supplementary Medical Insurance Benefits for the Aged and Disabled
Sec. 1846. Intermediate sanctions for providers or suppliers of clinical diagnostic laboratory tests
Part C—MEDICARE+CHOICE PROGRAM
Part D—Voluntary Prescription Drug Benefit Program
Subpart 1—Part D Eligible Individuals and Prescription Drug Benefits
Subpart 2—Prescription Drug Plans; PDP Sponsors; Financing
Subpart 3—Application to Medicare Advantage Program and Treatment of Employer-Sponsored Programs and Other Prescription Drug Plans
Subpart 4—Medicare Prescription Drug Discount Card and Transitional Assistance Program
Subpart 5—Definitions and Miscellaneous Provisions
Part E—Miscellaneous Provisions
[1] Title XVIII of the Social Security Act is administered by the Centers for Medicare and Medicaid Services.
Title XVIII appears in the United States Code as §§1395-1395ccc, subchapter XVIII, chapter 7, Title 42.
Regulations of the Secretary of Health and Human Services relating to Title XVIII are contained in chapter IV, Title 42, and in subtitle A, Title 45, Code of Federal Regulations.
See Vol. II, 31 U.S.C. 3716(c)(3)(D), with respect to the application of administrative offset provisions to Medicare provider or supplier payments; P.L. 78-410, §353(i)(3) and (n), with respect to clinical laboratories; P.L. 88-352, §601, for prohibition against discrimination in Federally assisted programs; P.L. 89-73, §§203 and 422(c), with respect to consultation with respect to programs and services for the aged; P.L. 93-288, §312(d), with respect to exclusion from income and resources of certain Federal major disaster and emergency assistance; P.L. 97-248, §119, with respect to private sector review initiative and restriction against recovery from beneficiaries; P.L. 98-369, §2355, with respect to waivers for social health maintenance organizations; P.L. 99-177, §257(b)(3) and (c)(3), with respect to the calculation of the baseline; P.L. 99-272, §9220, with respect to extension, terms, conditions, and period of approval of the extension of On Lok waiver; and §9215, with respect to the extension of certain medicare health services demonstration projects; P.L. 99-319, §105, with respect to systems requirements; P.L. 99-509, §9339(d) with respect to State standards for directors of clinical laboratories; §9342 with respect to Alzheimer’s disease demonstration projects; §9353(a)(4) with respect to a small-area analysis; and §9412 with respect to the waiver authority for chronically mentally ill and frail elderly; P.L. 99-660, Title IV, with respect to professional review activities; P.L. 100-203, §4008(d)(3), with respect to a report regarding hospital outlier payments; P.L. 100-204, §724(d), with respect to furnishing information to the United States Commission on Improving the Effectiveness of the United Nations; and §725(b), with respect to the detailing of Government personnel; P.L. 100-235, §§5–8, with respect to responsibilities of each Federal agency for computer systems security and privacy; P.L. 100-383, §§105(f)(2) and 206(d)(2), with respect to exclusions from income and resources of certain payments to certain individuals; P.L. 100-581, §§501, 502(b)(1), and 503, with respect to exclusion from income and resources of certain judgment funds; P.L. 100-647, §8411, with respect to treatment of certain nursing education programs; P.L. 100-690, §5301(a)(1)(C) and (d)(1)(B), with respect to benefits of drug traffickers and possessors; P.L. 100-713, §712, with respect to the provision of services in Montana; P.L. 101-121, with respect to the amounts collected by the Secretary of Health and Human Services under the authority of title IV of the Indian Health Care Improvement Act; P.L. 101-239, §6025, with respect to a dentist’s serving as hospital medical director; §6205(a)(1)(A) and (a)(2), with respect to recognition of costs of certain hospital-based nursing schools; P.L. 104-191, §261, with respect to purpose of administrative simplification; P.L. 106-554, §1(a)(6) [122], with respect to cancer prevention and treatment demonstrations for ethnic and racial minorities; and [128] with respect to a lifestyle modification program demonstration; P.L. 110-275, §186, with respect to a demonstration project to improve care to previously uninsured; P.L. 111-148, §1103, with respect to immediate information that allows consumers to identify affordable coverage options; §2602, with respect to providing Federal coverage and payment coordination for dual eligible beneficiaries; P.L. 111-240, §4241, with respect to the use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the medicare fee-for-service program, and P.L. 111-309, §206, with respect to funding for claims reprocessing.
[2] This table of contents does not appear in the law.
Part B SCOPE OF BENEFITS
Sec. 1832. [42 U.S.C. 1395k] (a) The benefits provided to an individual by the insurance program established by this part shall consist of—
(1) entitlement to have payment made to him or on his behalf (subject to the provisions of this part) for medical and other health services, except those described in subparagraphs (B) and (D) of paragraph (2) and subparagraphs (E) and (F) of section 1842(b)(6); and
(2) entitlement to have payment made on his behalf (subject to the provisions of this part) for—
(A) home health services (other than items described in subparagraph (G) or subparagraph (I));
(B) medical and other health services (other than items described in subparagraph (G) or subparagraph (I)) furnished by a provider of services or by others under arrangement with them made by a provider of services, excluding—
(i) physician services except where furnished by—
(I) a resident or intern of a hospital, or
(II) a physician to a patient in a hospital which has a teaching program approved as specified in paragraph (6) of section 1861(b) (including services in conjunction with the teaching programs of such hospital whether or not such patient is an inpatient of such hospital) where the conditions specified in paragraph (7) of such section are met,
(ii) services for which payment may be made pursuant to section 1835(b)(2),
(iii) services described by section 1861(s)(2)(K)(i), certified nurse-midwife services, qualified psychologist services, and services of a certified registered nurse anesthetist;
(iv) services of a nurse practitioner or clinical nurse specialist but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services; and
(C) outpatient physical therapy services (other than services to which the second sentence of section 1861(p) applies), outpatient occupational therapy services (other than services to which such sentence applies through the operation of section 1861(g), and outpatient speech-language pathology services (other than services to which the second sentence of section 1861(p) applies through the application of section 1861(ll)(2))[119];
(E) comprehensive outpatient rehabilitation facility services;
(F) facility services furnished in connection with surgical procedures specified by the Secretary—
(i) pursuant to section 1833(i)(1)(A) and performed in an ambulatory surgical center (which meets health, safety, and other standards specified by the Secretary in regulations) if the center has an agreement in effect with the Secretary by which the center agrees to accept the standard overhead amount determined under section 1833(i)(2)(A) as full payment for such services (including intraocular lens in cases described in section 1833(i)(2)(A)(iii)) and to accept an assignment described in section 1842(b)(3)(B)(ii) with respect to payment for all such services (including intraocular lens in cases described in section 1833(i)(2)(A)(iii)) furnished by the center to individuals enrolled under this part, or
(ii) pursuant to section 1833(i)(1)(B) and performed by a physician, described in paragraph (1), (2), or (3) of section 1861(r), in his office, if the Secretary has determined that—
(I) a quality control and peer review organization (having a contract with the Secretary under part B of title XI of this Act) is willing, able, and has agreed to carry out a review (on a sample or other reasonable basis) of the physician’s performing such procedures in the physician’s office,
(II) the particular physician involved has agreed to make available to such organization such records as the Secretary determines to be necessary to carry out the review, and
(III) the physician is authorized to perform the procedure in a hospital located in the area in which the office is located,
and if the physician agrees to accept the standard overhead amount determined under section 1833(i)(2)(B) as full payment for such services and to accept payment on an assignment-related basis with respect to payment for all services (including all pre-and post-operative services) described in paragraphs (1) and (2)(A) of section 1861(s) and furnished in connection with such surgical procedure to individuals enrolled under this part;
(G) covered items (described in section 1834(a)(13)) furnished by a provider of services or by others under arrangements with them made by a provider of services;
(H) outpatient critical access hospital services (as defined in section 1861(mm)(3));
(I) prosthetic devices and orthotics and prosthetics (described in section 1834(h)(4)) furnished by a provider of services or by others under arrangements with them made by a provider of services; and
(J) partial hospitalization services provided by a community mental health center (as described in section 1861(ff)(2)(B)).
(b) For definitions of “spell of illness”, “medical and other health services”, and other terms used in this part, see section 1861.
[119] P.L. 110-275, §143(b)(1)(B), inserted “, and outpatient speech-language pathology services (other than services to which the second sentence of section 1861(p) applies through the application of section 1861(ll)(2))”, applicable to services furnished on or after July 1, 2009. See Vol. II, P.L. 110-275, §143(d), with respect to a rule of construction regarding existing regulations and policies.
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