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42 U.S.C. § 1395eee — Clarification
Federal law — U.S. Code and appendices · legal_authorities
Any health insurance policy that provides reimbursement for expenses incurred for items and services for which payment may be made under title XVIII of the Social Security Act [[42 U.S.C. 1395](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395&num=0&edition=prelim) et seq.] but which are not reimbursable by reason of the applicability of deductibles, coinsurance, copayments or other limitations imposed by a Medicare Advantage plan (including a Medicare Advantage private fee-for-service plan) under part C of such title [[42 U.S.C. 1395w–21](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w-21&num=0&edition=prelim) et seq.] shall comply with the requirements of section 1882(o) of the such 11 So in original. Act ([42 U.S.C. 1395ss](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss&num=0&edition=prelim)(o)).
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395eee
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Stable record: federal_law:legal_authorities:record_usc_22b02c9db5ee6677b9d790e6
Source file: Laws/federal/codes/united-states-code/title-42/section-1395eee-clarification--b9aee9bc68.md
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Source location: Title 42, Chapter 7, § 1395eee; chapter-007-social-security.md
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Any health insurance policy that provides reimbursement for expenses incurred for items and services for which payment may be made under title XVIII of the Social Security Act [[42 U.S.C. 1395](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395&num=0&edition=prelim) et seq.] but which are not reimbursable by reason of the applicability of deductibles, coinsurance, copayments or other limitations imposed by a Medicare Advantage plan (including a Medicare Advantage private fee-for-service plan) under part C of such title [[42 U.S.C. 1395w–21](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w-21&num=0&edition=prelim) et seq.] shall comply with the requirements of section 1882(o) of the such 11 So in original. Act ([42 U.S.C. 1395ss](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss&num=0&edition=prelim)(o)).
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Federal law — U.S. Code and appendices · legal_authorities
The provisions of sections 406 and 416(j) of this title, and of subsections (a), (d), (e), (h), (i), (j), (k), and (l) of [section 405 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section405&num=0&edition=prelim), shall also apply with respect to this subchapter to the same extent as they are applicable with respect to subchapter II, except that, in applying such provisions with respect to this subchapter, any reference therein to the Commissioner of Social Security or the Social Security Administration shall be considered a reference to the Secretary or the Department of Health and Human Services, respectively.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395ss
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Federal law — U.S. Code and appendices · legal_authorities
This chapter may be cited as the “Social Security Act”.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1305
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Conditions of participation; protection of individual rights; notification of State entities; use of home health aides; medical equipment; individual’s plan of care; compliance with Federal, State, and local laws and regulations** The conditions of participation that a home health agency is required to meet under this subsection are as follows:
(1) The agency protects and promotes the rights of each individual under its care, including each of the following rights:
(A) The right to be fully informed in advance about the care and treatment to be provided by the agency, to be fully informed in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and treatment or changes in care or treatment.
(B) The right to voice grievances with respect to treatment or care that is (or fails to be) furnished without discrimination or reprisal for voicing grievances.
(C) The right to confidentiality of the clinical records described in section 1395x(o)(3) of this title.
(D) The right to have one’s property treated with respect.
(E) The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of—
(i) all items and services furnished by (or under arrangements with) the agency for which payment may be made under this subchapter,
(ii) the coverage available for such items and services under this subchapter, subchapter XIX, and any other Federal program of which the agency is reasonably aware,
(iii) any charges for items and services not covered under this subchapter and any charges the individual may have to pay with respect to items and services furn
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Receipt of benefits through enrollment in PACE program; definitions for PACE program related terms**
(1) **Benefits through enrollment in a PACE program** — In accordance with this section, in the case of an individual who is entitled to benefits under part A or enrolled under part B and who is a PACE program eligible individual (as defined in paragraph (5)) with respect to a PACE program offered by a PACE provider under a PACE program agreement—
(A) the individual may enroll in the program under this section; and
(B) so long as the individual is so enrolled and in accordance with regulations—
(i) the individual shall receive benefits under this subchapter solely through such program; and
(ii) the PACE provider is entitled to payment under and in accordance with this section and such agreement for provision of such benefits.
(2) **“PACE program” defined** — For purposes of this section, the term “PACE program” means a program of all-inclusive care for the elderly that meets the following requirements:
(A) *Operation* — The entity operating the program is a PACE provider (as defined in paragraph (3)).
(B) *Comprehensive benefits* — The program provides comprehensive health care services to PACE program eligible individuals in accordance with the PACE program agreement and regulations under this section.
(C) *Transition* — In the case of an individual who is enrolled under the program under this section and whose enrollment ceases for any reason (including that the individual no longer qualifies as a PACE program eligible individual, the termination of a PACE program agreement, or otherwise), the program provides assistance to the individual in obtaining necessary transitional care through appropriate referrals and making the individual’s
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395b–1
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Establishment**
(1) **11 So in original. No par. (2) has been enacted. In general** — Not later than January 1, 2012, the Secretary shall establish a shared savings program (in this section referred to as the “program”) that promotes accountability for a patient population and coordinates items and services under parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery. Under such program—
(A) groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (referred to in this section as an “ACO”); and
(B) ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings under subsection (d)(2).
**(b) Eligible ACOs**
(1) **In general** — Subject to the succeeding provisions of this subsection, as determined appropriate by the Secretary, the following groups of providers of services and suppliers which have established a mechanism for shared governance are eligible to participate as ACOs under the program under this section:
(A) ACO professionals in group practice arrangements.
(B) Networks of individual practices of ACO professionals.
(C) Partnerships or joint venture arrangements between hospitals and ACO professionals.
(D) Hospitals employing ACO professionals.
(E) Such other groups of providers of services and suppliers as the Secretary determines appropriate.
(2) **Requirements** — An ACO shall meet the following requirements:
(A) The ACO shall be willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395b–6
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Special rules relating to offering of qualified prescription drug coverage**
(1) **In general** — An MA organization on and after January 1, 2006—
(A) may not offer an MA plan described in [section 1395w–21(a)(2)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–21/a/2/A&num=0&edition=prelim) in an area unless either that plan (or another MA plan offered by the organization in that same service area) includes required prescription drug coverage (as defined in paragraph (2)); and
(B) may not offer prescription drug coverage (other than that required under parts A and B) to an enrollee—
(i) under an MSA plan; or
(ii) under another MA plan unless such drug coverage under such other plan provides qualified prescription drug coverage and unless the requirements of this section with respect to such coverage are met.
(2) **Qualifying coverage** — For purposes of paragraph (1)(A), the term “required coverage” means with respect to an MA–PD plan—
(A) basic prescription drug coverage; or
(B) qualified prescription drug coverage that provides supplemental prescription drug coverage, so long as there is no MA monthly supplemental beneficiary premium applied under the plan (due to the application of a credit against such premium of a rebate under [section 1395w–24(b)(1)(C) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–24/b/1/C&num=0&edition=prelim)).
**(b) Application of default enrollment rules**
(1) **Seamless continuation** — In applying [section 1395w–21(c)(3)(A)(ii) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–21/c/3/A/ii&num=0&edition=prelim), an individual who is enrolled in a health benefits p
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395bb
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Submission of policy by insurer**
(1) The Secretary shall establish a procedure whereby medicare supplemental policies (as defined in subsection (g)(1)) may be certified by the Secretary as meeting minimum standards and requirements set forth in subsection (c). Such procedure shall provide an opportunity for any insurer to submit any such policy, and such additional data as the Secretary finds necessary, to the Secretary for his examination and for his certification thereof as meeting the standards and requirements set forth in subsection (c). Subject to subsections (k)(3), (m), and (n), such certification shall remain in effect if the insurer files a notarized statement with the Secretary no later than June 30 of each year stating that the policy continues to meet such standards and requirements and if the insurer submits such additional data as the Secretary finds necessary to independently verify the accuracy of such notarized statement. Where the Secretary determines such a policy meets (or continues to meet) such standards and requirements, he shall authorize the insurer to have printed on such policy (but only in accordance with such requirements and conditions as the Secretary may prescribe) an emblem which the Secretary shall cause to be designed for use as an indication that a policy has received the Secretary’s certification. The Secretary shall provide each State commissioner or superintendent of insurance with a list of all the policies which have received his certification.
(2) No medicare supplemental policy may be issued in a State on or after the date specified in subsection (p)(1)(C) unless—
(A) the State’s regulatory program under subsection (b)(1) provides for the application and enforcement of the standards and requirements set forth in su
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395ddd
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Federal law — U.S. Code and appendices · legal_authorities
**(a) General administrative authority**
(1) **Beneficiary eligibility** — Except as otherwise provided by the Secretary, an individual shall only be eligible to receive benefits under the program under [section 1395cc–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395cc-1&num=0&edition=prelim) (in this section referred to as the “demonstration program”) if such individual—
(A) is enrolled under the program under part B and entitled to benefits under part A; and
(B) is not enrolled in a Medicare+Choice plan under part C, an eligible organization under a contract under [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim) (or a similar organization operating under a demonstration project authority), an organization with an agreement under section 1395l(a)(1)(A) of this title, or a PACE program under [section 1395eee of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395eee&num=0&edition=prelim).
(2) **Secretary’s discretion as to scope of program** — The Secretary may limit the implementation of the demonstration program to—
(A) a geographic area (or areas) that the Secretary designates for purposes of the program, based upon such criteria as the Secretary finds appropriate;
(B) a subgroup (or subgroups) of beneficiaries or individuals and entities furnishing items or services (otherwise eligible to participate in the program), selected on the basis of the number of such participants that the Secretary finds consistent with the effective and efficient implementation of the program;
(C) an element (or elements) of the program that the Secretary determines to be suitable for implementation
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395kk
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Implementation**
(1) **In general** — The Secretary shall establish a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health care services under this subchapter.
(2) **Definitions** — In this section:
(A) *Applicable beneficiary* — The term “applicable beneficiary” means an individual who—
(i) is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B of such subchapter, but not enrolled under part C or a PACE program under [section 1395eee of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395eee&num=0&edition=prelim); and
(ii) is admitted to a hospital for an applicable condition.
(B) *Applicable condition* — The term “applicable condition” means 1 or more of 10 conditions selected by the Secretary. In selecting conditions under the preceding sentence, the Secretary shall take into consideration the following factors:
(i) Whether the conditions selected include a mix of chronic and acute conditions.
(ii) Whether the conditions selected include a mix of surgical and medical conditions.
(iii) Whether a condition is one for which there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished while reducing total expenditures under this subchapter.
(iv) Whether a condition has significant variation in—
(I) the number of readmissions; and
(II) the amount of expenditures for post-acute care spending under this subchapter.
(v) Whether a condition is high-volume and has high post-acute care expenditures under this subchapter.
(vi) Which conditi
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395kk–2
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Establishment**
(1) **In general** — The Secretary shall conduct a demonstration program (in this section referred to as the “demonstration program”) to test a payment incentive and service delivery model that utilizes physician and nurse practitioner directed home-based primary care teams designed to reduce expenditures and improve health outcomes in the provision of items and services under this subchapter to applicable beneficiaries (as defined in subsection (d)).
(2) **Requirement** — The demonstration program shall test whether a model described in paragraph (1), which is accountable for providing comprehensive, coordinated, continuous, and accessible care to high-need populations at home and coordinating health care across all treatment settings, results in—
(A) reducing preventable hospitalizations;
(B) preventing hospital readmissions;
(C) reducing emergency room visits;
(D) improving health outcomes commensurate with the beneficiaries’ stage of chronic illness;
(E) improving the efficiency of care, such as by reducing duplicative diagnostic and laboratory tests;
(F) reducing the cost of health care services covered under this subchapter; and
(G) achieving beneficiary and family caregiver satisfaction.
**(b) Independence at home medical practice**
(1) **Independence at home medical practice defined** — In this section:
(A) *In general* — The term “independence at home medical practice” means a legal entity that—
(i) is comprised of an individual physician or nurse practitioner or group of physicians and nurse practitioners that provides care as part of a team that includes physicians, nurses, physician assistants, pharmacists, and other health and social services staff as appropriate who have experience providing home-based
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395ll
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