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42 U.S.C. § 1320c–2 — Contracts with quality improvement organizations

Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1320c–2 — Contracts with quality improvement organizations

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–2

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Stable record: federal_law:legal_authorities:record_usc_318fbac6a7811b2d67c5ed9a
Source file: Laws/federal/codes/united-states-code/title-42/section-1320c2-contracts-with-quality-improvement-organizations--9108e686e4.md
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Source location: Title 42, Chapter 7, § 1320c–2; chapter-007-social-security.md

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**(a) Establishment of geographic areas** The Secretary shall establish throughout the United States such local, State, regional, national, or other geographic areas as the Secretary determines appropriate with respect to which contracts under this part will be made. **(b) Organizations entitled to contract with Secretary** (1) The Secretary shall enter into contracts with one or more quality improvement organizations for each area established under subsection (a) if a qualified organization is available in such area and such organization and the Secretary have negotiated a proposed contract which the Secretary determines will be carried out by such organization in a manner consistent with the efficient and effective administration of this part. In entering into contracts with such qualified organizations, the Secretary shall, to the extent appropriate, seek to ensure that each of the functions described in [section 1320c–3(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c–3/a&num=0&edition=prelim) are carried out within an area established under subsection (a). If more than one such qualified organization will be operating in an area, the Secretary shall ensure that there is no duplication of the functions carried out by such organizations within the area. (2) (A) Prior to November 15, 1984, the Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), an entity (other than a self-insured employer) which directly or indirectly makes payments to any practitioner or provider whose health care services are reviewed by such entity or would be reviewed by such entity if it entered into a contract with the Secretary under this part. For purposes of this paragraph, an entity shall not be considered to be affiliated with another entity which makes payments (directly or indirectly) to any practitioner or provider, by reason of management, ownership, or common control, if the management, ownership, or common control consists only of members of the governing board being affiliated (through management, ownership, or common control) with a health maintenance organization or competitive medical plan which is an “eligible organization” as defined in [section 1395mm(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm/b&num=0&edition=prelim). (B) If, after November 14, 1984, the Secretary determines that there is no other entity available for an area with which the Secretary can enter into a contract under this part or the Secretary determines that there is a more qualified entity to perform one or more of the functions in [section 1320c–3(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c–3/a&num=0&edition=prelim), the Secretary may then enter into a contract under this part with an entity described in subparagraph (A) for such area if such entity otherwise meets the requirements of this part. (3) (A) The Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), a health care facility within the area served by such entity or which would be served by such entity if it entered into a contract with the Secretary under this part. (B) For purposes of subparagraph (A), an entity shall not be considered to be affiliated with a health care facility by reason of management, ownership, or common control if the management, ownership, or common control consists only of not more than 20 percent of the members of the governing board of the entity being affiliated (through management, ownership, or common control) with one or more of such facilities. (4) The Secretary may consider a variety of factors in selecting the contractors that the Secretary determines would provide for the most efficient and effective administration of this part, such as geographic location, size, and prior experience in health care quality improvement. Quality improvement organizations operating as of January 1, 2012, shall be allowed to compete for new contracts (as determined appropriate by the Secretary) along with other qualified organizations and are eligible for renewal of contracts for terms five years thereafter (as determined appropriate by the Secretary). **(c) Terms of contract** Each contract with an organization under this section shall provide that— (1) the organization shall perform a function or functions under [section 1320c–3 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c-3&num=0&edition=prelim) directly or may subcontract for the performance of all or some of such function or functions (and for purposes of paragraphs (2) and (3) of subsection (b), a subcontract under this paragraph shall not constitute an affiliation with the subcontractor); (2) the Secretary shall have the right to evaluate the quality and effectiveness of the organization in carrying out the functions specified in the contract; (3) the contract shall be for an initial term of five years and shall be renewable for terms of five years thereafter; (4) the Secretary shall include in the contract negotiated objectives against which the organization’s performance will be judged, and negotiated specifications for use of regional norms, or modifications thereof based on national norms, for performing review functions under the contract; and (5) reimbursement shall be made to the organization on a monthly basis, with payments for any month being made consistent with the Federal Acquisition Regulation. In evaluating the performance of quality improvement organizations under contracts under this part, the Secretary shall place emphasis on the performance of such organizations in educating providers and practitioners (particularly those in rural areas) concerning the review process and criteria being applied by the organization. **(d) Repealed. Pub. L. 112–40, title II, § 261(b)(3)(C), Oct. 21, 2011, 125 Stat. 424** **(e) Authority of Secretary** (1) Except as provided in paragraph (2), contracting authority of the Secretary under this section may be carried out without regard to any provision of law relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the purposes of this part. The Secretary may use different contracting methods with respect to different geographical areas. (2) If a quality improvement organization with a contract under this section is required to carry out a review function in addition to any function required to be carried out at the time the Secretary entered into or renewed the contract with the organization, the Secretary shall, before requiring such organization to carry out such additional function, negotiate the necessary contractual modifications, including modifications that provide for an appropriate adjustment (in light of the cost of such additional function) to the amount of reimbursement made to the organization. **(f) Termination not subject to judicial review** Any determination by the Secretary to terminate or not to renew a contract under this section shall not be subject to judicial review. **(g) Timely provision of hospital data to quality improvement organizations** The Secretary shall provide that fiscal intermediaries furnish to quality improvement organizations, each month on a timely basis, data necessary to initiate the review process under [section 1320c–3(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c–3/a&num=0&edition=prelim) on a timely basis. If the Secretary determines that a fiscal intermediary is unable to furnish such data on a timely basis, the Secretary shall require the hospital to do so. **(h) Publication of new policy or procedure and general criteria and standards for evaluation; performance comparison report** (1) The Secretary shall publish in the Federal Register any new policy or procedure adopted by the Secretary that affects substantially the performance of contract obligations under this section not less than 30 days before the date on which such policy or procedure is to take effect. This paragraph shall not apply to the extent it is inconsistent with a statutory deadline. (2) The Secretary shall publish in the Federal Register the general criteria and standards used for evaluating the efficient and effective performance of contract obligations under this section and shall provide opportunity for public comment with respect to such criteria and standards. (3) The Secretary shall regularly furnish each quality improvement organization with a contract under this section with a report that documents the performance of the organization in relation to the performance of other such organizations.

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395h — Health insurance advisory service for medicare beneficiaries

**(a) In general** The Secretary of Health and Human Services shall establish a health insurance advisory service program (in this section referred to as the “beneficiary assistance program”) to assist medicare-eligible individuals with the receipt of services under the medicare and medicaid programs and other health insurance programs. **(b) Outreach elements** The beneficiary assistance program shall provide assistance— (1) through operation using local Federal offices that provide information on the medicare program, (2) using community outreach programs, and (3) using a toll-free telephone information service. **(c) Assistance provided** The beneficiary assistance program shall provide for information, counseling, and assistance for medicare-eligible individuals with respect to at least the following: (1) With respect to the medicare program— (A) eligibility, (B) benefits (both covered and not covered), (C) the process of payment for services, (D) rights and process for appeals of determinations, (E) other medicare-related entities (such as peer review organizations, fiscal intermediaries, and carriers), and (F) recent legislative and administrative changes in the medicare program. (2) With respect to the medicaid program— (A) eligibility, benefits, and the application process, (B) linkages between the medicaid and medicare programs, and (C) referral to appropriate State and local agencies involved in the medicaid program. (3) With respect to medicare supplemental policies— (A) the program under [section 1395ss of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss&num=0&edition=prelim) and standards required under such program, (B) how to make informed decisions on whether to purcha

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395h

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395ww — Studies and recommendations

**(a) Health care of the aged and disabled** The Secretary shall carry on studies and develop recommendations to be submitted from time to time to the Congress relating to health care of the aged and the disabled, including studies and recommendations concerning (1) the adequacy of existing personnel and facilities for health care for purposes of the programs under parts A and B of this subchapter; (2) methods for encouraging the further development of efficient and economical forms of health care which are a constructive alternative to inpatient hospital care; and (3) the effects of the deductibles and coinsurance provisions upon beneficiaries, persons who provide health services, and the financing of the program. **(b) Operation and administration of insurance programs** The Secretary shall make a continuing study of the operation and administration of this subchapter (including a validation of the accreditation process of national accreditation bodies under [section 1395bb(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395bb/a&num=0&edition=prelim) 11 So in original. Probably should be followed by a comma. the operation and administration of health maintenance organizations authorized by section 226 of the Social Security Amendments of 1972 [[42 U.S.C. 1395mm](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim)], the experiments and demonstration projects authorized by section 402 of the Social Security Amendments of 1967 [[42 U.S.C. 1395b–1](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395b-1&num=0&edition=prelim)] and the experiments and demonstration projects authorized by section 222(a) of the Social Security Amendments of 1972 [[4

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395ww

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395cc — Special rules for employer-sponsored programs

**(a) Subsidy payment** (1) **In general** — The Secretary shall provide in accordance with this subsection for payment to the sponsor of a qualified retiree prescription drug plan (as defined in paragraph (2)) of a special subsidy payment equal to the amount specified in paragraph (3) for each qualified covered retiree under the plan (as defined in paragraph (4)). This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this section. (2) **Qualified retiree prescription drug plan defined** — For purposes of this subsection, the term “qualified retiree prescription drug plan” means employment-based retiree health coverage (as defined in subsection (c)(1)) if, with respect to a part D eligible individual who is a participant or beneficiary under such coverage, the following requirements are met: (A) *Attestation of actuarial equivalence to standard coverage* — The sponsor of the plan provides the Secretary, annually or at such other time as the Secretary may require, with an attestation that the actuarial value of prescription drug coverage under the plan (as determined using the processes and methods described in [section 1395w–111(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–111/c&num=0&edition=prelim)) is at least equal to the actuarial value of standard prescription drug coverage, not taking into account the value of— (i) for years prior to 2025, any discount or coverage provided during the gap in prescription drug coverage that occurs between the initial coverage limit under [section 1395w–102(b)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395cc

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1320c — Purpose

The purpose of this part is to establish the contracting process which the Secretary must follow pursuant to the requirements of [section 1395y(g) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/g&num=0&edition=prelim), including the definition of the quality improvement organizations with which the Secretary shall contract, the functions such quality improvement organizations are to perform, the confidentiality of medical records, and related administrative matters to facilitate the carrying out of the purposes of this part.

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c

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