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42 U.S.C. § 1395v — Scope of benefits; definitions

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42 U.S.C. § 1395v — Scope of benefits; definitions

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Source file: Laws/federal/codes/united-states-code/title-42/section-1395v-scope-of-benefits-definitions--297fddc80b.md
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Source location: Title 42, Chapter 7, § 1395v; chapter-007-social-security.md

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**(a) Scope of benefits** 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 1395u(b)(6) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395u/b/6&num=0&edition=prelim); 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 1395x(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/b&num=0&edition=prelim) (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 1395n(b)(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395n/b/2&num=0&edition=prelim), (iii) services described by [section 1395x(s)(2)(K)(i) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s/2/K/i&num=0&edition=prelim), certified nurse-midwife services, qualified psychologist services, and services of a certified registered nurse anesthetist; 11 So in original. The semicolon probably should be a comma. (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 22 So in original. The word “and” probably should not appear. (C) outpatient physical therapy services (other than services to which the second sentence of [section 1395x(p) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/p&num=0&edition=prelim) applies), outpatient occupational therapy services (other than services to which such sentence applies through the operation of [section 1395x(g) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/g&num=0&edition=prelim)), and outpatient speech-language pathology services (other than services to which the second sentence of [section 1395x(p) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/p&num=0&edition=prelim) applies through the application of section 1395x(ll)(2) of this title); (D) (i) rural health clinic services and (ii) Federally qualified health center services; (E) comprehensive outpatient rehabilitation facility services; (F) facility services furnished in connection with surgical procedures specified by the Secretary— (i) pursuant to section 1395l(i)(1)(A) of this title 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 1395l(i)(2)(A) of this title as full payment for such services (including intraocular lens in cases described in section 1395l(i)(2)(A)(iii) of this title) and to accept an assignment described in [section 1395u(b)(3)(B)(ii) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395u/b/3/B/ii&num=0&edition=prelim) with respect to payment for all such services (including intraocular lens in cases described in section 1395l(i)(2)(A)(iii) of this title) furnished by the center to individuals enrolled under this part, or (ii) pursuant to section 1395l(i)(1)(B) of this title and performed by a physician, described in paragraph (1), (2), or (3) of [section 1395x(r) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/r&num=0&edition=prelim), in his office, if the Secretary has determined that— (I) a quality improvement organization (having a contract with the Secretary under part B of subchapter XI of this chapter) 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 1395l(i)(2)(B) of this title 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 1395x(s) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s&num=0&edition=prelim) and furnished in connection with such surgical procedure to individuals enrolled under this part; (G) covered items (described in [section 1395m(a)(13) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395m/a/13&num=0&edition=prelim)) 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 1395x(mm)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/mm/3&num=0&edition=prelim)); (I) prosthetic devices and orthotics and prosthetics (described in [section 1395m(h)(4) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395m/h/4&num=0&edition=prelim)) furnished by a provider of services or by others under arrangements with them made by a provider of services; and (J) partial hospitalization services and intensive outpatient services provided by a community mental health center (as described in [section 1395x(ff)(2)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/ff/2/B&num=0&edition=prelim)). **(b) Definitions** For definitions of “spell of illness”, “medical and other health services”, and other terms used in this part, see [section 1395x of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x&num=0&edition=prelim).

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

42 U.S.C. § 1395d — Free choice by patient guaranteed

**(a) Basic freedom of choice** Any individual entitled to insurance benefits under this subchapter may obtain health services from any institution, agency, or person qualified to participate under this subchapter if such institution, agency, or person undertakes to provide him such services. **(b) Use of private contracts by medicare beneficiaries** (1) **In general** — Subject to the provisions of this subsection, nothing in this subchapter shall prohibit a physician or practitioner from entering into a private contract with a medicare beneficiary for any item or service— (A) for which no claim for payment is to be submitted under this subchapter, and (B) for which the physician or practitioner receives— (i) no reimbursement under this subchapter directly or on a capitated basis, and (ii) receives no amount for such item or service from an organization which receives reimbursement for such item or service under this subchapter directly or on a capitated basis. (2) **Beneficiary protections** (A) *In general* — Paragraph (1) shall not apply to any contract unless— (i) the contract is in writing and is signed by the medicare beneficiary before any item or service is provided pursuant to the contract; (ii) the contract contains the items described in subparagraph (B); and (iii) the contract is not entered into at a time when the medicare beneficiary is facing an emergency or urgent health care situation. (B) *Items required to be included in contract* — Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the medicare beneficiary that by signing such contract the beneficiary— (i) agrees not to submit a claim (or to request that the physician or practitioner submit a claim) under t

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

1 U.S.C. § 106 — Printing bills and joint resolutions

Every bill or joint resolution in each House of Congress shall, when such bill or resolution passes either House, be printed, and such printed copy shall be called the engrossed bill or resolution as the case may be. Said engrossed bill or resolution shall be signed by the Clerk of the House or the Secretary of the Senate, and shall be sent to the other House, and in that form shall be dealt with by that House and its officers, and, if passed, returned signed by said Clerk or Secretary. When such bill, or joint resolution shall have passed both Houses, it shall be printed and shall then be called the enrolled bill, or joint resolution, as the case may be, and shall be signed by the presiding officers of both Houses and sent to the President of the United States. During the last six days of a session such engrossing and enrolling of bills and joint resolutions may be done otherwise than as above prescribed, upon the order of Congress by concurrent resolution.

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

42 U.S.C. § 1395x — Manufacturer discount program

**(a) Establishment** The Secretary shall establish a manufacturer discount program (in this section referred to as the “program”). Under the program, the Secretary shall enter into agreements described in subsection (b) with manufacturers and provide for the performance of the duties described in subsection (c). **(b) Terms of agreement** (1) **In general** (A) *Agreement* — An agreement under this section shall require the manufacturer to provide, in accordance with this section, discounted prices for applicable drugs of the manufacturer that are dispensed to applicable beneficiaries on or after January 1, 2025. (B) *Clarification* — Nothing in this section shall be construed as affecting— (i) the application of a coinsurance of 25 percent of the negotiated price, as applied under paragraph (2)(A) of [section 1395w–102(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–102/b&num=0&edition=prelim), for costs described in such paragraph; or (ii) the application of the copayment amount described in paragraph (4)(A) of such section, with respect to costs described in such paragraph. (C) *Timing of agreement* (i) *Special rule for 2025* — In order for an agreement with a manufacturer to be in effect under this section with respect to the period beginning on January 1, 2025, and ending on December 31, 2025, the manufacturer shall enter into such agreement not later than March 1, 2024. (ii) *2026 and subsequent years* — In order for an agreement with a manufacturer to be in effect under this section with respect to plan year 2026 or a subsequent plan year, the manufacturer shall enter into such agreement not later than a calendar quarter or semi-annual deadline established by the Secretary. (2)

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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

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

42 U.S.C. § 1395c — Prohibition against any Federal interference

Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.

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

42 U.S.C. § 1395f — Incentives for economy while maintaining or improving quality in provision of health services

**(a) Grants and contracts to develop and engage in experiments and demonstration projects** (1) The Secretary of Health and Human Services is authorized, either directly or through grants to public or private agencies, institutions, and organizations or contracts with public or private agencies, institutions, and organizations, to develop and engage in experiments and demonstration projects for the following purposes: (A) to determine whether, and if so which, changes in methods of payment or reimbursement (other than those dealt with in section 222(a) of the Social Security Amendments of 1972) for health care and services under health programs established by this chapter, including a change to methods based on negotiated rates, would have the effect of increasing the efficiency and economy of health services under such programs through the creation of additional incentives to these ends without adversely affecting the quality of such services; (B) to determine whether payments for services other than those for which payment may be made under such programs (and which are incidental to services for which payment may be made under such programs) would, in the judgment of the Secretary, result in more economical provision and more effective utilization of services for which payment may be made under such program, where such services are furnished by organizations and institutions which have the capability of providing— (i) comprehensive health care services, (ii) mental health care services (as defined by section 2691(c) 11 See References in Text note below. of this title), (iii) ambulatory health care services (including surgical services provided on an outpatient basis), or (iv) institutional services which may substitute, at lower cost, for h

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

42 U.S.C. § 1395fff — Hospital providers of extended care services

**(a) Hospital facility agreements; reasonable costs of services** (1) Any hospital which has an agreement under [section 1395cc of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395cc&num=0&edition=prelim) may (subject to subsection (b)) enter into an agreement with the Secretary under which its inpatient hospital facilities may be used for the furnishing of services of the type which, if furnished by a skilled nursing facility, would constitute extended care services. (2) (A) Notwithstanding any other provision of this subchapter, payment to any hospital (other than a critical access hospital) for services furnished under an agreement entered into under this section shall be based upon the reasonable cost of the services as determined under subparagraph (B). (B) (i) The reasonable cost of the services consists of the reasonable cost of routine services (determined under clause (ii)) and the reasonable cost of ancillary services (determined under clause (iii)). (ii) The reasonable cost of routine services furnished during any calendar year by a hospital under an agreement under this section is equal to the product of— (I) the number of patient-days during the year for which the services were furnished, and (II) the average reasonable cost per patient-day, such average reasonable cost per patient-day being the average rate per patient-day paid for routine services during the most recent year for which cost reporting data are available with respect to such services (increased in a compounded manner by the applicable increase for payments for routine service costs of skilled nursing facilities under subsections (a) through (d) of [section 1395yy of this title](https://uscode.house.gov/view.xhtml?req

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42 U.S.C. § 1395j — Conditions of and limitations on payment for services

**(a) Requirement of requests and certifications** Except as provided in subsections (d) and (g) and in [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim), payment for services furnished an individual may be made only to providers of services which are eligible therefor under [section 1395cc of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395cc&num=0&edition=prelim) and only if— (1) written request, signed by such individual, except in cases in which the Secretary finds it impracticable for the individual to do so, is filed for such payment in such form, in such manner, and by such person or persons as the Secretary may by regulation prescribe, no later than the close of the period ending 1 calendar year after the date of service; (2) a physician, or, in the case of services described in subparagraph (B), a physician, or a nurse practitioner, a clinical nurse specialist, or a physician assistant (as those terms are defined in [section 1395x(aa)(5) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/aa/5&num=0&edition=prelim)) who does not have a direct or indirect employment relationship with the facility but is working in collaboration with a physician,,11 So in original. or, in the case of services described in subparagraph (C), a physician, a nurse practitioner or clinical nurse specialist (as such terms are defined in [section 1395x(aa)(5) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/aa/5&num=0&edition=prelim)) who is working in accordance with State law, or a physician assistant (as defined in [section 1395x(aa)(5) of this title](https://usc

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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.

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

42 U.S.C. § 1395m — Federal Hospital Insurance Trust Fund

**(a) Creation; deposits; transfers from Treasury** There is hereby created on the books of the Treasury of the United States a trust fund to be known as the “Federal Hospital Insurance Trust Fund” (hereinafter in this section referred to as the “Trust Fund”). The Trust Fund shall consist of such gifts and bequests as may be made as provided in [section 401(i)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section401/i/1&num=0&edition=prelim), and such amounts as may be deposited in, or appropriated to, such fund as provided in this part. There are hereby appropriated to the Trust Fund for the fiscal year ending June 30, 1966, and for each fiscal year thereafter, out of any moneys in the Treasury not otherwise appropriated, amounts equivalent to 100 per centum of— (1) the taxes imposed by sections 3101(b) and 3111(b) of the Internal Revenue Code of 1986 with respect to wages reported to the Secretary of the Treasury or his delegate pursuant to subtitle F of such Code after December 31, 1965, as determined by the Secretary of the Treasury by applying the applicable rates of tax under such sections to such wages, which wages shall be certified by the Commissioner of Social Security on the basis of records of wages established and maintained by the Commissioner of Social Security in accordance with such reports; and (2) the taxes imposed by section 1401(b) of the Internal Revenue Code of 1986 with respect to self-employment income reported to the Secretary of the Treasury or his delegate on tax returns under subtitle F of such Code, as determined by the Secretary of the Treasury by applying the applicable rate of tax under such section to such self-employment income, which self-employment income shall be certified by the Commission

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