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42 U.S.C. § 1395i–4 — Description of program
Federal law — U.S. Code and appendices · legal_authorities
The insurance program for which entitlement is established by sections 426 and 426–1 of this title provides basic protection against the costs of hospital, related post-hospital, home health services, and hospice care in accordance with this part for (1) individuals who are age 65 or over and are eligible for retirement benefits under subchapter II of this chapter (or would be eligible for such benefits if certain government employment were covered employment under such subchapter) or under the railroad retirement system, (2) individuals under age 65 who have been entitled for not less than 24 months to benefits under subchapter II of this chapter (or would have been so entitled to such benefits if certain government employment were covered employment under such subchapter) or under the railroad retirement system on the basis of a disability, and (3) certain individuals who do not meet the conditions specified in either clause (1) or (2) but who are medically determined to have end stage renal disease.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395i–4
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Stable record: federal_law:legal_authorities:record_usc_4e551d6635cc4e0d48d14a9d
Source file: Laws/federal/codes/united-states-code/title-42/section-1395i4-description-of-program--448978b193.md
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Passage SHA-256: 1699c15c289e6e31f83140b31938c11305809d5edbddc7754739f4a4b47026ae
Source location: Title 42, Chapter 7, § 1395i–4; chapter-007-social-security.md
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The insurance program for which entitlement is established by sections 426 and 426–1 of this title provides basic protection against the costs of hospital, related post-hospital, home health services, and hospice care in accordance with this part for (1) individuals who are age 65 or over and are eligible for retirement benefits under subchapter II of this chapter (or would be eligible for such benefits if certain government employment were covered employment under such subchapter) or under the railroad retirement system, (2) individuals under age 65 who have been entitled for not less than 24 months to benefits under subchapter II of this chapter (or would have been so entitled to such benefits if certain government employment were covered employment under such subchapter) or under the railroad retirement system on the basis of a disability, and (3) certain individuals who do not meet the conditions specified in either clause (1) or (2) but who are medically determined to have end stage renal disease.
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Federal law — U.S. Code and appendices · legal_authorities
**(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
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395d
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Administration** This subchapter shall be administered by the Railroad Retirement Board established by the Railroad Retirement Act of 1937 [[45 U.S.C. 228a](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title45-section228a&num=0&edition=prelim) et seq.] as an independent agency in the executive branch of the Government and composed of three members appointed by the President, by and with the advice and consent of the Senate. Each member shall hold office for a term of five years, except that any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of the term and any member holding office pursuant to appointment under the Railroad Retirement Act of 1937 when this subchapter becomes effective shall hold office until the term for which he was appointed under such Railroad Retirement Act of 1937 expires. One member shall be appointed from recommendations made by representatives of the employees and one member shall be appointed from recommendations made by representatives of employers as defined in paragraph (i) of [section 231(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title45-section231/a/1&num=0&edition=prelim), in both cases as the President shall direct, so as to provide representation on the Board satisfactory to the largest number, respectively, of employees and employers concerned. One member, who shall be the chairman of the Board, shall be appointed without recommendation by either employers or employees and shall not be in the employment of or be pecuniarily or otherwise interested in any employer or organization of employees. Vacancies in the Board shall not impair the powers or affect the duties of
Source: Supplied U.S. Code snapshot — release unconfirmed · 45 U.S.C. § 231f
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Federal law — U.S. Code and appendices · legal_authorities
For the purposes of this subchapter—
**(a) Employment** The term “employment” means any service performed after 1936 and prior to 1951 which was employment for the purposes of this subchapter under the law applicable to the period in which such service was performed, and any service, of whatever nature, performed after 1950 (A) by an employee for the person employing him, irrespective of the citizenship or residence of either, (i) within the United States, or (ii) on or in connection with an American vessel or American aircraft under a contract of service which is entered into within the United States or during the performance of which and while the employee is employed on the vessel or aircraft it touches at a port in the United States, if the employee is employed on and in connection with such vessel or aircraft when outside the United States, or (B) outside the United States by a citizen or resident of the United States as an employee (i) of an American employer (as defined in subsection (e) of this section), or (ii) of a foreign affiliate (as defined in section 3121(l)(6) of the Internal Revenue Code of 1986) of an American employer during any period for which there is in effect an agreement, entered into pursuant to section 3121(l) of such Code, with respect to such affiliate, or (C) if it is service, regardless of where or by whom performed, which is designated as employment or recognized as equivalent to employment under an agreement entered into under [section 433 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section433&num=0&edition=prelim); except that, in the case of service performed after 1950, such term shall not include—
(1) Service performed by foreign agricultural workers lawfully admitted to the United States fro
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 410
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Federal law — U.S. Code and appendices · legal_authorities
Nothing contained in this subchapter shall be construed to preclude any State from providing, or any individual from purchasing or otherwise securing, protection against the cost of any health services.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395e
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Individuals over 65 years** Every individual who—
(1) has attained age 65, and
(2)
(A) is entitled to monthly insurance benefits under [section 402 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section402&num=0&edition=prelim), would be entitled to those benefits except that he has not filed an application therefor (or application has not been made for a benefit the entitlement to which for any individual is a condition of entitlement therefor), or would be entitled to such benefits but for the failure of another individual, who meets all the criteria of entitlement to monthly insurance benefits, to meet such criteria throughout a month, and, in conformity with regulations of the Secretary, files an application for hospital insurance benefits under part A of subchapter XVIII,
(B) is a qualified railroad retirement beneficiary, or
(C)
(i) would meet the requirements of subparagraph (A) upon filing application for the monthly insurance benefits involved if medicare qualified government employment (as defined in [section 410(p) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section410/p&num=0&edition=prelim)) were treated as employment (as defined in [section 410(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section410/a&num=0&edition=prelim)) for purposes of this subchapter, and (ii) files an application, in conformity with regulations of the Secretary, for hospital insurance benefits under part A of subchapter XVIII,
shall be entitled to hospital insurance benefits under part A of subchapter XVIII for each month for which he meets the condition specified in paragraph (2), beginning with the first month after June 1966 for which he meet
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 426
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Federal law — U.S. Code and appendices · legal_authorities
**(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)
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395x
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Federal law — U.S. Code and appendices · legal_authorities
**(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
**(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
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.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395c
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Federal law — U.S. Code and appendices · legal_authorities
**(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
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395f
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