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42 U.S.C. § 1395k — Payments to providers of services
Federal law — U.S. Code and appendices · legal_authorities
**(a) Determination of amount** The Secretary shall periodically determine the amount which should be paid under this part to each provider of services with respect to the services furnished by it, and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) and prior to audit or settlement by the Government Accountability Office, from the Federal Hospital Insurance Trust Fund, the amounts so determined, with necessary adjustments on account of previously made overpayments or underpayments; except that no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period.
**(b) Conditions** No payment shall be made to a provider of services which is a hospital for or with respect to services furnished by it for any period with respect to which it is deemed, under [section 1395x(w)(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/w/2&num=0&edition=prelim), to have in effect an arrangement with a quality improvement organization for the conduct of utilization review activities by such organization unless such hospital has paid to such organization the amount due (as determined pursuant to such section) to such organization for the review activities conducted by it pursuant to such arrangements or such hospital has provided assurances satisfactory to the Secretary that such organization will promptly be paid the amount so due to it from the proceeds of the payment claimed by the hospital. Payment under this subchapter for utilization review activities
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Source file: Laws/federal/codes/united-states-code/title-42/section-1395k-payments-to-providers-of-services--ad71634d23.md
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Source location: Title 42, Chapter 7, § 1395k; chapter-007-social-security.md
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**(a) Determination of amount** The Secretary shall periodically determine the amount which should be paid under this part to each provider of services with respect to the services furnished by it, and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) and prior to audit or settlement by the Government Accountability Office, from the Federal Hospital Insurance Trust Fund, the amounts so determined, with necessary adjustments on account of previously made overpayments or underpayments; except that no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period.
**(b) Conditions** No payment shall be made to a provider of services which is a hospital for or with respect to services furnished by it for any period with respect to which it is deemed, under [section 1395x(w)(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/w/2&num=0&edition=prelim), to have in effect an arrangement with a quality improvement organization for the conduct of utilization review activities by such organization unless such hospital has paid to such organization the amount due (as determined pursuant to such section) to such organization for the review activities conducted by it pursuant to such arrangements or such hospital has provided assurances satisfactory to the Secretary that such organization will promptly be paid the amount so due to it from the proceeds of the payment claimed by the hospital. Payment under this subchapter for utilization review activities provided by a quality improvement organization pursuant to an arrangement or deemed arrangement with a hospital under [section 1395x(w)(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/w/2&num=0&edition=prelim) shall be calculated without any requirement that the reasonable cost of such activities be apportioned among the patients of such hospital, if any, to whom such activities were not applicable.
**(c) Payments under assignment or power of attorney** No payment which may be made to a provider of services under this subchapter for any service furnished to an individual shall be made to any other person under an assignment or power of attorney; but nothing in this subsection shall be construed (1) to prevent the making of such a payment in accordance with an assignment from the provider if such assignment is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction, or (2) to preclude an agent of the provider of services from receiving any such payment if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing or collection of payments due such provider under this subchapter is unrelated (directly or indirectly) to the amount of such payments or the billings therefor, and is not dependent upon the actual collection of any such payment.
**(d) Accrual of interest on balance of excess or deficit not paid** Whenever a final determination is made that the amount of payment made under this part to a provider of services was in excess of or less than the amount of payment that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate determined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments (or, in the case of such a determination made with respect to a payment made on or after March 27, 2020, and during the emergency period described in [section 1320b–5(g)(1)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320b–5/g/1/B&num=0&edition=prelim) under the program under subsection (e)(3), including such program as expanded pursuant to subsection (f), at a rate of 4 percent).
**(e) Periodic interim payments**
(1) The Secretary shall provide payment under this part for inpatient hospital services furnished by a subsection (d) hospital (as defined in [section 1395ww(d)(1)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/d/1/B&num=0&edition=prelim), and including a distinct psychiatric or rehabilitation unit of such a hospital) and a subsection (d) Puerto Rico hospital (as defined in [section 1395ww(d)(9)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/d/9/A&num=0&edition=prelim)) on a periodic interim payment basis (rather than on the basis of bills actually submitted) in the following cases:
(A) Upon the request of a hospital which is paid through an agency or organization with an agreement with the Secretary under [section 1395h of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395h&num=0&edition=prelim), if the agency or organization, for three consecutive calendar months, fails to meet the requirements of subsection (c)(2) of such section and if the hospital meets the requirements (in effect as of October 1, 1986) applicable to payment on such a basis, until such time as the agency or organization meets such requirements for three consecutive calendar months.
(B) In the case of a hospital that—
(i) has a disproportionate share adjustment percentage (as established in clause (iv) of such section) of at least 5.1 percent (as computed for purposes of establishing the average standardized amounts for discharges occurring during fiscal year 1987), and
(ii) requests payment on such basis,
(C) In the case of a hospital that—
(i) is located in a rural area,
(ii) has 100 or fewer beds, and
(iii) requests payment on such basis,
but only if the hospital was being paid for inpatient hospital services on such a periodic interim payment basis as of June 30, 1987, and continues to meet the requirements (in effect as of October 1, 1986) applicable to payment on such a basis.
(2) The Secretary shall provide (or continue to provide) for payment on a periodic interim payment basis (under the standards established under section 405.454(j) of title 42, Code of Federal Regulations, as in effect on October 1, 1986, in the cases described in subparagraphs (A) through (D)) with respect to—
(A) inpatient hospital services of a hospital that is not a subsection (d) hospital (as defined in [section 1395ww(d)(1)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/d/1/B&num=0&edition=prelim));
(B) a hospital which is receiving payment under a State hospital reimbursement system under section 1395f(b)(3) or 1395ww(c) of this title, if payment on a periodic interim payment basis is an integral part of such reimbursement system;
(C) extended care services;
(D) hospice care; and
(E) inpatient critical access hospital services;
if the provider of such services elects to receive, and qualifies for, such payments.
(3) Subject to subsection (f), in the case of a subsection (d) hospital or a subsection (d) Puerto Rico hospital (as defined for purposes of [section 1395ww of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww&num=0&edition=prelim)) which has significant cash flow problems resulting from operations of its intermediary or from unusual circumstances of the hospital’s operation, the Secretary may make available appropriate accelerated payments.
(4) A hospital created by the merger or consolidation of 2 or more hospitals or hospital campuses shall be eligible to receive periodic interim payment on the basis described in paragraph (1)(B) if—
(A) at least one of the hospitals or campuses received periodic interim payment on such basis prior to the merger or consolidation; and
(B) the merging or consolidating hospitals or campuses would each meet the requirement of paragraph (1)(B)(i) if such hospitals or campuses were treated as independent hospitals for purposes of this subchapter.
**(f) Expansion of accelerated payment program during COVID–19 public health emergency**
(1) During the emergency period described in [section 1320b–5(g)(1)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320b–5/g/1/B&num=0&edition=prelim), the Secretary shall expand the program under subsection (e)(3) pursuant to paragraph (2).
(2) In expanding the program under subsection (e)(3), the following shall apply:
(A)
(i) In addition to the hospitals described in subsection (e)(3), the following hospitals shall be eligible to participate in the program:
(I) Hospitals described in clause (iii) of [section 1395ww(d)(1)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/d/1/B&num=0&edition=prelim).
(II) Hospitals described in clause (v) of such section.
(III) Critical access hospitals (as defined in [section 1395x(mm)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/mm/1&num=0&edition=prelim)).
(ii) Subject to appropriate safeguards against fraud, waste, and abuse, upon a request of a hospital described in clause (i), the Secretary shall (or, with respect to requests submitted to the Secretary after April 26, 2020, may) provide accelerated payments under the program to such hospital.
(B) Upon the request of the hospital, the Secretary may do any of the following:
(i) Make accelerated payments on a periodic or lump sum basis.
(ii) Increase the amount of payment that would otherwise be made to hospitals under the program up to 100 percent (or, in the case of critical access hospitals, up to 125 percent).
(iii) Extend the period that accelerated payments cover so that it covers up to a 6-month period.
(C) In the case of a payment made under the terms of the program under subsection (e)(3), including such program as expanded pursuant to this subsection, on or after March 27, 2020, and so made during the emergency period described in [section 1320b–5(g)(1)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320b–5/g/1/B&num=0&edition=prelim), upon request of a hospital, the Secretary shall—
(i) provide 1 year before payments for items and services furnished by the hospital are offset to recoup payments under such program;
(ii) provide that any such offset be an amount equal to—
(I) during the first 11 months in which any such offsets are made with respect to payment for items and services furnished by the hospital, 25 percent of the amount of such payment for such items and services; and
(II) during the succeeding 6 months, 50 percent of the amount of such payment for such items and services; and
(iii) allow 29 months from the date of the first payment under such program to such provider before requiring that the outstanding balance be paid in full.
(3) Nothing in this subsection shall preclude the Secretary from carrying out the provisions described in clauses (i), (ii), and (iii) of paragraph (2)(B) and clauses (i) and (ii) of paragraph (2)(C) under the program under subsection (e)(3) after the period for which this subsection applies.
(4) Notwithstanding any other provision of law, the Secretary may implement the provisions of this subsection by program instruction or otherwise.
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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) 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
**(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) Grants** The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall make grants to States, with approved State regulatory programs under [section 1395ss of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss&num=0&edition=prelim), that submit applications to the Secretary that meet the requirements of this section for the purpose of providing information, counseling, and assistance relating to the procurement of adequate and appropriate health insurance coverage to individuals who are eligible to receive benefits under this subchapter (in this section referred to as “eligible individuals”). The Secretary shall prescribe regulations to establish a minimum level of funding for a grant issued under this section.
**(b) Grant applications**
(1) In submitting an application under this section, a State may consolidate and coordinate an application that consists of parts prepared by more than one agency or department of such State.
(2) As part of an application for a grant under this section, a State shall submit a plan for a State-wide health insurance information, counseling, and assistance program. Such program shall—
(A) establish or improve upon a health insurance information, counseling, and assistance program that provides counseling and assistance to eligible individuals in need of health insurance information, including—
(i) information that may assist individuals in obtaining benefits and filing claims under this subchapter and subchapter XIX of this chapter;
(ii) policy comparison information for medicare supplemental policies (as described in [section 1395ss(g)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss/g/1
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395i
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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) Notice of medicare benefits** The Secretary shall prepare (in consultation with groups representing the elderly and with health insurers) and provide for distribution of a notice containing—
(1) a clear, simple explanation of the benefits available under this subchapter and the major categories of health care for which benefits are not available under this subchapter,
(2) the limitations on payment (including deductibles and coinsurance amounts) that are imposed under this subchapter, and
(3) a description of the limited benefits for long-term care services available under this subchapter and generally available under State plans approved under subchapter XIX.
Such notice shall be mailed annually to individuals entitled to benefits under part A or part B of this subchapter and when an individual applies for benefits under part A or enrolls under part B.
**(b) Medicare and medigap information** The Secretary shall provide information via a toll-free telephone number on the programs under this subchapter. The Secretary shall provide, through the toll-free telephone number 1–800–MEDICARE, for a means by which individuals seeking information about, or assistance with, such programs who phone such toll-free number are transferred (without charge) to appropriate entities for the provision of such information or assistance. Such toll-free number shall be the toll-free number listed for general information and assistance in the annual notice under subsection (a) instead of the listing of numbers of individual contractors.
**(c) Contents of notice** The notice provided under subsection (a) shall include—
(1) a statement which indicates that because errors do occur and because medicare fraud, waste, and abuse is a significant problem, beneficiaries should carefully ch
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395g
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Federal law — U.S. Code and appendices · legal_authorities
**(a) In general** Subject to subsections (c) and (d), payment under this part may be made for inpatient hospital services or post-hospital extended care services furnished an individual in a religious nonmedical health care institution and for home health services furnished an individual by a religious nonmedical health care institution only if—
(1) the individual has an election in effect for such benefits under subsection (b); and
(2) the individual has a condition such that the individual would qualify for benefits under this part for inpatient hospital services, extended care services, or home health services, respectively, if the individual were an inpatient or resident in a hospital or skilled nursing facility, or receiving services from a home health agency, that was not such an institution.
**(b) Election**
(1) **In general** — An individual may make an election under this subsection in a form and manner specified by the Secretary consistent with this subsection. Unless otherwise provided, such an election shall take effect immediately upon its execution. Such an election, once made, shall continue in effect until revoked.
(2) **Form** — The election form under this subsection shall include the following:
(A) A written statement, signed by the individual (or such individual’s legal representative), that—
(i) the individual is conscientiously opposed to acceptance of nonexcepted medical treatment; and
(ii) the individual’s acceptance of nonexcepted medical treatment would be inconsistent with the individual’s sincere religious beliefs.
(B) A statement that the receipt of nonexcepted medical services shall constitute a revocation of the election and may limit further receipt of services described in subsection (a).
(3) **Revocation** — An el
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395t
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Federal law — U.S. Code and appendices · legal_authorities
**(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
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395fff
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Federal law — U.S. Code and appendices · legal_authorities
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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Federal law — U.S. Code and appendices · legal_authorities
**(a) Making or causing to be made false statements or representations** Whoever—
(1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program (as defined in subsection (f)),
(2) at any time knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment,
(3) having knowledge of the occurrence of any event affecting (A) his initial or continued right to any such benefit or payment, or (B) the initial or continued right to any such benefit or payment of any other individual in whose behalf he has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized,
(4) having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts such benefit or payment or any part thereof to a use other than for the use and benefit of such other person,
(5) presents or causes to be presented a claim for a physician’s service for which payment may be made under a Federal health care program and knows that the individual who furnished the service was not licensed as a physician, or
(6) for a fee knowingly and willfully counsels or assists an individual to dispose of assets (including by any transfer in trust) in order for the individual to become eligible for medical assistance under a State plan under subchapter XIX, if disposing of the assets results in the imposition of a per
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320a–7b
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