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42 U.S.C. § 1395l — Provisions relating to the administration of part A
Federal law — U.S. Code and appendices · legal_authorities
**(a) In general** The administration of this part shall be conducted through contracts with medicare administrative contractors under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim).
**(b) Repealed. Pub. L. 108–173, title IX, § 911(b)(3), Dec. 8, 2003, 117 Stat. 2383**
**(c) Prompt payment of claims**
(1) Repealed. Pub. L. 108–173, title IX, § 911(b)(4)(A), Dec. 8, 2003, 117 Stat. 2383.
(2)
(A) Each contract under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim) that provides for making payments under this part shall provide that payment shall be issued, mailed, or otherwise transmitted with respect to not less than 95 percent of all claims submitted under this subchapter—
(i) which are clean claims, and
(ii) for which payment is not made on a periodic interim payment basis,
within the applicable number of calendar days after the date on which the claim is received.
(B) In this paragraph:
(i) The term “clean claim” means a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this subchapter.
(ii) The term “applicable number of calendar days” means—
(I) with respect to claims received in the 12-month period beginning October 1, 1986, 30 calendar days,
(II) with respect to claims received in the 12-month period beginning October 1, 1987, 26 calendar days,
(III) with respect to claims received in the 12-month period beginning October 1, 1988, 25 calendar days,
(I
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Stable record: federal_law:legal_authorities:record_usc_50bcf9f20604f7a83bec11e9
Source file: Laws/federal/codes/united-states-code/title-42/section-1395l-provisions-relating-to-the-administration-of-part-a--3b0fbe3cfe.md
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Source location: Title 42, Chapter 7, § 1395l; chapter-007-social-security.md
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**(a) In general** The administration of this part shall be conducted through contracts with medicare administrative contractors under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim).
**(b) Repealed. Pub. L. 108–173, title IX, § 911(b)(3), Dec. 8, 2003, 117 Stat. 2383**
**(c) Prompt payment of claims**
(1) Repealed. Pub. L. 108–173, title IX, § 911(b)(4)(A), Dec. 8, 2003, 117 Stat. 2383.
(2)
(A) Each contract under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim) that provides for making payments under this part shall provide that payment shall be issued, mailed, or otherwise transmitted with respect to not less than 95 percent of all claims submitted under this subchapter—
(i) which are clean claims, and
(ii) for which payment is not made on a periodic interim payment basis,
within the applicable number of calendar days after the date on which the claim is received.
(B) In this paragraph:
(i) The term “clean claim” means a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this subchapter.
(ii) The term “applicable number of calendar days” means—
(I) with respect to claims received in the 12-month period beginning October 1, 1986, 30 calendar days,
(II) with respect to claims received in the 12-month period beginning October 1, 1987, 26 calendar days,
(III) with respect to claims received in the 12-month period beginning October 1, 1988, 25 calendar days,
(IV) with respect to claims received in the 12-month period beginning October 1, 1989, and claims received in any succeeding 12-month period ending on or before September 30, 1993, 24 calendar days, and
(V) with respect to claims received in the 12-month period beginning October 1, 1993, and claims received in any succeeding 12-month period, 30 calendar days.
(C) If payment is not issued, mailed, or otherwise transmitted within the applicable number of calendar days (as defined in clause (ii) of subparagraph (B)) after a clean claim (as defined in clause (i) of such subparagraph) is received from a hospital, critical access hospital, skilled nursing facility, home health agency, hospice program, comprehensive outpatient rehabilitation facility, or rehabilitation agency that is not receiving payments on a periodic interim payment basis with respect to such services, interest shall be paid at the rate used for purposes of [section 3902(a) of title 31](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title31-section3902/a&num=0&edition=prelim) (relating to interest penalties for failure to make prompt payments) for the period beginning on the day after the required payment date and ending on the date on which payment is made.
(3)
(A) Each contract under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim) that provides for making payments under this part shall provide that no payment shall be issued, mailed, or otherwise transmitted with respect to any claim submitted under this subchapter within the applicable number of calendar days after the date on which the claim is received.
(B) In this paragraph, the term “applicable number of calendar days” means—
(i) with respect to claims submitted electronically as prescribed by the Secretary, 13 days, and
(ii) with respect to claims submitted otherwise, 28 days.
**(d) to (i). Repealed. Pub. L. 108–173, title IX, § 911(b)(5), Dec. 8, 2003, 117 Stat. 2383**
**(j) Denial of claim; notification and reconsideration** A contract with a medicare administrative contractor under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim) with respect to the administration of this part shall require that, with respect to a claim for home health services, extended care services, or post-hospital extended care services submitted by a provider to such medicare administrative contractor that is denied, such medicare administrative contractor—
(1) furnish the provider and the individual with respect to whom the claim is made with a written explanation of the denial and of the statutory or regulatory basis for the denial; and
(2) in the case of a request for reconsideration of a denial, promptly notify such individual and the provider of the disposition of such reconsideration.
**(k) Annual reporting requirement on erroneous payment recovery** A contract with a medicare administrative contractor under [section 1395kk–1 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395kk-1&num=0&edition=prelim) with respect to the administration of this part shall require that such medicare administrative contractor submit an annual report to the Secretary describing the steps taken to recover payments made for items or services for which payment has been or could be made under a primary plan (as defined in [section 1395y(b)(2)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/b/2/A&num=0&edition=prelim)).
**(l) Repealed. Pub. L. 108–173, title IX, § 911(b)(7), Dec. 8, 2003, 117 Stat. 2383**
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Federal law — U.S. Code and appendices · legal_authorities
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
**(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
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Accreditation by American Osteopathic Association or other national accreditation body**
(1) If the Secretary finds that accreditation of a provider entity (as defined in paragraph (4)) by the American Osteopathic Association or any other national accreditation body demonstrates that all of the applicable conditions or requirements of this subchapter (other than the requirements of [section 1395m(j) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395m/j&num=0&edition=prelim)) are met or exceeded—
(A) in the case of a provider entity not described in paragraph (3)(B), the Secretary shall treat such entity as meeting those conditions or requirements with respect to which the Secretary made such finding; or
(B) in the case of a provider entity described in paragraph (3)(B), the Secretary may treat such entity as meeting those conditions or requirements with respect to which the Secretary made such finding.
(2) In making such a finding, the Secretary shall consider, among other factors with respect to a national accreditation body, its requirements for accreditation, its survey procedures, its ability to provide adequate resources for conducting required surveys and supplying information for use in enforcement activities, its monitoring procedures for provider entities found out of compliance with the conditions or requirements, and its ability to provide the Secretary with necessary data for validation.
(3)
(A) Except as provided in subparagraph (B), not later than 60 days after the date of receipt of a written request for a finding under paragraph (1) (with any documentation necessary to make a determination on the request), the Secretary shall publish a notice identifying the national accreditation body making
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395hh
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Federal law — U.S. Code and appendices · legal_authorities
There is hereby established a voluntary insurance program to provide medical insurance benefits in accordance with the provisions of this part for aged and disabled individuals who elect to enroll under such program, to be financed from premium payments by enrollees together with contributions from funds appropriated by the Federal Government.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395u
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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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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
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Federal law — U.S. Code and appendices · legal_authorities
Page 3023
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395l
1395bb, 1395cc, 1395ww, 1396a, and 1396n of this title, en-
acting provisions set out as notes under this section,
and amending provisions set out as a note under sec-
tion 1395ww of this title] shall contravene provisions of
State law relating to the practice of medicine or nurs-
ing or State law requirements or institutional require-
ments regarding the administration of anesthesia and
its medical direction or supervision.’’
REPORT ON IMMUNOSUPPRESSIVE DRUG BENEFIT
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 227(d)],
Nov. 29, 1999, 113 Stat. 1536, 1501A–356, which required
the Secretary of Health and Human Services to submit
to Congress not later than Mar. 1, 2003, a report on the
operation of section 1000(a)(6) [title II, § 227] of Pub. L.
106–113, amending this section and section 1395x of this
title, including an analysis of impact and recommenda-
tions regarding an appropriate cost-effective method
for providing coverage of immunosuppressive drugs
under the medicare program on a permanent basis, was
repealed by Pub. L. 106–554, § 1(a)(6) [title I, § 113(b)(2)],
Dec. 21, 2000, 114 Stat. 2763, 2763A–473.
QUALITY AND UTILIZATION OF IN-HOME CARE FOR
CHRONICALLY DEPENDENT INDIVIDUALS
Pub. L. 100–360, title II, § 205(e)(2), July 1, 1988, 102
Stat. 731, directed Secretary of Health and Human
Services to take appropriate efforts to assure quality
and provide for appropriate utilization of in-home care
for chronically dependent individuals under the amend-
ments made by section 205 of Pub. L. 100–360 [amending
this section and sections 1395l, 1395n, 1395x, and 1395y of
this title], prior to repeal by Pub. L. 101–234, title II,
§ 201(a), Dec. 13, 1989, 103 Stat. 1981.
STUDY OF ALTERNAT
Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 1395l
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