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42 U.S.C. § 1395pp — Practicing Physicians Advisory Council; Council for Technology and Innovation

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

42 U.S.C. § 1395pp — Practicing Physicians Advisory Council; Council for Technology and Innovation

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Source file: Laws/federal/codes/united-states-code/title-42/section-1395pp-practicing-physicians-advisory-council-council-for-technology-and-innova--b18c3703c7.md
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Source location: Title 42, Chapter 7, § 1395pp; chapter-007-social-security.md

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**(a) Repealed. Pub. L. 111–148, title III, § 3134(b)(2), Mar. 23, 2010, 124 Stat. 435** **(b) Council for Technology and Innovation** (1) **Establishment** — The Secretary shall establish a Council for Technology and Innovation within the Centers for Medicare & Medicaid Services (in this section referred to as “CMS”). (2) **Composition** — The Council shall be composed of senior CMS staff and clinicians and shall be chaired by the Executive Coordinator for Technology and Innovation (appointed or designated under paragraph (4)). (3) **Duties** — The Council shall coordinate the activities of coverage, coding, and payment processes under this subchapter with respect to new technologies and procedures, including new drug therapies, and shall coordinate the exchange of information on new technologies between CMS and other entities that make similar decisions. (4) **Executive Coordinator for Technology and Innovation** — The Secretary shall appoint (or designate) a noncareer appointee (as defined in [section 3132(a)(7) of title 5](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section3132/a/7&num=0&edition=prelim)) who shall serve as the Executive Coordinator for Technology and Innovation. Such executive coordinator shall report to the Administrator of CMS, shall chair the Council, shall oversee the execution of its duties, and shall serve as a single point of contact for outside groups and entities regarding the coverage, coding, and payment processes under this subchapter. **(c) Physician-focused payment models** (1) **Technical Advisory Committee** (A) *Establishment* — There is established an ad hoc committee to be known as the “Physician-Focused Payment Model Technical Advisory Committee” (referred to in this subsection as the “Committee”). (B) *Membership* (i) *Number and appointment* — The Committee shall be composed of 11 members appointed by the Comptroller General of the United States. (ii) *Qualifications* — The membership of the Committee shall include individuals with national recognition for their expertise in physician-focused payment models and related delivery of care. No more than 5 members of the Committee shall be providers of services or suppliers, or representatives of providers of services or suppliers. (iii) *Prohibition on Federal employment* — A member of the Committee shall not be an employee of the Federal Government. (iv) *Ethics disclosure* — The Comptroller General shall establish a system for public disclosure by members of the Committee of financial and other potential conflicts of interest relating to such members. Members of the Committee shall be treated as employees of Congress for purposes of applying subchapter I of chapter 131 of title 5. (v) *Date of initial appointments* — The initial appointments of members of the Committee shall be made by not later than 180 days after April 16, 2015. (C) *Term; vacancies* (i) *Term* — The terms of members of the Committee shall be for 3 years except that the Comptroller General shall designate staggered terms for the members first appointed. (ii) *Vacancies* — Any member appointed to fill a vacancy occurring before the expiration of the term for which the member’s predecessor was appointed shall be appointed only for the remainder of that term. A member may serve after the expiration of that member’s term until a successor has taken office. A vacancy in the Committee shall be filled in the manner in which the original appointment was made. (D) *Duties* — The Committee shall meet, as needed, to provide comments and recommendations to the Secretary, as described in paragraph (2)(C), on physician-focused payment models. (E) *Compensation of members* (i) *In general* — Except as provided in clause (ii), a member of the Committee shall serve without compensation. (ii) *Travel expenses* — A member of the Committee shall be allowed travel expenses, including per diem in lieu of subsistence, at rates authorized for an employee of an agency under subchapter I of chapter 57 of title 5 while away from the home or regular place of business of the member in the performance of the duties of the Committee. (F) *Operational and technical support* (i) *In general* — The Assistant Secretary for Planning and Evaluation shall provide technical and operational support for the Committee, which may be by use of a contractor. The Office of the Actuary of the Centers for Medicare & Medicaid Services shall provide to the Committee actuarial assistance as needed. (ii) *Funding* — The Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under [section 1395t of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395t&num=0&edition=prelim), such amounts as are necessary to carry out this paragraph (not to exceed $5,000,000) for fiscal year 2015 and each subsequent fiscal year. Any amounts transferred under the preceding sentence for a fiscal year shall remain available until expended. (G) *Application* — [Section 1013 of title 5](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section1013&num=0&edition=prelim) shall not apply to the Committee. (2) **Criteria and process for submission and review of physician-focused payment models** (A) *Criteria for assessing physician-focused payment models* (i) *Rulemaking* — Not later than November 1, 2016, the Secretary shall, through notice and comment rulemaking, following a request for information, establish criteria for physician-focused payment models, including models for specialist physicians, that could be used by the Committee for making comments and recommendations pursuant to paragraph (1)(D). (ii) *MedPAC submission of comments* — During the comment period for the proposed rule described in clause (i), the Medicare Payment Advisory Commission may submit comments to the Secretary on the proposed criteria under such clause. (iii) *Updating* — The Secretary may update the criteria established under this subparagraph through rulemaking. (B) *Stakeholder submission of physician-focused payment models* — On an ongoing basis, individuals and stakeholder entities may submit to the Committee proposals for physician-focused payment models that such individuals and entities believe meet the criteria described in subparagraph (A). (C) *Committee review of models submitted* — The Committee, on a periodic basis— (i) shall review models submitted under subparagraph (B); (ii) may provide individuals and stakeholder entities who submitted such models with— (I) initial feedback on such models regarding the extent to which such models meet the criteria described in subparagraph (A); and (II) an explanation of the basis for the feedback provided under subclause (I); and (iii) shall prepare comments and recommendations regarding whether such models meet the criteria described in subparagraph (A) and submit such comments and recommendations to the Secretary. (D) *Secretary review and response* — The Secretary shall review the comments and recommendations submitted by the Committee under subparagraph (C) and post a detailed response to such comments and recommendations on the Internet website of the Centers for Medicare & Medicaid Services. (3) **Rule of construction** — Nothing in this subsection shall be construed to impact the development or testing of models under this subchapter or subchapters XI, XIX, or XXI.

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

5 U.S.C. § 1013 — Termination of advisory committees

**(a) In General.—** (1) **Advisory committees in existence on january 5, 1973.—** — Each advisory committee that is in existence on January 5, 1973, shall terminate not later than the expiration of the 2-year period following that date unless— (A) in the case of an advisory committee established by the President or an officer of the Federal Government, such advisory committee is renewed by the President or that officer by appropriate action prior to the expiration of such 2-year period; or (B) in the case of an advisory committee established by an Act of Congress, its duration is otherwise provided for by law. (2) **Advisory committees established after january 5, 1973.—** — Each advisory committee established after January 5, 1973, shall terminate not later than the expiration of the 2-year period beginning on the date of its establishment unless— (A) in the case of an advisory committee established by the President or an officer of the Federal Government 11 So in original. Probably should be followed by a comma. such advisory committee is renewed by the President or such officer by appropriate action prior to the end of such period; or (B) in the case of an advisory committee established by an Act of Congress, its duration is otherwise provided for by law. **(b) Charters.—** (1) **Upon renewal.—** — Upon the renewal of an advisory committee, the advisory committee shall file a charter in accordance with [section 1008(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section1008/c&num=0&edition=prelim). (2) **Upon expiration of successive 2-year periods.—** — An advisory committee established by an Act of Congress shall file a charter in accordance with [section 1008(c) of this title](https://uscode.house.gov/view.x

Source: Supplied U.S. Code snapshot — release unconfirmed · 5 U.S.C. § 1013

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

42 U.S.C. § 1395t — Conditions for coverage of religious nonmedical health care institutional services

**(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

42 U.S.C. § 1320c–3 — Functions of quality improvement organizations

**(a) Review of professional activities; determination of payment; determination of review authority; consultation with professional health care practitioners; standards of health care; other duties** Subject to subsection (b), any quality improvement organization entering into a contract with the Secretary under this part must perform one or more of the following functions: (1) The organization shall review some or all of the professional activities in the area, subject to the terms of the contract and subject to the requirements of subsection (d), of physicians and other health care practitioners and institutional and noninstitutional providers of health care services in the provision of health care services and items for which payment may be made (in whole or in part) under subchapter XVIII (including where payment is made for such services to eligible organizations pursuant to contracts under [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim), to Medicare Advantage organizations pursuant to contracts under part C, and to prescription drug sponsors pursuant to contracts under part D) for the purpose of determining whether— (A) such services and items are or were reasonable and medically necessary and whether such services and items are not allowable under subsection (a)(1) or (a)(9) of [section 1395y of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y&num=0&edition=prelim); (B) the quality of such services meets professionally recognized standards of health care; and (C) in case such services and items are proposed to be provided in a hospital or other health care facility on an inpatient basis, such services and items could, con

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–3

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

42 U.S.C. § 1395w — Payment of benefits

**(a) Amounts** Except as provided in [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim), and subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are payable under this part, amounts equal to— (1) in the case of services described in [section 1395k(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395k/a/1&num=0&edition=prelim)—80 percent of the reasonable charges for the services; except that (A) an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis (and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services) may elect to be paid 80 percent of the reasonable cost of services for which payment may be made under this part on behalf of individuals enrolled in such organization in lieu of 80 percent of the reasonable charges for such services if the organization undertakes to charge such individuals no more than 20 percent of such reasonable cost plus any amounts payable by them as a result of subsection (b), (B) with respect to items and services described in [section 1395x(s)(10)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s/10/A&num=0&edition=prelim), the amounts paid shall be 100 percent of the reasonable charges for such items and services, (C) with respect to expenses incurred for those physicians

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

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

42 U.S.C. § 1395pp — Limitation on liability where claims are

Page 3749 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395pp ‘‘(1) the amendments made by section 602(h)(2)(A) of that Act [amending this section] shall be effective with respect to any appeal or action brought on or after April 20, 1983; and ‘‘(2) the amendments made by section 602(h)(2)(B) of that Act [amending this section] shall be effective with respect to any appeal or action brought on or after the date of the enactment of this Act [July 18, 1984].’’ § 1395pp. Limitation on liability where claims are disallowed (a) Conditions prerequisite to payment for items and services notwithstanding determination of disallowance Where— (1) a determination is made that, by reason of section 1395y(a)(1) or (9) of this title or by reason of a coverage denial described in sub- section (g), payment may not be made under part A or part B of this subchapter for any ex- penses incurred for items or services furnished an individual by a provider of services or by another person pursuant to an assignment under section 1395u(b)(3)(B)(ii) of this title, and (2) both such individual and such provider of services or such other person, as the case may be, did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B, then to the extent permitted by this subchapter, payment shall, notwithstanding such determina- tion, be made for such items or services (and for such period of time as the Secretary finds will carry out the objectives of this subchapter), as though section 1395y(a)(1) and section 1395y(a)(9) of this title did not apply and as though the cov- erage denial described in subsection (g) had not occurred. In each such case the Secretary shall notify both such in

Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 1395pp

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