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42 U.S.C. § 1395g — Notice of medicare benefits; medicare and medigap information

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

42 U.S.C. § 1395g — Notice of medicare benefits; medicare and medigap information

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Stable record: federal_law:legal_authorities:record_usc_a2e05554739354a9d458e67f
Source file: Laws/federal/codes/united-states-code/title-42/section-1395g-notice-of-medicare-benefits-medicare-and-medigap-information--4d3fbb191d.md
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Source location: Title 42, Chapter 7, § 1395g; chapter-007-social-security.md

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**(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 check any explanation of benefits or itemized statement furnished pursuant to [section 1395b–7 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395b-7&num=0&edition=prelim) for accuracy and report any errors or questionable charges by calling the toll-free phone number described in paragraph (4); (2) a statement of the beneficiary’s right to request an itemized statement for medicare items and services (as provided in [section 1395b–7(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395b–7/b&num=0&edition=prelim)); (3) a description of the program to collect information on medicare fraud and abuse established under [section 1395b–5(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395b–5/b&num=0&edition=prelim); and (4) a toll-free telephone number maintained by the Inspector General in the Department of Health and Human Services for the receipt of complaints and information about waste, fraud, and abuse in the provision or billing of services under this subchapter. **(d) Medicare opioid safety education** The notice provided under subsection (a) shall include— (1) references to educational resources regarding opioid use and pain management; (2) a description of categories of alternative, non-opioid pain management treatments covered under this subchapter; and (3) a suggestion for the beneficiary to talk to a physician regarding opioid use and pain management.

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

42 U.S.C. § 1395ss — Application of certain provisions of subchapter II

The provisions of sections 406 and 416(j) of this title, and of subsections (a), (d), (e), (h), (i), (j), (k), and (l) of [section 405 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section405&num=0&edition=prelim), shall also apply with respect to this subchapter to the same extent as they are applicable with respect to subchapter II, except that, in applying such provisions with respect to this subchapter, any reference therein to the Commissioner of Social Security or the Social Security Administration shall be considered a reference to the Secretary or the Department of Health and Human Services, respectively.

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

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

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

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

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

42 U.S.C. § 1395 — Conditions of participation for home health agencies; home health quality

**(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

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

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

42 U.S.C. § 1395b–2 — Prospective payment for home health services

**(a) In general** Notwithstanding [section 1395x(v) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/v&num=0&edition=prelim), the Secretary shall provide, for portions of cost reporting periods occurring on or after October 1, 2000, for payments for home health services in accordance with a prospective payment system established by the Secretary under this section. **(b) System of prospective payment for home health services** (1) **In general** — The Secretary shall establish under this subsection a prospective payment system for payment for all costs of home health services. Under the system under this subsection all services covered and paid on a reasonable cost basis under the medicare home health benefit as of August 5, 1997, including medical supplies, shall be paid for on the basis of a prospective payment amount determined under this subsection and applicable to the services involved. In implementing the system, the Secretary may provide for a transition (of not longer than 4 years) during which a portion of such payment is based on agency-specific costs, but only if such transition does not result in aggregate payments under this subchapter that exceed the aggregate payments that would be made if such a transition did not occur. (2) **Unit of payment** (A) *In general* — In defining a prospective payment amount under the system under this subsection, the Secretary shall consider an appropriate unit of service and the number, type, and duration of visits provided within that unit, potential changes in the mix of services provided within that unit and their cost, and a general system design that provides for continued access to quality services. (B) *30-day unit of service* — For purposes of implementing t

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395b–2

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

42 U.S.C. § 1395iii — Payments to hospitals for inpatient hospital services

**(a) Determination of costs for inpatient hospital services; limitations; exemptions; “operating costs of inpatient hospital services” defined** (1) (A) (i) The Secretary, in determining the amount of the payments that may be made under this subchapter with respect to operating costs of inpatient hospital services (as defined in paragraph (4)) shall not recognize as reasonable (in the efficient delivery of health services) costs for the provision of such services by a hospital for a cost reporting period to the extent such costs exceed the applicable percentage (as determined under clause (ii)) of the average of such costs for all hospitals in the same grouping as such hospital for comparable time periods. (ii) For purposes of clause (i), the applicable percentage for hospital cost reporting periods beginning— (I) on or after October 1, 1982, and before October 1, 1983, is 120 percent; (II) on or after October 1, 1983, and before October 1, 1984, is 115 percent; and (III) on or after October 1, 1984, is 110 percent. (B) (i) For purposes of subparagraph (A) the Secretary shall establish case mix indexes for all short-term hospitals, and shall set limits for each hospital based upon the general mix of types of medical cases with respect to which such hospital provides services for which payment may be made under this subchapter. (ii) The Secretary shall set such limits for a cost reporting period of a hospital— (I) by updating available data for a previous period to the immediate preceding cost reporting period by the estimated average rate of change of hospital costs industry-wide, and (II) by projecting for the cost reporting period by the applicable percentage increase (as defined in subsection (b)(3)(B)).

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

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

42 U.S.C. § 1395k — Payments to providers of services

**(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

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

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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. § 1395w–23 — Provisions relating to the administration of part B

**(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) Determination of reasonable charges** (1) Repealed. Pub. L. 108–173, title IX, § 911(c)(3)(A), Dec. 8, 2003, 117 Stat. 2384. (2) (A) , (B) Repealed. Pub. L. 108–173, title IX, § 911(c)(3)(B)(i), Dec. 8, 2003, 117 Stat. 2384. (C) In the case of residents of nursing facilities who receive services described in clause (i) or (ii) of [section 1395x(s)(2)(K) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s/2/K&num=0&edition=prelim) performed by a member of a team, the Secretary shall instruct medicare administrative contractors to develop mechanisms which permit routine payment under this part for up to 1.5 visits per month per resident. In the previous sentence, the term “team” refers to a physician and includes a physician assistant acting under the supervision of the physician or a nurse practitioner working in collaboration with that physician, or both. (3) The Secretary— (A) shall take such action as may be necessary to assure that, where payment under this part for a service is on a cost basis, the cost is reasonable cost (as determined under [section 1395x(v) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/v&num=0&edition=prelim)); (B) shall take such action as may be necessary to assure that, where payment under this part for a service is on a charge basis, such charge will be reasonable and not higher than the charge applicable, for a comparable service and under comparable ci

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395w–23

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

42 U.S.C. § 1396a — State plans for medical assistance

**(a) Contents** A State plan for medical assistance must— (1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them; (2) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under [section 1396b of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396b&num=0&edition=prelim) are authorized by this subchapter; and, effective July 1, 1969, provide for financial participation by the State equal to all of such non-Federal share or provide for distribution of funds from Federal or State sources, for carrying out the State plan, on an equalization or other basis which will assure that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services available under the plan; (3) provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness; (4) provide (A) such methods of administration (including methods relating to the establishment and maintenance of personnel standards on a merit basis, except that the Secretary shall exercise no authority with respect to the selection, tenure of office, and compensation of any individual employed in accordance with such methods, including provision for utilization of professional medical personnel in the administration and, where administered locally, supervision of administration of the plan, and, subject to [section 1396b(i) of this title](https://uscode.house.gov/view.xhtml?req=granulei

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1396a

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

42 U.S.C. § 1395g — Payments to providers of services

Page 2958 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395g WAIVER OF LIMITATIONS TO ALLOW PRE-EXISTING HOSPICES TO PARTICIPATE AS A HOSPICE PROGRAM Pub. L. 97–248, title I, § 122(k), formerly § 122(j), Sept. 3, 1982, 96 Stat. 363, as redesignated and amended by Pub. L. 97–448, title III, § 309(a)(6), (7), Jan. 12, 1983, 96 Stat. 2408, provided that: ‘‘The Secretary of Health and Human Services shall grant waivers of the limitations imposed by section 1814(i)(2) of the Social Security Act [42 U.S.C. 1395f(i)(2)] (relating to the cap amount), sec- tion 1861(dd)(1)(G) of such Act [42 U.S.C. 1395x(dd)(1)(G)] (relating to the limitations on the frequency and num- ber of respite care days), and section 1861(dd)(2)(A)(iii) of such Act [42 U.S.C. 1395x(dd)(2)(A)(iii)] (relating to the aggregate limit on the number of days of inpatient care), as may be necessary to allow any institution which commenced operations as a hospice prior to Jan- uary 1, 1975, to participate until October 1, 1986, in a viable manner as a hospice program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].’’ MEDICARE PAYMENT BASIS FOR SERVICES PROVIDED BY AGENCIES AND PROVIDERS; EFFECTIVE DATE Pub. L. 93–233, § 16, Dec. 31, 1973, 87 Stat. 967, provided that: ‘‘In the administration of titles V, XVIII, and XIX of the Social Security Act [42 U.S.C. 701 et seq., 1395 et seq., 1396 et seq.], the amount payable under such title to any provider of services on account of services pro- vided by such hospital, skilled nursing facility, or home health agency shall be determined (for any period with respect to which the amendments made by section 233 of Public Law 92–603 [this section and sections 706, 709, 1395l, and 1396b of this title] would, except for the provisions

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

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