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42 U.S.C. § 1320d — Definitions
Federal law — U.S. Code and appendices · legal_authorities
For purposes of this part:
(1) **Code set** — The term “code set” means any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.
(2) **Health care clearinghouse** — The term “health care clearinghouse” means a public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements.
(3) **Health care provider** — The term “health care provider” includes a provider of services (as defined in [section 1395x(u) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/u&num=0&edition=prelim)), a provider of medical or other health services (as defined in [section 1395x(s) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s&num=0&edition=prelim)), and any other person furnishing health care services or supplies.
(4) **Health information** — The term “health information” means any information, whether oral or recorded in any form or medium, that—
(A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
(B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.
(5) **Health plan** — The term “health plan” means an individual or group plan that provides, or pays the cost of, medical care (as such term is defined in [section 300gg–91 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg-9
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Source file: Laws/federal/codes/united-states-code/title-42/section-1320d-definitions--7707b07dba.md
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Source location: Title 42, Chapter 7, § 1320d; chapter-007-social-security.md
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For purposes of this part:
(1) **Code set** — The term “code set” means any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.
(2) **Health care clearinghouse** — The term “health care clearinghouse” means a public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements.
(3) **Health care provider** — The term “health care provider” includes a provider of services (as defined in [section 1395x(u) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/u&num=0&edition=prelim)), a provider of medical or other health services (as defined in [section 1395x(s) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s&num=0&edition=prelim)), and any other person furnishing health care services or supplies.
(4) **Health information** — The term “health information” means any information, whether oral or recorded in any form or medium, that—
(A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
(B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.
(5) **Health plan** — The term “health plan” means an individual or group plan that provides, or pays the cost of, medical care (as such term is defined in [section 300gg–91 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg-91&num=0&edition=prelim)). Such term includes the following, and any combination thereof:
(A) A group health plan (as defined in [section 300gg–91(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–91/a&num=0&edition=prelim)), but only if the plan—
(i) has 50 or more participants (as defined in [section 1002(7) of title 29](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1002/7&num=0&edition=prelim)); or
(ii) is administered by an entity other than the employer who established and maintains the plan.
(B) A health insurance issuer (as defined in [section 300gg–91(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–91/b&num=0&edition=prelim)).
(C) A health maintenance organization (as defined in [section 300gg–91(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–91/b&num=0&edition=prelim)).
(D) Parts 11 So in original. Probably should be “Part”. A, B, C, or D of the Medicare program under subchapter XVIII.
(E) The medicaid program under subchapter XIX.
(F) A Medicare supplemental policy (as defined in [section 1395ss(g)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss/g/1&num=0&edition=prelim)).
(G) A long-term care policy, including a nursing home fixed indemnity policy (unless the Secretary determines that such a policy does not provide sufficiently comprehensive coverage of a benefit so that the policy should be treated as a health plan).
(H) An employee welfare benefit plan or any other arrangement which is established or maintained for the purpose of offering or providing health benefits to the employees of 2 or more employers.
(I) The health care program for active military personnel under title 10.
(J) The veterans health care program under chapter 17 of title 38.
(K) The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), as defined in [section 1072(4) of title 10](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1072/4&num=0&edition=prelim).
(L) The Indian health service program under the Indian Health Care Improvement Act ([25 U.S.C. 1601](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title25-section1601&num=0&edition=prelim) et seq.).
(M) The Federal Employees Health Benefit Plan under chapter 89 of title 5.
(6) **Individually identifiable health information** — The term “individually identifiable health information” means any information, including demographic information collected from an individual, that—
(A) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual, and—
(i) identifies the individual; or
(ii) with respect to which there is a reasonable basis to believe that the information can be used to identify the individual.
(7) **Standard** — The term “standard”, when used with reference to a data element of health information or a transaction referred to in [section 1320d–2(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320d–2/a/1&num=0&edition=prelim), means any such data element or transaction that meets each of the standards and implementation specifications adopted or established by the Secretary with respect to the data element or transaction under sections 1320d–1 through 1320d–3 of this title.
(8) **Standard setting organization** — The term “standard setting organization” means a standard setting organization accredited by the American National Standards Institute, including the National Council for Prescription Drug Programs, that develops standards for information transactions, data elements, or any other standard that is necessary to, or will facilitate, the implementation of this part.
(9) **Operating rules** — The term “operating rules” means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part.
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Establishment** There is hereby established the Medicaid and CHIP Payment and Access Commission (in this section referred to as “MACPAC”).
**(b) Duties**
(1) **Review of access policies for all States and annual reports** — MACPAC shall—
(A) review policies of the Medicaid program established under this subchapter (in this section referred to as “Medicaid”) and the State Children’s Health Insurance Program established under subchapter XXI (in this section referred to as “CHIP”) affecting access to covered items and services, including topics described in paragraph (2);
(B) make recommendations to Congress, the Secretary, and States concerning such access policies;
(C) by not later than March 15 of each year (beginning with 2010), submit a report to Congress containing the results of such reviews and MACPAC’s recommendations concerning such policies; and
(D) by not later than June 15 of each year (beginning with 2010), submit a report to Congress containing an examination of issues affecting Medicaid and CHIP, including the implications of changes in health care delivery in the United States and in the market for health care services on such programs.
(2) **Specific topics to be reviewed** — Specifically, MACPAC shall review and assess the following:
(A) *Medicaid and CHIP payment policies* — Payment policies under Medicaid and CHIP, including—
(i) the factors affecting expenditures for the efficient provision of items and services in different sectors, including the process for updating payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics, managed care entities, and providers of ot
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1396
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Federal law — U.S. Code and appendices · legal_authorities
$10,000,000 shall remain available until expended, for the establishment of an Indian Catastrophic Health Emergency Fund (hereinafter referred to as the “Fund”). On and after October 18, 1986, the Fund is to cover the Indian Health Service portion of the medical expenses of catastrophic illness falling within the responsibility of the Service and shall be administered by the Secretary of Health and Human Services, acting through the central office of the Indian Health Service. No part of the Fund or its administration shall be subject to contract or grant under the Indian Self-Determination and Education Assistance Act (Public Law 93–638) [[25 U.S.C. 5301](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title25-section5301&num=0&edition=prelim) et seq.]. There shall be deposited into the Fund all amounts recovered under the authority of the Federal Medical Care Recovery Act ([42 U.S.C. 2651](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2651&num=0&edition=prelim) et seq.), which shall become available for obligation upon receipt and which shall remain available for obligation until expended. The Fund shall not be used to pay for health services provided to eligible Indians to the extent that alternate Federal, State, local, or private insurance resources for payment: (1) are available and accessible to the beneficiary; or (2) would be available and accessible if the beneficiary were to apply for them; or (3) would be available and accessible to other citizens similarly situated under Federal, State, or local law or regulation or private insurance program notwithstanding Indian Health Service eligibility or residency on or off a Federal Indian reservation.
Source: Supplied U.S. Code snapshot — release unconfirmed · 25 U.S.C. § 1601
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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
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
**(a) In eligibility to enroll**
(1) **In general** — Subject to paragraph (2), a group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
(A) Health status.
(B) Medical condition (including both physical and mental illnesses).
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability (including conditions arising out of acts of domestic violence).
(H) Disability.
(2) **No application to benefits or exclusions** — To the extent consistent with [section 1181 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1181&num=0&edition=prelim), paragraph (1) shall not be construed—
(A) to require a group health plan, or group health insurance coverage, to provide particular benefits other than those provided under the terms of such plan or coverage, or
(B) to prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.
(3) **Construction** — For purposes of paragraph (1), rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for such enrollment.
**(b) In premium contributions**
(1) **In general** — A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, m
Source: Supplied U.S. Code snapshot — release unconfirmed · 29 U.S.C. § 1182
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Standards to enable electronic exchange**
(1) **In general** — The Secretary shall adopt standards for transactions, and data elements for such transactions, to enable health information to be exchanged electronically, that are appropriate for—
(A) the financial and administrative transactions described in paragraph (2); and
(B) other financial and administrative transactions determined appropriate by the Secretary, consistent with the goals of improving the operation of the health care system and reducing administrative costs, and subject to the requirements under paragraph (5).
(2) **Transactions** — The transactions referred to in paragraph (1)(A) are transactions with respect to the following:
(A) Health claims or equivalent encounter information.
(B) Health claims attachments.
(C) Enrollment and disenrollment in a health plan.
(D) Eligibility for a health plan.
(E) Health care payment and remittance advice.
(F) Health plan premium payments.
(G) First report of injury.
(H) Health claim status.
(I) Referral certification and authorization.
(J) Electronic funds transfers.
(3) **Accommodation of specific providers** — The standards adopted by the Secretary under paragraph (1) shall accommodate the needs of different types of health care providers.
(4) **Requirements for financial and administrative transactions**
(A) *In general* — The standards and associated operating rules adopted by the Secretary shall—
(i) to the extent feasible and appropriate, enable determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care;
(ii) be comprehensive, requiring minimal augmentation by paper or other communications;
(iii) provide for timely acknowledg
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320d–2
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Conduct of transactions by plans**
(1) **In general** — If a person desires to conduct a transaction referred to in [section 1320d–2(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320d–2/a/1&num=0&edition=prelim) with a health plan as a standard transaction—
(A) the health plan may not refuse to conduct such transaction as a standard transaction;
(B) the insurance plan may not delay such transaction, or otherwise adversely affect, or attempt to adversely affect, the person or the transaction on the ground that the transaction is a standard transaction; and
(C) the information transmitted and received in connection with the transaction shall be in the form of standard data elements of health information.
(2) **Satisfaction of requirements** — A health plan may satisfy the requirements under paragraph (1) by—
(A) directly transmitting and receiving standard data elements of health information; or
(B) submitting nonstandard data elements to a health care clearinghouse for processing into standard data elements and transmission by the health care clearinghouse, and receiving standard data elements through the health care clearinghouse.
(3) **Timetable for compliance** — Paragraph (1) shall not be construed to require a health plan to comply with any standard, implementation specification, or modification to a standard or specification adopted or established by the Secretary under sections 1320d–1 through 1320d–3 of this title at any time prior to the date on which the plan is required to comply with the standard or specification under subsection (b).
**(b) Compliance with standards**
(1) **Initial compliance**
(A) *In general* — Not later than 24 months after the date on which an initial standar
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320d–4
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Filing of agreements; eligibility for payment; charges with respect to items and services**
(1) Any provider of services (except a fund designated for purposes of section 1395f(g) and [section 1395n(e) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395n/e&num=0&edition=prelim)) shall be qualified to participate under this subchapter and shall be eligible for payments under this subchapter if it files with the Secretary an agreement—
(A)
(i) not to charge, except as provided in paragraph (2), any individual or any other person for items or services for which such individual is entitled to have payment made under this subchapter (or for which he would be so entitled if such provider of services had complied with the procedural and other requirements under or pursuant to this subchapter or for which such provider is paid pursuant to the provisions of [section 1395f(e) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395f/e&num=0&edition=prelim)), and (ii) not to impose any charge that is prohibited under [section 1396a(n)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a/n/3&num=0&edition=prelim),
(B) not to charge any individual or any other person for items or services for which such individual is not entitled to have payment made under this subchapter because payment for expenses incurred for such items or services may not be made by reason of the provisions of paragraph (1) or (9) of [section 1395y(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/a&num=0&edition=prelim), but only if (i) such individual was without fault in incurring such expenses and (ii) the Secret
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395ii
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Authority**
(1) **Authority to enter into contracts** — The Secretary may enter into contracts with any eligible entity to serve as a medicare administrative contractor with respect to the performance of any or all of the functions described in paragraph (4) or parts of those functions (or, to the extent provided in a contract, to secure performance thereof by other entities).
(2) **Eligibility of entities** — An entity is eligible to enter into a contract with respect to the performance of a particular function described in paragraph (4) only if—
(A) the entity has demonstrated capability to carry out such function;
(B) the entity complies with such conflict of interest standards as are generally applicable to Federal acquisition and procurement;
(C) the entity has sufficient assets to financially support the performance of such function; and
(D) the entity meets such other requirements as the Secretary may impose.
(3) **Medicare administrative contractor defined** — For purposes of this subchapter and subchapter XI—
(A) *In general* — The term “medicare administrative contractor” means an agency, organization, or other person with a contract under this section.
(B) *Appropriate medicare administrative contractor* — With respect to the performance of a particular function in relation to an individual entitled to benefits under part A or enrolled under part B, or both, a specific provider of services or supplier (or class of such providers of services or suppliers), the “appropriate” medicare administrative contractor is the medicare administrative contractor that has a contract under this section with respect to the performance of that function in relation to that individual, provider of services or supplier or class of provider of services o
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395uu
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Application of contract requirements** In the case of a business associate of a covered entity that obtains or creates protected health information pursuant to a written contract (or other written arrangement) described in section 164.502(e)(2) of title 45, Code of Federal Regulations, with such covered entity, the business associate may use and disclose such protected health information only if such use or disclosure, respectively, is in compliance with each applicable requirement of section 164.504(e) of such title. The additional requirements of this subchapter that relate to privacy and that are made applicable with respect to covered entities shall also be applicable to such a business associate and shall be incorporated into the business associate agreement between the business associate and the covered entity.
**(b) Application of knowledge elements associated with contracts** Section 164.504(e)(1)(ii) of title 45, Code of Federal Regulations, shall apply to a business associate described in subsection (a), with respect to compliance with such subsection, in the same manner that such section applies to a covered entity, with respect to compliance with the standards in sections 164.502(e) and 164.504(e) of such title, except that in applying such section 164.504(e)(1)(ii) each reference to the business associate, with respect to a contract, shall be treated as a reference to the covered entity involved in such contract.
**(c) Application of civil and criminal penalties** In the case of a business associate that violates any provision of subsection (a) or (b), the provisions of sections 1176 and 1177 of the Social Security Act ([42 U.S.C. 1320d–5](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320d-5&num=0&edition=prelim), 1320
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 17935
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Application of HIPAA State preemption** Section 1178 of the Social Security Act ([42 U.S.C. 1320d–7](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320d-7&num=0&edition=prelim)) shall apply to a provision or requirement under this subchapter in the same manner that such section applies to a provision or requirement under part C of title XI of such Act [[42 U.S.C. 1320d](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320d&num=0&edition=prelim) et seq.] or a standard or implementation specification adopted or established under sections 1172 through 1174 of such Act [[42 U.S.C. 1320d–1](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320d-1&num=0&edition=prelim) to 1320d–3].
**(b) Health Insurance Portability and Accountability Act of 1996** The standards governing the privacy and security of individually identifiable health information promulgated by the Secretary under sections 262(a) and 264 of the Health Insurance Portability and Accountability Act of 1996 shall remain in effect to the extent that they are consistent with this subchapter. The Secretary shall by rule amend such Federal regulations as required to make such regulations consistent with this subchapter.
**(c) Construction** Nothing in this subchapter shall constitute a waiver of any privilege otherwise applicable to an individual with respect to the protected health information of such individual.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 17952
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