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42 U.S.C. § 1395y — Selected drug subsidy program

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

42 U.S.C. § 1395y — Selected drug subsidy program

With respect to covered part D drugs that would be applicable drugs (as defined in [section 1395w–114c(g)(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–114c/g/2&num=0&edition=prelim)) but for the application of subparagraph (B) of such section, the Secretary shall provide a process whereby, in the case of an applicable beneficiary (as defined in [section 1395w–114c(g)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–114c/g/1&num=0&edition=prelim)) who, with respect to a year, is enrolled in a prescription drug plan or is enrolled in an MA–PD plan, has not incurred costs that are equal to or exceed the annual out-of-pocket threshold specified in [section 1395w–102(b)(4)(B)(i) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–102/b/4/B/i&num=0&edition=prelim), and is dispensed such a drug, the Secretary (periodically and on a timely basis) provides the PDP sponsor or the MA organization offering the plan, a subsidy with respect to such drug that is equal to 10 percent of the negotiated price (as defined in [section 1395w–114c(g)(6) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–114c/g/6&num=0&edition=prelim)) of such drug.

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Source file: Laws/federal/codes/united-states-code/title-42/section-1395y-selected-drug-subsidy-program--bdaf1a7d0f.md
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Source location: Title 42, Chapter 7, § 1395y; chapter-007-social-security.md

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

10 U.S.C. § 1097c — TRICARE program: relationship with employer-sponsored group health plans

**(a) Prohibition on Financial Incentives Not to Enroll in a Group Health Plan.—** (1) Except as provided in this subsection, the provisions of section 1862(b)(3)(C) of the Social Security Act shall apply with respect to financial or other incentives for a TRICARE-eligible employee not to enroll (or to terminate enrollment) under a health plan which would (in the case of such enrollment) be a primary plan under sections 1079(j)(1) 11 See References in Text note below. and 1086(g) of this title in the same manner as such section 1862(b)(3)(C) applies to financial or other incentives for an individual entitled to benefits under title XVIII of the Social Security Act not to enroll (or to terminate enrollment) under a group health plan or a large group health plan which would (in the case of enrollment) be a primary plan (as defined in section 1862(b)(2)(A) of such Act). (2) (A) The Secretary of Defense may by regulation adopt such additional exceptions to the prohibition referenced and applied under paragraph (1) as the Secretary deems appropriate and such paragraph (1) shall be implemented taking into account the adoption of such exceptions. (B) The Secretary of Defense and the Secretary of Health and Human Services are authorized to enter into agreements for carrying out this subsection. Any such agreement shall provide that any expenses incurred by the Secretary of Health and Human Services pertaining to carrying out this subsection shall be reimbursed by the Secretary of Defense. (C) Authorities of the Inspector General of the Department of Defense shall be available for oversight and investigations of responsibilities of employers and other entities under this subsection. (D) Information obtained under [section 1095(k) of this title](https://uscode.house

Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1097c

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

26 U.S.C. § 5000 — Certain group health plans

**(a) Imposition of tax** There is hereby imposed on any employer (including a self-employed person) or employee organization that contributes to a nonconforming group health plan a tax equal to 25 percent of the employer’s or employee organization’s expenses incurred during the calendar year for each group health plan to which the employer or employee organization contributes. **(b) Group health plan and large group health plan** For purposes of this section— (1) **Group health plan** — The term “group health plan” means a plan (including a self-insured plan) of, or contributed to by, an employer (including a self-employed person) or employee organization to provide health care (directly or otherwise) to the employees, former employees, the employer, others associated or formerly associated with the employer in a business relationship, or their families. (2) **Large group health plan** — The term “large group health plan” means a plan of, or contributed to by, an employer or employee organization (including a self-insured plan) to provide health care (directly or otherwise) to the employees, former employees, the employer, others associated or formerly associated with the employer in a business relationship, or their families, that covers employees of at least one employer that normally employed at least 100 employees on a typical business day during the previous calendar year. For purposes of the preceding sentence— (A) all employers treated as a single employer under subsection (a) or (b) of section 52 shall be treated as a single employer, (B) all employees of the members of an affiliated service group (as defined in section 414(m)) shall be treated as employed by a single employer, and (C) leased employees (as defined in section 414(n)(2)) shall be trea

Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 5000

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

26 U.S.C. § 6103 — Confidentiality and disclosure of returns and return information

**(a) General rule** Returns and return information shall be confidential, and except as authorized by this title— (1) no officer or employee of the United States, (2) no officer or employee of any State, any local law enforcement agency receiving information under subsection (i)(1)(C) or (7)(A), any tribal or local child support enforcement agency, or any local agency administering a program listed in subsection (l)(7)(D) who has or had access to returns or return information under this section or section 6104(c), and (3) no other person (or officer or employee thereof) who has or had access to returns or return information under subsection (c), subsection (e)(1)(D)(iii), paragraph (10), (13), (14), or (15) of subsection (k), paragraph (6), (8), (10), (12), (13) (other than subparagraphs (D)(v) and (D)(vi) thereof), (16), (19), (20), or (21) of subsection (l), paragraph (2) or (4)(B) of subsection (m), or subsection (n), shall disclose any return or return information obtained by him in any manner in connection with his service as such an officer or an employee or otherwise or under the provisions of this section. For purposes of this subsection, the term “officer or employee” includes a former officer or employee. **(b) Definitions** For purposes of this section— (1) **Return** — The term “return” means any tax or information return, declaration of estimated tax, or claim for refund required by, or provided for or permitted under, the provisions of this title which is filed with the Secretary by, on behalf of, or with respect to any person, and any amendment or supplement thereto, including supporting schedules, attachments, or lists which are supplemental to, or part of, the return so filed. (2) **Return information** — The term “return information” means— (

Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 6103

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

42 U.S.C. § 1305 — Short title of chapter

This chapter may be cited as the “Social Security Act”.

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1305

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

42 U.S.C. § 1314 — Public advisory groups

**(a) Advisory Council on Public Welfare; appointment and functions of initial Council** The Secretary shall, during 1964, appoint an Advisory Council on Public Welfare for the purpose of reviewing the administration of the public assistance and child welfare services programs for which funds are appropriated pursuant to this chapter and making recommendations for improvement of such administration, and reviewing the status of and making recommendations with respect to the public assistance programs for which funds are so appropriated, especially in relation to the old-age, survivors, and disability insurance program, with respect to the fiscal capacities of the States and the Federal Government, and with respect to any other matters bearing on the amount and proportion of the Federal and State shares in the public assistance and child welfare services programs. **(b) Membership and representation of interests on initial Council** The Council shall be appointed by the Secretary without regard to the provisions of title 5 governing appointments in the competitive service and shall consist of twelve persons who shall, to the extent possible, be representatives of employers and employees in equal numbers, representatives of State or Federal agencies concerned with the administration or financing of the public assistance and child welfare services programs, representatives of nonprofit private organizations concerned with social welfare programs, other persons with special knowledge, experience, or qualifications with respect to such programs, and members of the public. **(c) Technical and other assistance for initial Council; availability of data** The Council is authorized to engage such technical assistance as may be required to carry out its functions, and the Secreta

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1314

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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. § 1395d — Free choice by patient guaranteed

**(a) Basic freedom of choice** Any individual entitled to insurance benefits under this subchapter may obtain health services from any institution, agency, or person qualified to participate under this subchapter if such institution, agency, or person undertakes to provide him such services. **(b) Use of private contracts by medicare beneficiaries** (1) **In general** — Subject to the provisions of this subsection, nothing in this subchapter shall prohibit a physician or practitioner from entering into a private contract with a medicare beneficiary for any item or service— (A) for which no claim for payment is to be submitted under this subchapter, and (B) for which the physician or practitioner receives— (i) no reimbursement under this subchapter directly or on a capitated basis, and (ii) receives no amount for such item or service from an organization which receives reimbursement for such item or service under this subchapter directly or on a capitated basis. (2) **Beneficiary protections** (A) *In general* — Paragraph (1) shall not apply to any contract unless— (i) the contract is in writing and is signed by the medicare beneficiary before any item or service is provided pursuant to the contract; (ii) the contract contains the items described in subparagraph (B); and (iii) the contract is not entered into at a time when the medicare beneficiary is facing an emergency or urgent health care situation. (B) *Items required to be included in contract* — Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the medicare beneficiary that by signing such contract the beneficiary— (i) agrees not to submit a claim (or to request that the physician or practitioner submit a claim) under t

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

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

42 U.S.C. § 1395dd — Definitions

For purposes of this subchapter— **(a) Spell of illness** The term “spell of illness” with respect to any individual means a period of consecutive days— (1) beginning with the first day (not included in a previous spell of illness) (A) on which such individual is furnished inpatient hospital services, inpatient critical access hospital services or extended care services, and (B) which occurs in a month for which he is entitled to benefits under part A, and (2) ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital or critical access hospital nor an inpatient of a facility described in [section 1395i–3(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395i–3/a/1&num=0&edition=prelim) or subsection (y)(1). **(b) Inpatient hospital services** The term “inpatient hospital services” means the following items and services furnished to an inpatient of a hospital and (except as provided in paragraph (3)) by the hospital— (1) bed and board; (2) such nursing services and other related services, such use of hospital facilities, and such medical social services as are ordinarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital for the care and treatment of inpatients; and (3) such other diagnostic or therapeutic items or services, furnished by the hospital or by others under arrangements with them made by the hospital, as are ordinarily furnished to inpatients either by such hospital or by others under such arrangements; (4) medical or surgical services provided by a physician, resident, or intern

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

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

42 U.S.C. § 1395ee — Exclusions from coverage and medicare as secondary payer

**(a) Items or services specifically excluded** Notwithstanding any other provision of this subchapter, no payment may be made under part A or part B for any expenses incurred for items or services— (1) (A) which, except for items and services described in a succeeding subparagraph or additional preventive services (as described in [section 1395x(ddd)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/ddd/1&num=0&edition=prelim)), are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, (B) in the case of items and services described in [section 1395x(s)(10) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s/10&num=0&edition=prelim), which are not reasonable and necessary for the prevention of illness, (C) in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness, (D) in the case of clinical care items and services provided with the concurrence of the Secretary and with respect to research and experimentation conducted by, or under contract with, the Medicare Payment Advisory Commission or the Secretary, which are not reasonable and necessary to carry out the purposes of [section 1395ww(e)(6) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/e/6&num=0&edition=prelim),11 See References in Text note below. (E) in the case of research conducted pursuant to [section 1320b–12 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320b-12&num=0&edition=prelim), which is not reasonable and necessary to carry out the purposes of that sec

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

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

42 U.S.C. § 1395ii — Agreements with providers of services; enrollment processes

**(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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