42 U.S.C. § 1395qq — Indian Health Service facilities

Page 3752 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395qq submit to Congress a report on the use of advance bene- ficiary notices under title XVIII of such Act [42 U.S.C. 1395 et seq.]. Such report shall include information con- cerning the providers of services and other persons that have provided such notices and the response of bene- ficiaries to such notices. ‘‘(4) GAO REPORT ON USE OF PRIOR DETERMINATION PROCESS.—Not later than 36 months after the date on which section 1869(h) of the Social Security Act [42 U.S.C. 1395ff(h)] (as added by subsection (a)) takes ef- fect, the Comptroller General of the United States shall submit to Congress a report on the use of the prior de- termination process under such section. Such report shall include— ‘‘(A) information concerning— ‘‘(i) the number and types of procedures for which a prior determination has been sought; ‘‘(ii) determinations made under the process; ‘‘(iii) the percentage of beneficiaries prevailing; ‘‘(iv) in those cases in which the beneficiaries do not prevail, the reasons why such beneficiaries did not prevail; and ‘‘(v) changes in receipt of services resulting from the application of such process; ‘‘(B) an evaluation of whether the process was use- ful for physicians (and other suppliers) and bene- ficiaries, whether it was timely, and whether the amount of information required was burdensome to physicians and beneficiaries; and ‘‘(C) recommendations for improvements or con- tinuation of such process. ‘‘(5) ADVANCE BENEFICIARY NOTICE DEFINED.—In this subsection, the term ‘advance beneficiary notice’ means a written notice provided under section 1879(a) of the Social Security Act (42 U.S.C. 1395pp(a)) to an in- dividual entitled to benefits under part A or enrolled under part B of title XVIII of such Act [42 U.S.C. 1395c et seq., 1395j et seq.] before items or services are fur- nished under such part in cases where a provider of services or other person that would furnish the item or service believes that payment will not be made for some or all of such items or services under such title [42 U.S.C. 1395 et seq.].’’ REPORTS TO CONGRESS ON DENIALS OF BILLS FOR PAYMENT Pub. L. 99–509, title IX, § 9305(g)(2), Oct. 21, 1986, 100 Stat. 1992, directed Secretary of Health and Human Services to report to Congress annually in March of 1987 and 1988 information on frequency and distribution (by type of provider) of denials of bills for payment under this subchapter for extended care services, home health services, and hospice care, by reason of section 1395y(a)(1) or (9) of this title, and coverage denials de- scribed in subsec. (g) of this section, and such other in- formation as appropriate to evaluate the appropriate- ness of any percentage standards established for the granting of favorable presumptions with respect to such denials. § 1395qq. Indian Health Service facilities (a) Eligibility for payments; conditions and re- quirements A hospital or skilled nursing facility of the In- dian Health Service, whether operated by such Service or by an Indian tribe or tribal organiza- tion (as those terms are defined in section 1603 of title 25), shall be eligible for payments under this subchapter, notwithstanding sections 1395f(c) and 1395n(d) of this title, if and for so long as it meets all of the conditions and re- quirements for such payments which are appli- cable generally to hospitals or skilled nursing facilities (as the case may be) under this sub- chapter. (b) Eligibility based on submission of plan to achieve compliance with conditions and re- quirements; twelve-month period Notwithstanding subsection (a), a hospital or skilled nursing facility of the Indian Health Service which does not meet all of the condi- tions and requirements of this subchapter which are applicable generally to hospitals or skilled nursing facilities (as the case may be), but which submits to the Secretary within six months after September 30, 1976, an acceptable plan for achieving compliance with such condi- tions and requirements, shall be deemed to meet such conditions and requirements (and to be eli- gible for payments under this subchapter), with- out regard to the extent of its actual compliance with such conditions and requirements, during the first 12 months after the month in which such plan is submitted. (c) Payments into special fund for improvements to achieve compliance with conditions and requirements; certification of compliance by Secretary Notwithstanding any other provision of this subchapter, payments to which any hospital or skilled nursing facility of the Indian Health Service is entitled by reason of this section shall be placed in a special fund to be held by the Sec- retary and used by him (to such extent or in such amounts as are provided in appropriation Acts) exclusively for the purpose of making any improvements in the hospitals and skilled nurs- ing facilities of such Service which may be nec- essary to achieve compliance with the applica- ble conditions and requirements of this sub- chapter. The preceding sentence shall cease to apply when the Secretary determines and cer- tifies that substantially all of the hospitals and skilled nursing facilities of such Service in the United States are in compliance with such con- ditions and requirements. (d) Report by Secretary; status of facilities in complying with conditions and requirements The annual report of the Secretary which is required by section 1671 of title 25 shall include (along with the matters specified in section 1643 of title 25) a detailed statement of the status of the hospitals and skilled nursing facilities of the Service in terms of their compliance with the applicable conditions and requirements of this subchapter and of the progress being made by such hospitals and facilities (under plans sub- mitted under subsection (b) and otherwise) to- ward the achievement of such compliance. (e) Services provided by Indian Health Service, Indian tribe, or tribal organization (1)(A) Notwithstanding section 1395n(d) of this title, subject to subparagraph (B), the Secretary shall make payment under part B to a hospital or an ambulatory care clinic (whether provider- based or freestanding) that is operated by the Indian Health Service or by an Indian tribe or tribal organization (as defined for purposes of subsection (a)) for services described in para- graph (2) (and for items and services furnished on or after January 1, 2005, all items and serv- ices for which payment may be made under part B) furnished in or at the direction of the hos- pital or clinic under the same situations, terms, Page 3753 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395rr 1 See References in Text note below. and conditions as would apply if the services were furnished in or at the direction of such a hospital or clinic that was not operated by such Service, tribe, or organization. (B) Payment shall not be made for services under subparagraph (A) to the extent that pay- ment is otherwise made for such services under this subchapter. (2) The services described in this paragraph are the following: (A) Services for which payment is made under section 1395w–4 of this title. (B) Services furnished by a practitioner de- scribed in section 1395u(b)(18)(C) of this title for which payment under part B is made under a fee schedule. (C) Services furnished by a physical thera- pist or occupational therapist as described in section 1395x(p) of this title for which payment under part B is made under a fee schedule. (3) Subsection (c) shall not apply to payments made under this subsection. (f) Cross reference For provisions relating to the authority of cer- tain Indian tribes, tribal organizations, and Alaska Native health organizations to elect to directly bill for, and receive payment for, health care services provided by a hospital or clinic of such tribes or organizations and for which pay- ment may be made under this subchapter, see section 1645 of title 25.1 (Aug. 14, 1935, ch. 531, title XVIII, § 1880, as added Pub. L. 94–437, title IV, § 401(b), Sept. 30, 1976, 90 Stat. 1408; amended Pub. L. 102–573, title VII, § 701(d), Oct. 29, 1992, 106 Stat. 4572; Pub. L. 106–417, § 3(b)(1), Nov. 1, 2000, 114 Stat. 1815; Pub. L. 106–554, § 1(a)(6) [title IV, § 432(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–525; Pub. L. 108–173, title VI, § 630, Dec. 8, 2003, 117 Stat. 2321; Pub. L. 111–148, title II, § 2902(a), title X, § 10221(a), (b)(4), Mar. 23, 2010, 124 Stat. 333, 935, 936.) Editorial Notes REFERENCES IN TEXT Section 1645 of title 25, referred to in subsec. (f), was amended generally by section 10221(a) of title X of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 935, and, as so amend- ed, no longer contains provisions relating to direct bill- ing of medicare, medicaid, and other third party payors. CODIFICATION Pub. L. 111–148, § 10221(a), enacted into law S. 1790, One Hundred Eleventh Congress, as reported by the Committee on Indian Affairs of the Senate in Dec. 2009, ‘‘[e]xcept as provided in’’ section 10221(b) of Pub. L. 111–148. Section 201(a) of S. 1790 would have amended this section but was stricken out by section 10221(b)(4) of Pub. L. 111–148. AMENDMENTS 2010—Subsec. (e)(1)(A). Pub. L. 111–148, § 2902(a), sub- stituted ‘‘on or after’’ for ‘‘during the 5-year period be- ginning on’’. 2003—Subsec. (e)(1)(A). Pub. L. 108–173 inserted ‘‘(and for items and services furnished during the 5-year pe- riod beginning on January 1, 2005, all items and serv- ices for which payment may be made under part B)’’ after ‘‘for services described in paragraph (2)’’. 2000—Subsec. (e). Pub. L. 106–554, § 1(a)(6) [title IV, § 432(a)(2)], added subsec. (e). Former subsec. (e) redesig- nated (f). Pub. L. 106–417 added subsec. (e). Subsec. (f). Pub. L. 106–554, § 1(a)(6) [title IV, § 432(a)(1)], redesignated subsec. (e) as (f). 1992—Subsec. (d). Pub. L. 102–573 made technical amendment to the reference to section 1671 of title 25 to reflect renumbering of corresponding section of original act. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2010 AMENDMENT Pub. L. 111–148, title II, § 2902(b), Mar. 23, 2010, 124 Stat. 333, provided that: ‘‘The amendments made by this section [amending this section] shall apply to items or services furnished on or after January 1, 2010.’’ EFFECTIVE DATE OF 2000 AMENDMENT Amendment by section 1(a)(6) [title IV, § 432(a)] of Pub. L. 106–554 applicable to services furnished on or after July 1, 2001, see section 1(a)(6) [title IV, § 432(c)] of Pub. L. 106–554, set out as a note under section 1395u of this title. Amendment by Pub. L. 106–417 effective Oct. 1, 2000, see section 3(c) of Pub. L. 106–417, set out as a note under section 1645 of Title 25, Indians. MEDICARE PAYMENTS NOT CONSIDERED IN DETERMINING APPROPRIATIONS FOR INDIAN HEALTH CARE Pub. L. 94–437, title IV, § 401(c), Sept. 30, 1976, 90 Stat. 1409, provided that any payments received for services provided to beneficiaries under this section were not to be considered in determining appropriations for health care and services to Indians, prior to the general amendment of section 401 of Pub. L. 94–437 by Pub. L. 102–573, title IV, § 401(a), Oct. 29, 1992, 106 Stat. 4565. Similar provisions are contained in section 401(a) of Pub. L. 94–437, which is classified to section 1641(a) of Title 25, Indians. PREFERENCE IN SERVICES FOR INDIANS WITH MEDICARE COVERAGE NOT AUTHORIZED Pub. L. 94–437, title IV, § 401(d), Sept. 30, 1976, 90 Stat. 1409, which provided that nothing in this section au- thorized the Secretary to provide services to an Indian beneficiary with coverage under this subchapter, in preference to an Indian beneficiary without such cov- erage, prior to the general amendment of section 401 of Pub. L. 94–437 by Pub. L. 102–573, title IV, § 401(a), Oct. 29, 1992, 106 Stat. 4565. Similar provisions are contained in section 401(b) of Pub. L. 94–437, which is classified to section 1641(b) of Title 25, Indians. § 1395rr. End stage renal disease program (a) Type, duration, and scope of benefits The benefits provided by parts A and B of this subchapter shall include benefits for individuals who have been determined to have end stage renal disease as provided in section 426–1 of this title, and benefits for kidney donors as provided in subsection (d) of this section. Notwith- standing any other provision of this subchapter, the type, duration, and scope of the benefit pro- vided by parts A and B with respect to individ- uals who have been determined to have end stage renal disease and who are entitled to such benefits without regard to section 426–1 of this title shall in no case be less than the type, dura- tion, and scope of the benefits so provided for in- dividuals entitled to such benefits solely by rea- son of that section.