42 U.S.C. § 1396k — Assignment, enforcement, and collection

Page 4220 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1396k by reason of this section were to be placed in a special fund of the Secretary for improvements of facilities of the Service to comply with requirements of this sub- chapter, required minimum funding for each service unit making collections for such facilities, and pro- vided for section 402(c) of Pub. L. 94–437 to cease to apply when Secretary determined that substantially all such facilities complied with requirements of this sub- chapter, prior to the general amendment of section 402 of Pub. L. 94–437 by Pub. L. 102–573, title IV, § 401(b)(1), Oct. 29, 1992, 106 Stat. 4565. Similar provisions are con- tained in section 401(c) of Pub. L. 94–437, which is clas- sified to section 1641(c) of Title 25, Indians. MEDICAID PAYMENTS NOT CONSIDERED IN DETERMINING APPROPRIATIONS FOR INDIAN HEALTH CARE Pub. L. 94–437, title IV, § 402(d), Sept. 30, 1976, 90 Stat. 1410, provided that any payments received for services provided recipients under this section were not to be considered in determining appropriations for the provi- sion of health care and services to Indians, prior to the general amendment of section 402 of Pub. L. 94–437 by Pub. L. 102–573, title IV, § 401(b)(1), 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. § 1396k. Assignment, enforcement, and collection of rights of payments for medical care; estab- lishment of procedures pursuant to State plan; amounts retained by State (a) For the purpose of assisting in the collec- tion of medical support payments and other pay- ments for medical care owed to recipients of medical assistance under the State plan ap- proved under this subchapter, a State plan for medical assistance shall— (1) provide that, as a condition of eligibility for medical assistance under the State plan to an individual who has the legal capacity to execute an assignment for himself, the indi- vidual is required— (A) to assign the State any rights, of the individual or of any other person who is eli- gible for medical assistance under this sub- chapter and on whose behalf the individual has the legal authority to execute an assign- ment of such rights, to support (specified as support for the purpose of medical care by a court or administrative order) and to pay- ment for medical care from any third party; (B) to cooperate with the State (i) in es- tablishing the paternity of such person (re- ferred to in subparagraph (A)) if the person is a child born out of wedlock, and (ii) in ob- taining support and payments (described in subparagraph (A)) for himself and for such person, unless (in either case) the individual is described in section 1396a(l)(1)(A) of this title or the individual is found to have good cause for refusing to cooperate as deter- mined by the State agency in accordance with standards prescribed by the Secretary, which standards shall take into consider- ation the best interests of the individuals in- volved; and (C) to cooperate with the State in identi- fying, and providing information to assist the State in pursuing, any third party who may be liable to pay for care and services available under the plan, unless such indi- vidual has good cause for refusing to cooper- ate as determined by the State agency in ac- cordance with standards prescribed by the Secretary, which standards shall take into consideration the best interests of the indi- viduals involved; and (2) provide for entering into cooperative ar- rangements (including financial arrange- ments), with any appropriate agency of any State (including, with respect to the enforce- ment and collection of rights of payment for medical care by or through a parent, with a State’s agency established or designated under section 654(3) of this title) and with appro- priate courts and law enforcement officials, to assist the agency or agencies administering the State plan with respect to (A) the enforce- ment and collection of rights to support or payment assigned under this section and (B) any other matters of common concern. (b) Such part of any amount collected by the State under an assignment made under the pro- visions of this section shall be retained by the State as is necessary to reimburse it for medical assistance payments made on behalf of an indi- vidual with respect to whom such assignment was executed (with appropriate reimbursement of the Federal Government to the extent of its participation in the financing of such medical assistance), and the remainder of such amount collected shall be paid to such individual. (Aug. 14, 1935, ch. 531, title XIX, § 1912, as added Pub. L. 95–142, § 11(b), Oct. 25, 1977, 91 Stat. 1196; amended Pub. L. 98–369, div. B, title III, § 2367(b), July 18, 1984, 98 Stat. 1109; Pub. L. 99–272, title IX, § 9503(e), Apr. 7, 1986, 100 Stat. 207; Pub. L. 101–508, title IV, § 4606(a), Nov. 5, 1990, 104 Stat. 1388–170; Pub. L. 113–67, div. A, title II, § 202(b)(2), Dec. 26, 2013, 127 Stat. 1177; Pub. L. 115–123, div. E, title XII, § 53102(b)(1), Feb. 9, 2018, 132 Stat. 298.) Editorial Notes AMENDMENTS 2018—Subsec. (a)(1)(A). Pub. L. 115–123, § 53102(b)(1), re- pealed Pub. L. 113–67, § 202(b)(2), and provided that the provisions amended by section 202(b) shall be applied and administered as if such amendment had never been enacted. See 2013 Amendment note below. 2013—Subsec. (a)(1)(A). Pub. L. 113–67, § 202(b)(2), which directed substitution of ‘‘any payment from a third party that has a legal liability to pay for care and services available under the plan’’ for ‘‘payment for medical care from any third party’’, was repealed by Pub. L. 115–123, § 53102(b)(1). 1990—Subsec. (a)(1)(B). Pub. L. 101–508 inserted ‘‘the individual is described in section 1396a(l)(1)(A) of this title or’’ after ‘‘unless (in either case)’’. 1986—Subsec. (a)(1)(C). Pub. L. 99–272 added subpar. (C). 1984—Subsec. (a). Pub. L. 98–369 substituted ‘‘State plan for medical assistance shall’’ for ‘‘State plan for medical assistance may’’. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2018 AMENDMENT Pub. L. 115–123, div. E, title XII, § 53102(b)(1), Feb. 9, 2018, 132 Stat. 298, provided that the repeal of section 202(b) of Pub. L. 113–67 is effective Sept. 30, 2017, and the provisions amended by section 202(b) shall be applied and administered as if such amendments had never been enacted. In addition, such repeal by section Page 4221 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1396m 1 So in original, ‘‘, respectively,’’ probably should not appear. 53102(b)(1) of Pub. L. 115–123 applicable with respect to any open claims, including claims pending, generated, or filed, after Sept. 30, 2017, see section 53102(b)(3) of Pub. L. 115–123, set out as a note under section 1396a of this title. EFFECTIVE DATE OF 1990 AMENDMENT Pub. L. 101–508, title IV, § 4606(b), Nov. 5, 1990, 104 Stat. 1388–170, provided that: ‘‘The amendment made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Nov. 5, 1990].’’ EFFECTIVE DATE OF 1986 AMENDMENT Amendment by Pub. L. 99–272 applicable to calendar quarters beginning on or after Apr. 7, 1986, except as otherwise provided, see section 9503(g)(1), (2) of Pub. L. 99–272, set out as a note under section 1396a of this title. EFFECTIVE DATE OF 1984 AMENDMENT Amendment by Pub. L. 98–369 effective Oct. 1, 1984, except as otherwise provided, see section 2367(c) of Pub. L. 98–369, set out as a note under section 1396a of this title. § 1396l. Hospital providers of nursing facility services (a) Notwithstanding any other provision of this subchapter, payment may be made, in ac- cordance with this section, under a State plan approved under this subchapter for nursing fa- cility services furnished by a hospital which has in effect an agreement under section 1395tt of this title and which, with respect to the provi- sion of such services, meets the requirements of subsections (b) through (d) of section 1396r of this title. (b)(1) Except as provided in paragraph (3), pay- ment to any such hospital, for any nursing facil- ity services furnished pursuant to subsection (a), shall be at a rate equal to the average rate per patient-day paid for routine services during the previous calendar year under the State plan to nursing facilities, respectively,1 located in the State in which the hospital is located. The reasonable cost of ancillary services shall be de- termined in the same manner as the reasonable cost of ancillary services provided for inpatient hospital services. (2) With respect to any period for which a hos- pital has an agreement under section 1395tt of this title, in order to allocate routine costs be- tween hospital and long-term care services, the total reimbursement for routine services due from all classes of long-term care patients (in- cluding subchapter XVIII, this subchapter, and private pay patients) shall be subtracted from the hospital total routine costs before calcula- tions are made to determine reimbursement for routine hospital services under the State plan. (3) Payment to all such hospitals, for any nursing facility services furnished pursuant to subsection (a), may be made at a payment rate established by the State in accordance with the requirements of section 1396a(a)(13)(A) of this title. (Aug. 14, 1935, ch. 531, title XIX, § 1913, as added Pub. L. 96–499, title IX, § 904(b), Dec. 5, 1980, 94 Stat. 2617; amended Pub. L. 98–369, div. B, title III, § 2369(a), July 18, 1984, 98 Stat. 1110; Pub. L. 100–203, title IV, § 4211(h)(9), Dec. 22, 1987, 101 Stat. 1330–206.) Editorial Notes AMENDMENTS 1987—Pub. L. 100–203, § 4211(h)(9)(A), substituted ‘‘nursing facility services’’ for ‘‘skilled nursing and in- termediate care services’’ in section catchline. Subsec. (a). Pub. L. 100–203, § 4211(h)(9)(B), substituted ‘‘nursing facility services’’ for ‘‘skilled nursing facility services and intermediate care facility services’’ and inserted ‘‘and which, with respect to the provision of such services, meets the requirements of subsections (b) through (d) of section 1396r of this title’’ before pe- riod at end. Subsec. (b)(1). Pub. L. 100–203, § 4211(h)(9)(C), sub- stituted ‘‘nursing facility services’’ for ‘‘skilled nursing or intermediate care facility services’’ and ‘‘nursing fa- cilities’’ for ‘‘skilled nursing and intermediate care fa- cilities’’. Subsec. (b)(3). Pub. L. 100–203, § 4211(h)(9)(D), sub- stituted ‘‘nursing facility services’’ for ‘‘skilled nursing or intermediate care facility services’’. 1984—Subsec. (b)(1). Pub. L. 98–369, § 2369(a)(1), sub- stituted ‘‘Except as provided in paragraph (3), pay- ment’’ for ‘‘Payment’’. Subsec. (b)(3). Pub. L. 98–369, § 2369(a)(2), added par. (3). Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1987 AMENDMENT Amendment by Pub. L. 100–203 applicable to nursing facility services furnished on or after Oct. 1, 1990, with- out regard to whether regulations implementing such amendment are promulgated by such date, except as otherwise specifically provided in section 1396r of this title, with transitional rule, see section 4214(a), (b)(2) of Pub. L. 100–203, as amended, set out as an Effective Date note under section 1396r of this title. EFFECTIVE DATE OF 1984 AMENDMENT Pub. L. 98–369, div. B, title III, § 2369(b), July 18, 1984, 98 Stat. 1110, provided that: ‘‘The amendments made by this section [amending this section] shall apply to pay- ments for services furnished after the date of the enact- ment of this Act [July 18, 1984].’’ EFFECTIVE DATE Section effective on date on which final regulations to implement the section are first issued, see section 904(d) of Pub. L. 96–499, set out as an Effective Date note under section 1395tt of this title. § 1396m. Withholding of Federal share of pay- ments for certain medicare providers (a) Adjustment of Federal matching payments The Secretary may adjust, in accordance with this section, the Federal matching payment to a State with respect to expenditures for medical assistance for care or services furnished in any quarter by— (1) an institution (A) which has or previously had in effect an agreement with the Secretary under section 1395cc of this title; and (B)(i) from which the Secretary has been unable to recover overpayments made under subchapter XVIII, or (ii) from which the Secretary has been unable to collect the information nec- essary to enable him to determine the amount (if any) of the overpayments made to such in- stitution under subchapter XVIII; and (2) any person (A) who (i) has previously ac- cepted payment on the basis of an assignment under section 1395u(b)(3)(B)(ii) of this title, and (ii) during the annual period immediately preceding such quarter submitted no claims