r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE wiki — defined terms
The statute’s own glossary: every term Title 42 defines, in section order.
“renegotiation-eligible drug” applies in that section
the term “renegotiation-eligible drug” means a selected drug that is any of the following: (A) Addition of new indication A selected drug for which a new indication is added to the drug. (B) Change of status to an extended-monopoly drug A selected drug that— (i) is not an extended-monopoly or a long-monopoly drug; and (ii) for which there is a change in status to that of an extended-monopoly drug. (C) Change of status to a long-monopoly drug A selected drug that— (i) is not a long-monopoly drug; and (ii) for which there is a change in status to that of a long-monopoly drug.
“compensation” applies in that section
the term “compensation” means cash benefits payable to individuals with respect to their unemployment, exclusive of expenses of administration. (b) The Secretary of the Treasury shall, prior to audit or settlement by the Government Accountability Office, transfer in monthly installments from the Federal unemployment account to the account of the State in the Unemployment Trust Fund the amount certified under subsection (a) by the Secretary of Labor (but not exceeding that portion of the balance in the Federal unemployment account at the time of the transfer which is not restricted as to use pursuant to section 1103(b)(1) of this title ).
“voluntary repayment” applies in that section
the term “voluntary repayment” means any repayment made under subsection (a). (7) This subsection shall only apply to advances made on or after April 1, 1982 . (8) (A) With respect to interest due under this section on September 30 of 1983, 1984, or 1985 (other than interest previously deferred under paragraph (3)(C)), a State may pay 80 percent of such interest in four annual installments of at least 20 percent beginning with the year after the year in which it is otherwise due, if such State meets the criteria of subparagraph (B). No interest shall accrue on such deferred interest.
“Governor” applies throughout its subchapter
the term “Governor” includes the Mayor of the District of Columbia.
“aid to the permanently and totally disabled” applies throughout its subchapter
the term “aid to the permanently and totally disabled” means money payments to needy individuals eighteen years of age or older who are permanently and totally disabled, but does not include any such payments to or care in behalf of any individual who is an inmate of a public institution (except as a patient in a medical institution) or any individual who is a patient in an institution for tuberculosis or mental diseases.
“gross income” applies in that section
the term “gross income” has the same meaning as when used in chapter 1 of the Internal Revenue Code of 1986. (e) Limitation on eligibility of certain individuals (1) (A) Except as provided in subparagraphs (B), (C), (D), (E), and (G), no person shall be an eligible individual or eligible spouse for purposes of this subchapter with respect to any month if throughout such month he is an inmate of a public institution.
“asset” applies in that section
the term “asset” includes any income or resource of the individual (or of the individual’s spouse), including— (i) any income excluded by section 1382a(b) of this title ; (ii) any resource otherwise excluded by this section; and (iii) any other payment or property to which the individual (or of the individual’s spouse) is entitled but does not receive or have access to because of action by— (I) the individual or spouse; (II) a person or entity (including a court) with legal authority to act in place of, or on behalf of, the individual or spouse; or (III) a person or entity (including a court) acting at the direction of, or on the request of, the individual or spouse.
“assistance” applies in that section
the term “assistance” includes interest thereon which is excluded from income under section 1382a(b)(12) of this title ; (7) any amount received from the United States which is attributable to underpayments of benefits due for one or more prior months, under this subchapter or subchapter II, to such individual (or spouse) or to any other person whose income is deemed to be included in such individual’s (or spouse’s) income for purposes of this subchapter; but the application of this paragraph in the case of any such individual (and eligible spouse if any), with respect to any amount so received from the United States, shall be limited to the first 9 months following the month in which such …
“benefits under this subchapter” applies in that section
the term “benefits under this subchapter” includes payments of the type described in section 1382e(a) of this title and of the type described in section 212(b) of Public Law 93–66 ;
“corpus” applies in that section
the term “corpus” means, with respect to a trust, all property and other interests held by the trust, including accumulated earnings and any other addition to the trust after its establishment (except that such term does not include any such earnings or addition in the month in which the earnings or addition is credited or otherwise transferred to the trust); and;
“institutionalized individual” applies in that section
the term “institutionalized individual” has the meaning given such term in section 1396p(e)(3) 2 of this title; and;
“trust” applies in that section
the term “trust” has the meaning given such term in subsection (e)(6)(A) of this section. (2) (A) At the time an individual (and the individual’s eligible spouse, if any) applies for benefits under this subchapter, and at the time the eligibility of an individual (and such spouse, if any) for such benefits is redetermined, the Commissioner of Social Security shall— (i) inform such individual of the provisions of paragraph (1) and section 1396p(c) of this title providing for a period of ineligibility for benefits under this subchapter and subchapter XIX, respectively, for individuals who make certain dispositions of resources for less than fair market value, and inform such individual that …
“aged, blind, or disabled individual” applies throughout its subchapter
the term “aged, blind, or disabled individual” means an individual who— (A) is 65 years of age or older, is blind (as determined under paragraph (2)), or is disabled (as determined under paragraph (3)), and (B) (i) is a resident of the United States, and is either (I) a citizen or (II) an alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law (including any alien who is lawfully present in the United States as a result of the application of the provisions of section 1182(d)(5) of title 8 ), or (ii) is a child who is a citizen of the United States, and who is living with a parent of the child who is a member of the Armed …
“child” applies throughout its subchapter
the term “child” means an individual who is neither married nor (as determined by the Commissioner of Social Security) the head of a household, and who is (1) under the age of eighteen, or (2) under the age of twenty-two and (as determined by the Commissioner of Social Security) a student regularly attending a school, college, or university, or a course of vocational or technical training designed to prepare him for gainful employment.
“eligible spouse” applies throughout its subchapter
the term “eligible spouse” means an aged, blind, or disabled individual who is the husband or wife of another aged, blind, or disabled individual, and who, in a month, is living with such aged, blind, or disabled individual on the first day of the month or, in any case in which either spouse files an application for benefits, on the first day of the month following the date the application is filed, or, in any case in which either spouse requests restoration of eligibility under this subchapter during the month, at the time the request is filed.
“applicable rate” applies throughout its subchapter
the term “applicable rate” means— (i) for fiscal year 1994, $1.67; (ii) for fiscal year 1995, $3.33; (iii) for fiscal year 1996, $5.00; (iv) for fiscal year 1997, $5.00; (v) for fiscal year 1998, $6.20; (vi) for fiscal year 1999, $7.60; (vii) for fiscal year 2000, $7.80; (viii) for fiscal year 2001, $8.10; (ix) for fiscal year 2002, $8.50; and (x) for fiscal year 2003 and each succeeding fiscal year— (I) the applicable rate in the preceding fiscal year, increased by the percentage, if any, by which the Consumer Price Index for the month of June of the calendar year of the increase exceeds the Consumer Price Index for the month of June of the calendar year preceding the calendar year of the …
“supplemental security income benefits” applies in that section
the term “supplemental security income benefits” includes payments made pursuant to an agreement under section 1382e(a) of this title or under section 212(b) of Public Law 93–66 . (3) At the beginning of each fiscal year in which the pilot program under this section is in effect, each State that does not intend to use the allotment to which it is entitled for such year (or any allotment which was made to it for a prior fiscal year), or that does not intend to use the full amount of any such allotment, shall certify to the Commissioner of Social Security the amount of such allotment which it does not intend to use, and the State’s allotment for the fiscal year (or years) involved shall …
“benefits under this subchapter” applies in that section
the term “benefits under this subchapter” includes supplementary payments pursuant to an agreement for Federal administration under section 1382e(a) of this title , and payments pursuant to an agreement entered into under section 212(b) of Public Law 93–66 .
“certified community-based nonprofit social service agency” applies in that section
the term “certified community-based nonprofit social service agency” means a community-based nonprofit social service agency which is in compliance with requirements, under regulations which shall be prescribed by the Commissioner, for annual certification to the Commissioner that it is bonded in accordance with requirements specified by the Commissioner and that it is licensed in each State in which it serves as a representative payee (if licensing is available in the State) in accordance with requirements specified by the Commissioner. Any such annual certification shall include a copy of any independent audit on the agency which may have been performed since the previous certification.
“delinquent amount” applies in that section
the term “delinquent amount” means an amount— (i) in excess of the correct amount of payment under this subchapter; (ii) paid to a person after such person has attained 18 years of age; and (iii) determined by the Commissioner of Social Security, under regulations, to be otherwise unrecoverable under this section after such person ceases to be a beneficiary under this subchapter. (6) For payments for which adjustments are made by reason of a retroactive payment of benefits under subchapter II, see section 1320a–6 of this title .
“qualified organization” applies in that section
the term “qualified organization” means any State or local government agency whose mission is to carry out income maintenance, social service, or health care-related activities, any State or local government agency with fiduciary responsibilities, or any certified community-based nonprofit social service agency (as defined in subparagraph (I)), if the agency, in accordance with any applicable regulations of the Commissioner of Social Security— (I) regularly provides services as a representative payee pursuant to subparagraph (A)(ii) or section 405(j)(4) or 1007 of this title concurrently to 5 or more individuals; and (II) demonstrates to the satisfaction of the Commissioner of Social …
“benefits under this subchapter” applies in that section
the term “benefits under this subchapter” includes payments of the type described in section 1382e(a) of this title or of the type described in section 212(a) of Public Law 93–66 . (c) Loss of benefits upon entitlement to child’s insurance benefits based on disability If any individual who has attained the age of 18 and is receiving benefits under this subchapter on the basis of blindness or a disability which began before he or she attained the age of 22— (1) becomes entitled, on or after the effective date of this subsection, to child’s insurance benefits which are payable under section 402(d) of this title on the basis of such disability or to an increase in the amount of the child’s …
“eligible disabled widow or widower” applies in that section
the term “eligible disabled widow or widower” means an individual who— (A) was entitled to a monthly insurance benefit under subchapter II for December 1983, (B) was entitled to a widow’s or widower’s insurance benefit based on a disability under section 402(e) or (f) of this title for January 1984 and with respect to whom a benefit under this subchapter was paid in that month, and (C) because of the increase in the amount of his or her widow’s or widower’s insurance benefits which resulted from the amendments made by section 134 of the Social Security Amendments of 1983 ( Public Law 98–21 ) (eliminating the additional reduction factor for disabled widows and widowers under age 60), was …
“applicable 2-year period” applies in that section
the term “applicable 2-year period” means, with respect to an affidavit of a physician or practitioner under subparagraph (B), the 2-year period beginning on the date the affidavit is signed and includes each subsequent 2-year period unless the physician or practitioner involved provides notice to the Secretary (in a form and manner specified by the Secretary), not later than 30 days before the end of the previous 2-year period, that the physician or practitioner does not want to extend the application of the affidavit for such subsequent 2-year period.
“medicare beneficiary” applies in that section
The term “medicare beneficiary” means an individual who is entitled to benefits under part A or enrolled under part B. (B) Physician
“opt-out physician or practitioner” applies in that section
The term “opt-out physician or practitioner” means a physician or practitioner who has in effect an affidavit under paragraph (3)(B).
“physician” applies in that section
The term “physician” has the meaning given such term by paragraphs (1), (2), (3), and (4) of section 1395x(r) of this title . (C) Practitioner
“practitioner” applies in that section
The term “practitioner” has the meaning given such term by section 1395u(b)(18)(C) of this title . (D) Opt-out physician or practitioner
“multi-stakeholder group” applies in that section
the term “multi-stakeholder group” means, with respect to a quality and efficiency measure, a voluntary collaborative of organizations representing a broad group of stakeholders interested in or affected by the use of such quality and efficiency measure. (8) Transmission of multi-stakeholder input Not later than February 1 of each year (beginning with 2012), the entity shall transmit to the Secretary the input of multi-stakeholder groups provided under paragraph (7).
“provider entity” applies in that section
the term “provider entity” means a provider of services, supplier, facility (including a renal dialysis facility), clinic, agency, or laboratory. (b) Disclosure of accreditation survey The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency or, beginning on December 27, 2020 , a hospice program) made and released to the Secretary by the American Osteopathic Association or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the …
“home health aide” applies in that section
the term “home health aide” means any individual who provides the items and services described in section 1395x(m) of this title , but does not include an individual— (i) who is a licensed health professional (as defined in subparagraph (F)), or (ii) who volunteers to provide such services without monetary compensation. (F) In this paragraph,
“licensed health professional” applies in that section
the term “licensed health professional” means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, physical or occupational therapy assistant, registered professional nurse, licensed practical nurse, or licensed or certified social worker. (4) The agency includes an individual’s plan of care required under section 1395x(m) of this title as part of the clinical records described in section 1395x( o )(3) of this title.
“appropriate committees of Congress” applies in that section
the term “appropriate committees of Congress” means the Committees on Ways and Means and Commerce of the House of Representatives and the Committee on Finance of the Senate. (7) Voting and reporting requirements With respect to each recommendation contained in a report submitted under paragraph (1), each member of the Commission shall vote on the recommendation, and the Commission shall include, by member, the results of that vote in the report containing the recommendation. (8) Examination of budget consequences Before making any recommendations, the Commission shall examine the budget consequences of such recommendations, directly or through consultation with appropriate expert entities.
“care management plan” applies in that section
The term “care management plan” means a plan established under subsection (d) for a participant in a chronic care improvement program. (D) Threshold condition
“chronic care improvement organization” applies in that section
The term “chronic care improvement organization” means an entity that has entered into an agreement under subsection (b) or (c) to provide, directly or through contracts with subcontractors, a chronic care improvement program under this section. Such an entity may be a disease management organization, health insurer, integrated delivery system, physician group practice, a consortium of such entities, or any other legal entity that the Secretary determines appropriate to carry out a chronic care improvement program under this section. (C) Care management plan
“chronic care improvement program” applies in that section
The term “chronic care improvement program” means a program described in paragraph (1) that is offered under an agreement under subsection (b) or (c). (B) Chronic care improvement organization
“medicare beneficiary” applies in that section
the term “medicare beneficiary” means an individual who is entitled to benefits under part A, enrolled under part B, or both, and who resides in the United States. (4) Site selection In selecting geographic areas in which agreements are entered into under this subsection, the Secretary shall ensure that each chronic care improvement program is conducted in a geographic area in which at least 10,000 targeted beneficiaries reside among other individuals entitled to benefits under part A, enrolled under part B, or both to serve as a control population.
“targeted beneficiary” applies in that section
The term “targeted beneficiary” means, with respect to a chronic care improvement program, an individual who— (i) is entitled to benefits under part A and enrolled under part B, but not enrolled in a plan under part C; (ii) has one or more threshold conditions covered under such program; and (iii) has been identified under subsection (d)(1) as a potential participant in such program.
“threshold condition” applies in that section
The term “threshold condition” means a chronic condition, such as congestive heart failure, diabetes, chronic obstructive pulmonary disease (COPD), or other diseases or conditions, as selected by the Secretary as appropriate for the establishment of a chronic care improvement program. (E) Targeted beneficiary
“advance directive” applies in that section
the term “advance directive” means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) and relating to the provision of such care when the individual is incapacitated. (4) For construction relating to this subsection, see section 14406 of this title (relating to clarification respecting assisted suicide, euthanasia, and mercy killing).
“applicable provider of services or supplier” applies in that section
The term “applicable provider of services or supplier” means a provider of services or supplier that has the same taxpayer identification number assigned under section 6109 of the Internal Revenue Code of 1986 as is assigned to the obligated provider of services or supplier under such section, regardless of whether the applicable provider of services or supplier is assigned a different billing number or national provider identification number under the program under this subchapter than is assigned to the obligated provider of services or supplier. (ii) Obligated provider of services or supplier
“obligated provider of services or supplier” applies in that section
The term “obligated provider of services or supplier” means a provider of services or supplier that owes an amount that is more than the amount required to be paid under the program under this subchapter (as determined by the Secretary).
“provider of services” applies in that section
the term “provider of services” shall include— (1) a clinic, rehabilitation agency, or public health agency if, in the case of a clinic or rehabilitation agency, such clinic or agency meets the requirements of section 1395x(p)(4)(A) of this title (or meets the requirements of such section through the operation of subsection (g) or ( ll )(2) of section 1395x of this title ), or if, in the case of a public health agency, such agency meets the requirements of section 1395x(p)(4)(B) of this title (or meets the requirements of such section through the operation of subsection (g) or ( ll )(2) of section 1395x of this title ), but only with respect to the furnishing of outpatient physical therapy …
“health care group” applies in that section
The term “health care group” means a group of physicians (as defined in subparagraph (A)) organized at least in part for the purpose of providing physicians’ services under this subchapter. As the Secretary finds appropriate, a health care group may include a hospital and any other individual or entity furnishing items or services for which payment may be made under this subchapter that is affiliated with the health care group under an arrangement structured so that such individual or entity participates in a demonstration under this section and will share in any bonus earned under subsection (d).
“physician” applies in that section
the term “physician” means any individual who furnishes services which may be paid for as physicians’ services under this subchapter. (B) Health care group
“beneficiary” applies in that section
The term “beneficiary” means an individual who is entitled to benefits under part A and enrolled under part B, including any individual who is enrolled in a Medicare Advantage plan under part C. (2) Health care group (A) In general
“health care group” applies in that section
The term “health care group” means— (i) a group of physicians that is organized at least in part for the purpose of providing physician’s services under this subchapter; (ii) an integrated health care delivery system that delivers care through coordinated hospitals, clinics, home health agencies, ambulatory surgery centers, skilled nursing facilities, rehabilitation facilities and clinics, and employed, independent, or contracted physicians; or (iii) an organization representing regional coalitions of groups or systems described in clause (i) or (ii).
“physician” applies in that section
the term “physician” means any individual who furnishes services that may be paid for as physicians’ services under this subchapter. (b) Demonstration projects The Secretary shall establish a demonstration program under which the Secretary shall approve demonstration projects that examine health delivery factors that encourage the delivery of improved quality in patient care, including— (1) the provision of incentives to improve the safety of care provided to beneficiaries; (2) the appropriate use of best practice guidelines by providers and services by beneficiaries; (3) reduced scientific uncertainty in the delivery of care through the examination of variations in the utilization and …
“applicable beneficiary” applies in that section
The term “applicable beneficiary” means an individual who— (i) is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B of such subchapter, but not enrolled under part C or a PACE program under section 1395eee of this title ; and (ii) is admitted to a hospital for an applicable condition. (B) Applicable condition
“applicable condition” applies in that section
The term “applicable condition” means 1 or more of 10 conditions selected by the Secretary. In selecting conditions under the preceding sentence, the Secretary shall take into consideration the following factors: (i) Whether the conditions selected include a mix of chronic and acute conditions. (ii) Whether the conditions selected include a mix of surgical and medical conditions. (iii) Whether a condition is one for which there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished while reducing total expenditures under this subchapter.
“applicable services” applies in that section
The term “applicable services” means the following: (i) Acute care inpatient services. (ii) Physicians’ services delivered in and outside of an acute care hospital setting. (iii) Outpatient hospital services, including emergency department services. (iv) Post-acute care services, including home health services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services furnished by a long-term care hospital. (v) Other services the Secretary determines appropriate. (D) Episode of care (i) In general Subject to clause (ii),
“continuing care hospital” applies in that section
the term “continuing care hospital” means an entity that has demonstrated the ability to meet patient care and patient safety standards and that provides under common management the medical and rehabilitation services provided in inpatient rehabilitation hospitals and units (as defined in section 1395ww(d)(1)(B)(ii) of this title ), long term care hospitals (as defined in section 1395ww(d)(1)(B)(iv)(I) 2 of this title), and skilled nursing facilities (as defined in section 1395i–3(a) of this title ) that are located in a hospital described in section 1395ww(d) of this title .
“episode of care” applies in that section
the term “episode of care” means, with respect to an applicable condition and an applicable beneficiary, the period that includes— (I) the 3 days prior to the admission of the applicable beneficiary to a hospital for the applicable condition; (II) the length of stay of the applicable beneficiary in such hospital; and (III) the 30 days following the discharge of the applicable beneficiary from such hospital. (ii) Establishment of period by the Secretary The Secretary, as appropriate, may establish a period (other than the period described in clause (i)) for an episode of care under the pilot program. (E) Physicians’ services
“physicians’ services” applies in that section
The term “physicians’ services” has the meaning given such term in section 1395x(q) of this title . (F) Pilot program
“pilot program” applies in that section
The term “pilot program” means the pilot program under this section. (G) Provider of services
“provider of services” applies in that section
The term “provider of services” has the meaning given such term in section 1395x(u) of this title . (H) Readmission
“readmission” applies in that section
The term “readmission” has the meaning given such term in section 1395ww(q)(5)(E) of this title . (I) Supplier
“supplier” applies in that section
The term “supplier” has the meaning given such term in section 1395x(d) of this title . (3) Deadline for implementation The Secretary shall establish the pilot program not later than January 1, 2013 . (b) Developmental phase (1) Determination of patient assessment instrument The Secretary shall determine which patient assessment instrument (such as the Continuity Assessment Record and Evaluation (CARE) tool) shall be used under the pilot program to evaluate the applicable condition of an applicable beneficiary for purposes of determining the most clinically appropriate site for the provision of post-acute care to the applicable beneficiary.
“applicable beneficiary” applies in that section
the term “applicable beneficiary” means, with respect to a qualifying independence at home medical practice, an individual who the practice has determined— (A) is entitled to benefits under part A and enrolled for benefits under part B; (B) is not enrolled in a Medicare Advantage plan under part C or a PACE program under section 1395eee of this title ; (C) has 2 or more chronic illnesses, such as congestive heart failure, diabetes, other dementias designated by the Secretary, chronic obstructive pulmonary disease, ischemic heart disease, stroke, Alzheimer’s Disease and neurodegenerative diseases, and other diseases and conditions designated by the Secretary which result in high costs under …
“independence at home medical practice” applies in that section
The term “independence at home medical practice” means a legal entity that— (i) is comprised of an individual physician or nurse practitioner or group of physicians and nurse practitioners that provides care as part of a team that includes physicians, nurses, physician assistants, pharmacists, and other health and social services staff as appropriate who have experience providing home-based primary care to applicable beneficiaries, make in-home visits, and are available 24 hours per day, 7 days per week to carry out plans of care that are tailored to the individual beneficiary’s chronic conditions and designed to achieve the results in subsection (a); (ii) is organized at least in part for …
“physician” applies in that section
The term “physician” includes, except as the Secretary may otherwise provide, any individual who furnishes services for which payment may be made as physicians’ services and has the medical training or experience to fulfill the physician’s role described in subparagraph (A)(i).
“applicable beneficiary” applies in that section
the term “applicable beneficiary” means an individual who— (A) is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B; (B) is not enrolled in a Medicare Advantage plan under part C; (C) has a current diagnosis for an opioid use disorder; and (D) meets such other criteria as the Secretary determines appropriate. Such term shall include an individual who is dually eligible for benefits under this subchapter and subchapter XIX if such individual satisfies the criteria described in subparagraphs (A) through (D).
“eligible practitioner” applies in that section
the term “eligible practitioner” means a physician or other health care practitioner, such as a nurse practitioner, that— (A) is enrolled under section 1395cc(j)(1) of this title ; and (B) is authorized to prescribe or dispense narcotic drugs to individuals for maintenance treatment or detoxification treatment. (d) Participation of applicable beneficiaries (1) Applicable beneficiary defined In this section,
“opioid use disorder care team” applies in that section
the term “opioid use disorder care team” means a team of health care practitioners established by a participant described in paragraph (1)(A) that— (i) shall include— (I) at least one physician (as defined in section 1395x(r)(1) of this title ) furnishing primary care services or addiction treatment services to an applicable beneficiary; and (II) at least one eligible practitioner (as defined in paragraph (3)), who may be a physician who meets the criterion in subclause (I); and (ii) may include other practitioners licensed under State law to furnish psychiatric, psychological, counseling, and social services to applicable beneficiaries.
“opioid use disorder treatment services” applies in that section
the term “opioid use disorder treatment services”— (A) means, with respect to an applicable beneficiary, services that are furnished for the treatment of opioid use disorders and that utilize drugs approved under section 355 of title 21 for the treatment of opioid use disorders in an outpatient setting; and (B) includes— (i) medication-assisted treatment; (ii) treatment planning; (iii) psychiatric, psychological, or counseling services (or any combination of such services), as appropriate; (iv) social support services, as appropriate; and (v) care management and care coordination services, including coordination with other providers of services and suppliers not on an opioid use disorder …
“participant” applies in that section
the term “participant” means an entity or individual— (i) that is otherwise enrolled under this subchapter and that is— (I) a physician (as defined in section 1395x(r)(1) of this title ); (II) a group practice comprised of at least one physician described in subclause (I); (III) a hospital outpatient department; (IV) a federally qualified health center (as defined in section 1395x(aa)(4) of this title ); (V) a rural health clinic (as defined in section 1395x(aa)(2) of this title ); (VI) a community mental health center (as defined in section 1395x(ff)(3)(B) of this title ); (VII) a clinic certified as a certified community behavioral health clinic pursuant to section 223 of the Protecting …
“emergency medical condition” applies in that section
The term “emergency medical condition” means— (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part; or (B) with respect to a pregnant woman who is having contractions— (i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a …
“hospital” applies in that section
The term “hospital” includes a critical access hospital (as defined in section 1395x(mm)(1) of this title ) and a rural emergency hospital (as defined in section 1395x(kkk)(2) of this title ). (f) Preemption The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section.
“participating hospital” applies in that section
The term “participating hospital” means a hospital that has entered into a provider agreement under section 1395cc of this title . (3);
“stabilized” applies in that section
The term “stabilized” means, with respect to an emergency medical condition described in paragraph (1)(A), that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B), that the woman has delivered (including the placenta).;
“to stabilize” applies in that section
The term “to stabilize” means, with respect to an emergency medical condition described in paragraph (1)(A), to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B), to deliver (including the placenta).;
“transfer” applies in that section
The term “transfer” means the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (A) has been declared dead, or (B) leaves the facility without the permission of any such person.;
“consent settlement” applies in that section
the term “consent settlement” means an agreement between the Secretary and a provider of services or supplier whereby both parties agree to settle a projected overpayment based on less than a statistically valid sample of claims and the provider of services or supplier agrees not to appeal the claims involved.
“medicare contractor” applies in that section
the term “medicare contractor” has the meaning given such term in section 1395zz(g) of this title . (3) Limitation on use of extrapolation A medicare contractor may not use extrapolation to determine overpayment amounts to be recovered by recoupment, offset, or otherwise unless the Secretary determines that— (A) there is a sustained or high level of payment error; or (B) documented educational intervention has failed to correct the payment error. There shall be no administrative or judicial review under section 1395ff of this title , section 1395 oo of this title, or otherwise, of determinations by the Secretary of sustained or high levels of payment errors under this paragraph.
“hospice coinsurance period” applies in that section
the term “hospice coinsurance period” means, for an individual, a period of consecutive days beginning with the first day for which an election under section 1395d(d) of this title is in effect for the individual and ending with the close of the first period of 14 consecutive days on each of which such an election is not in effect for the individual. (B) During the period of an election by an individual under section 1395d(d)(1) of this title , no copayments or deductibles other than those under subparagraph (A) shall apply with respect to services furnished to such individual which constitute hospice care, regardless of the setting in which such services are furnished.
“noncompliant behavior” applies in that section
the term “noncompliant behavior” includes repeated noncompliance with medical advice and repeated failure to appear for appointments. (iii) Timely review of proposed nonvoluntary disenrollment A proposed disenrollment, other than a voluntary disenrollment, shall be subject to timely review and final determination by the Secretary or by the State administering agency (as applicable), prior to the proposed disenrollment becoming effective.
“PACE demonstration waiver program” applies in that section
the term “PACE demonstration waiver program” means a demonstration program under either of the following sections (as in effect before the date of their repeal): (A) Section 603(c) of the Social Security Amendments of 1983 ( Public Law 98–21 ), as extended by section 9220 of the Consolidated Omnibus Budget Reconciliation Act of 1985 ( Public Law 99–272 ). (B) Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 ( Public Law 99–509 ). (8) “State administering agency” defined For purposes of this section,
“PACE program” applies in that section
the term “PACE program” means a program of all-inclusive care for the elderly that meets the following requirements: (A) Operation The entity operating the program is a PACE provider (as defined in paragraph (3)). (B) Comprehensive benefits The program provides comprehensive health care services to PACE program eligible individuals in accordance with the PACE program agreement and regulations under this section.
“PACE program agreement” applies in that section
the term “PACE program agreement” means, with respect to a PACE provider, an agreement, consistent with this section, section 1396u–4 of this title (if applicable), and regulations promulgated to carry out such sections, between the PACE provider and the Secretary, or an agreement between the PACE provider and a State administering agency for the operation of a PACE program by the provider under such sections. (5) “PACE program eligible individual” defined For purposes of this section,
“PACE program eligible individual” applies in that section
the term “PACE program eligible individual” means, with respect to a PACE program, an individual who— (A) is 55 years of age or older; (B) subject to subsection (c)(4), is determined under subsection (c) to require the level of care required under the State medicaid plan for coverage of nursing facility services; (C) resides in the service area of the PACE program; and (D) meets such other eligibility conditions as may be imposed under the PACE program agreement for the program under subsection (e)(2)(A)(ii). (6) “PACE protocol” defined For purposes of this section,
“PACE protocol” applies in that section
the term “PACE protocol” means the Protocol for the Program of All-inclusive Care for the Elderly (PACE), as published by On Lok, Inc., as of April 14, 1995 , or any successor protocol that may be agreed upon between the Secretary and On Lok, Inc. (7) “PACE demonstration waiver program” defined For purposes of this section,
“PACE provider” applies in that section
the term “PACE provider” means an entity that— (i) subject to subparagraph (B), is (or is a distinct part of) a public entity or a private, nonprofit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986; and (ii) has entered into a PACE program agreement with respect to its operation of a PACE program.
“State administering agency” applies in that section
the term “State administering agency” means, with respect to the operation of a PACE program in a State, the agency of that State (which may be the single agency responsible for administration of the State plan under subchapter XIX in the State) responsible for administering PACE program agreements under this section and section 1396u–4 of this title in the State. (9) “Trial period” defined (A) In general For purposes of this section,
“trial period” applies in that section
the term “trial period” means, with respect to a PACE program operated by a PACE provider under a PACE program agreement, the first 3 contract years under such agreement with respect to such program. (B) Treatment of entities previously operating PACE demonstration waiver programs Each contract year (including a year occurring before the effective date of this section) during which an entity has operated a PACE demonstration waiver program shall be counted under subparagraph (A) as a contract year during which the entity operated a PACE program as a PACE provider under a PACE program agreement.
“ancillary services” applies in that section
the term “ancillary services” shall mean those special services for which charges are customarily made in addition to routine services. (e) Payment for inpatient hospital services prior to notification of noneligibility Notwithstanding that an individual is not entitled to have payment made under this part for inpatient hospital services furnished by any hospital, payment shall be made to such hospital (unless it elects not to receive such payment or, if payment has already been made by or on behalf of such individual, fails to refund such payment within the time specified by the Secretary) for such services which are furnished to the individual prior to notification to such hospital from …
“certified EHR technology” applies in that section
the terms “certified EHR technology”, “eligible hospital”, “EHR reporting period”, and “payment year” have the meanings given such terms in sections 1395ww(n) of this title. (4) (A) Subject to subparagraph (C), for cost reporting periods beginning in fiscal year 2015 or a subsequent fiscal year, in the case of a critical access hospital that is not a meaningful EHR user (as would be determined under paragraph (3) of section 1395ww(n) of this title if such critical access hospital was treated as an eligible hospital under such section) for an EHR reporting period with respect to such fiscal year, paragraph (1) shall be applied by substituting the applicable percent under subparagraph (B) for …
“EHR reporting period” applies in that section
the terms “certified EHR technology”, “eligible hospital”, “EHR reporting period”, and “payment year” have the meanings given such terms in sections 1395ww(n) of this title. (4) (A) Subject to subparagraph (C), for cost reporting periods beginning in fiscal year 2015 or a subsequent fiscal year, in the case of a critical access hospital that is not a meaningful EHR user (as would be determined under paragraph (3) of section 1395ww(n) of this title if such critical access hospital was treated as an eligible hospital under such section) for an EHR reporting period with respect to such fiscal year, paragraph (1) shall be applied by substituting the applicable percent under subparagraph (B) for …
“eligible hospital” applies in that section
the terms “certified EHR technology”, “eligible hospital”, “EHR reporting period”, and “payment year” have the meanings given such terms in sections 1395ww(n) of this title. (4) (A) Subject to subparagraph (C), for cost reporting periods beginning in fiscal year 2015 or a subsequent fiscal year, in the case of a critical access hospital that is not a meaningful EHR user (as would be determined under paragraph (3) of section 1395ww(n) of this title if such critical access hospital was treated as an eligible hospital under such section) for an EHR reporting period with respect to such fiscal year, paragraph (1) shall be applied by substituting the applicable percent under subparagraph (B) for …
“payment year” applies in that section
the terms “certified EHR technology”, “eligible hospital”, “EHR reporting period”, and “payment year” have the meanings given such terms in sections 1395ww(n) of this title. (4) (A) Subject to subparagraph (C), for cost reporting periods beginning in fiscal year 2015 or a subsequent fiscal year, in the case of a critical access hospital that is not a meaningful EHR user (as would be determined under paragraph (3) of section 1395ww(n) of this title if such critical access hospital was treated as an eligible hospital under such section) for an EHR reporting period with respect to such fiscal year, paragraph (1) shall be applied by substituting the applicable percent under subparagraph (B) for …
“routine services” applies in that section
the term “routine services” shall mean the regular room, dietary, and nursing services, minor medical and surgical supplies and the use of equipment and facilities for which a separate charge is not customarily made;
“local coverage determination” applies in that section
the term “local coverage determination” means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1395y(a)(1)(A) of this title . (C) Local coverage determinations for clinical diagnostic laboratory tests For provisions relating to local coverage determinations for clinical diagnostic laboratory tests, see section 1395m–1(g) of this title .
“national coverage determination” applies in that section
the term “national coverage determination” means a determination by the Secretary with respect to whether or not a particular item or service is covered nationally under this subchapter, but does not include a determination of what code, if any, is assigned to a particular item or service covered under this subchapter or a determination with respect to the amount of payment made for a particular item or service so covered. (2) Local coverage determination (A) In general Review of any local coverage determination shall be subject to the following limitations: (i) Upon the filing of a complaint by an aggrieved party, such a determination shall be reviewed by an administrative law judge.
“participation agreement” applies in that section
the term “participation agreement” means an agreement relating to the provision of health care services by the individual and does not include the provision of services as a reviewer under this subsection. (3) Limitations on reviewer compensation Compensation provided by a qualified independent contractor to a reviewer in connection with a review under this section shall not be contingent on the decision rendered by the reviewer.
“qualified independent contractor” applies in that section
the term “qualified independent contractor” means an entity or organization that is independent of any organization under contract with the Secretary that makes initial determinations under subsection (a)(1), and that meets the requirements established by the Secretary consistent with paragraph (3).
“related party” applies in that section
the term “related party” means, with respect to a case under this subchapter involving a specific individual entitled to benefits under part A or enrolled under part B, or both, any of the following: (A) The Secretary, the medicare administrative contractor involved, or any fiduciary, officer, director, or employee of the Department of Health and Human Services, or of such contractor. (B) The individual (or authorized representative). (C) The health care professional that provides the items or services involved in the case. (D) The institution at which the items or services (or treatment) involved in the case are provided.
“review entity” applies in that section
the term “review entity” means an entity of up to three reviewers who are administrative law judges or members of the Departmental Appeals Board selected for purposes of making determinations under this paragraph. (3) Requiring full and early presentation of evidence by providers A provider of services or supplier may not introduce evidence in any appeal under this section that was not presented at the reconsideration conducted by the qualified independent contractor under subsection (c), unless there is good cause which precluded the introduction of such evidence at or before that reconsideration.
“home health applicable increase percentage” applies in that section
the term “home health applicable increase percentage” means, with respect to— (I) each of fiscal years 2002 and 2003, the home health market basket percentage increase (as defined in clause (iii)) minus 1.1 percentage points; (II) for 1 the last calendar quarter of 2003 and the first calendar quarter of 2004, the home health market basket percentage increase; (III) the last 3 calendar quarters of 2004, and all of 2005 2 the home health market basket percentage increase minus 0.8 percentage points; (IV) 2006, 0 percent; and (V) any subsequent year, subject to clauses (v) and (vi), the home health market basket percentage increase.
“home health market basket percentage increase” applies in that section
the term “home health market basket percentage increase” means, with respect to a fiscal year or year, a percentage (estimated by the Secretary before the beginning of the fiscal year or year) determined and applied with respect to the mix of goods and services included in home health services in the same manner as the market basket percentage increase under section 1395ww(b)(3)(B)(iii) of this title is determined and applied to the mix of goods and services comprising inpatient hospital services for the fiscal year or year. Notwithstanding the previous sentence, the home health market basket percentage increase for 2018 shall be 1 percent and for 2020 shall be 1.5 percent.
“applicable number of calendar days” applies in that section
The term “applicable number of calendar days” means— (I) with respect to claims received in the 12-month period beginning October 1, 1986 , 30 calendar days, (II) with respect to claims received in the 12-month period beginning October 1, 1987 , 26 calendar days, (III) with respect to claims received in the 12-month period beginning October 1, 1988 , 25 calendar days, (IV) with respect to claims received in the 12-month period beginning October 1, 1989 , and claims received in any succeeding 12-month period ending on or before September 30, 1993 , 24 calendar days, and (V) with respect to claims received in the 12-month period beginning October 1, 1993 , and claims received in any …
“clean claim” applies in that section
The term “clean claim” means a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this subchapter.;
“regulations” applies throughout its subchapter
the term “regulations” means, unless the context otherwise requires, regulations prescribed by the Secretary. (2) No rule, requirement, or other statement of policy (other than a national coverage determination) that establishes or changes a substantive legal standard governing the scope of benefits, the payment for services, or the eligibility of individuals, entities, or organizations to furnish or receive services or benefits under this subchapter shall take effect unless it is promulgated by the Secretary by regulation under paragraph (1).
“qualifying hospital” applies in that section
the term “qualifying hospital” means a hospital or an entity described in paragraph (3) that— (A) is engaged in research in the causes, prevention, and treatment of cancer; and (B) is designated as a cancer center for the National Cancer Institute or is designated by the State legislature as the official cancer institute of the State and such designation by the State legislature occurred prior to December 8, 2003 .
“Hospital Insurance Trust Fund ratio” applies in that section
the term “Hospital Insurance Trust Fund ratio” means, with respect to any calendar year, the ratio of— (I) the balance in the Federal Hospital Insurance Trust Fund, as of the last day of such calendar year; to (II) the amount estimated by the Secretary to be the total amount to be paid from the Federal Hospital Insurance Trust Fund during the calendar year following such calendar year (other than payments of interest on, and repayments of, loans from the Federal Old-Age and Survivors Insurance Trust Fund and the Federal Disability Insurance Trust Fund under paragraph (1)), and reducing the amount of any transfer to the Railroad Retirement Account by the amount of any transfers into such …
“OASDI trust fund ratio” applies in that section
the term “OASDI trust fund ratio” means, with respect to any month, the ratio of— (i) the combined balance in the Federal Old-Age and Survivors Insurance Trust Fund and the Federal Disability Insurance Trust Fund, reduced by the outstanding amount of any loan (including interest thereon) theretofore made to either such Trust Fund from the Federal Hospital Insurance Trust Fund under section 401( l ) of this title, as of the last day of the second month preceding such month, to (ii) the amount obtained by multiplying by twelve the total amount which (as estimated by the Secretary) will be paid from the Federal Old-Age and Survivors Insurance Trust Fund and the Federal Disability Insurance …
“qualified State or local government retiree group” applies in that section
the term “qualified State or local government retiree group” means all of the individuals who retire prior to a specified date that is before January 1, 2002 , from employment in one or more occupations or other broad classes of employees of— (i) the State; (ii) a political subdivision of the State; or (iii) an agency or instrumentality of the State or political subdivision of the State.
“qualified State or local government retirement system” applies throughout its part
the term “qualified State or local government retirement system” means a retirement system that— (i) is established or maintained by a State or political subdivision thereof, or an agency or instrumentality of one or more States or political subdivisions thereof; (ii) covers positions of some or all employees of such a State, subdivision, agency, or instrumentality; and (iii) does not adjust cash retirement benefits based on eligibility for a reduction in premium under this paragraph.
“licensed health professional” applies in that section
the term “licensed health professional” means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, physical or occupational therapy assistant, registered professional nurse, licensed practical nurse, licensed or certified social worker, registered respiratory therapist, or certified respiratory therapy technician.
“nurse aide” applies in that section
the term “nurse aide” means any individual providing nursing or nursing-related services to residents in a skilled nursing facility, but does not include an individual— (i) who is a licensed health professional (as defined in subparagraph (G)) or a registered dietician, or (ii) who volunteers to provide such services without monetary compensation. Such term includes an individual who provides such services through an agency or under a contract with the facility. (G) “Licensed health professional” defined In this paragraph,
“skilled nursing facility” applies throughout its subchapter
the term “skilled nursing facility” means an institution (or a distinct part of an institution) which— (1) is primarily engaged in providing to residents— (A) skilled nursing care and related services for residents who require medical or nursing care, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; (2) has in effect a transfer agreement (meeting the requirements of section 1395x( l ) of this title) with one or more hospitals having agreements in effect under section 1395cc of this title ; and (3) meets the requirements for a skilled nursing facility described in subsections (b), …
“eligible critical access hospital” applies in that section
the term “eligible critical access hospital” means a critical access hospital that has an average daily acute census of less than 0.5 and an average daily swing bed census of greater than 10.0. (h) Grandfathering provisions (1) In general Any medical assistance facility operating in Montana and any rural primary care hospital designated by the Secretary under this section prior to August 5, 1997 , shall be deemed to have been certified by the Secretary under subsection (e) as a critical access hospital if such facility or hospital is otherwise eligible to be designated by the State as a critical access hospital under subsection (c).
“eligible small rural hospital” applies in that section
the term “eligible small rural hospital” means a non-Federal, short-term general acute care hospital that— (i) is located in a rural area (as defined for purposes of section 1395ww(d) of this title ); and (ii) has less than 50 beds. (C) Application A hospital seeking a grant under this paragraph shall submit an application to the Secretary on or before such date and in such form and manner as the Secretary specifies. (D) Amount of grant A grant to a hospital under this paragraph may not exceed $50,000.
“rural health network” applies in that section
the term “rural health network” means, with respect to a State, an organization consisting of— (A) at least 1 facility that the State has designated or plans to designate as a critical access hospital; and (B) at least 1 hospital that furnishes acute care services. (2) Agreements (A) In general Each critical access hospital that is a member of a rural health network shall have an agreement with respect to each item described in subparagraph (B) with at least 1 hospital that is a member of the network. (B) Items described The items described in this subparagraph are the following: (i) Patient referral and transfer.
“excepted medical treatment” applies in that section
The term “excepted medical treatment” means medical care or treatment (including medical and other health services)— (i) received involuntarily, (ii) required under Federal or State law or law of a political subdivision of a State, or (iii) effective beginning on December 29, 2022 , that is a COVID–19 vaccine and its administration described in section 1395x(s)(10)(A) of this title . (B) Nonexcepted medical treatment
“nonexcepted medical treatment” applies in that section
The term “nonexcepted medical treatment” means medical care or treatment (including medical and other health services) other than excepted medical treatment. (c) Monitoring and safeguard against excessive expenditures (1) Estimate of expenditures Before the beginning of each fiscal year (beginning with fiscal year 2000), the Secretary shall estimate the level of expenditures under this part for services described in subsection (a) for that fiscal year.
“ACO professional” applies in that section
The term “ACO professional” means— (A) a physician (as defined in section 1395x(r)(1) of this title ); and (B) a practitioner described in section 1395u(b)(18)(C)(i) of this title . (2) Hospital
“applicable ACO” applies in that section
The term “applicable ACO” means an ACO participating in a model tested or expanded under section 1315a of this title or under this section— (i) that operates under a two-sided model— (I) described in section 425.600(a) of title 42, Code of Federal Regulations; or (II) tested or expanded under section 1315a of this title ; and (ii) for which Medicare fee-for-service beneficiaries are assigned to the ACO using a prospective assignment method, as determined appropriate by the Secretary. (B) Home
“home” applies in that section
The term “home” means, with respect to a Medicare fee-for-service beneficiary, the place of residence used as the home of the beneficiary. (3) Telehealth services received in the home In the case of telehealth services described in paragraph (1) where the home of a Medicare fee-for-service beneficiary is the originating site, the following shall apply: (A) No facility fee There shall be no facility fee paid to the originating site under section 1395m(m)(2)(B) of this title . (B) Exclusion of certain services No payment may be made for such services that are inappropriate to furnish in the home setting such as services that are typically furnished in inpatient settings such as a hospital.
“hospital” applies in that section
The term “hospital” means a subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of this title ). (3) Medicare fee-for-service beneficiary
“Medicare fee-for-service beneficiary” applies in that section
The term “Medicare fee-for-service beneficiary” means an individual who is enrolled in the original Medicare fee-for-service program under parts A and B and is not enrolled in an MA plan under part C, an eligible organization under section 1395mm of this title , or a PACE program under section 1395eee of this title . (i) Option to use other payment models (1) In general If the Secretary determines appropriate, the Secretary may use any of the payment models described in paragraph (2) or (3) for making payments under the program rather than the payment model described in subsection (d).
“fee-for-service enrollment” applies in that section
the term “fee-for-service enrollment” means aggregate enrollment (including receipt of benefits other than through enrollment) under— (A) part A only; (B) part B only; and (C) both part A and part B.
“qualified entity” applies in that section
the term “qualified entity” means a public or private entity that— (A) is qualified (as determined by the Secretary) to use claims data to evaluate the performance of providers of services and suppliers on measures of quality, efficiency, effectiveness, and resource use; and (B) agrees to meet the requirements described in paragraph (4) and meets such other requirements as the Secretary may specify, such as ensuring security of data.
“medicare administrative contractor” applies throughout its subchapter
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 …
“authorized user” applies in that section
The term “authorized user” means the following: (i) A provider of services. (ii) A supplier. (iii) An employer (as defined in section 1002(5) of title 29 ). (iv) A health insurance issuer (as defined in section 300gg–91 of this title ). (v) A medical society or hospital association. (vi) Any entity not described in clauses (i) through (v) that is approved by the Secretary (other than an employer or health insurance issuer not described in clauses (iii) and (iv), respectively, as determined by the Secretary). (B) Provider of services
“provider of services” applies in that section
The term “provider of services” has the meaning given such term in section 1861(u) of the Social Security Act ( 42 U.S.C. 1395x(u) ). (C) Qualified entity
“qualified entity” applies in that section
The term “qualified entity” has the meaning given such term in section 1874(e)(2) of the Social Security Act ( 42 U.S.C. 1395kk(e) ). 3 (D) Secretary
“Secretary” applies in that section
The term “Secretary” means the Secretary of Health and Human Services. (E) Supplier
“supplier” applies in that section
The term “supplier” has the meaning given such term in section 1861(d) of the Social Security Act ( 42 U.S.C. 1395x(d) ). (b) Access to Medicare data by qualified clinical data registries to facilitate quality improvement (1) Access (A) In general To the extent consistent with applicable information, privacy, security, and disclosure laws, beginning July 1, 2016 , the Secretary shall, at the request of a qualified clinical data registry under section 1848(m)(3)(E) of the Social Security Act ( 42 U.S.C.
“alternative payment model” applies in that section
The term “alternative payment model” means, other than for purposes of subparagraphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of paragraph (2), any of the following: (i) A model under section 1315a of this title (other than a health care innovation award). (ii) The shared savings program under section 1395jjj of this title . (iii) A demonstration under section 1395cc–3 of this title . (iv) A demonstration required by Federal law. (D) Eligible alternative payment entity
“applicable items and services” applies in that section
the term “applicable items and services” means items and services other than items and services furnished by a dedicated emergency department (as defined in section 489.24(b) of title 42 of the Code of Federal Regulations). (B) Off-campus outpatient department of a provider (i) In general For purposes of paragraph (1)(B)(v) and this paragraph, subject to the subsequent provisions of this subparagraph,
“applicable percentage” applies in that section
the term “applicable percentage” means a percentage specified by the Secretary up to (but not to exceed)— (I) for a year (or portion of a year) before 2004, 2.5 percent; and (II) for 2004 and thereafter, 3.0 percent.
“ASC proportion” applies in that section
The term “ASC proportion” means 25 percent for cost reporting periods beginning in fiscal year 1988, 50 percent for portions of cost reporting periods beginning on or after October 1, 1988 , and ending on or before December 31, 1990 , and 58 percent for portions of cost reporting periods beginning on or after January 1, 1991 .
“charge proportion” applies throughout its subchapter
The term “charge proportion” means 100 percent minus the cost proportion. (o) Limitation on benefit for payment for therapeutic shoes for individuals with severe diabetic foot disease (1) In the case of shoes described in section 1395x(s)(12) of this title — (A) no payment may be made under this part, with respect to any individual for any year, for the furnishing of— (i) more than one pair of custom molded shoes (including inserts provided with such shoes) and 2 additional pairs of inserts for such shoes, or (ii) more than one pair of extra-depth shoes (not including inserts provided with such shoes) and 3 pairs of inserts for such shoes, and (B) with respect to expenses incurred in any …
“cost proportion” applies in that section
The term “cost proportion” means 75 percent for cost reporting periods beginning in fiscal year 1988, 50 percent for portions of cost reporting periods beginning on or after October 1, 1988 , and ending on or before December 31, 1990 , and 42 percent for portions of cost reporting periods beginning on or after January 1, 1991 .;
“covered OPD services” applies in that section
the term “covered OPD services”— (i) means hospital outpatient services designated by the Secretary; (ii) subject to clause (iv), includes inpatient hospital services designated by the Secretary that are covered under this part and furnished to a hospital inpatient who (I) is entitled to benefits under part A but has exhausted benefits for inpatient hospital services during a spell of illness, or (II) is not so entitled; (iii) includes implantable items described in paragraph (3), (6), or (8) of section 1395x(s) of this title ; (iv) does not include any therapy services described in subsection (a)(8) or ambulance services, for which payment is made under a fee schedule described in section …
“covered professional services” applies in that section
The term “covered professional services” has the meaning given that term in section 1395w–4(k)(3)(A) of this title . (B) Eligible professional
“eligible alternative payment entity” applies in that section
The term “eligible alternative payment entity” means, with respect to a year, an entity that— (i) participates in an alternative payment model that— (I) requires participants in such model to use certified EHR technology (as defined in subsection ( o )(4)); and (II) provides for payment for covered professional services based on quality measures comparable to measures under the performance category described in section 1395w–4(q)(2)(B)(i) of this title ; and (ii) (I) bears financial risk for monetary losses under such alternative payment model that are in excess of a nominal amount; or (II) is a medical home expanded under section 1315a(c) of this title .
“eligible professional” applies in that section
The term “eligible professional” has the meaning given that term in section 1395w–4(k)(3)(B) of this title and includes a group that includes such professionals. (C) Alternative payment model;
“eye or eye and ear unit” applies in that section
the term “eye or eye and ear unit” means a physically separate or distinct unit containing separate surgical suites devoted solely to eye or eye and ear services. (5) (A) The Secretary is authorized to provide by regulations that in the case of a surgical procedure, specified by the Secretary pursuant to paragraph (1)(A), performed in an ambulatory surgical center described in such paragraph, there shall be paid (in lieu of any amounts otherwise payable under this part) with respect to the facility services furnished by such center and with respect to all related services (including physicians’ services, laboratory, X-ray, and diagnostic services) a single all-inclusive fee established …
“general surgeon” applies in that section
the term “general surgeon” means a physician (as described in section 1395x(r)(1) of this title ) who has designated CMS specialty code 02–General Surgery as their primary specialty code in the physician’s enrollment under section 1395cc(j) of this title . (B) Major surgical procedures
“innovator multiple source drug” applies in that section
The term “innovator multiple source drug” has the meaning given such term in section 1396r–8(k)(7)(A)(ii) of this title . (iii) Noninnovator multiple source drugs
“major surgical procedures” applies in that section
The term “major surgical procedures” means physicians’ services which are surgical procedures for which a 10-day or 90-day global period is used for payment under the fee schedule under section 1395w–4(b) of this title . (3) Coordination with other payments The amount of the additional payment for a service under this subsection and subsection (m) shall be determined without regard to any additional payment for the service under subsection (m) and this subsection, respectively.
“non-opioid treatment for pain relief” applies in that section
the term “non-opioid treatment for pain relief” means a drug, biological product, or medical device that— (I) in the case of a drug or biological product, has a label indication approved by the Food and Drug Administration to reduce postoperative pain, or produce postsurgical or regional analgesia, without acting upon the body’s opioid receptors; (II) in case of a medical device, is used to deliver a therapy to reduce postoperative pain, or produce postsurgical or regional analgesia, and has— (aa) an application under section 360e of title 21 that has been approved with respect to the device, been cleared for market under section 360(k) of such title, or is exempt from the requirements of …
“noninnovator multiple source drug” applies in that section
The term “noninnovator multiple source drug” has the meaning given such term in section 1396r–8(k)(7)(A)(iii) of this title . (G) Reference average wholesale price
“off-campus outpatient department of a provider” applies in that section
the term “off-campus outpatient department of a provider” means a department of a provider (as defined in section 413.65(a)(2) of title 42 of the Code of Federal Regulations, as in effect as of November 2, 2015 ) that is not located— (I) on the campus (as defined in such section 413.65(a)(2)) of such provider; or (II) within the distance (described in such definition of campus) from a remote location of a hospital facility (as defined in such section 413.65(a)(2)).
“physician” applies in that section
the term “physician” means a physician described in section 1395x(r)(1) of this title and
“PPS amount” applies in that section
the term “PPS amount” means, with respect to covered OPD services, the amount payable under this subchapter for such services (determined without regard to this paragraph), including amounts payable as copayment under paragraph (8), coinsurance under section 1395cc(a)(2)(A)(ii) of this title , and the deductible under subsection (b).
“primary care physician” applies in that section
the term “primary care physician” means a physician who is identified in the available data as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist. (7) Publication of list of counties; posting on website With respect to a year for which a county or area is identified or revised under paragraph (4), the Secretary shall identify such counties or areas as part of the proposed and final rule to implement the physician fee schedule under section 1395w–4 of this title for the applicable year.
“primary care practitioner” applies in that section
The term “primary care practitioner” means an individual— (i) who— (I) is a physician (as described in section 1395x(r)(1) of this title ) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or (II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1395x(aa)(5) of this title ); and (ii) for whom primary care services accounted for at least 60 percent of the allowed charges under this part for such physician or practitioner in a prior period as determined appropriate by the Secretary. (B) Primary care services
“primary care services” applies in that section
The term “primary care services” means services identified, as of January 1, 2009 , by the following HCPCS codes (and as subsequently modified by the Secretary): (i) 99201 through 99215. (ii) 99304 through 99340. (iii) 99341 through 99350. (3) Coordination with other payments The amount of the additional payment for a service under this subsection and subsection (m) shall be determined without regard to any additional payment for the service under subsection (m) and this subsection, respectively.
“qualified hospital laboratory” applies in that section
the term “qualified hospital laboratory” means a hospital laboratory, in a sole community hospital (as defined in section 1395ww(d)(5)(D)(iii) of this title ), which provides some clinical diagnostic laboratory tests 24 hours a day in order to serve a hospital emergency room which is available to provide services 24 hours a day and 7 days a week.