r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE wiki — defined terms

“cardiac rehabilitation program” applies in that section

The term “cardiac rehabilitation program” means a program (as described in paragraph (2)) that furnishes the items and services described in paragraph (3) under the supervision of a physician (as defined in subsection (r)(1)) or a physician assistant, nurse practitioner, or clinical nurse specialist (as those terms are defined in subsection (aa)(5)).

“cardiovascular screening blood test” applies in that section

The term “cardiovascular screening blood test” means a blood test for the early detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) that tests for the following: (A) Cholesterol levels and other lipid or triglyceride levels. (B) Such other indications associated with the presence of, or an elevated risk for, cardiovascular disease as the Secretary may approve for all individuals (or for some individuals determined by the Secretary to be at risk for cardiovascular disease), including indications measured by noninvasive testing.

“certified nurse-midwife” applies in that section

The term “certified nurse-midwife” means a registered nurse who has successfully completed a program of study and clinical experience meeting guidelines prescribed by the Secretary, or has been certified by an organization recognized by the Secretary. (hh) Clinical social worker; clinical social worker services;

“certified nurse-midwife services” applies in that section

The term “certified nurse-midwife services” means such services furnished by a certified nurse-midwife (as defined in paragraph (2)) and such services and supplies furnished as an incident to the nurse-midwife’s service which the certified nurse-midwife is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) as would otherwise be covered if furnished by a physician or as an incident to a physicians’ service.;

“certified registered nurse anesthetist” applies throughout its subchapter

The term “certified registered nurse anesthetist” means a certified registered nurse anesthetist licensed by the State who meets such education, training, and other requirements relating to anesthesia services and related care as the Secretary may prescribe. In prescribing such requirements the Secretary may use the same requirements as those established by a national organization for the certification of nurse anesthetists. Such term also includes, as prescribed by the Secretary, an anesthesiologist assistant. (cc) Comprehensive outpatient rehabilitation facility services;

“clinical nurse specialist” applies throughout its subchapter

The term “clinical nurse specialist” means, for purposes of this subchapter, an individual who— (i) is a registered nurse and is licensed to practice nursing in the State in which the clinical nurse specialist services are performed; and (ii) holds a master’s degree in a defined clinical area of nursing from an accredited educational institution.;

“clinical social worker” applies in that section

The term “clinical social worker” means an individual who— (A) possesses a master’s or doctor’s degree in social work; (B) after obtaining such degree has performed at least 2 years of supervised clinical social work; and (C) (i) is licensed or certified as a clinical social worker by the State in which the services are performed, or (ii) in the case of an individual in a State which does not provide for licensure or certification— (I) has completed at least 2 years or 3,000 hours of post-master’s degree supervised clinical social work practice under the supervision of a master’s level social worker in an appropriate setting (as determined by the Secretary), and (II) meets such other …

“clinical social worker services” applies in that section

The term “clinical social worker services” means services performed by a clinical social worker (as defined in paragraph (1)) for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital and other than services furnished to an inpatient of a skilled nursing facility which the facility is required to provide as a requirement for participation) which the clinical social worker is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed as would otherwise be covered if furnished by a physician or as an incident to a physician’s professional …

“collaboration” applies throughout its subchapter

The term “collaboration” means a process in which a nurse practitioner works with a physician to deliver health care services within the scope of the practitioner’s professional expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as defined by the law of the State in which the services are performed.

“colorectal cancer screening test” applies in that section

The term “colorectal cancer screening test” means any of the following procedures furnished to an individual for the purpose of early detection of colorectal cancer: (A) Screening fecal-occult blood test. (B) Screening flexible sigmoidoscopy. (C) Screening colonoscopy. (D) Such other tests or procedures, and modifications to tests and procedures under this subsection, with such frequency and payment limits, as the Secretary determines appropriate, in consultation with appropriate organizations.

“community mental health center” applies in that section

the term “community mental health center” means an entity that— (i) (I) provides the mental health services described in section 1913(c)(1) of the Public Health Service Act [ 42 U.S.C. 300x–2(c)(1) ]; or (II) in the case of an entity operating in a State that by law precludes the entity from providing itself the service described in subparagraph (E) of such section, provides for such service by contract with an approved organization or entity (as determined by the Secretary); (ii) meets applicable licensing or certification requirements for community mental health centers in the State in which it is located; (iii) provides at least 40 percent of its services to individuals who are not …

“comprehensive outpatient rehabilitation facility” applies throughout its subchapter

The term “comprehensive outpatient rehabilitation facility” means a facility which— (A) is primarily engaged in providing (by or under the supervision of physicians) diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of injured, disabled, or sick persons; (B) provides at least the following comprehensive outpatient rehabilitation services: (i) physicians’ services (rendered by physicians, as defined in subsection (r)(1), who are available at the facility on a full- or part-time basis); (ii) physical therapy; and (iii) social or psychological services; (C) maintains clinical records on all patients; (D) has policies established by a group of professional …

“comprehensive outpatient rehabilitation facility services” applies throughout its subchapter

The term “comprehensive outpatient rehabilitation facility services” means the following items and services furnished by a physician or other qualified professional personnel (as defined in regulations by the Secretary) to an individual who is an outpatient of a comprehensive outpatient rehabilitation facility under a plan (for furnishing such items and services to such individual) established and periodically reviewed by a physician— (A) physicians’ services; (B) physical therapy, occupational therapy, speech-language pathology services, and respiratory therapy; (C) prosthetic and orthotic devices, including testing, fitting, or training in the use of prosthetic and orthotic devices; (D) …

“covered osteoporosis drug” applies in that section

The term “covered osteoporosis drug” means an injectable drug approved for the treatment of post-menopausal osteoporosis provided to an individual by a home health agency if, in accordance with regulations promulgated by the Secretary— (1) the individual’s attending physician, nurse practitioner or clinical nurse specialist (as those terms are defined in subsection (aa)(5)), certified nurse-midwife (as defined in subsection (gg)), or physician assistant (as defined in subsection (aa)(5)) certifies that the individual has suffered a bone fracture related to post-menopausal osteoporosis and that the individual is unable to learn the skills needed to self-administer such drug or is otherwise …

“critical access hospital” applies in that section

The term “critical access hospital” means a facility certified by the Secretary as a critical access hospital under section 1395i–4(e) of this title .;

“diabetes outpatient self-management training services” applies in that section

The term “diabetes outpatient self-management training services” means educational and training services furnished (at such times as the Secretary determines appropriate) to an individual with diabetes by a certified provider (as described in paragraph (2)(A)) in an outpatient setting by an individual or entity who meets the quality standards described in paragraph (2)(B), but only if the physician who is managing the individual’s diabetic condition certifies that such services are needed under a comprehensive plan of care related to the individual’s diabetic condition to ensure therapy compliance or to provide the individual with necessary skills and knowledge (including skills related to …

“diabetes screening tests” applies in that section

The term “diabetes screening tests” means testing furnished to an individual at risk for diabetes (as defined in paragraph (2)) for the purpose of early detection of diabetes, including— (A) a fasting plasma glucose test; and (B) such other tests, and modifications to tests, as the Secretary determines appropriate, in consultation with appropriate organizations. (2) For purposes of paragraph (1),

“durable medical equipment” applies throughout its subchapter

The term “durable medical equipment” includes iron lungs, oxygen tents, hospital beds, and wheelchairs (which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a vehicle is determined to be necessary on the basis of the individual’s medical and physical condition and the vehicle meets such safety requirements as the Secretary may prescribe) used in the patient’s home (including an institution used as his home other than an institution that meets the requirements of subsection (e)(1) of this section or section 1395i–3(a)(1) of this title ), whether furnished on a rental basis or purchased, and includes blood-testing strips and …

“end-of-life planning” applies in that section

the term “end-of-life planning” means verbal or written information regarding— (A) an individual’s ability to prepare an advance directive in the case that an injury or illness causes the individual to be unable to make health care decisions; and (B) whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive. (4) For purposes of paragraph (1),

“extended care services” applies throughout its subchapter

The term “extended care services” means the following items and services furnished to an inpatient of a skilled nursing facility and (except as provided in paragraphs (3), (6), and (7)) by such skilled nursing facility— (1) nursing care provided by or under the supervision of a registered professional nurse; (2) bed and board in connection with the furnishing of such nursing care; (3) physical or occupational therapy or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility; (4) medical social services; (5) such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled …

“Federally qualified health center” applies throughout its subchapter

The term “Federally qualified health center” means an entity which— (A) (i) is receiving a grant under section 330 of the Public Health Service Act [ 42 U.S.C. 254b ], or (ii) (I) is receiving funding from such a grant under a contract with the recipient of such a grant, and (II) meets the requirements to receive a grant under section 330 of such Act [ 42 U.S.C.

“Federally qualified health center services” applies throughout its subchapter

The term “Federally qualified health center services” means— (A) services of the type described in subparagraphs (A) through (D) of paragraph (1) and preventive services (as defined in subsection (ddd)(3)); and (B) preventive primary health services that a center is required to provide under section 330 of the Public Health Service Act [ 42 U.S.C.

“home” applies in that section

The term “home” means a place of residence used as the home of an individual (as defined for purposes of subsection (n)).;

“home health agency” applies throughout its subchapter

The term “home health agency” means a public agency or private organization, or a subdivision of such an agency or organization, which— (1) is primarily engaged in providing skilled nursing services and other therapeutic services; (2) has policies, established by a group of professional personnel (associated with the agency or organization), including one or more physicians, nurse practitioners or clinical nurse specialists (as those terms are defined in subsection (aa)(5)), certified nurse-midwives (as defined in subsection (gg)), or physician assistants (as defined in subsection (aa)(5)) and one or more registered professional nurses, to govern the services (referred to in paragraph (1)) …

“home health services” applies throughout its subchapter

The term “home health services” means the following items and services furnished to an individual, who is under the care of a physician, a nurse practitioner or a clinical nurse specialist (as those terms are defined in subsection (aa)(5)), or a physician assistant (as defined in subsection (aa)(5)), by a home health agency or by others under arrangements with them made by such agency, under a plan (for furnishing such items and services to such individual) established and periodically reviewed by a physician, a nurse practitioner, a clinical nurse specialist, or a physician assistant, which items and services are, except as provided in paragraph (7), provided on a visiting basis in a place …

“home infusion drug” applies in that section

The term “home infusion drug” means a parenteral drug or biological administered intravenously, or subcutaneously for an administration period of 15 minutes or more, in the home of an individual through a pump that is an item of durable medical equipment (as defined in subsection (n)). Such term does not include the following: (i) Insulin pump systems. (ii) A self-administered drug or biological on a self-administered drug exclusion list.

“home infusion therapy” applies in that section

The term “home infusion therapy” means the items and services described in paragraph (2) furnished by a qualified home infusion therapy supplier (as defined in paragraph (3)(D)) which are furnished in the individual’s home (as defined in paragraph (3)(B)) to an individual— (A) who is under the care of an applicable provider (as defined in paragraph (3)(A)); and (B) with respect to whom a plan prescribing the type, amount, and duration of infusion therapy services that are to be furnished such individual has been established by a physician (as defined in subsection (r)(1)) and is periodically reviewed by a physician (as so defined) in coordination with the furnishing of home infusion drugs …

“hospice care” applies throughout its subchapter

The term “hospice care” means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual’s attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program— (A) nursing care provided by or under the supervision of a registered professional nurse, (B) physical or occupational therapy, or speech-language pathology services, (C) medical social services under the direction of a physician, (D) (i) services of a home health aide who has …

“hospice program” applies throughout its subchapter

The term “hospice program” means a public agency or private organization (or a subdivision thereof) which— (A) (i) is primarily engaged in providing the care and services described in paragraph (1) and makes such services available (as needed) on a 24-hour basis and which also provides bereavement counseling for the immediate family of terminally ill individuals and services described in section 1395d(a)(5) of this title , (ii) provides for such care and services in individuals’ homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization, except that— (I) the agency or organization must routinely provide directly …

“individual at risk for diabetes” applies in that section

the term “individual at risk for diabetes” means an individual who has any of the following risk factors for diabetes: (A) Hypertension. (B) Dyslipidemia. (C) Obesity, defined as a body mass index greater than or equal to 30 kg/m 2 . (D) Previous identification of an elevated impaired fasting glucose. (E) Previous identification of impaired glucose tolerance. (F) A risk factor consisting of at least 2 of the following characteristics: (i) Overweight, defined as a body mass index greater than 25, but less than 30, kg/m 2 . (ii) A family history of diabetes. (iii) A history of gestational diabetes mellitus or delivery of a baby weighing greater than 9 pounds. (iv) 65 years of age or older.

“initial preventive physical examination” applies in that section

The term “initial preventive physical examination” means physicians’ services consisting of a physical examination (including measurement of height, weight body mass index,, 10 and blood pressure) with the goal of health promotion and disease detection and includes education, counseling, and referral with respect to screening and other preventive services described in paragraph (2), end-of-life planning (as defined in paragraph (3)) upon the agreement with the individual, and the furnishing of a review of any current opioid prescriptions (as defined in paragraph (4)), but does not include clinical laboratory tests.

“inpatient critical access hospital services” applies in that section

The term “inpatient critical access hospital services” means items and services, furnished to an inpatient of a critical access hospital by such facility, that would be inpatient hospital services if furnished to an inpatient of a hospital by a hospital.;

“inpatient hospital services” applies throughout its subchapter

The term “inpatient hospital services” means the following items and services furnished to an inpatient of a hospital and (except as provided in paragraph (3)) by the hospital— (1) bed and board; (2) such nursing services and other related services, such use of hospital facilities, and such medical social services as are ordinarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital for the care and treatment of inpatients; and (3) such other diagnostic or therapeutic items or services, furnished by the hospital or by others under …

“inpatient psychiatric hospital services” applies throughout its subchapter

The term “inpatient psychiatric hospital services” means inpatient hospital services furnished to an inpatient of a psychiatric hospital. (d) Supplier

“intensive cardiac rehabilitation program” applies in that section

The term “intensive cardiac rehabilitation program” means a program (as described in paragraph (2)) that furnishes the items and services described in paragraph (3) under the supervision of a physician (as defined in subsection (r)(1)) or a physician assistant, nurse practitioner, or clinical nurse specialist (as those terms are defined in subsection (aa)(5)) and has shown, in peer-reviewed published research, that it accomplished— (i) one or more of the following: (I) positively affected the progression of coronary heart disease; or (II) reduced the need for coronary bypass surgery; or (III) reduced the need for percutaneous coronary interventions; and (ii) a statistically significant …

“intensive outpatient services” applies in that section

The term “intensive outpatient services” has the meaning given the term “partial hospitalization services” in paragraph (1), except that— (A) section 1395n(a)(2)(F)(i) of this title shall not apply; (B) the reference in such paragraph to an individual “determined (not less frequently than monthly) by a physician to have a need for such services for a minimum of 20 hours per week” shall be treated as a reference to an individual “determined (not less frequently than once every other month) by a physician to have a need for such services for a minimum of 9 hours per week”; and (C) the reference to “a community mental health center (as defined in subparagraph (B))” in paragraph (3) shall be …

“intravenous immune globulin” applies in that section

The term “intravenous immune globulin” means an approved pooled plasma derivative for the treatment in the patient’s home of a patient with a diagnosed primary immune deficiency disease, but not including items or services furnished before January 1, 2024 , related to the administration of the derivative, if a physician determines administration of the derivative in the patient’s home is medically appropriate.

“kidney disease education services” applies in that section

The term “kidney disease education services” means educational services that are— (A) furnished to an individual with stage IV chronic kidney disease who, according to accepted clinical guidelines identified by the Secretary, will require dialysis or a kidney transplant; (B) furnished, upon the referral of the physician managing the individual’s kidney condition, by a qualified person (as defined in paragraph (2)); and (C) designed— (i) to provide comprehensive information (consistent with the standards set under paragraph (3)) regarding— (I) the management of comorbidities, including for purposes of delaying the need for dialysis; (II) the prevention of uremic complications; and (III) each …

“long-term care hospital” applies in that section

The term “long-term care hospital” means a hospital which— (1) is primarily engaged in providing inpatient services, by or under the supervision of a physician, to Medicare beneficiaries whose medically complex conditions require a long hospital stay and programs of care provided by a long-term care hospital; (2) has an average inpatient length of stay (as determined by the Secretary) of greater than 25 days, or meets the requirements of clause (II) 8 of section 1395ww(d)(1)(B)(iv) of this title ; (3) satisfies the requirements of subsection (e); and (4) meets the following facility criteria: (A) the institution has a patient review process, documented in the patient medical record, that …

“lymphedema compression treatment items” applies in that section

The term “lymphedema compression treatment items” means standard and custom fitted gradient compression garments and other items determined by the Secretary that are— (1) furnished on or after January 1, 2024 , to an individual with a diagnosis of lymphedema for the treatment of such condition; (2) primarily and customarily used to serve a medical purpose and for the treatment of lymphedema, as determined by the Secretary; and (3) prescribed by a physician (or a physician assistant, nurse practitioner, or a clinical nurse specialist (as those terms are defined in section 1395x(aa)(5) of this title ) to the extent authorized under State law).

“marriage and family therapist” applies in that section

The term “marriage and family therapist” means an individual who— (A) possesses a master’s or doctor’s degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law of the State in which such individual furnishes the services described in paragraph (1); (B) is licensed or certified as a marriage and family therapist by the State in which such individual furnishes such services; (C) after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and (D) meets such other requirements as specified by the Secretary. (3) Mental health counselor services

“marriage and family therapist services” applies in that section

The term “marriage and family therapist services” means services furnished by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital), which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are furnished, as would otherwise be covered if furnished by a physician or as an incident to a physician’s professional service. (2) Marriage and family therapist

“medical and other health services” applies in that section

The term “medical and other health services” means any of the following items or services: (1) physicians’ services; (2) (A) services and supplies (including drugs and biologicals which are not usually self-administered by the patient) furnished as an incident to a physician’s professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in the physicians’ bills (or would have been so included but for the application of section 1395w–3b of this title ); (B) hospital services (including drugs and biologicals which are not usually self-administered by the patient) incident to physicians’ services rendered to …

“medical nutrition therapy services” applies in that section

The term “medical nutrition therapy services” means nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition professional (as defined in paragraph (2)) pursuant to a referral by a physician (as defined in subsection (r)(1)). (2) Subject to paragraph (3),

“mental health counselor” applies in that section

The term “mental health counselor” means an individual who— (A) possesses a master’s or doctor’s degree which qualifies for licensure or certification as a mental health counselor, clinical professional counselor, or professional counselor under the State law of the State in which such individual furnishes the services described in paragraph (3); (B) is licensed or certified as a mental health counselor, clinical professional counselor, or professional counselor by the State in which the services are furnished; (C) after obtaining such a degree has performed at least 2 years of clinical supervised experience in mental health counseling; and (D) meets such other requirements as specified by …

“mental health counselor services” applies in that section

The term “mental health counselor services” means services furnished by a mental health counselor (as defined in paragraph (4)) for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital), which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are furnished, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service. (4) Mental health counselor

“multi-cancer early detection screening test” applies in that section

The term “multi-cancer early detection screening test” means a test furnished to an individual for the concurrent detection of multiple cancer types across multiple organ sites on or after January 1, 2029 , that— (A) is cleared under section 360(k) of title 21 , classified under section 360c(f)(2) of title 21 , or approved under section 360e of title 21 ; (B) is— (i) a genomic sequencing blood or blood product test that includes the analysis of cell-free nucleic acids; or (ii) a test based on samples of biological material that provide results comparable to those obtained with a test described in clause (i), as determined by the Secretary; and (C) the Secretary determines is— (i) reasonable …

“nurse practitioner” applies throughout its subchapter

the term “nurse practitioner” mean, for purposes of this subchapter, a physician assistant or nurse practitioner who performs such services as such individual is legally authorized to perform (in the State in which the individual performs such services) in accordance with State law (or the State regulatory mechanism provided by State law), and who meets such training, education, and experience requirements (or any combination thereof) as the Secretary may prescribe in regulations.;

“opioid treatment program” applies in that section

The term “opioid treatment program” means an entity that is an opioid treatment program (as defined in section 8.2 of title 42 of the Code of Federal Regulations, or any successor regulation) that— (A) is enrolled under section 1395cc(j) of this title ; (B) has in effect a certification by the Substance Abuse and Mental Health Services Administration for such a program; (C) is accredited by an accrediting body approved by the Substance Abuse and Mental Health Services Administration; and (D) meets such additional conditions as the Secretary may find necessary to ensure— (i) the health and safety of individuals being furnished services under such program; and (ii) the effective and efficient …

“opioid use disorder treatment services” applies in that section

The term “opioid use disorder treatment services” means items and services that are furnished by an opioid treatment program for the treatment of opioid use disorder, including— (A) opioid agonist and antagonist treatment medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration under section 355 of title 21 for use in the treatment of opioid use disorder; (B) dispensing and administration of such medications, if applicable; (C) substance use counseling by a professional to the extent authorized under State law to furnish such services; (D) individual and group therapy with a physician or psychologist (or other mental health …

“outpatient critical access hospital services” applies in that section

The term “outpatient critical access hospital services” means medical and other health services furnished by a critical access hospital on an outpatient basis. (nn) Screening pap smear; screening pelvic exam;

“outpatient occupational therapy services” applies throughout its subchapter

The term “outpatient occupational therapy services” has the meaning given the term “outpatient physical therapy services” in subsection (p), except that “occupational” shall be substituted for “physical” each place it appears therein. (h) Extended care services

“outpatient physical therapy services” applies throughout its subchapter

The term “outpatient physical therapy services” means physical therapy services furnished by a provider of services, a clinic, rehabilitation agency, or a public health agency, or by others under an arrangement with, and under the supervision of, such provider, clinic, rehabilitation agency, or public health agency to an individual as an outpatient— (1) who is under the care of a physician (as defined in paragraph (1), (3), or (4) of subsection (r)), and (2) with respect to whom a plan prescribing the type, amount, and duration of physical therapy services that are to be furnished such individual has been established by a physician (as so defined) or by a qualified physical therapist and is …

“outpatient speech-language pathology services” applies in that section

The term “outpatient speech-language pathology services” has the meaning given the term “outpatient physical therapy services” in subsection (p), except that in applying such subsection— (A) “speech-language pathology” shall be substituted for “physical therapy” each place it appears; and (B) “speech-language pathologist” shall be substituted for “physical therapist” each place it appears.;

“part-time or intermittent services” applies throughout its subchapter

the term “part-time or intermittent services” means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week).

“partial hospitalization services” applies throughout its subchapter

The term “partial hospitalization services” means the items and services described in paragraph (2) prescribed by a physician for an individual determined (not less frequently than monthly) by a physician to have a need for such services for a minimum of 20 hours per week and provided under a program described in paragraph (3) under the supervision of a physician pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such program), which plan sets forth the physician’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the …

“personalized prevention plan services” applies in that section

The term “personalized prevention plan services” means the creation of a plan for an individual— (A) that includes a health risk assessment (that meets the guidelines established by the Secretary under paragraph (4)(A)) of the individual that is completed prior to or as part of the same visit with a health professional described in paragraph (3); and (B) that— (i) takes into account the results of the health risk assessment; and (ii) may contain the elements described in paragraph (2). (2) Subject to paragraph (4)(H), the elements described in this paragraph are the following: (A) The establishment of, or an update to, the individual’s medical and family history.

“physicians’ services” applies in that section

The term “physicians’ services” means professional services performed by physicians, including surgery, consultation, and home, office, and institutional calls (but not including services described in subsection (b)(6)).

“post-hospital extended care services” applies throughout its subchapter

The term “post-hospital extended care services” means extended care services furnished an individual after transfer from a hospital in which he was an inpatient for not less than 3 consecutive days before his discharge from the hospital in connection with such transfer.

“post-institutional home health services” applies in that section

The term “post-institutional home health services” means home health services furnished to an individual— (A) after discharge from a hospital or critical access hospital in which the individual was an inpatient for not less than 3 consecutive days before such discharge if such home health services were initiated within 14 days after the date of such discharge; or (B) after discharge from a skilled nursing facility in which the individual was provided post-hospital extended care services if such home health services were initiated within 14 days after the date of such discharge.

“preventive services” applies in that section

The term “preventive services” means the following: (A) The screening and preventive services described in subsection (ww)(2) (other than the service described in subparagraph (M) of such subsection). (B) An initial preventive physical examination (as defined in subsection (ww)). (C) Personalized prevention plan services (as defined in subsection (hhh)(1)). (eee) Cardiac rehabilitation program; intensive cardiac rehabilitation program;

“prostate cancer screening test” applies in that section

The term “prostate cancer screening test” means a test that consists of any (or all) of the procedures described in paragraph (2) provided for the purpose of early detection of prostate cancer to a man over 50 years of age who has not had such a test during the preceding year. (2) The procedures described in this paragraph are as follows: (A) A digital rectal examination. (B) A prostate-specific antigen blood test.

“provider of services” applies in that section

The term “provider of services” means a hospital, critical access hospital, rural emergency hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1395f(g) and section 1395n(e) of this title , a fund.

“psychiatric hospital” applies throughout its subchapter

The term “psychiatric hospital” means an institution which— (1) is primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons; (2) satisfies the requirements of paragraphs (3) through (9) of subsection (e); (3) maintains clinical records on all patients and maintains such records as the Secretary finds to be necessary to determine the degree and intensity of the treatment provided to individuals entitled to hospital insurance benefits under part A; and (4) meets such staffing requirements as the Secretary finds necessary for the institution to carry out an active program of treatment for …

“pulmonary rehabilitation program” applies in that section

The term “pulmonary rehabilitation program” means a program (as described in subsection (eee)(2) with respect to a program under this subsection) that furnishes the items and services described in paragraph (2) under the supervision of a physician (as defined in subsection (r)(1)) or a physician assistant, nurse practitioner, or clinical nurse specialist (as those terms are defined in subsection (aa)(5)).

“qualified audiologist” applies in that section

The term “qualified audiologist” means an individual with a master’s or doctoral degree in audiology who— (i) is licensed as an audiologist by the State in which the individual furnishes such services, or (ii) in the case of an individual who furnishes services in a State which does not license audiologists, has successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), performed not less than 9 months of supervised full-time audiology services after obtaining a master’s or doctoral degree in audiology or a related field, and successfully completed a national examination in audiology approved by the …

“qualified home infusion therapy supplier” applies in that section

The term “qualified home infusion therapy supplier” means a pharmacy, physician, or other provider of services or supplier licensed by the State in which the pharmacy, physician, or provider or services or supplier furnishes items or services and that— (I) furnishes infusion therapy to individuals with acute or chronic conditions requiring administration of home infusion drugs; (II) ensures the safe and effective provision and administration of home infusion therapy on a 7-day-a-week, 24-hour-a-day basis; (III) is accredited by an organization designated by the Secretary pursuant to section 1395m(u)(5) of this title ; and (IV) meets such other requirements as the Secretary determines …

“qualified individual” applies in that section

the term “qualified individual” means an individual who is (in accordance with regulations prescribed by the Secretary)— (A) an estrogen-deficient woman at clinical risk for osteoporosis; (B) an individual with vertebral abnormalities; (C) an individual receiving long-term glucocorticoid steroid therapy; (D) an individual with primary hyperparathyroidism; or (E) an individual being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy. (3) The Secretary shall establish such standards regarding the frequency with which a qualified individual shall be eligible to be provided benefits for bone mass measurement under this subchapter.

“qualified person” applies in that section

The term “qualified person” means— (i) a physician (as defined in subsection (r)(1)) or a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in subsection (aa)(5)), who furnishes services for which payment may be made under the fee schedule established under section 1395w–4 of this title ; and (ii) a provider of services located in a rural area (as defined in section 1395ww(d)(2)(D) of this title ). (B) Such term does not include a provider of services (other than a provider of services described in subparagraph (A)(ii)) or a renal dialysis facility.

“qualified psychologist services” applies in that section

The term “qualified psychologist services” means such services and such services and supplies furnished as an incident to his service furnished by a clinical psychologist (as defined by the Secretary) which the psychologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) as would otherwise be covered if furnished by a physician or as an incident to a physician’s service. (jj) Screening mammography

“qualified speech-language pathologist” applies in that section

The term “qualified speech-language pathologist” means an individual with a master’s or doctoral degree in speech-language pathology who— (i) is licensed as a speech-language pathologist by the State in which the individual furnishes such services, or (ii) in the case of an individual who furnishes services in a State which does not license speech-language pathologists, has successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), performed not less than 9 months of supervised full-time speech-language pathology services after obtaining a master’s or doctoral degree in speech-language pathology or a …

“registered dietitian or nutrition professional” applies in that section

the term “registered dietitian or nutrition professional” means an individual who— (A) holds a baccalaureate or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as accredited by an appropriate national accreditation organization recognized by the Secretary for this purpose; (B) has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and (C) (i) is licensed or certified as a dietitian or nutrition professional by the State in which the services are …

“religious nonmedical health care institution” applies in that section

The term “religious nonmedical health care institution” means an institution that— (A) is described in subsection (c)(3) of section 501 of the Internal Revenue Code of 1986 and is exempt from taxes under subsection (a) of such section; (B) is lawfully operated under all applicable Federal, State, and local laws and regulations; (C) provides only nonmedical nursing items and services exclusively to patients who choose to rely solely upon a religious method of healing and for whom the acceptance of medical health services would be inconsistent with their religious beliefs; (D) provides such nonmedical items and services exclusively through nonmedical nursing personnel who are experienced in …

“rural emergency hospital” applies in that section

The term “rural emergency hospital” means a facility described in paragraph (3) that— (A) is enrolled under section 1395cc(j) of this title , submits the additional information described in paragraph (4)(A) for purposes of such enrollment, and makes the detailed transition plan described in clause (i) of such paragraph available to the public, in a form and manner determined appropriate by the Secretary; (B) does not provide any acute care inpatient services, other than those described in paragraph (6)(A); (C) has in effect a transfer agreement with a level I or level II trauma center; 2 (D) meets— (i) licensure requirements as described in paragraph (5); (ii) the requirements of a staffed …

“rural emergency hospital services” applies in that section

The term “rural emergency hospital services” means the following services furnished by a rural emergency hospital (as defined in paragraph (2)) that do not exceed an annual per patient average of 24 hours in such rural emergency hospital: (i) Emergency department services and observation care. (ii) At the election of the rural emergency hospital, with respect to services furnished on an outpatient basis, other medical and health services as specified by the Secretary through rulemaking.

“rural health clinic” applies in that section

The term “rural health clinic” means a facility which— (A) is primarily engaged in furnishing to outpatients services described in subparagraphs (A) and (B) of paragraph (1); (B) in the case of a facility which is not a physician-directed clinic, has an arrangement (consistent with the provisions of State and local law relative to the practice, performance, and delivery of health services) with one or more physicians (as defined in subsection (r)(1)) under which provision is made for the periodic review by such physicians of covered services furnished by physician assistants and nurse practitioners, the supervision and guidance by such physicians of physician assistants and nurse …

“rural health clinic services” applies in that section

The term “rural health clinic services” means— (A) physicians’ services and such services and supplies as are covered under subsection (s)(2)(A) if furnished as an incident to a physician’s professional service and items and services described in subsection (s)(10), (B) such services furnished by a physician assistant or a nurse practitioner (as defined in paragraph (5)), by a clinical psychologist (as defined by the Secretary), by a clinical social worker (as defined in subsection (hh)(1)), by a marriage and family therapist (as defined in subsection ( lll )(2)), or by a mental health counselor (as defined in subsection ( lll )(4)), and such services and supplies furnished as an incident …

“screening for glaucoma” applies in that section

The term “screening for glaucoma” means a dilated eye examination with an intraocular pressure measurement, and a direct ophthalmoscopy or a slit-lamp biomicroscopic examination for the early detection of glaucoma which is furnished by or under the direct supervision of an optometrist or ophthalmologist who is legally authorized to furnish such services under State law (or the State regulatory mechanism provided by State law) of the State in which the services are furnished, as would otherwise be covered if furnished by a physician or as an incident to a physician’s professional service, if the individual involved has not had such an examination in the preceding year.

“screening mammography” applies in that section

The term “screening mammography” means a radiologic procedure provided to a woman for the purpose of early detection of breast cancer and includes a physician’s interpretation of the results of the procedure. (kk) Covered osteoporosis drug

“screening pap smear” applies in that section

The term “screening pap smear” means a diagnostic laboratory test consisting of a routine exfoliative cytology test (Papanicolaou test) provided to a woman for the purpose of early detection of cervical or vaginal cancer and includes a physician’s interpretation of the results of the test, if the individual involved has not had such a test during the preceding 2 years, or during the preceding year in the case of a woman described in paragraph (3).;

“screening pelvic exam” applies in that section

The term “screening pelvic exam” means a pelvic examination provided to a woman if the woman involved has not had such an examination during the preceding 2 years, or during the preceding year in the case of a woman described in paragraph (3), and includes a clinical breast examination. (3) A woman described in this paragraph is a woman who— (A) is of childbearing age and has had a test described in this subsection during any of the preceding 3 years that indicated the presence of cervical or vaginal cancer or other abnormality; or (B) is at high risk of developing cervical or vaginal cancer (as determined pursuant to factors identified by the Secretary).

“services of a certified registered nurse anesthetist” applies throughout its subchapter

The term “services of a certified registered nurse anesthetist” means anesthesia services and related care furnished by a certified registered nurse anesthetist (as defined in paragraph (2)) which the nurse anesthetist is legally authorized to perform as such by the State in which the services are furnished.;

“skilled nursing facility” applies throughout its subchapter

The term “skilled nursing facility” has the meaning given such term in section 1395i–3(a) of this title . (k) Utilization review A utilization review plan of a hospital or skilled nursing facility shall be considered sufficient if it is applicable to services furnished by the institution to individuals entitled to insurance benefits under this subchapter and if it provides— (1) for the review, on a sample or other basis, of admissions to the institution, the duration of stays therein, and the professional services (including drugs and biologicals) furnished, (A) with respect to the medical necessity of the services, and (B) for the purpose of promoting the most efficient use of available …

“speech-language pathology services” applies in that section

The term “speech-language pathology services” means such speech, language, and related function assessment and rehabilitation services furnished by a qualified speech-language pathologist as the speech-language pathologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) as would otherwise be covered if furnished by a physician.;

“State” applies in that section

The terms “State” and “United States” have the meaning given to them by subsections (h) and (i), respectively, of section 410 of this title . (y) Extended care in religious nonmedical health care institutions (1) The term “skilled nursing facility” also includes a religious nonmedical health care institution (as defined in subsection (ss)(1)), but only (except for purposes of subsection (a)(2)) with respect to items and services ordinarily furnished by such an institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the …

“supplier” applies throughout its subchapter

The term “supplier” means, unless the context otherwise requires, a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services under this subchapter.

“ultrasound screening for abdominal aortic aneurysm” applies in that section

The term “ultrasound screening for abdominal aortic aneurysm” means— (1) a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, that the Secretary may specify) provided for the early detection of abdominal aortic aneurysm; and (2) includes a physician’s interpretation of the results of the procedure. (ccc) Long-term care hospital

“United States” applies in that section

The terms “State” and “United States” have the meaning given to them by subsections (h) and (i), respectively, of section 410 of this title . (y) Extended care in religious nonmedical health care institutions (1) The term “skilled nursing facility” also includes a religious nonmedical health care institution (as defined in subsection (ss)(1)), but only (except for purposes of subsection (a)(2)) with respect to items and services ordinarily furnished by such an institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the …

“applicable plan” applies in that section

the term “applicable plan” means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement: (i) Liability insurance (including self-insurance). (ii) No fault insurance. (iii) Workers’ compensation laws or plans. (G) Sharing of information (i) In general The Secretary may share information collected under this paragraph as necessary for purposes of the proper coordination of benefits.

“claimant” applies in that section

the term “claimant” includes— (i) an individual filing a claim directly against the applicable plan; and (ii) an individual filing a claim against an individual or entity insured or covered by the applicable plan. (E) Enforcement (i) In general An applicable plan that fails to comply with the requirements under subparagraph (A) with respect to any claimant may be subject to a civil money penalty of up to $1,000 for each day of noncompliance with respect to each claimant.

“employer” applies in that section

The term “employer” includes a self-employed person. (iv) Application to certain Postal Service annuitants or family members Nothing in this paragraph shall prohibit a group health plan from determining an individual’s eligibility to enroll in a health benefits plan offered under the Postal Service Health Benefits Program under section 8903c of title 5 in accordance with subsection (e) of such section.

“group health plan” applies in that section

the term “group health plan” has the meaning given such term in section 5000(b)(1) of the Internal Revenue Code of 1986, without regard to section 5000(d) of such Code. (B) Disabled individuals in large group health plans (i) In general A large group health plan (as defined in clause (iii)) may not take into account that an individual (or a member of the individual’s family) who is covered under the plan by virtue of the individual’s current employment status with an employer is entitled to benefits under this subchapter under section 426(b) of this title .

“large group health plan” applies in that section

the term “large group health plan” has the meaning given such term in section 5000(b)(2) of the Internal Revenue Code of 1986, without regard to section 5000(d) of such Code. (C) Individuals with end stage renal disease A group health plan (as defined in subparagraph (A)(v))— (i) may not take into account that an individual is entitled to or eligible for benefits under this subchapter under section 426–1 of this title during the 12-month period which begins with the first month in which the individual becomes entitled to benefits under part A under the provisions of section 426–1 of this title , or, if earlier, the first month in which the individual would have been entitled to benefits …

“local coverage determination” applies in that section

The term “local coverage determination” has the meaning given that in section 1395ff(f)(2)(B) of this title . (m) Coverage of routine costs associated with certain clinical trials of category A devices (1) In general In the case of an individual entitled to benefits under part A, or enrolled under part B, or both who participates in a category A clinical trial, the Secretary shall not exclude under subsection (a)(1) payment for coverage of routine costs of care (as defined by the Secretary) furnished to such individual in the trial.

“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. (B) Local coverage determination

“primary plan” applies in that section

the term “primary plan” means a group health plan or large group health plan, to the extent that clause (i) applies, and a workmen’s compensation law or plan, an automobile or liability insurance policy or plan (including a self-insured plan) or no fault insurance, to the extent that clause (ii) applies. An entity that engages in a business, trade, or profession shall be deemed to have a self-insured plan if it carries its own risk (whether by a failure to obtain insurance, or otherwise) in whole or in part.

“protected period” applies in that section

the term “protected period” means, with respect to a settlement, judgment, award or other payment relating to an injury or incident, the portion (if any) of the period beginning on the date of notice under subclause (I) with respect to such settlement, judgment, award, or other payment that is after the end of a Secretarial response period beginning on the date of such notice to the Secretary. Such Secretarial response period shall be a period of 65 days, except that such period may be extended by the Secretary for a period of an additional 30 days if the Secretary determines that additional time is required to address claims for which payment has been made.

“small provider of services or supplier” applies in that section

the term “small provider of services or supplier” means— (A) a provider of services with fewer than 25 full-time equivalent employees; or (B) a physician, practitioner, facility, or supplier (other than provider of services) with fewer than 10 full-time equivalent employees.

“website” applies in that section

the term “website” includes any successor technology. (viii) Right of appeal for secondary payer determinations relating to liability insurance (including self-insurance), no fault insurance, and workers’ compensation laws and plans The Secretary shall promulgate regulations establishing a right of appeal and appeals process, with respect to any determination under this subsection for a payment made under this subchapter for an item or service for which the Secretary is seeking to recover conditional payments from an applicable plan (as defined in paragraph (8)(F)) that is a primary plan under subsection (A)(ii), 5 under which the applicable plan involved, or an attorney, agent, or third …

“all costs” applies in that section

The term “all costs” means routine service costs, ancillary costs, and capital-related costs of covered skilled nursing facility services, but does not include costs associated with approved educational activities.

“applicable percent” applies in that section

the term “applicable percent” means, with respect to fiscal year 2019 and succeeding fiscal years, 2 percent. (7) Announcement of net result of adjustments Under the SNF VBP Program, the Secretary shall, not later than 60 days prior to the fiscal year involved, inform each skilled nursing facility of the adjustments to payments to the skilled nursing facility for services furnished by such facility during the fiscal year under paragraphs (5) and (6).

“covered skilled nursing facility services” applies in that section

The term “covered skilled nursing facility services”— (I) means post-hospital extended care services as defined in section 1395x(i) of this title for which benefits are provided under part A; and (II) includes all items and services (other than items and services described in clauses (ii), (iii), and (iv)) for which payment may be made under part B and which are furnished to an individual who is a resident of a skilled nursing facility during the period in which the individual is provided covered post-hospital extended care services.

“first cost reporting period” applies in that section

The term “first cost reporting period” means, with respect to a skilled nursing facility, the first cost reporting period of the facility beginning on or after July 1, 1998 . (E) Transition period (i) In general

“skilled nursing facility market basket percentage” applies in that section

the term “skilled nursing facility market basket percentage” means, for a fiscal year or other annual period and as calculated by the Secretary, the percentage change in the skilled nursing facility market basket index (established under subparagraph (A)) from the midpoint of the prior fiscal year (or period) to the midpoint of the fiscal year (or other period) involved. (ii) Adjustment For fiscal year 2012 and each subsequent fiscal year, subject to clauses (iii) and (iv), after determining the percentage described in clause (i), the Secretary shall reduce such percentage by the productivity adjustment described in section 1395ww(b)(3)(B)(xi)(II) of this title .

“transition period” applies in that section

The term “transition period” means, with respect to a skilled nursing facility, the 3 cost reporting periods of the facility beginning with the first cost reporting period. (ii) Treatment of new skilled nursing facilities In the case of a skilled nursing facility that first received payment for services under this subchapter on or after October 1, 1995 , payment for such services shall be made under this subsection as if all services were furnished after the transition period.

“medicare contractor” applies in that section

the term “medicare contractor” includes the following: (1) A medicare administrative contractor with a contract under section 1395kk–1 of this title , including a fiscal intermediary with a contract under section 1395h of this title and a carrier with a contract under section 1395u of this title . (2) An eligible entity with a contract under section 1395ddd of this title . Such term does not include, with respect to activities of a specific provider of services or supplier an entity that has no authority under this subchapter or subchapter IX with respect to such activities and such provider of services or supplier.

“small provider of services or supplier” applies in that section

the term “small provider of services or supplier” means— (A) a provider of services with fewer than 25 full-time-equivalent employees; or (B) a supplier with fewer than 10 full-time-equivalent employees.

“appropriate committees of Congress” applies in that section

the term “appropriate committees of Congress” means the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate. (9) Voting and reporting requirements With respect to each recommendation contained in a report submitted under paragraph (1), each member of MACPAC shall vote on the recommendation, and MACPAC shall include, by member, the results of that vote in the report containing the recommendation.

“active duty relocated individual” applies in that section

The term “active duty relocated individual” means an individual— (A) who— (i) is enrolled under the State plan (or waiver of such plan); or (ii) with respect to an individual described in subparagraph (C)(ii), would be so enrolled pursuant to subsection (a)(10)(A)(ii)(VI) if such individual began receiving home and community-based services; (B) who— (i) is a member of the Armed Forces engaged in active duty service and is relocated to another State (in this subsection referred to as the “military service relocation State”) by reason of such service; (ii) would be described in clause (i) except that the individual stopped being engaged in active duty service (including by reason of …

“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. (5) For construction relating to this subsection, see section 14406 of this title (relating to clarification respecting assisted suicide, euthanasia, and mercy killing).

“applicable individual” applies in that section

The term “applicable individual” means an individual (other than a specified excluded individual (as defined in clause (ii)))— (I) who is eligible to enroll (or is enrolled) under the State plan under subsection (a)(10)(A)(i)(VIII); or (II) who— (aa) is otherwise eligible to enroll (or is enrolled) under a waiver of such plan that provides coverage that is equivalent to minimum essential coverage (as described in section 5000A(f)(1)(A) of the Internal Revenue Code of 1986 and as determined in accordance with standards prescribed by the Secretary in regulations); and (bb) has attained the age of 19 and is under 65 years of age, is not pregnant, is not entitled to, or enrolled for, benefits …

“child” applies in that section

the term “child” means an individual under 19 years of age, or, at the option of a State, such higher age, not to exceed 21 years of age, as the State may elect. (H) State option to rely on state income tax data or return .— At the option of the State, a finding from an Express Lane agency may include gross income or adjusted gross income shown by State income tax records or returns. (I) Application .— This paragraph shall not apply with respect to eligibility determinations made after September 30, 2029 .

“COBRA continuation coverage” applies in that section

the term “COBRA continuation coverage” means coverage under a group health plan provided by an employer with 75 or more employees provided pursuant to title XXII of the Public Health Service Act [ 42 U.S.C. 300bb–1 et seq.], section 4980B of the Internal Revenue Code of 1986, or title VI 1 of the Employee Retirement Income Security Act of 1974.

“COBRA premiums” applies in that section

the term “COBRA premiums” means the applicable premium imposed with respect to COBRA continuation coverage. (3) In this subsection,

“educational program” applies in that section

The term “educational program” includes— (i) an institution of higher education (as defined in section 1001 of title 20 ); and (ii) a program of career and technical education (as defined in section 2302 of title 20 ). (C) State

“effective date” applies in that section

the term “effective date” means, with respect to a termination described in subparagraph (A), the later of— (i) the date on which such termination is effective, as specified in the notice of such termination; or (ii) the date on which all appeal rights applicable to such termination have been exhausted or the timeline for any such appeal has expired. (9) Other State oversight Nothing in this subsection shall be interpreted to preclude or limit the ability of a State to engage in provider and supplier screening or enhanced provider and supplier oversight activities beyond those required by the Secretary.

“eligible juvenile” applies in that section

The term “eligible juvenile” means a juvenile who is an inmate of a public institution and who— (A) was determined eligible for medical assistance under the State plan (or waiver of such plan) immediately before becoming an inmate of such a public institution; or (B) is determined eligible for such medical assistance while an inmate of a public institution. (3) Inmate of a public institution

“error rate” applies in that section

the term “error rate” means the rate of erroneous excess payments for medical assistance (as defined in section 1396b(u)(1)(D) of this title ) for the period involved, except that such payments shall be limited to individuals for which eligibility determinations are made under this paragraph and except that in applying this paragraph under subchapter XXI, there shall be substituted for references to provisions of this subchapter corresponding provisions within subchapter XXI. (F) Express lane agency.— (i) In general .— In this paragraph,

“exclude” applies in that section

the term “exclude” includes the refusal to enter into or renew a participation agreement or the termination of such an agreement. (q) Minimum monthly personal needs allowance deduction; “institutionalized individual or couple” defined (1) (A) In order to meet the requirement of subsection (a)(50), the State plan must provide that, in the case of an institutionalized individual or couple described in subparagraph (B), in determining the amount of the individual’s or couple’s income to be applied monthly to payment for the cost of care in an institution, there shall be deducted from the monthly income (in addition to other allowances otherwise provided under the State plan) a monthly personal …

“Express Lane agency” applies in that section

the term “Express Lane agency” means a public agency that— (I) is determined by the State Medicaid agency or the State CHIP agency (as applicable) to be capable of making the determinations of one or more eligibility requirements described in subparagraph (A)(i); (II) is identified in the State Medicaid plan or the State CHIP plan; and (III) notifies the child’s family— (aa) of the information which shall be disclosed in accordance with this paragraph; (bb) that the information disclosed will be used solely for purposes of determining eligibility for medical assistance under the State Medicaid plan or for child health assistance under the State CHIP plan; and (cc) that the family may elect …

“home and community-based services waiting list” applies in that section

The term “home and community-based services waiting list” means, in the case of a State that has a limit on the number of individuals who may receive home and community-based services under section 1315(a) of this title or section 1396n(c) of this title , a list maintained by such State of individuals who are requesting to receive such services under 1 or more such sections but for whom the State has not yet completed an assessment and rendered a decision with respect to the eligibility of such individuals to receive the relevant home and community-based services at the time a slot for such services becomes available due to such limit.

“household income” applies in that section

the terms “modified adjusted gross income” and “household income” have the meanings given such terms in section 36B(d)(2) of the Internal Revenue Code of 1986. (H) Continued application of medicaid rules regarding point-in-time income and sources of income .— The requirement under this paragraph for States to use modified adjusted gross income and household income to determine income eligibility for medical assistance under the State plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required shall not be construed as affecting or limiting the application of— (i) the requirement under this subchapter and …

“inmate of a public institution” applies in that section

The term “inmate of a public institution” has the meaning given such term for purposes of applying the subdivision (A) following the last numbered paragraph of section 1396d(a) of this title , taking into account the exception in such subdivision for a patient of a medical institution.

“institutionalized individual or couple” applies in that section

the term “institutionalized individual or couple” means an individual or married couple— (i) who is an inpatient (or who are inpatients) in a medical institution or nursing facility for which payments are made under this subchapter throughout a month, and (ii) who is or are determined to be eligible for medical assistance under the State plan. (2) The minimum monthly personal needs allowance described in this paragraph 15 is $30 for an institutionalized individual and $60 for an institutionalized couple (if both are aged, blind, or disabled, and their incomes are considered available to each other in determining eligibility).

“juvenile” applies in that section

The term “juvenile” means an individual who is— (A) under 21 years of age; or (B) described in subsection (a)(10)(A)(i)(IX). (2) Eligible juvenile

“minimum enrollment period” applies throughout its subchapter

the term “minimum enrollment period” means, with respect to an individual’s enrollment with an organization or entity under a State plan, a period, established by the State, of not more than six months beginning on the date the individual’s enrollment with the organization or entity becomes effective.

“modified adjusted gross income” applies in that section

the terms “modified adjusted gross income” and “household income” have the meanings given such terms in section 36B(d)(2) of the Internal Revenue Code of 1986. (H) Continued application of medicaid rules regarding point-in-time income and sources of income .— The requirement under this paragraph for States to use modified adjusted gross income and household income to determine income eligibility for medical assistance under the State plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required shall not be construed as affecting or limiting the application of— (i) the requirement under this subchapter and …

“parent” applies throughout its subchapter

the term “parent” includes an individual treated as a caretaker relative for purposes of carrying out section 1396u–1 of this title . (l) Description of group (1) Individuals described in this paragraph are— (A) women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy), (B) infants under one year of age, (C) children who have attained one year of age but have not attained 6 years of age, and (D) children born after September 30, 1983 (or, at the option of a State, after any earlier date), who have attained 6 years of age but have not attained 19 years of age, who are not described in any of subclauses (I) through (III) of subsection (a)(10)(A)(i) and …

“primary care services” applies in that section

the term “primary care services” means— (1) evaluation and management services that are procedure codes (for services covered under subchapter XVIII) for services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System (established by the Secretary under section 1395w–4(c)(5) of this title as of December 31, 2009 , and as subsequently modified); and (2) services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such System.

“qualified lottery winnings” applies in that section

the term “qualified lottery winnings” means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment. (vi) Qualified lump sum income defined .— In this subparagraph,

“qualified lump sum income” applies in that section

the term “qualified lump sum income” means income that is received as a lump sum from monetary winnings from gambling (as defined by the Secretary and including gambling activities described in section 1955(b)(4) of title 18 ).

“residential pediatric recovery center” applies in that section

the term “residential pediatric recovery center” means a center or facility that furnishes items and services for which medical assistance is available under the State plan to infants with the diagnosis of neonatal abstinence syndrome without any other significant medical risk factors. (2) Counseling and services A residential pediatric recovery center may offer counseling and other services to mothers (and other appropriate family members and caretakers) of infants receiving treatment at such centers if such services are otherwise covered under the State plan under this subchapter or under a waiver of such plan.

“specified excluded individual” applies in that section

the term “specified excluded individual” means an individual, as determined by the State (in accordance with standards specified by the Secretary)— (I) who is described in subsection (a)(10)(A)(i)(IX); (II) who— (aa) is an Indian or an Urban Indian (as such terms are defined in paragraphs (13) and (28) of section 1603 of title 25 ); (bb) is a California Indian described in section 1679(a) of such title; or (cc) has otherwise been determined eligible as an Indian for the Indian Health Service under regulations promulgated by the Secretary; (III) who is the parent, guardian, caretaker relative, or family caregiver (as defined in section 2 of the RAISE Family Caregivers Act) of a dependent …

“State” applies in that section

The term “State” means 1 of the 50 States or the District of Columbia. (II) State chip agency .—

“State CHIP agency” applies in that section

The term “State CHIP agency” means the State agency responsible for administering the State CHIP plan. (III) State chip plan .—

“State CHIP plan” applies in that section

The term “State CHIP plan” means the State child health plan established under subchapter XXI and includes any waiver of such plan. (IV) State medicaid agency .—

“State Medicaid agency” applies in that section

The term “State Medicaid agency” means the State agency responsible for administering the State Medicaid plan. (V) State medicaid plan .—

“State Medicaid plan” applies in that section

The term “State Medicaid plan” means the State plan established under subchapter XIX and includes any waiver of such plan. (G) Child defined .— For purposes of this paragraph,

“TB-related services” applies in that section

the term “TB-related services” means each of the following services relating to treatment of infection with tuberculosis: (A) Prescribed drugs. (B) Physicians’ services and services described in section 1396d(a)(2) of this title . (C) Laboratory and X-ray services (including services to confirm the presence of infection). (D) Clinic services and Federally-qualified health center services. (E) Case management services (as defined in section 1396n(g)(2) of this title ). (F) Services (other than room and board) designed to encourage completion of regimens of prescribed drugs by outpatients, including services to observe directly the intake of prescribed drugs.

“uninsured individual” applies in that section

the term “uninsured individual” means, notwithstanding any other provision of this subchapter, any individual who is— (1) not described in subsection (a)(10)(A)(i) (excluding subclause (VIII) of such subsection if the individual is a resident of a State which does not furnish medical assistance to individuals described in such subclause); and (2) not enrolled in a Federal health care program (as defined in section 1320a–7b(f) of this title ), a group health plan, group or individual health insurance coverage offered by a health insurance issuer (as such terms are defined in section 300gg–91 of this title ), or a health plan offered under chapter 89 of title 5, except that individuals who …

“work program” applies in that section

The term “work program” has the meaning given such term in section 6( o )(1) of the Food and Nutrition Act of 2008 [ 7 U.S.C. 2015 ( o )(1)]. (10) Prohibiting waiver of community engagement requirements Notwithstanding section 1315(a) of this title , the provisions of this subsection may not be waived.

“average allowable costs” applies in that section

The term “average allowable costs” means, with respect to certified EHR technology of Medicaid providers described in paragraph (2)(A) for— (i) the first year of payment with respect to such a provider, the average costs for the purchase and initial implementation or upgrade of such technology (and support services including training that is for, or is necessary for the adoption and initial operation of, such technology) for such providers, as determined by the Secretary based upon studies conducted under paragraph (4)(C); and (ii) a subsequent year of payment with respect to such a provider, the average costs not described in clause (i) relating to the operation, maintenance, and use of …

“board and care facility” applies in that section

the term “board and care facility” means a residential setting which receives payment (regardless of whether such payment is made under the State plan under this subchapter) from or on behalf of two or more unrelated adults who reside in such facility, and for whom one or both of the following is provided: (i) Nursing care services provided by, or under the supervision of, a registered nurse, licensed practical nurse, or licensed nursing assistant.

“bona fide provider-related donation” applies in that section

the term “bona fide provider-related donation” means a provider-related donation that has no direct or indirect relationship (as determined by the Secretary) to payments made under this subchapter to that provider, to providers furnishing the same class of items and services as that provider, or to any related entity, as established by the State to the satisfaction of the Secretary. The Secretary may by regulation specify types of provider-related donations described in the previous sentence that will be considered to be bona fide provider-related donations.

“broad-based health care related tax” applies in that section

the term “broad-based health care related tax” means a health care related tax which is imposed with respect to a class of health care items or services (as described in paragraph (7)(A)) or with respect to providers of such items or services and which, except as provided in subparagraphs (D), (E), and (F)— (i) is imposed at least with respect to all items or services in the class furnished by all non-Federal, nonpublic providers in the State (or, in the case of a tax imposed by a unit of local government, the area over which the unit has jurisdiction) or is imposed with respect to all non-Federal, nonpublic providers in the class; and (ii) is imposed uniformly (in accordance with …

“certified EHR technology” applies in that section

The term “certified EHR technology” means a qualified electronic health record (as defined in 9 300jj(13) of this title) that is certified pursuant to section 300jj–11(c)(5) of this title as meeting standards adopted under section 300jj–14 of this title that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals).;

“control” applies in that section

the term “control” means the possession, whether direct or indirect, of the power to direct or cause the direction of the management and policies of the organization through membership, board representation, or an ownership interest equal to or greater than 50.1 percent.

“electronic visit verification system” applies in that section

The term “electronic visit verification system” means, with respect to personal care services or home health care services, a system under which visits conducted as part of such services are electronically verified with respect to— (i) the type of service performed; (ii) the individual receiving the service; (iii) the date of the service; (iv) the location of service delivery; (v) the individual providing the service; and (vi) the time the service begins and ends.;

“eligible professional” applies in that section

The term “eligible professional” means a— (i) physician; (ii) dentist; (iii) certified nurse mid-wife; (iv) nurse practitioner; and (v) physician assistant insofar as the assistant is practicing in a rural health clinic that is led by a physician assistant or is practicing in a Federally qualified health center that is so led.;

“emergency medical condition” applies in that section

the term “emergency medical condition” means a medical condition (including emergency labor and delivery) 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— (A) placing the patient’s health in serious jeopardy, (B) serious impairment to bodily functions, or (C) serious dysfunction of any bodily organ or part.