42 U.S.C. § 1395w — Appropriations to cover Government

Page 3243 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395w 1 See References in Text note below. mentary medical insurance program established under part B of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], and (2) provisions will be made for payment of the monthly premiums of such individuals for such program.’’ § 1395w. Appropriations to cover Government contributions and contingency reserve (a) In general There are authorized to be appropriated from time to time, out of any moneys in the Treasury not otherwise appropriated, to the Federal Sup- plementary Medical Insurance Trust Fund— (1)(A) a Government contribution equal to the aggregate premiums payable for a month for enrollees age 65 and over under this part and deposited in the Trust Fund, multiplied by the ratio of— (i) twice the dollar amount of the actuari- ally adequate rate per enrollee age 65 and over as determined under section 1395r(a)(1) of this title for such month minus the dollar amount of the premium per enrollee for such month, as determined under section 1395r(a)(3) of this title, to (ii) the dollar amount of the premium per enrollee for such month, plus (B) a Government contribution equal to the aggregate premiums payable for a month for enrollees under age 65 under this part and de- posited in the Trust Fund, multiplied by the ratio of— (i) twice the dollar amount of the actuari- ally adequate rate per enrollee under age 65 as determined under section 1395r(a)(4) of this title for such month minus the dollar amount of the premium per enrollee for such month, as determined under section 1395r(a)(3) of this title, to (ii) the dollar amount of the premium per enrollee for such month; minus (C) the aggregate amount of additional pre- mium payments attributable to the applica- tion of section 1395r(i) of this title; plus (2) such sums as the Secretary deems nec- essary to place the Trust Fund, at the end of any fiscal year occurring after June 30, 1967, in the same position in which it would have been at the end of such fiscal year if (A) a Govern- ment contribution representing the excess of the premiums deposited in the Trust Fund during the fiscal year ending June 30, 1967, over the Government contribution actually appropriated to the Trust Fund during such fiscal year had been appropriated to it on June 30, 1967, and (B) the Government contribution for premiums deposited in the Trust Fund after June 30, 1967, had been appropriated to it when such premiums were deposited; plus (3) a Government contribution equal to the amount of payment incentives payable under sections 1395w–4(o) and 1395w–23(l)(3) of this title; plus (4) a Government contribution equal to the estimated aggregate reduction in premiums payable under part B that results from estab- lishing the premium at 15 percent of the actu- arial rate (as would be determined in accord- ance with section 1395r(a)(1) of this title if the reference to ‘‘one-half’’ in such section were a reference to ‘‘100 percent’’) under section 1395r(j) of this title instead of 25 percent of such rate (as so determined) for individuals enrolled only for the purpose of coverage of immunosuppressive drugs under section 1395o(b) of this title. In applying paragraph (1), the amounts trans- ferred under subsection (d)(1) with respect to en- rollees described in subparagraphs (A) and (B) of such subsection shall be treated as premiums payable and deposited in the Trust Fund under subparagraphs (A) and (B), respectively, of para- graph (1). In applying paragraph (1), the amounts transferred under subsection (e)(1) with respect to enrollees described in subparagraphs (A) and (B) of such subsection shall be treated as premiums payable and deposited in the Trust Fund under subparagraphs (A) and (B), respec- tively, of paragraph (1). The Government con- tribution under paragraph (4) shall be treated as premiums payable and deposited for purposes of subparagraphs (A) and (B) of paragraph (1). (b) Contingency reserve In order to assure prompt payment of benefits provided under this part and the administrative expenses thereunder during the early months of the program established by this part, and to pro- vide a contingency reserve, there is also author- ized to be appropriated, out of any moneys in the Treasury not otherwise appropriated, to re- main available through the calendar year 1969 for repayable advances (without interest) to the Trust Fund, an amount equal to $18 multiplied by the number of individuals (as estimated by the Secretary) who could be covered in July 1966 by the insurance program established by this part if they had theretofore enrolled under this part. (c) Election under section 1395w–24 The Secretary shall determine the Govern- ment contribution under subparagraphs (A) and (B) of subsection (a)(1) without regard to any premium reduction resulting from an election under section 1395w–24(f)(1)(E) of this title or any credits provided under section 1395w–24(b)(1)(C)(iv) 1 of this title and without re- gard to any premium adjustment effected under sections 1395r(h) and 1395w–29(f) 1 of this title and without regard to any premium adjustment under section 1395r(i) of this title. (d) Transfer of certain General Fund amounts for 2016 (1) For 2016, there shall be transferred from the General Fund to the Trust Fund an amount, as estimated by the Chief Actuary of the Centers for Medicare & Medicaid Services, equal to the reduction in aggregate premiums payable under this part for a month in such year (excluding any changes in amounts collected under section 1395r(i) of this title) that is attributable to the application of section 1395r(a)(5)(A) of this title with respect to— (A) enrollees age 65 and over; and (B) enrollees under age 65. Such amounts shall be transferred from time to time as appropriate. Page 3244 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395w (2) Premium increases affected under section 1395r(a)(6) of this title shall not be taken into account in applying subsection (a). (3) There shall be transferred from the Trust Fund to the General Fund of the Treasury amounts equivalent to the additional premiums payable as a result of the application of section 1395r(a)(6) of this title, excluding the aggregate payments attributable to the application of sec- tion 1395r(i)(3)(A)(ii)(II) of this title. (e) Transfer of certain General Fund amounts for 2021 (1) For 2021, there shall be transferred from the General Fund to the Trust Fund an amount, as estimated by the Chief Actuary of the Centers for Medicare & Medicaid Services, equal to the reduction in aggregate premiums payable under this part for a month in such year (excluding any changes in amounts collected under section 1395r(i) of this title) that are attributable to the application of section 1395r(a)(7) of this title with respect to— (A) enrollees age 65 and over; and (B) enrollees under age 65. Such amounts shall be transferred from time to time as appropriate. (2) Premium increases affected under section 1395r(a)(6) of this title shall not be taken into account in applying subsection (a). (3) There shall be transferred from the Trust Fund to the General Fund of the Treasury amounts equivalent to the additional premiums payable as a result of the application of section 1395r(a)(6) of this title, excluding the aggregate payments attributable to the application of sec- tion 1395r(i)(3)(A)(ii)(II) of this title. (f) Transfer of certain General Fund amounts for COVID–19 public health emergency period (1) There shall be transferred from the General Fund of the Treasury to the Trust Fund an amount, as estimated by the Chief Actuary of the Centers for Medicare & Medicaid Services, equal to amounts paid in advance for items and services under this part during the period begin- ning on the first day of the emergency period de- scribed in section 1320b–5(g)(1)(B) of this title and ending on October 1, 2020. (2) There shall be transferred from the Trust Fund to the General Fund of the Treasury amounts equivalent to the sum of— (A) the amounts by which claims have offset (in whole or in part) the amount of such pay- ments described in paragraph (1); and (B) the amount of such payments that have been repaid (in whole or in part). (3) Amounts described in paragraphs (1) and (2) shall be transferred from time to time as appro- priate. (Aug. 14, 1935, ch. 531, title XVIII, § 1844, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 313; amended Pub. L. 90–248, title I, § 167, Jan. 2, 1968, 81 Stat. 874; Pub. L. 92–603, title II, § 203(e), Oct. 30, 1972, 86 Stat. 1377; Pub. L. 97–248, title I, § 124(c), Sept. 3, 1982, 96 Stat. 364; Pub. L. 98–21, title VI, § 606(a)(3)(F), (G), Apr. 20, 1983, 97 Stat. 171; Pub. L. 98–369, div. B, title III, § 2354(b)(16), July 18, 1984, 98 Stat. 1101; Pub. L. 100–360, title II, § 211(c)(2), July 1, 1988, 102 Stat. 738; Pub. L. 101–234, title II, § 202(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L. 105–33, title IV, § 4571(b)(2), Aug. 5, 1997, 111 Stat. 464; Pub. L. 106–554, § 1(a)(6) [title VI, § 606(a)(2)(D)], Dec. 21, 2000, 114 Stat. 2763, 2763A–558; Pub. L. 108–173, title II, §§ 222(l)(2)(C), 241(b)(2)(B), title VIII, § 811(b)(2), Dec. 8, 2003, 117 Stat. 2206, 2221, 2368; Pub. L. 111–5, div. B, title IV, § 4103(a)(2), Feb. 17, 2009, 123 Stat. 487; Pub. L. 114–74, title VI, § 601(b), Nov. 2, 2015, 129 Stat. 595; Pub. L. 116–159, div. C, title IV, § 2401(b), (c), Oct. 1, 2020, 134 Stat. 732, 733; Pub. L. 116–260, div. CC, title IV, § 402(e), Dec. 27, 2020, 134 Stat. 3001.) Editorial Notes REFERENCES IN TEXT Section 1395w–24(b)(1)(C)(iv) of this title, referred to in subsec. (c), was redesignated section 1395w–24(b)(1)(C)(v) of this title by Pub. L. 111–148, title III, § 3202(b)(1)(B), Mar. 23, 2010, 124 Stat. 454, and subse- quently redesignated section 1395w–24(b)(1)(C)(viii) of this title by Pub. L. 111–152, title I, § 1102(d)(2), Mar. 30, 2010, 124 Stat. 1045. Section 1395w–29 of this title, referred to in subsec. (c), was repealed by Pub. L. 111–152, title I, § 1102(f), Mar. 30, 2010, 124 Stat. 1046. AMENDMENTS 2020—Subsec. (a). Pub. L. 116–260, § 402(e)(3), inserted at end of concluding provisions ‘‘The Government con- tribution under paragraph (4) shall be treated as pre- miums payable and deposited for purposes of subpara- graphs (A) and (B) of paragraph (1).’’ Pub. L. 116–159, § 2401(b)(1), inserted at end of con- cluding provisions ‘‘In applying paragraph (1), the amounts transferred under subsection (e)(1) with re- spect to enrollees described in subparagraphs (A) and (B) of such subsection shall be treated as premiums payable and deposited in the Trust Fund under sub- paragraphs (A) and (B), respectively, of paragraph (1).’’ Subsec. (a)(4). Pub. L. 116–260, § 402(e), added par. (4). Subsec. (e). Pub. L. 116–159, § 2401(b)(2), added subsec. (e). Subsec. (f). Pub. L. 116–159, § 2401(c), added subsec. (f). 2015—Subsec. (a). Pub. L. 114–74, § 601(b)(1), inserted concluding provisions. Subsec. (d). Pub. L. 114–74, § 601(b)(2), added subsec. (d). 2009—Subsec. (a)(2), (3). Pub. L. 111–5 in par. (2) sub- stituted ‘‘; plus’’ for period at end and added par. (3). 2003—Subsec. (a)(1)(B)(ii). Pub. L. 108–173, § 811(b)(2)(A)(i), substituted ‘‘minus’’ for ‘‘plus’’. Subsec. (a)(1)(C). Pub. L. 108–173, § 811(b)(2)(A)(ii), added subpar. (C). Subsec. (c). Pub. L. 108–173, § 811(b)(2)(B), inserted ‘‘and without regard to any premium adjustment under section 1395r(i) of this title’’ before period at end. Pub. L. 108–173, § 241(b)(2)(B), inserted ‘‘and without regard to any premium adjustment effected under sec- tions 1395r(h) and 1395w–29(f) of this title’’ before period at end. Pub. L. 108–173, § 222(l)(2)(C), inserted ‘‘or any credits provided under section 1395w–24(b)(1)(C)(iv) of this title’’ after ‘‘section 1395w–24(f)(1)(E) of this title’’. 2000—Subsec. (c). Pub. L. 106–554 added subsec. (c). 1997—Subsec. (a)(1)(A)(i), (B)(i). Pub. L. 105–33 sub- stituted ‘‘section 1395r(a)(3) of this title’’ for ‘‘section 1395r(a)(3) or 1395r(e) of this title, as the case may be’’. 1989—Subsec. (a). Pub. L. 101–234 repealed Pub. L. 100–360, § 211(c)(2), and provided that the provisions of law amended or repealed by such section are restored or revised as if such section had not been enacted, see 1988 Amendment note below. 1988—Subsec. (a). Pub. L. 100–360 inserted at end ‘‘In computing the amount of aggregate premiums and pre- miums per enrollee under paragraph (1), there shall not Page 3245 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395w–2 be taken into account premiums attributable to section 1395r(g) of this title or section 59B of the Internal Rev- enue Code of 1986.’’ 1984—Subsec. (a)(1)(B)(ii). Pub. L. 98–369 substituted ‘‘; plus’’ for a period. 1983—Subsec. (a)(1)(A)(i). Pub. L. 98–21, § 606(a)(3)(F), substituted ‘‘section 1395r(a)(1)’’ for ‘‘section 1395r(c)(1)’’ and ‘‘section 1395r(a)(3) or 1395r(e)’’ for ‘‘sec- tion 1395r(c)(3) or 1395r(g)’’. Subsec. (a)(1)(B)(i). Pub. L. 98–21, § 606(a)(3)(G), sub- stituted ‘‘1395r(a)(4)’’ for ‘‘1395r(c)(4)’’ and ‘‘1395r(a)(3) or 1395r(e)’’ for ‘‘1395r(c)(3) or 1395r(g)’’. 1982—Subsec. (a)(1)(A)(i), (B)(i). Pub. L. 97–248 sub- stituted ‘‘section 1395r(c)(3) or 1395r(g) of this title, as the case may be’’ for ‘‘section 1395r(c)(3) of this title’’. 1972—Subsec. (a)(1). Pub. L. 92–603 designated existing provisions as subpar. (A), substituted provisions relat- ing to Government contributions equal to aggregate premiums payable for a month for enrollees age 65 and over under this part and deposited in Trust Fund, and multiplied by specified ratio, for provisions relating to Government contributions equal to aggregate pre- miums payable under this part and deposited in Trust Fund, and added subpar. (B). 1968—Subsec. (a). Pub. L. 90–248, § 167(a), designated existing provisions as par. (1), inserted provision for de- posit of Government contribution in Trust Fund, and added par. (2). Subsec. (b). Pub. L. 90–248, § 167(b), substituted ‘‘1969’’ for ‘‘1967’’. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2003 AMENDMENT Amendment by section 222(l)(2)(C) of Pub. L. 108–173 applicable with respect to plan years beginning on or after Jan. 1, 2006, see section 223(a) of Pub. L. 108–173, set out as a note under section 1395w–21 of this title. EFFECTIVE DATE OF 2000 AMENDMENT Amendment by Pub. L. 106–554 applicable to years be- ginning with 2003, see section 1(a)(6) [title VI, § 606(b)] of Pub. L. 106–554, set out as a note under section 1395r of this title. EFFECTIVE DATE OF 1989 AMENDMENT Amendment by Pub. L. 101–234 effective Jan. 1, 1990, and applicable to premiums for months beginning after Dec. 31, 1989, see section 202(b) of Pub. L. 101–234, set out as a note under section 401 of this title. EFFECTIVE DATE OF 1988 AMENDMENT Amendment by Pub. L. 100–360 applicable, except as otherwise specified in such amendment, to monthly premiums for months beginning with January 1989, see section 211(d) of Pub. L. 100–360, set out as a note under section 1395r of this title. EFFECTIVE DATE OF 1984 AMENDMENT Amendment by Pub. L. 98–369 effective July 18, 1984, but not to be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2354(e)(1) of Pub. L. 98–369, set out as a note under section 1320a–1 of this title. EFFECTIVE DATE OF 1983 AMENDMENT; TRANSITIONAL RULE Amendment by Pub. L. 98–21 applicable to premiums for months beginning with January 1984, but for months after June 1983 and before January 1984, the amount of Government contributions under subsec. (a)(1) of this section shall be computed with the actu- arially adequate rate which would have been in effect but for the amendments made by this section and using the amount of the premium in effect for June 1983, see section 606(c) of Pub. L. 98–21, set out as a note under section 1395r of this title. EFFECTIVE DATE OF 1972 AMENDMENT Pub. L. 92–603, title II, § 203(e), Oct. 30, 1972, 86 Stat. 1377, provided that the amendment made by that sec- tion is effective with respect to enrollee premiums pay- able for months after June 1973. CONSTRUCTION OF 2015 AMENDMENT; CONDITIONAL APPLICATION TO 2017 For provisions relating to construction and applica- tion of amendment by Pub. L. 114–74, see sections 601(d) and 601(e) of Pub. L. 114–74, set out as notes under sec- tion 1395r of this title. § 1395w–1. Repealed. Pub. L. 105–33, title IV, § 4022(b)(2)(A), Aug. 5, 1997, 111 Stat. 354 Section, act Aug. 14, 1935, ch. 531, title XVIII, § 1845, as added and amended Apr. 7, 1986, Pub. L. 99–272, title IX, § 9305, 100 Stat. 190; Oct. 21, 1986, Pub. L. 99–509, title IX, §§ 9331(e), 9344(a)(1), 100 Stat. 2021, 2042; Dec. 22, 1987, Pub. L. 100–203, title IV, §§ 4045(b), 4083(a)(1), (c)(1), 4085(a), (i)(8), 101 Stat. 1330–87, 1330–129, 1330–130, 1330–132; July 1, 1988, Pub. L. 100–360, title IV, § 411(i)(4)(A), 102 Stat. 788; Nov. 10, 1988, Pub. L. 100–647, title VIII, § 8425(a), 102 Stat. 3803; Nov. 5, 1990, Pub. L. 101–508, title IV, §§ 4002(g)(3), 4118(j)(1), 104 Stat. 1388–37, 1388–70; Oct. 31, 1994, Pub. L. 103–432, title I, § 126(g)(8), 108 Stat. 4416, related to Physician Payment Review Commission. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF REPEAL Repeal effective Nov. 1, 1997, the date of termination of the Prospective Payment Assessment Commission and the Physician Payment Review Commission, see section 4022(c)(2) of Pub. L. 105–33 set out as an Effec- tive Date; Transition; Transfer of Functions note under section 1395b–6 of this title. § 1395w–2. Intermediate sanctions for providers or suppliers of clinical diagnostic laboratory tests (a) If the Secretary determines that any pro- vider or clinical laboratory approved for partici- pation under this subchapter no longer substan- tially meets the conditions of participation or for coverage specified under this subchapter with respect to the provision of clinical diag- nostic laboratory tests under this part, the Sec- retary may (for a period not to exceed one year) impose intermediate sanctions developed pursu- ant to subsection (b), in lieu of terminating im- mediately the provider agreement or cancelling immediately approval of the clinical laboratory. (b)(1) The Secretary shall develop and imple- ment— (A) a range of intermediate sanctions to apply to providers or clinical laboratories under the conditions described in subsection (a), and (B) appropriate procedures for appealing de- terminations relating to the imposition of such sanctions. (2)(A) The intermediate sanctions developed under paragraph (1) shall include— (i) directed plans of correction, (ii) civil money penalties in an amount not to exceed $10,000 for each day of substantial noncompliance, (iii) payment for the costs of onsite moni- toring by an agency responsible for conducting surveys, and (iv) suspension of all or part of the payments to which a provider or clinical laboratory