42 U.S.C. § 1395j — Establishment of supplementary medical

Page 3018 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395j (I) a range of remedies to apply to hos- pice programs under the conditions de- scribed in paragraphs (1) through (4); and (II) appropriate procedures for appeal- ing determinations relating to the impo- sition of such remedies. Remedies developed pursuant to the pre- ceding sentence shall include the remedies specified in subparagraph (B). (ii) Conditions of imposition of remedies Not later than October 1, 2022, the Sec- retary shall develop and implement spe- cific procedures with respect to the condi- tions under which each of the remedies de- veloped under clause (i) is to be applied, including the amount of any fines and the severity of each of these remedies. Such procedures shall be designed so as to mini- mize the time between identification of de- ficiencies and imposition of these remedies and shall provide for the imposition of in- crementally more severe fines for repeated or uncorrected deficiencies. (B) Specified remedies The remedies specified in this subpara- graph are the following: (i) Civil money penalties in an amount not to exceed $10,000 for each day of non- compliance by a hospice program with the requirements specified in section 1395x(dd) of this title. (ii) Suspension of all or part of the pay- ments to which a hospice program would otherwise be entitled under this sub- chapter with respect to items and services furnished by a hospice program on or after the date on which the Secretary deter- mines that remedies should be imposed pursuant to paragraphs (1) and (2). (iii) The appointment of temporary man- agement to oversee the operation of the hospice program and to protect and assure the health and safety of the individuals under the care of the program while im- provements are made in order to bring the program into compliance with all such re- quirements. (C) Procedures (i) Civil money penalties (I) In general Subject to subclause (II), the provi- sions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subsection in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title. (II) Retention of amounts for hospice program improvements The Secretary may provide that any portion of civil money penalties col- lected under this subsection may be used to support activities that benefit indi- viduals receiving hospice care, including education and training programs to en- sure hospice program compliance with the requirements of section 1395x(dd) of this title. (ii) Suspension of payment A finding to suspend payment under sub- paragraph (B)(ii) shall terminate when the Secretary finds that the program is in sub- stantial compliance with all requirements of section 1395x(dd) of this title. (iii) Temporary management The temporary management under sub- paragraph (B)(iii) shall not be terminated until the Secretary has determined that the program has the management capa- bility to ensure continued compliance with all the requirements referred to in such subparagraph. (D) Relationship to other remedies The remedies developed under subpara- graph (A) are in addition to sanctions other- wise available under State or Federal law and shall not be construed as limiting other remedies, including any remedy available to an individual at common law. (Aug. 14, 1935, ch. 531, title XVIII, § 1822, as added Pub. L. 116–260, div. CC, title IV, § 407(a)(1), Dec. 27, 2020, 134 Stat. 3003.) Editorial Notes REFERENCES IN TEXT Section 3(a)(2) of the Improving Medicare Post-Acute Care Transformation Act of 2014, referred to in subsec. (a)(5), means section 3(a)(2) of Pub. L. 113–185, Oct. 6, 2014, 128 Stat. 1968, which is not classified to the Code. PART B—SUPPLEMENTARY MEDICAL INSURANCE BENEFITS FOR AGED AND DISABLED § 1395j. Establishment of supplementary medical insurance program for aged and disabled There is hereby established a voluntary insur- ance program to provide medical insurance ben- efits in accordance with the provisions of this part for aged and disabled individuals who elect to enroll under such program, to be financed from premium payments by enrollees together with contributions from funds appropriated by the Federal Government. (Aug. 14, 1935, ch. 531, title XVIII, § 1831, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 301; amended Pub. L. 92–603, title II, § 201(a)(3), Oct. 30, 1972, 86 Stat. 1371.) Editorial Notes AMENDMENTS 1972—Pub. L. 92–603 substituted ‘‘aged and disabled in- dividuals’’ for ‘‘individuals 65 years of age or over’’. Statutory Notes and Related Subsidiaries STUDY REGARDING COVERAGE UNDER PART B OF MEDI- CARE FOR NONREIMBURSABLE SERVICES PROVIDED BY OPTOMETRISTS FOR PROSTHETIC LENSES FOR PA- TIENTS WITH APHAKIA Pub. L. 94–182, title I, § 109, Dec. 31, 1975, 89 Stat. 1053, provided that the Secretary of Health, Education, and Welfare conduct a study on the appropriateness of re- imbursement under the insurance program established Page 3019 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395k 1 So in original. The semicolon probably should be a comma. 2 So in original. The word ‘‘and’’ probably should not appear. by this part for services performed by optometrists with respect to the provision of prosthetic lenses for patients with aphakia and submit such study to Con- gress not later than 4 months after Dec. 31, 1975. STUDY TO DETERMINE FEASIBILITY OF INCLUSION OF CERTAIN ADDITIONAL SERVICES UNDER PART B Pub. L. 90–248, title I, § 141, Jan. 2, 1968, 81 Stat. 855, directed Secretary to conduct a study relating to inclu- sion under the supplementary medical insurance pro- gram under this part of services of additional types of licensed practitioners performing health services in independent practice and submit such study to Con- gress prior to Jan. 1, 1969. § 1395k. Scope of benefits; definitions (a) Scope of benefits The benefits provided to an individual by the insurance program established by this part shall consist of— (1) entitlement to have payment made to him or on his behalf (subject to the provisions of this part) for medical and other health serv- ices, except those described in subparagraphs (B) and (D) of paragraph (2) and subparagraphs (E) and (F) of section 1395u(b)(6) of this title; and (2) entitlement to have payment made on his behalf (subject to the provisions of this part) for— (A) home health services (other than items described in subparagraph (G) or subpara- graph (I)); (B) medical and other health services (other than items described in subparagraph (G) or subparagraph (I)) furnished by a pro- vider of services or by others under arrange- ment with them made by a provider of serv- ices, excluding— (i) physician services except where fur- nished by— (I) a resident or intern of a hospital, or (II) a physician to a patient in a hos- pital which has a teaching program ap- proved as specified in paragraph (6) of section 1395x(b) of this title (including services in conjunction with the teach- ing programs of such hospital whether or not such patient is an inpatient of such hospital) where the conditions specified in paragraph (7) of such section are met, (ii) services for which payment may be made pursuant to section 1395n(b)(2) of this title, (iii) services described by section 1395x(s)(2)(K)(i) of this title, certified nurse-midwife services, qualified psycholo- gist services, and services of a certified registered nurse anesthetist; 1 (iv) services of a nurse practitioner or clinical nurse specialist but only if no fa- cility or other provider charges or is paid any amounts with respect to the fur- nishing of such services; and 2 (C) outpatient physical therapy services (other than services to which the second sen- tence of section 1395x(p) of this title applies), outpatient occupational therapy services (other than services to which such sentence applies through the operation of section 1395x(g) of this title), and outpatient speech- language pathology services (other than services to which the second sentence of sec- tion 1395x(p) of this title applies through the application of section 1395x(ll)(2) of this title); (D)(i) rural health clinic services and (ii) Federally qualified health center services; (E) comprehensive outpatient rehabilita- tion facility services; (F) facility services furnished in connec- tion with surgical procedures specified by the Secretary— (i) pursuant to section 1395l(i)(1)(A) of this title and performed in an ambulatory surgical center (which meets health, safe- ty, and other standards specified by the Secretary in regulations) if the center has an agreement in effect with the Secretary by which the center agrees to accept the standard overhead amount determined under section 1395l(i)(2)(A) of this title as full payment for such services (including intraocular lens in cases described in sec- tion 1395l(i)(2)(A)(iii) of this title) and to accept an assignment described in section 1395u(b)(3)(B)(ii) of this title with respect to payment for all such services (including intraocular lens in cases described in sec- tion 1395l(i)(2)(A)(iii) of this title) fur- nished by the center to individuals en- rolled under this part, or (ii) pursuant to section 1395l(i)(1)(B) of this title and performed by a physician, described in paragraph (1), (2), or (3) of sec- tion 1395x(r) of this title, in his office, if the Secretary has determined that— (I) a quality improvement organization (having a contract with the Secretary under part B of subchapter XI of this chapter) is willing, able, and has agreed to carry out a review (on a sample or other reasonable basis) of the physician’s performing such procedures in the physi- cian’s office, (II) the particular physician involved has agreed to make available to such or- ganization such records as the Secretary determines to be necessary to carry out the review, and (III) the physician is authorized to per- form the procedure in a hospital located in the area in which the office is located, and if the physician agrees to accept the standard overhead amount determined under section 1395l(i)(2)(B) of this title as full payment for such services and to ac- cept payment on an assignment-related basis with respect to payment for all serv- ices (including all pre- and post-operative services) described in paragraphs (1) and (2)(A) of section 1395x(s) of this title and furnished in connection with such surgical procedure to individuals enrolled under this part; (G) covered items (described in section 1395m(a)(13) of this title) furnished by a pro- vider of services or by others under arrange-