§ 1395lll. Standardized post-acute care (PAC) as-
sessment data for quality, payment, and dis-
charge planning
(a) Requirement for standardized assessment
data
(1) In general
The Secretary shall—
(A) require under the applicable reporting
provisions post-acute care providers (as de-
fined in paragraph (2)(A)) to report—
(i) standardized patient assessment data
in accordance with subsection (b);
(ii) data on quality measures under sub-
section (c)(1); and
(iii) data on resource use and other
measures under subsection (d)(1);
(B) require data described in subparagraph
(A) to be standardized and interoperable so
as to allow for the exchange of such data
among such post-acute care providers and
other providers and the use by such pro-
viders of such data that has been so ex-
changed, including by using common stand-
ards and definitions, in order to provide ac-
cess to longitudinal information for such
providers to facilitate coordinated care and
improved Medicare beneficiary outcomes;
and
(C) in accordance with subsections (b)(1)
and (c)(2), modify PAC assessment instru-
ments (as defined in paragraph (2)(B)) appli-
cable to post-acute care providers to—
(i) provide for the submission of stand-
ardized patient assessment data under this
subchapter with respect to such providers;
and
(ii) enable comparison of such assess-
ment data across all such providers to
whom such data are applicable.
(2) Definitions
For purposes of this section:
(A) Post-acute care (PAC) provider
The terms ‘‘post-acute care provider’’ and
‘‘PAC provider’’ mean—
(i) a home health agency;
(ii) a skilled nursing facility;
(iii) an inpatient rehabilitation facility;
and
(iv) a long-term care hospital (other
than a hospital classified under section
1395ww(d)(1)(B)(vi) of
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Page 4003
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395lll
visions of, or amendments made by, section 3403 of Pub.
L. 111–148 (enacting this section and section 1395kkk–1
of this title and amending section 1395b–6 of this title
and section 207 of Title 18, Crimes and Criminal Proce-
dure) to the ‘‘Independent Medicare Advisory Board’’ be
deemed to be a reference to the ‘‘Independent Payment
Advisory Board’’, was repealed by Pub. L. 115–123, div.
E, title XI, § 52001(b)(4), Feb. 9, 2018, 132 Stat. 298.
CONSTRUCTION
Pub. L. 111–148, title X, § 10320(c), Mar. 23, 2010, 124
Stat. 952, which provided that nothing in the amend-
ments made by section 10320 of Pub. L. 111–148 pre-
cluded the Independent Medicare Advisory Board (re-
named the Independent Payment Advisory Board) from
solely using data from public or private sources to
carry out former subsection (f)(3)(B) of this section,
was repealed by Pub. L. 115–123, div. E, title XI,
§ 52001(b)(5), Feb. 9, 2018, 132 Stat. 298.
§ 1395kkk–1. Repealed. Pub. L. 115–123, div. E,
title XI, § 52001(b)(2), Feb. 9, 2018, 132 Stat.
298
Section, Pub. L. 111–148, title III, § 3403(b), Mar. 23,
2010, 124 Stat. 506, related to GAO study and report on
determination and implementation of payment and
coverage policies under the Medicare program.
§ 1395lll. Standardized post-acute care (PAC) as-
sessment data for quality, payment, and dis-
charge planning
(a) Requirement for standardized assessment
data
(1) In general
The Secretary shall—
(A) require under the applicable reporting
provisions post-acute care providers (as de-
fined in paragraph (2)(A)) to report—
(i) standardized patient assessment data
in accordance with subsection (b);
(ii) data on quality measures under sub-
section (c)(1); and
(iii) data on resource use and other
measures under subsection (d)(1);
(B) require data described in subparagraph
(A) to be standardized and interoperable so
as to allow for the exchange of such data
among such post-acute care providers and
other providers and the use by such pro-
viders of such data that has been so ex-
changed, including by using common stand-
ards and definitions, in order to provide ac-
cess to longitudinal information for such
providers to facilitate coordinated care and
improved Medicare beneficiary outcomes;
and
(C) in accordance with subsections (b)(1)
and (c)(2), modify PAC assessment instru-
ments (as defined in paragraph (2)(B)) appli-
cable to post-acute care providers to—
(i) provide for the submission of stand-
ardized patient assessment data under this
subchapter with respect to such providers;
and
(ii) enable comparison of such assess-
ment data across all such providers to
whom such data are applicable.
(2) Definitions
For purposes of this section:
(A) Post-acute care (PAC) provider
The terms ‘‘post-acute care provider’’ and
‘‘PAC provider’’ mean—
(i) a home health agency;
(ii) a skilled nursing facility;
(iii) an inpatient rehabilitation facility;
and
(iv) a long-term care hospital (other
than a hospital classified under section
1395ww(d)(1)(B)(vi) of this title).
(B) PAC assessment instrument
The term ‘‘PAC assessment instrument’’
means—
(i) in the case of home health agencies,
the instrument used for purposes of report-
ing and assessment with respect to the
Outcome and Assessment Information Set
(OASIS), as described in sections 484.55 and
484.250 of title 42, the Code of Federal Reg-
ulations, or any successor regulation, or
any other instrument used with respect to
home health agencies for such purposes;
(ii) in the case of skilled nursing facili-
ties, the resident’s assessment under sec-
tion 1395i–3(b)(3) of this title;
(iii) in the case of inpatient rehabilita-
tion facilities, any Medicare beneficiary
assessment instrument established by the
Secretary for purposes of section 1395ww(j)
of this title; and
(iv) in the case of long-term care hos-
pitals, the Medicare beneficiary assess-
ment instrument used with respect to such
hospitals for the collection of data ele-
ments
necessary
to
calculate
quality
measures as described in the August 18,
2011,
Federal
Register
(76
Fed.
Reg.
51754–51755), including for purposes of sec-
tion 1395ww(m)(5)(C) of this title, or any
other instrument used with respect to such
hospitals for assessment purposes.
(C) Applicable reporting provision
The term ‘‘applicable reporting provision’’
means—
(i) for home health agencies, section
1395fff(b)(3)(B)(v) of this title;
(ii) for skilled nursing facilities, section
1395yy(e)(6) of this title;
(iii) for inpatient rehabilitation facili-
ties, section 1395ww(j)(7) of this title; and
(iv) for long-term care hospitals, section
1395ww(m)(5) of this title.
(D) PAC payment system
The term ‘‘PAC payment system’’ means—
(i) with respect to a home health agency,
the prospective payment system under sec-
tion 1395fff of this title;
(ii) with respect to a skilled nursing fa-
cility, the prospective payment system
under section 1395yy(e) of this title;
(iii) with respect to an inpatient reha-
bilitation facility, the prospective pay-
ment system under section 1395ww(j) of
this title; and
(iv) with respect to a long-term care hos-
pital, the prospective payment system
under section 1395ww(m) of this title.
(E) Specified application date
The term ‘‘specified application date’’
means the following:
(i) Quality measures
In the case of quality measures under
subsection (c)(1)—
Page 4004
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395lll
(I) with respect to the domain de-
scribed in subsection (c)(1)(A) (relating
to functional status, cognitive function,
and changes in function and cognitive
function)—
(aa) for PAC providers described in
clauses (ii) and (iii) of paragraph (2)(A),
October 1, 2016;
(bb) for PAC providers described in
clause (iv) of such paragraph, October
1, 2018; and
(cc) for PAC providers described in
clause (i) of such paragraph, January 1,
2019;
(II) with respect to the domain de-
scribed in subsection (c)(1)(B) (relating
to skin integrity and changes in skin in-
tegrity)—
(aa) for PAC providers described in
clauses (ii), (iii), and (iv) of paragraph
(2)(A), October 1, 2016; and
(bb) for PAC providers described in
clause (i) of such paragraph, January 1,
2017;
(III) with respect to the domain de-
scribed in subsection (c)(1)(C) (relating
to medication reconciliation)—
(aa) for PAC providers described in
clause (i) of such paragraph, January 1,
2017; and
(bb) for PAC providers described in
clauses (ii), (iii), and (iv) of such para-
graph, October 1, 2018;
(IV) with respect to the domain de-
scribed in subsection (c)(1)(D) (relating
to incidence of major falls)—
(aa) for PAC providers described in
clauses (ii), (iii), and (iv) of paragraph
(2)(A), October 1, 2016; and
(bb) for PAC providers described in
clause (i) of such paragraph, January 1,
2019; and
(V) with respect to the domain de-
scribed in subsection (c)(1)(E) (relating
to accurately communicating the exist-
ence of and providing for the transfer of
health
information
and
care
pref-
erences)—
(aa) for PAC providers described in
clauses (ii), (iii), and (iv) of paragraph
(2)(A), October 1, 2018; and
(bb) for PAC providers described in
clause (i) of such paragraph, January 1,
2019.
(ii) Resource use and other measures
In the case of resource use and other
measures under subsection (d)(1)—
(I) for PAC providers described in
clauses (ii), (iii), and (iv) of paragraph
(2)(A), October 1, 2016; and
(II) for PAC providers described in
clause (i) of such paragraph, January 1,
2017.
(F) Medicare beneficiary
The term ‘‘Medicare beneficiary’’ means
an individual entitled to benefits under part
A or, as appropriate, enrolled for benefits
under part B.
(b) Standardized patient assessment data
(1) Requirement for reporting assessment data
(A) In general
Beginning not later than October 1, 2018,
for PAC providers described in clauses (ii),
(iii), and (iv) of subsection (a)(2)(A) and Jan-
uary 1, 2019, for PAC providers described in
clause (i) of such subsection, the Secretary
shall require PAC providers to submit to the
Secretary, under the applicable reporting
provisions and through the use of PAC as-
sessment instruments, the standardized pa-
tient assessment data described in subpara-
graph (B). The Secretary shall require such
data be submitted with respect to admission
and discharge of an individual (and may be
submitted more frequently as the Secretary
deems appropriate).
(B) Standardized patient assessment data de-
scribed
For purposes of subparagraph (A), the
standardized patient assessment data de-
scribed in this subparagraph is data required
for at least the quality measures described
in subsection (c)(1) and that is with respect
to the following categories:
(i) Functional status, such as mobility
and self care at admission to a PAC pro-
vider and before discharge from a PAC pro-
vider.
(ii) Cognitive function, such as ability to
express ideas and to understand, and men-
tal status, such as depression and demen-
tia.
(iii) Special services, treatments, and
interventions, such as need for ventilator
use, dialysis, chemotherapy, central line
placement, and total parenteral nutrition.
(iv)
Medical
conditions
and
co-
morbidities, such as diabetes, congestive
heart failure, and pressure ulcers.
(v) Impairments, such as incontinence
and an impaired ability to hear, see, or
swallow.
(vi) Other categories deemed necessary
and appropriate by the Secretary.
(2) Alignment of claims data with standardized
patient assessment data
To the extent practicable, not later than Oc-
tober 1, 2018, for PAC providers described in
clauses (ii), (iii), and (iv) of subsection
(a)(2)(A), and January 1, 2019, for PAC pro-
viders described in clause (i) of such sub-
section, the Secretary shall match claims data
with assessment data pursuant to this section
for purposes of assessing prior service use and
concurrent service use, such as antecedent
hospital or PAC provider use, and may use
such matched data for such other uses as the
Secretary determines appropriate.
(3) Replacement of certain existing data
In the case of patient assessment data being
used with respect to a PAC assessment instru-
ment that duplicates or overlaps with stand-
ardized patient assessment data within a cat-
egory described in paragraph (1), the Secretary
shall, as soon as practicable, revise or replace
such existing data with the standardized data.
Page 4005
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395lll
(4) Clarification
Standardized patient assessment data sub-
mitted pursuant to this subsection shall not
be used to require individuals to be provided
post-acute care by a specific type of PAC pro-
vider in order for such care to be eligible for
payment under this subchapter.
(c) Quality measures
(1) Requirement for reporting quality meas-
ures
Not later than the specified application
date, as applicable to measures and PAC pro-
viders, the Secretary shall specify quality
measures on which PAC providers are required
under the applicable reporting provisions to
submit standardized patient assessment data
described in subsection (b)(1) and other nec-
essary data specified by the Secretary. Such
measures shall be with respect to at least the
following domains:
(A) Functional status, cognitive function,
and changes in function and cognitive func-
tion.
(B) Skin integrity and changes in skin in-
tegrity.
(C) Medication reconciliation.
(D) Incidence of major falls.
(E) Accurately communicating the exist-
ence of and providing for the transfer of
health information and care preferences of
an individual to the individual, family care-
giver of the individual, and providers of serv-
ices furnishing items and services to the in-
dividual, when the individual transitions—
(i) from a hospital or critical access hos-
pital to another applicable setting, includ-
ing a PAC provider or the home of the in-
dividual; or
(ii) from a PAC provider to another ap-
plicable setting, including a different PAC
provider, a hospital, a critical access hos-
pital, or the home of the individual.
(2) Reporting through PAC assessment instru-
ments
(A) In general
To the extent possible, the Secretary shall
require such reporting by a PAC provider of
quality
measures
under
paragraph
(1)
through the use of a PAC assessment instru-
ment and shall modify such PAC assessment
instrument as necessary to enable the use of
such instrument with respect to such qual-
ity measures.
(B) Limitation
The Secretary may not make significant
modifications to a PAC assessment instru-
ment more than once per calendar year or
fiscal year, as applicable, unless the Sec-
retary publishes in the Federal Register a
justification for such significant modifica-
tion.
(3) Adjustments
(A) In general
The Secretary shall consider applying ad-
justments to the quality measures under
this subsection taking into consideration
the studies under section 2(d) of the IMPACT
Act of 2014.
(B) Risk adjustment
Such quality measures shall be risk ad-
justed, as determined appropriate by the
Secretary.
(d) Resource use and other measures
(1) Requirement for resource use and other
measures
Not later than the specified application
date, as applicable to measures and PAC pro-
viders, the Secretary shall specify resource
use and other measures on which PAC pro-
viders are required under the applicable re-
porting provisions to submit any necessary
data specified by the Secretary, which may in-
clude standardized assessment data in addi-
tion to claims data. Such measures shall be
with respect to at least the following domains:
(A) Resource use measures, including total
estimated
Medicare
spending
per
bene-
ficiary.
(B) Discharge to community.
(C) Measures to reflect all-condition risk-
adjusted potentially preventable hospital re-
admission rates.
(2) Aligning methodology adjustments for re-
source use measures
(A) Period of time
With respect to the period of time used for
calculating measures under paragraph (1)(A),
the Secretary shall, to the extent the Sec-
retary determines appropriate, align re-
source use with the methodology used for
purposes of section 1395ww(o)(2)(B)(ii) of this
title.
(B) Geographic and other adjustments
The Secretary shall standardize measures
with respect to the domain described in
paragraph (1)(A) for geographic payment
rate differences and payment differentials
(and other adjustments, as applicable) con-
sistent with the methodology published in
the Federal Register on August 18, 2011 (76
Fed. Reg. 51624 through 51626), or any subse-
quent modifications made to the method-
ology.
(C) Medicare spending per beneficiary
The Secretary shall adjust, as appropriate,
measures with respect to the domain de-
scribed in paragraph (1)(A) for the factors
applied under section 1395ww(o)(2)(B)(ii) of
this title.
(3) Adjustments
(A) In general
The Secretary shall consider applying ad-
justments to the resource use and other
measures specified under this subsection
with respect to the domain described in
paragraph (1)(A), taking into consideration
the studies under section 2(d) of the IMPACT
Act of 2014.
(B) Risk adjustment
Such resource use and other measures
shall be risk adjusted, as determined appro-
priate by the Secretary.
Page 4006
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395lll
(e) Measurement implementation phases; selec-
tion of quality measures and resource use
and other measures
(1) Measurement implementation phases
In the case of quality measures specified
under subsection (c)(1) and resource use and
other measures specified under subsection
(d)(1), the provisions of this section shall be
implemented in accordance with the following
phases:
(A) Initial implementation phase
The initial implementation phase, with re-
spect to such a measure, shall, in accordance
with subsections (c) and (d), as applicable,
consist of—
(i) measure specification, including in-
forming the public of the measure’s nu-
merator, denominator, exclusions, and any
other aspects the Secretary determines
necessary;
(ii) data collection, including, in the case
of quality measures, requiring PAC pro-
viders to report data elements needed to
calculate such a measure; and
(iii) data analysis, including, in the case
of resource use and other measures, the
use of claims data to calculate such a
measure.
(B) Second implementation phase
The second implementation phase, with re-
spect to such a measure, shall consist of the
provision of feedback reports to PAC pro-
viders, in accordance with subsection (f).
(C) Third implementation phase
The third implementation phase, with re-
spect to such a measure, shall consist of pub-
lic reporting of PAC providers’ performance
on such measure in accordance with sub-
section (g).
(2) Consensus-based entity
(A) In general
Subject to subparagraph (B), each measure
specified by the Secretary under this section
shall be endorsed by the entity with a con-
tract under section 1395aaa(a) of this title.
(B) Exception
In the case of a specified area or medical
topic determined appropriate by the Sec-
retary for which a feasible and practical
measure has not been endorsed by the entity
with a contract under section 1395aaa(a) of
this title, the Secretary may specify a meas-
ure that is not so endorsed as long as due
consideration is given to measures that have
been endorsed or adopted by a consensus or-
ganization identified by the Secretary.
(3) Treatment of application of pre-rulemaking
process (measure applications partnership
process)
(A) In general
Subject to subparagraph (B), the provi-
sions of section 1395aaa–1 of this title shall
apply in the case of a quality measure speci-
fied under subsection (c) or a resource use or
other measure specified under subsection (d).
(B) Exceptions
(i) Expedited procedures
For purposes of satisfying subparagraph
(A), the Secretary may use expedited pro-
cedures, such as ad-hoc reviews, as nec-
essary, in the case of a quality measure
specified under subsection (c) or a resource
use or other measure specified in sub-
section (d) required with respect to data
submissions under the applicable reporting
provisions during the 1-year period before
the specified application date applicable to
such a measure and provider involved.
(ii) Option to waive provisions
The Secretary may waive the applica-
tion of the provisions of section 1395aaa–1
of this title in the case of a quality meas-
ure or resource use or other measure de-
scribed in clause (i), if the application of
such provisions (including through the use
of an expedited procedure described in
such clause) would result in the inability
of the Secretary to satisfy any deadline
specified in this section with respect to
such measure.
(f) Feedback reports to PAC providers
(1) In general
Beginning one year after the specified appli-
cation date, as applicable to PAC providers
and quality measures and resource use and
other measures under this section, the Sec-
retary shall provide confidential feedback re-
ports to such PAC providers on the perform-
ance of such providers with respect to such
measures required under the applicable provi-
sions.
(2) Frequency
To the extent feasible, the Secretary shall
provide feedback reports described in para-
graph (1) not less frequently than on a quar-
terly basis. Notwithstanding the previous sen-
tence, with respect to measures described in
such paragraph that are reported on an annual
basis, the Secretary may provide such feed-
back reports on an annual basis.
(g) Public reporting of PAC provider perform-
ance
(1) In general
Subject to the succeeding paragraphs of this
subsection, the Secretary shall provide for
public reporting of PAC provider performance
on quality measures under subsection (c)(1)
and the resource use and other measures under
subsection (d)(1), including by establishing
procedures for making available to the public
information regarding the performance of in-
dividual PAC providers with respect to such
measures.
(2) Opportunity to review
The procedures under paragraph (1) shall en-
sure, including through a process consistent
with
the
process
applied
under
section
1395ww(b)(3)(B)(viii)(VII) of this title for simi-
lar purposes, that a PAC provider has the op-
portunity to review and submit corrections to
the data and information that is to be made
Page 4007
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395lll
public with respect to the provider prior to
such data being made public.
(3) Timing
Such procedures shall provide that the data
and information described in paragraph (1),
with respect to a measure and PAC provider, is
made publicly available beginning not later
than two years after the specified application
date applicable to such a measure and pro-
vider.
(4) Coordination with existing programs
Such procedures shall provide that data and
information described in paragraph (1) with re-
spect to quality measures and resource use
and other measures under subsections (c)(1)
and (d)(1) shall be made publicly available con-
sistent with the following provisions:
(A) In the case of home health agencies,
section 1395fff(b)(3)(B)(v)(III) of this title.
(B) In the case of skilled nursing facilities,
sections 1395i–3(i) and 1396r(i) of this title.
(C) In the case of inpatient rehabilitation
facilities, section 1395ww(j)(7)(E) of this
title.
(D) In the case of long-term care hospitals,
section 1395ww(m)(5)(E) of this title.
(h) Removing, suspending, or adding measures
(1) In general
The Secretary may remove, suspend, or add
a quality measure or resource use or other
measure described in subsection (c)(1) or (d)(1),
so long as, subject to paragraph (2), the Sec-
retary publishes in the Federal Register (with
a notice and comment period) a justification
for such removal, suspension, or addition.
(2) Exception
In the case of such a quality measure or re-
source use or other measure for which there is
a reason to believe that the continued collec-
tion of such measure raises potential safety
concerns or would cause other unintended con-
sequences, the Secretary may promptly sus-
pend or remove such measure and satisfy para-
graph (1) by publishing in the Federal Register
a justification for such suspension or removal
in the next rulemaking cycle following such
suspension or removal.
(i) Use of standardized assessment data, quality
measures, and resource use and other meas-
ures to inform discharge planning and incor-
porate patient preference
(1) In general
Not later than January 1, 2016, and periodi-
cally thereafter (but not less frequently than
once every 5 years), the Secretary shall pro-
mulgate regulations to modify conditions of
participation
and
subsequent
interpretive
guidance applicable to PAC providers, hos-
pitals, and critical access hospitals. Such reg-
ulations and interpretive guidance shall re-
quire such providers to take into account
quality, resource use, and other measures
under the applicable reporting provisions
(which, as available, shall include measures
specified under subsections (c) and (d), and
other relevant measures) in the discharge
planning process. Specifically, such regula-
tions and interpretive guidance shall address
the settings to which a patient may be dis-
charged in order to assist subsection (d) hos-
pitals, critical access hospitals, hospitals de-
scribed in section 1395ww(d)(1)(B)(v) of this
title, PAC providers, patients, and families of
such patients with discharge planning from in-
patient settings, including such hospitals, and
from PAC provider settings. In addition, such
regulations and interpretive guidance shall in-
clude procedures to address—
(A) treatment preferences of patients; and
(B) goals of care of patients.
(2) Discharge planning
All requirements applied pursuant to para-
graph (1) shall be used to help inform and
mandate the discharge planning process.
(3) Clarification
Such regulations shall not require an indi-
vidual to be provided post-acute care by a spe-
cific type of PAC provider in order for such
care to be eligible for payment under this sub-
chapter.
(j) Stakeholder input
Before the initial rulemaking process to im-
plement this section, the Secretary shall allow
for stakeholder input, such as through town
halls, open door forums, and mail-box submis-
sions.
(k) Funding
For purposes of carrying out this section, the
Secretary shall provide for the transfer to the
Centers for Medicare & Medicaid Services Pro-
gram Management Account, from the Federal
Hospital Insurance Trust Fund under section
1395i of this title and the Federal Supple-
mentary Medical Insurance Trust Fund under
section 1395t of this title, in such proportion as
the
Secretary
determines
appropriate,
of
$130,000,000. Fifty percent of such amount shall
be available on October 6, 2014, and fifty percent
of such amount shall be equally proportioned for
each of fiscal years 2015 through 2019. Such sums
shall remain available until expended.
(l) Limitation
There shall be no administrative or judicial
review under sections 1395ff and 1395oo of this
title or otherwise of the specification of stand-
ardized patient assessment data required, the
determination of measures, and the systems to
report such standardized data under this sec-
tion.
(m) Non-application of Paperwork Reduction Act
Chapter 35 of title 44 (commonly referred to as
the ‘‘Paperwork Reduction Act of 1995’’) shall
not apply to this section and the sections ref-
erenced in subsection (a)(2)(B) that require
modification in order to achieve the standard-
ization of patient assessment data.
(Aug. 14, 1935, ch. 531, title XVIII, § 1899B, as
added Pub. L. 113–185, § 2(a), Oct. 6, 2014, 128 Stat.
1952; amended Pub. L. 114–255, div. C, title XV,
§ 15008(d)(1), Dec. 13, 2016, 130 Stat. 1321.)
Page 4008
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1395lll
Editorial Notes
REFERENCES IN TEXT
Section 2(d) of the IMPACT Act of 2014, referred to in
subsecs. (c)(3)(A) and (d)(3)(A), is section 2(d) of Pub. L.
113–185, which is set out as a note under this section.
AMENDMENTS
2016—Subsec. (a)(2)(A)(iv). Pub. L. 114–255 substituted
‘‘1395ww(d)(1)(B)(vi)’’ for ‘‘1395ww(d)(1)(B)(iv)(II)’’.
Statutory Notes and Related Subsidiaries
PERMITTING
OCCUPATIONAL
THERAPISTS
TO
CONDUCT
THE INITIAL ASSESSMENT VISIT
AND COMPLETE
THE
COMPREHENSIVE ASSESSMENT WITH RESPECT TO CER-
TAIN
REHABILITATION
SERVICES
FOR
HOME
HEALTH
AGENCIES UNDER THE MEDICARE PROGRAM
Pub. L. 116–260, div. CC, title I, § 115, Dec. 27, 2020, 134
Stat. 2948, provided that: ‘‘Not later than January 1,
2022, the Secretary of Health and Human Services shall
revise subsections (a)(2) and (b)(3) of section 484.55 of
title 42, Code of Federal Regulations, or a successor
regulation, to permit an occupational therapist to con-
duct the initial assessment visit and to complete the
comprehensive assessment (as such terms are described
in such subsections, respectively) for home health serv-
ices for an individual under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) if the home health
plan of care for such individual—
‘‘(1) does not initially include skilled nursing care;
‘‘(2) includes occupational therapy; and
‘‘(3) includes physical therapy or speech language
pathology.’’
IMPROVING PAYMENT ACCURACY UNDER THE PAC PAY-
MENT SYSTEMS AND OTHER MEDICARE PAYMENT SYS-
TEMS
Pub. L. 113–185, § 2(d), Oct. 6, 2014, 128 Stat. 1966, pro-
vided that:
‘‘(1) STUDIES AND REPORTS OF EFFECT OF CERTAIN IN-
FORMATION ON QUALITY AND RESOURCE USE.—
‘‘(A) STUDY USING EXISTING MEDICARE DATA.—
‘‘(i) STUDY.—The Secretary of Health and Human
Services (in this subsection referred to as the ‘Sec-
retary’) shall conduct a study that examines the ef-
fect of individuals’ socioeconomic status on quality
measures and resource use and other measures for
individuals under the Medicare program under title
XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) (such as to recognize that less healthy individ-
uals may require more intensive interventions).
The study shall use information collected on such
individuals in carrying out such program, such as
urban and rural location, eligibility for Medicaid
under title XIX of such Act (42 U.S.C. 1396 et seq.)
(recognizing and accounting for varying Medicaid
eligibility across States), and eligibility for bene-
fits under the supplemental security income (SSI)
program. The Secretary shall carry out this para-
graph acting through the Assistant Secretary for
Planning and Evaluation.
‘‘(ii) REPORT.—Not later than 2 years after the
date of the enactment of this Act [Oct. 6, 2014], the
Secretary shall submit to Congress a report on the
study conducted under clause (i).
‘‘(B) STUDY USING OTHER DATA.—
‘‘(i) STUDY.—The Secretary shall conduct a study
that examines the impact of risk factors, such as
those described in section 1848(p)(3) of the Social
Security Act (42 U.S.C. 1395w–4(p)(3)), race, health
literacy, limited English proficiency (LEP), and
Medicare beneficiary activation, on quality meas-
ures and resource use and other measures under the
Medicare program (such as to recognize that less
healthy individuals may require more intensive
interventions). In conducting such study the Sec-
retary may use existing Federal data and collect
such additional data as may be necessary to com-
plete the study.
‘‘(ii) REPORT.—Not later than 5 years after the
date of the enactment of this Act, the Secretary
shall submit to Congress a report on the study con-
ducted under clause (i).
‘‘(C) EXAMINATION OF DATA IN CONDUCTING STUDIES.—
In conducting the studies under subparagraphs (A)
and (B), the Secretary shall examine what non-Medi-
care data sets, such as data from the American Com-
munity Survey (ACS), can be useful in conducting the
types of studies under such paragraphs and how such
data sets that are identified as useful can be coordi-
nated with Medicare administrative data in order to
improve the overall data set available to do such
studies and for the administration of the Medicare
program.
‘‘(D) RECOMMENDATIONS TO ACCOUNT FOR INFORMA-
TION
IN
PAYMENT
ADJUSTMENT
MECHANISMS.—If the
studies conducted under subparagraphs (A) and (B)
find a relationship between the factors examined in
the studies and quality measures and resource use
and other measures, then the Secretary shall also
provide recommendations for how the Centers for
Medicare & Medicaid Services should—
‘‘(i) obtain access to the necessary data (if such
data is not already being collected) on such factors,
including recommendations on how to address bar-
riers to the Centers in accessing such data; and
‘‘(ii) account for such factors—
‘‘(I) in quality measures, resource use measures,
and other measures under title XVIII of the So-
cial Security Act (including such measures speci-
fied under subsections (c) and (d) of section 1899B
of such Act [42 U.S.C. 1395lll], as added by sub-
section (a)); and
‘‘(II) in determining payment adjustments
based on such measures in other applicable provi-
sions of such title.
‘‘(E) FUNDING.—There are hereby appropriated to
the Secretary from the Federal Hospital Insurance
Trust Fund under section 1817 of the Social Security
Act (42 U.S.C. 1395i) and the Federal Supplementary
Medical Insurance Trust Fund under section 1841 of
such Act (42 U.S.C. 1395t) (in proportions determined
appropriate by the Secretary) to carry out this para-
graph $6,000,000, to remain available until expended.
‘‘(2) CMS ACTIVITIES.—
‘‘(A) IN GENERAL.—Taking into account the relevant
studies conducted and recommendations made in re-
ports under paragraph (1) and, as appropriate, other
information, including information collected before
completion of such studies and recommendations, the
Secretary, on an ongoing basis, shall, as the Sec-
retary determines appropriate and based on an indi-
vidual’s health status and other factors—
‘‘(i) assess appropriate adjustments to quality
measures, resource use measures, and other meas-
ures under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) (including measures specified in
subsections (c) and (d) of section 1899B of such Act,
as added by subsection (a)); and
‘‘(ii) assess and implement appropriate adjust-
ments to payments under such title based on meas-
ures described in clause (i).
‘‘(B) ACCESSING DATA.—The Secretary shall collect
or otherwise obtain access to the data necessary to
carry out this paragraph through existing and new
data sources.
‘‘(C) PERIODIC ANALYSES.—The Secretary shall carry
out periodic analyses, at least every 3 years, based on
the factors referred to in subparagraph (A) so as to
monitor changes in possible relationships.
‘‘(D) FUNDING.—There are hereby appropriated to
the Secretary from the Federal Hospital Insurance
Trust Fund under section 1817 of the Social Security
Act (42 U.S.C. 1395i) and the Federal Supplementary
Medical Insurance Trust Fund under section 1841 of
such Act (42 U.S.C. 1395t) (in proportions determined
appropriate by the Secretary) to carry out this para-
graph $10,000,000, to remain available until expended.
‘‘(3) STRATEGIC PLAN FOR ACCESSING RACE AND ETH-
NICITY DATA.—Not later than 18 months after the date
Page 4009
TITLE 42—THE PUBLIC HEALTH AND WELFARE
§ 1396
of the enactment of this Act [Oct. 6, 2014], the Sec-
retary shall develop and report to Congress on a stra-
tegic plan for collecting or otherwise accessing data on
race and ethnicity for purposes of specifying quality
measures and resource use and other measures under
subsections (c) and (d) of section 1899B of the Social Se-
curity Act, as added by subsection (a), and, as the Sec-
retary determines appropriate, other similar provisions
of, including payment adjustments under, title XVIII of
such Act (42 U.S.C. 1395 et seq.).’’
SUBCHAPTER XIX—GRANTS TO STATES
FOR MEDICAL ASSISTANCE PROGRAMS
§ 1396. Medicaid and CHIP Payment and Access
Commission
(a) Establishment
There is hereby established the Medicaid and
CHIP Payment and Access Commission (in this
section referred to as ‘‘MACPAC’’).
(b) Duties
(1) Review of access policies for all States and
annual reports
MACPAC shall—
(A) review policies of the Medicaid pro-
gram established under this subchapter (in
this section referred to as ‘‘Medicaid’’) and
the State Children’s Health Insurance Pro-
gram established under subchapter XXI (in
this section referred to as ‘‘CHIP’’) affecting
access to covered items and services, includ-
ing topics described in paragraph (2);
(B) make recommendations to Congress,
the Secretary, and States concerning such
access policies;
(C) by not later than March 15 of each year
(beginning with 2010), submit a report to
Congress containing the results of such re-
views and MACPAC’s recommendations con-
cerning such policies; and
(D) by not later than June 15 of each year
(beginning with 2010), submit a report to
Congress
containing
an
examination
of
issues affecting Medicaid and CHIP, includ-
ing the implications of changes in health
care delivery in the United States and in the
market for health care services on such pro-
grams.
(2) Specific topics to be reviewed
Specifically, MACPAC shall review and as-
sess the following:
(A) Medicaid and CHIP payment policies
Payment policies under Medicaid and
CHIP, including—
(i) the factors affecting expenditures for
the efficient provision of items and serv-
ices in different sectors, including the
process for updating payments to medical,
dental, and health professionals, hospitals,
residential and long-term care providers,
providers of home and community based
services, Federally-qualified health cen-
ters and rural health clinics, managed care
entities, and providers of other covered
items and services;
(ii) payment methodologies; and
(iii) the relationship of such factors and
methodologies to access and quality of
care for Medicaid and CHIP beneficiaries
(including how such factors and meth-
odologies enable such beneficiaries to ob-
tain the services for which they are eligi-
ble, affect provider supply, and affect pro-
viders that serve a disproportionate share
of low-income and other vulnerable popu-
lations).
(B) Eligibility policies
Medicaid and CHIP eligibility policies, in-
cluding a determination of the degree to
which Federal and State policies provide
health care coverage to needy populations.
(C) Enrollment and retention processes
Medicaid and CHIP enrollment and reten-
tion processes, including a determination of
the degree to which Federal and State poli-
cies encourage the enrollment of individuals
who are eligible for such programs and
screen out individuals who are ineligible,
while minimizing the share of program ex-
penses devoted to such processes.
(D) Coverage policies
Medicaid and CHIP benefit and coverage
policies, including a determination of the de-
gree to which Federal and State policies pro-
vide access to the services enrollees require
to improve and maintain their health and
functional status.
(E) Quality of care
Medicaid and CHIP policies as they relate
to the quality of care provided under those
programs, including a determination of the
degree to which Federal and State policies
achieve their stated goals and interact with
similar goals established by other pur-
chasers of health care services.
(F) Interaction of Medicaid and CHIP pay-
ment policies with health care delivery
generally
The effect of Medicaid and CHIP payment
policies on access to items and services for
children and other Medicaid and CHIP popu-
lations other than under this subchapter or
subchapter XXI and the implications of
changes in health care delivery in the
United States and in the general market for
health care items and services on Medicaid
and CHIP.
(G) Interactions with Medicare and Medicaid
Consistent with paragraph (11), the inter-
action of policies under Medicaid and the
Medicare program under subchapter XVIII,
including with respect to how such inter-
actions affect access to services, payments,
and dual eligible individuals.
(H) Other access policies
The effect of other Medicaid and CHIP
policies on access to covered items and serv-
ices, including policies relating to transpor-
tation and language barriers and preventive,
acute, and long-term services and supports.
(3) Recommendations and reports of State-spe-
cific data
MACPAC shall—
(A) review national and State-specific
Medicaid and CHIP data; and
Cross-references
Connections may be documented source relationships, shared citations or nearby passages. Each explains its basis; a connection alone does not establish applicability to your situation.
Federal law — U.S. Code and appendices · legal_authorities
**(a) Conditions of participation; protection of individual rights; notification of State entities; use of home health aides; medical equipment; individual’s plan of care; compliance with Federal, State, and local laws and regulations** The conditions of participation that a home health agency is required to meet under this subsection are as follows:
(1) The agency protects and promotes the rights of each individual under its care, including each of the following rights:
(A) The right to be fully informed in advance about the care and treatment to be provided by the agency, to be fully informed in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and treatment or changes in care or treatment.
(B) The right to voice grievances with respect to treatment or care that is (or fails to be) furnished without discrimination or reprisal for voicing grievances.
(C) The right to confidentiality of the clinical records described in section 1395x(o)(3) of this title.
(D) The right to have one’s property treated with respect.
(E) The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of—
(i) all items and services furnished by (or under arrangements with) the agency for which payment may be made under this subchapter,
(ii) the coverage available for such items and services under this subchapter, subchapter XIX, and any other Federal program of which the agency is reasonably aware,
(iii) any charges for items and services not covered under this subchapter and any charges the individual may have to pay with respect to items and services furn
Stored review status: release_metadata_unconfirmed. The source passage cites 42 U.S.C. § 1395. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
§ 1395. Prohibition against any Federal inter-
ference
Nothing in this subchapter shall be construed
to authorize any Federal officer or employee to
exercise any supervision or control over the
practice of medicine or the manner in which
medical services are provided, or over the selec-
tion, tenure, or compensation of any officer or
employee of any institution, agency, or person
providing health services; or to exercise any su-
pervision or control over the administration or
operation of any such institution, agency, or
person.
(Aug. 14, 1935, ch. 531, title XVIII, § 1801, as added
Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79
Stat. 291.)
Statutory Notes and Related Subsidiaries
SHORT TITLE
For short title of title I of Pub. L. 89–97, which en-
acted this subchapter as the ‘‘Health Insurance for the
Aged Act’’, see section 100 of Pub. L. 89–97, set out as
a Short Title of 1965 Amendment note under section
1305 of this title.
PROTECTING AND IMPROVING GUARANTEED MEDICARE
BENEFITS
Pub. L. 111–148, title III, § 3601, Mar. 23, 2010, 124 Stat.
538, provided that:
‘‘(a) PROTECTING GUARANTEED MEDICARE BENEFITS.—
Nothing in the provisions of, or amendments made by,
this Act [see Short Title note set out under section
18001 of this title] shall result in a reduction of guaran-
teed benefits under title XVIII of the Social Security
Act [42 U.S.C. 1395 et seq.].
‘‘(b) ENSURING THAT MEDICARE SAVINGS BENEFIT THE
MEDICARE
PROGRAM
AND
MEDICARE
BENEFICIARIES.—
Savings generated for the Medicare program under title
XVIII of the Social Security Act under the provisions
of, and amendments made by, this Act shall extend the
solvency of the Medicare trust funds, reduce Medicare
premiums and other cost-sharing for beneficiaries, and
improve or expand gu
Stored review status: historical_2024_not_currentness_verified. The source passage cites 42 U.S.C. § 1395. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
**(a) Grants** The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall make grants to States, with approved State regulatory programs under [section 1395ss of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss&num=0&edition=prelim), that submit applications to the Secretary that meet the requirements of this section for the purpose of providing information, counseling, and assistance relating to the procurement of adequate and appropriate health insurance coverage to individuals who are eligible to receive benefits under this subchapter (in this section referred to as “eligible individuals”). The Secretary shall prescribe regulations to establish a minimum level of funding for a grant issued under this section.
**(b) Grant applications**
(1) In submitting an application under this section, a State may consolidate and coordinate an application that consists of parts prepared by more than one agency or department of such State.
(2) As part of an application for a grant under this section, a State shall submit a plan for a State-wide health insurance information, counseling, and assistance program. Such program shall—
(A) establish or improve upon a health insurance information, counseling, and assistance program that provides counseling and assistance to eligible individuals in need of health insurance information, including—
(i) information that may assist individuals in obtaining benefits and filing claims under this subchapter and subchapter XIX of this chapter;
(ii) policy comparison information for medicare supplemental policies (as described in [section 1395ss(g)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ss/g/1
Stored review status: release_metadata_unconfirmed. The source passage cites 42 U.S.C. § 1395i. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
§ 1395i. Federal Hospital Insurance Trust Fund
(a) Creation; deposits; transfers from Treasury
There is hereby created on the books of the
Treasury of the United States a trust fund to be
known as the ‘‘Federal Hospital Insurance Trust
Fund’’ (hereinafter in this section referred to as
the ‘‘Trust Fund’’). The Trust Fund shall consist
of such gifts and bequests as may be made as
provided in section 401(i)(1) of this title, and
such amounts as may be deposited in, or appro-
priated to, such fund as provided in this part.
There are hereby appropriated to the Trust
Fund for the fiscal year ending June 30, 1966, and
for each fiscal year thereafter, out of any mon-
eys in the Treasury not otherwise appropriated,
amounts equivalent to 100 per centum of—
(1) the taxes imposed by sections 3101(b) and
3111(b) of the Internal Revenue Code of 1986
with respect to wages reported to the Sec-
retary of the Treasury or his delegate pursu-
ant to subtitle F of such Code after December
31, 1965, as determined by the Secretary of the
Treasury by applying the applicable rates of
tax under such sections to such wages, which
wages shall be certified by the Commissioner
of Social Security on the basis of records of
wages established and maintained by the Com-
missioner of Social Security in accordance
with such reports; and
(2) the taxes imposed by section 1401(b) of
the Internal Revenue Code of 1986 with respect
to self-employment income reported to the
Secretary of the Treasury or his delegate on
tax returns under subtitle F of such Code, as
determined by the Secretary of the Treasury
by applying the applicable rate of tax under
such section to such self-employment income,
which self-employment income shall be cer-
tified by the Commissioner of Social Securi
Stored review status: historical_2024_not_currentness_verified. The source passage cites 42 U.S.C. § 1395i. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
**(a) Contract**
(1) **In general** — For purposes of activities conducted under this chapter, the Secretary shall identify and have in effect a contract with a consensus-based entity, such as the National Quality Forum, that meets the requirements described in subsection (c). Such contract shall provide that the entity will perform the duties described in subsection (b).
(2) **Timing for first contract** — As soon as practicable after July 15, 2008, the Secretary shall enter into the first contract under paragraph (1).
(3) **Period of contract** — A contract under paragraph (1) shall be for a period of 4 years (except as may be renewed after a subsequent bidding process).
(4) **Competitive procedures** — Competitive procedures (as defined in [section 132 of title 41](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title41-section132&num=0&edition=prelim)) shall be used to enter into a contract under paragraph (1).
**(b) Duties** The duties described in this subsection are the following:
(1) **Priority setting process** — The entity shall synthesize evidence and convene key stakeholders to make recommendations, with respect to activities conducted under this chapter, on an integrated national strategy and priorities for health care performance measurement in all applicable settings. In making such recommendations, the entity shall—
(A) ensure that priority is given to measures—
(i) that address the health care provided to patients with prevalent, high-cost chronic diseases;
(ii) with the greatest potential for improving the quality, efficiency, and patient-centeredness of health care; and
(iii) that may be implemented rapidly due to existing evidence, standards of care, or other reasons; and
(B) take into account measures that—
**(a) In general** Subject to subsections (c) and (d), payment under this part may be made for inpatient hospital services or post-hospital extended care services furnished an individual in a religious nonmedical health care institution and for home health services furnished an individual by a religious nonmedical health care institution only if—
(1) the individual has an election in effect for such benefits under subsection (b); and
(2) the individual has a condition such that the individual would qualify for benefits under this part for inpatient hospital services, extended care services, or home health services, respectively, if the individual were an inpatient or resident in a hospital or skilled nursing facility, or receiving services from a home health agency, that was not such an institution.
**(b) Election**
(1) **In general** — An individual may make an election under this subsection in a form and manner specified by the Secretary consistent with this subsection. Unless otherwise provided, such an election shall take effect immediately upon its execution. Such an election, once made, shall continue in effect until revoked.
(2) **Form** — The election form under this subsection shall include the following:
(A) A written statement, signed by the individual (or such individual’s legal representative), that—
(i) the individual is conscientiously opposed to acceptance of nonexcepted medical treatment; and
(ii) the individual’s acceptance of nonexcepted medical treatment would be inconsistent with the individual’s sincere religious beliefs.
(B) A statement that the receipt of nonexcepted medical services shall constitute a revocation of the election and may limit further receipt of services described in subsection (a).
(3) **Revocation** — An el
Stored review status: release_metadata_unconfirmed. The source passage cites 42 U.S.C. § 1395t. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
§ 1395t. Federal Supplementary Medical Insur-
ance Trust Fund
(a) Creation; deposits; fund transfers
There is hereby created on the books of the
Treasury of the United States a trust fund to be
known as the ‘‘Federal Supplementary Medical
Insurance Trust Fund’’ (hereinafter in this sec-
tion referred to as the ‘‘Trust Fund’’). The Trust
Fund shall consist of such gifts and bequests as
may be made as provided in section 401(i)(1) of
this title, such amounts as may be deposited in,
or appropriated to, such fund as provided in this
part or section 9008(c) 1 of the Patient Protection
and Affordable Care Act of 2009, and such
amounts as may be deposited in, or appropriated
to, the Medicare Prescription Drug Account es-
tablished by section 1395w–116 of this title or the
Transitional Assistance Account established by
section 1395w–141(k)(1) of this title.
(b) Board of Trustees; composition; meetings; du-
ties
With respect to the Trust Fund, there is here-
by created a body to be known as the Board of
Trustees of the Trust Fund (hereinafter in this
section referred to as the ‘‘Board of Trustees’’)
composed of the Commissioner of Social Secu-
rity, the Secretary of the Treasury, the Sec-
retary of Labor, and the Secretary of Health and
Human Services, all ex officio, and of two mem-
bers of the public (both of whom may not be
from the same political party), who shall be
nominated by the President for a term of four
years and subject to confirmation by the Sen-
ate. A member of the Board of Trustees serving
as a member of the public and nominated and
confirmed to fill a vacancy occurring during a
term shall be nominated and confirmed only for
the remainder of such term. An individual nomi-
nated and confirmed as a member of the public
may serve in s
Stored review status: historical_2024_not_currentness_verified. The source passage cites 42 U.S.C. § 1395t. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
**(a) Amounts** Except as provided in [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim), and subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are payable under this part, amounts equal to—
(1) in the case of services described in [section 1395k(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395k/a/1&num=0&edition=prelim)—80 percent of the reasonable charges for the services; except that (A) an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis (and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services) may elect to be paid 80 percent of the reasonable cost of services for which payment may be made under this part on behalf of individuals enrolled in such organization in lieu of 80 percent of the reasonable charges for such services if the organization undertakes to charge such individuals no more than 20 percent of such reasonable cost plus any amounts payable by them as a result of subsection (b), (B) with respect to items and services described in [section 1395x(s)(10)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s/10/A&num=0&edition=prelim), the amounts paid shall be 100 percent of the reasonable charges for such items and services, (C) with respect to expenses incurred for those physicians
Stored review status: release_metadata_unconfirmed. The source passage cites 42 U.S.C. § 1395w. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
§ 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 repr
Stored review status: historical_2024_not_currentness_verified. The source passage cites 42 U.S.C. § 1395w. This identifies an authority to review, not proof of applicability.
Federal law — U.S. Code and appendices · legal_authorities
**(a) Establishment** There is hereby established the Medicaid and CHIP Payment and Access Commission (in this section referred to as “MACPAC”).
**(b) Duties**
(1) **Review of access policies for all States and annual reports** — MACPAC shall—
(A) review policies of the Medicaid program established under this subchapter (in this section referred to as “Medicaid”) and the State Children’s Health Insurance Program established under subchapter XXI (in this section referred to as “CHIP”) affecting access to covered items and services, including topics described in paragraph (2);
(B) make recommendations to Congress, the Secretary, and States concerning such access policies;
(C) by not later than March 15 of each year (beginning with 2010), submit a report to Congress containing the results of such reviews and MACPAC’s recommendations concerning such policies; and
(D) by not later than June 15 of each year (beginning with 2010), submit a report to Congress containing an examination of issues affecting Medicaid and CHIP, including the implications of changes in health care delivery in the United States and in the market for health care services on such programs.
(2) **Specific topics to be reviewed** — Specifically, MACPAC shall review and assess the following:
(A) *Medicaid and CHIP payment policies* — Payment policies under Medicaid and CHIP, including—
(i) the factors affecting expenditures for the efficient provision of items and services in different sectors, including the process for updating payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics, managed care entities, and providers of ot
Stored review status: release_metadata_unconfirmed. The source passage cites 42 U.S.C. § 1396. This identifies an authority to review, not proof of applicability.