42 U.S.C. § 1395d — Scope of benefits

Page 2931 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395d such services entered into an agreement under sec- tion 1866 of the Social Security Act [42 U.S.C. 1395cc] and (ii) the hospital’s plan for utilization re- view, as provided for in section 1861(k) of such Act [42 U.S.C. 1395x(k)], has, in accordance with section 1814 of such Act [42 U.S.C. 1395f], been applied to the services furnished such individual, or ‘‘(B) 20 days in any spell of illness, if the hospital did not meet the conditions of clauses (i) and (ii) of subparagraph (A). ‘‘(c)(1) The amounts payable in accordance with sub- section (a) with respect to inpatient hospital services shall, subject to paragraph (2) of this subsection, be paid from the Federal Hospital Insurance Trust Fund in amounts equal to 60 percent of the hospital’s reason- able charges for routine services furnished in the ac- commodations occupied by the individual or in semi- private accommodations (as defined in section 1861(v)(4) of the Social Security Act [42 U.S.C. 1395x(v)(4)]) which- ever is less, plus 80 percent of the hospital’s reasonable charges for ancillary services. If separate charges for routine and ancillary services are not made by the hos- pital, reimbursement may be based on two-thirds of the hospital’s reasonable charges for the services received but not to exceed the charges which would have been made if the patient had occupied semi-private accom- modations (as so defined). For purposes of the pre- ceding provisions of this paragraph, the term ‘routine services’ shall mean the regular room, dietary, and nursing services, minor medical and surgical supplies and the use of equipment and facilities for which a sep- arate charge is not customarily made; the term ‘ancil- lary services’ shall mean those special services for which charges are customarily made in addition to rou- tine services. ‘‘(2) Before applying paragraph (1), payments made under this section shall be reduced to the extent pro- vided for under section 1813 of the Social Security Act [42 U.S.C. 1395e] in the case of benefits payable to pro- viders of services under part A of title XVIII of such Act [42 U.S.C. 1395c et seq.]. ‘‘(d) For the purposes of this section— ‘‘(1) the 90-day period, referred to in subsection (b)(3)(A), shall be reduced by the number of days of inpatient hospital services furnished to such indi- vidual during the spell of illness, referred to therein, and with respect to which he was entitled to have payment made under part A of title XVIII of the So- cial Security Act [42 U.S.C. 1395c et seq.]; ‘‘(2) the 20-day period, referred to in subsection (b)(3)(B) shall be reduced by the number of days in ex- cess of 70 days of inpatient hospital services furnished during the spell of illness, referred to therein, and with respect to which such individual was entitled to have payment made under such part A [42 U.S.C. 1395c et seq.]; ‘‘(3) the term ‘spell of illness’ shall have the mean- ing assigned to it by subsection (a) of section 1861 of such Act [42 U.S.C. 1395x(a)] except that the term ‘in- patient hospital services’ as it appears in such sub- section shall have the meaning assigned to it by sub- section (a) of this section.’’ § 1395d. Scope of benefits (a) Entitlement to payment for inpatient hospital services, post-hospital extended care serv- ices, home health services, and hospice care The benefits provided to an individual by the insurance program under this part shall consist of entitlement to have payment made on his be- half or, in the case of payments referred to in section 1395f(d)(2) of this title to him (subject to the provisions of this part) for— (1) inpatient hospital services or inpatient critical access hospital services for up to 150 days during any spell of illness minus 1 day for each day of such services in excess of 90 re- ceived during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies in accordance with regulations of the Secretary that he does not desire to have such payment made); (2)(A) post-hospital extended care services for up to 100 days during any spell of illness, and (B) to the extent provided in subsection (f), extended care services that are not post- hospital extended care services; (3) in the case of individuals not enrolled in part B, home health services, and in the case of individuals so enrolled, post-institutional home health services furnished during a home health spell of illness for up to 100 visits dur- ing such spell of illness; (4) in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each and an unlim- ited number of subsequent periods of 60 days each with respect to which the individual makes an election under subsection (d)(1); and (5) for individuals who are terminally ill, have not made an election under subsection (d)(1), and have not previously received serv- ices under this paragraph, services that are furnished by a physician (as defined in section 1395x(r)(1) of this title) who is either the med- ical director or an employee of a hospice pro- gram and that— (A) consist of— (i) an evaluation of the individual’s need for pain and symptom management, in- cluding the individual’s need for hospice care; and (ii) counseling the individual with re- spect to hospice care and other care op- tions; and (B) may include advising the individual re- garding advanced care planning. (b) Services not covered Payment under this part for services furnished an individual during a spell of illness may not (subject to subsection (c)) be made for— (1) inpatient hospital services furnished to him during such spell after such services have been furnished to him for 150 days during such spell minus 1 day for each day of inpatient hospital services in excess of 90 received dur- ing any preceding spell of illness (if such indi- vidual was entitled to have payment for such services made under this part unless he speci- fies in accordance with regulations of the Sec- retary that he does not desire to have such payment made); (2) post-hospital extended care services fur- nished to him during such spell after such services have been furnished to him for 100 days during such spell; or (3) inpatient psychiatric hospital services furnished to him after such services have been furnished to him for a total of 190 days during his lifetime. Payment under this part for post-institutional home health services furnished an individual during a home health spell of illness may not be made for such services beginning after such services have been furnished for a total of 100 visits during such spell. Page 2932 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395d (c) Inpatients of psychiatric hospitals If an individual is an inpatient of a psychiatric hospital on the first day of the first month for which he is entitled to benefits under this part, the days on which he was an inpatient of such a hospital in the 150-day period immediately be- fore such first day shall be included in deter- mining the number of days limit under sub- section (b)(1) insofar as such limit applies to (1) inpatient psychiatric hospital services, or (2) in- patient hospital services for an individual who is an inpatient primarily for the diagnosis or treatment of mental illness (but shall not be in- cluded in determining such number of days limit insofar as it applies to other inpatient hospital services or in determining the 190-day limit under subsection (b)(3)). (d) Hospice care; election; waiver of rights; rev- ocation; change of election (1) Payment under this part may be made for hospice care provided with respect to an indi- vidual only during two periods of 90 days each and an unlimited number of subsequent periods of 60 days each during the individual’s lifetime and only, with respect to each such period, if the individual makes an election under this para- graph to receive hospice care under this part provided by, or under arrangements made by, a particular hospice program instead of certain other benefits under this subchapter. (2)(A) Except as provided in subparagraphs (B) and (C) and except in such exceptional and un- usual circumstances as the Secretary may pro- vide, if an individual makes such an election for a period with respect to a particular hospice program, the individual shall be deemed to have waived all rights to have payment made under this subchapter with respect to— (i) hospice care provided by another hospice program (other than under arrangements made by the particular hospice program) dur- ing the period, and (ii) services furnished during the period that are determined (in accordance with guidelines of the Secretary) to be— (I) related to the treatment of the individ- ual’s condition with respect to which a diag- nosis of terminal illness has been made or (II) equivalent to (or duplicative of) hos- pice care; except that clause (ii) shall not apply to physi- cians’ services furnished by the individual’s at- tending physician (if not an employee of the hospice program) or to services provided by (or under arrangements made by) the hospice pro- gram. (B) After an individual makes such an election with respect to a 90-day period or a subsequent 60-day period, the individual may revoke the election during the period, in which case— (i) the revocation shall act as a waiver of the right to have payment made under this part for any hospice care benefits for the remaining time in such period and (for purposes of sub- section (a)(4) and subparagraph (A)) the indi- vidual shall be deemed to have been provided such benefits during such entire period, and (ii) the individual may at any time after the revocation execute a new election for a subse- quent period, if the individual otherwise is en- titled to hospice care benefits with respect to such a period. (C) An individual may, once in each such pe- riod, change the hospice program with respect to which the election is made and such change shall not be considered a revocation of an elec- tion under subparagraph (B). (D) For purposes of this subchapter, an indi- vidual’s election with respect to a hospice pro- gram shall no longer be considered to be in ef- fect with respect to that hospice program after the date the individual’s revocation or change of election with respect to that election takes ef- fect. (e) Services taken into account For purposes of subsections (b) and (c), inpa- tient hospital services, inpatient psychiatric hospital services, and post-hospital extended care services shall be taken into account only if payment is or would be, except for this section or the failure to comply with the request and certification requirements of or under section 1395f(a) of this title, made with respect to such services under this part. (f) Coverage of extended care services without regard to three-day prior hospitalization re- quirement (1) The Secretary shall provide for coverage, under clause (B) of subsection (a)(2), of extended care services which are not post-hospital ex- tended care services at such time and for so long as the Secretary determines, and under such terms and conditions (described in paragraph (2)) as the Secretary finds appropriate, that the inclusion of such services will not result in any increase in the total of payments made under this subchapter and will not alter the acute care nature of the benefit described in subsection (a)(2). (2) The Secretary may provide— (A) for such limitations on the scope and ex- tent of services described in subsection (a)(2)(B) and on the categories of individuals who may be eligible to receive such services, and (B) notwithstanding sections 1395f, 1395x(v), and 1395ww of this title, for such restrictions and alternatives on the amounts and methods of payment for services described in such sub- section, as may be necessary to carry out paragraph (1). (g) ‘‘Spell of illness’’ defined For definitions of ‘‘spell of illness’’, and for definitions of other terms used in this part, see section 1395x of this title. (Aug. 14, 1935, ch. 531, title XVIII, § 1812, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 291; amended Pub. L. 90–248, title I, §§ 129(c)(2), 137(a), 138(a), 143(b), 146(a), Jan. 2, 1968, 81 Stat. 847, 853, 854, 857, 859; Pub. L. 96–499, title IX, §§ 930(b)–(d), 931(a), Dec. 5, 1980, 94 Stat. 2631, 2633; Pub. L. 97–35, title XXI, § 2121(a), Aug. 13, 1981, 95 Stat. 796; Pub. L. 97–248, title I, §§ 122(b), 123, Sept. 3, 1982, 96 Stat. 356, 364; Pub. L. 97–448, title III, § 309(b)(5), Jan. 12, 1983, 96 Stat. 2409; Pub. L. 100–360, title I, § 101, July 1, 1988, 102 Stat. 684; Pub. L. 101–234, title I, § 101(a), Dec. 13, 1989, 103 Stat. 1979; Pub. L. 101–239, title Page 2933 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395d VI, § 6003(g)(3)(B)(i), Dec. 19, 1989, 103 Stat. 2152; Pub. L. 101–508, title IV, § 4006(a), Nov. 5, 1990, 104 Stat. 1388–43; Pub. L. 103–432, title I, § 102(g)(1), Oct. 31, 1994, 108 Stat. 4404; Pub. L. 105–33, title IV, §§ 4201(c)(1), 4443(a), (b)(1), 4611(a), Aug. 5, 1997, 111 Stat. 373, 423, 472; Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 321(k)(1)], Nov. 29, 1999, 113 Stat. 1536, 1501A–366; Pub. L. 108–173, title V, § 512(a), title VII, § 736(c)(1), Dec. 8, 2003, 117 Stat. 2299, 2356.) Editorial Notes AMENDMENTS 2003—Subsec. (a)(3). Pub. L. 108–173, § 736(c)(1), sub- stituted ‘‘in the case of individuals not’’ for ‘‘for indi- viduals not’’ and ‘‘in the case of individuals so’’ for ‘‘for individuals so’’. Subsec. (a)(5). Pub. L. 108–173, § 512(a), added par. (5). 1999—Subsec. (b). Pub. L. 106–113 inserted ‘‘during’’ after ‘‘100 visits’’ in concluding provisions. 1997—Subsec. (a)(1). Pub. L. 105–33, § 4201(c)(1), sub- stituted ‘‘critical access’’ for ‘‘rural primary care’’. Subsec. (a)(3). Pub. L. 105–33, § 4611(a)(1), substituted ‘‘for individuals not enrolled in part B, home health services, and for individuals so enrolled, post-institu- tional home health services furnished during a home health spell of illness for up to 100 visits during such spell of illness’’ for ‘‘home health services’’. Subsec. (a)(4). Pub. L. 105–33, § 4443(a), substituted ‘‘and an unlimited number of subsequent periods of 60 days each’’ for ‘‘, a subsequent period of 30 days, and a subsequent extension period’’. Subsec. (b). Pub. L. 105–33, § 4611(a)(2), inserted closing provisions. Subsec. (d)(1). Pub. L. 105–33, § 4443(a), substituted ‘‘and an unlimited number of subsequent periods of 60 days each’’ for ‘‘, a subsequent period of 30 days, and a subsequent extension period’’. Subsec. (d)(2)(B). Pub. L. 105–33, § 4443(b)(1), sub- stituted ‘‘90-day period or a subsequent 60-day period’’ for ‘‘90- or 30-day period or a subsequent extension pe- riod’’. 1994—Subsec. (a)(1). Pub. L. 103–432 substituted ‘‘inpa- tient hospital services or inpatient rural primary care hospital services’’ for ‘‘inpatient hospital services’’ be- fore ‘‘for up to 150 days’’ and ‘‘such services’’ for ‘‘inpa- tient hospital services’’ before ‘‘in excess of 90’’ and struck out ‘‘and inpatient rural primary care hospital services’’ after ‘‘such payment made)’’. 1990—Subsec. (a)(4). Pub. L. 101–508, § 4006(a)(1), sub- stituted ‘‘90 days each, a subsequent period of 30 days, and a subsequent extension period’’ for ‘‘90 days each and one subsequent period of 30 days’’. Subsec. (d)(1). Pub. L. 101–508, § 4006(a)(2)(A), sub- stituted ‘‘90 days each, a subsequent period of 30 days, and a subsequent extension period during the individ- ual’s lifetime’’ for ‘‘90 days each and one subsequent pe- riod of 30 days during the individual’s lifetime’’. Subsec. (d)(2)(B). Pub. L. 101–508, § 4006(a)(2)(B), sub- stituted ‘‘a 90- or 30-day period or a subsequent exten- sion period’’ for ‘‘a 90- or 30-day period’’. 1989—Subsec. (a). Pub. L. 101–234 repealed Pub. L. 100–360, § 101(1), and provided that the provisions of law amended or repealed by such section are restored or re- vived as if such section had not been enacted, see 1988 Amendment note below. Subsec. (a)(1). Pub. L. 101–239 inserted ‘‘and inpatient rural primary care hospital services’’ before semicolon at end. Subsecs. (b) to (d)(1), (2)(B), (e) to (g). Pub. L. 101–234 repealed Pub. L. 100–360, § 101(2)–(6), and provided that the provisions of law amended or repealed by such sec- tion are restored or revived as if such section had not been enacted, see 1988 Amendment notes below. 1988—Subsec. (a). Pub. L. 100–360, § 101(1), struck out former pars. (1) to (4) and added new pars. (1) to (4) which read as follows: ‘‘(1) inpatient hospital services; ‘‘(2) extended care services for up to 150 days during any calendar year; ‘‘(3) home health services; and ‘‘(4) in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each, a subsequent period of 30 days, and a subsequent extension period with respect to which the individual makes an election under subsection (d)(1) of this section.’’ Subsec. (b). Pub. L. 100–360, § 101(2), amended subsec. (b) generally, striking out par. (1) and renumbering and amending pars. (2) and (3) as (1) and (2), respectively. Subsec. (c). Pub. L. 100–360, § 101(3), amended subsec. (c) generally, substituting pars. (1) to (4) limiting peri- ods for inpatients of psychiatric hospitals for former single paragraph. Subsec. (d)(1). Pub. L. 100–360, § 101(4)(A), substituted ‘‘, a subsequent period of 30 days, and a subsequent ex- tension period’’ for ‘‘and one subsequent period of 30 days’’. Subsec. (d)(2)(B). Pub. L. 100–360, § 101(4)(B), inserted ‘‘or a subsequent extension period’’ after ‘‘30-day pe- riod’’ in introductory provisions. Subsec. (e). Pub. L. 100–360, § 101(5), struck out ‘‘post- hospital’’ before ‘‘extended care services’’. Subsec. (f). Pub. L. 100–360, § 101(6), struck out subsec. (f) which provided coverage of extended care services without regard to three-day prior hospitalization re- quirement. Subsec. (g). Pub. L. 100–360, § 101(6), struck out subsec. (g) which cross-referenced section 1395x of this title for definitions of ‘‘spell of illness’’ and other terms used in this part. 1983—Subsec. (d)(2)(A). Pub. L. 97–448 substituted ‘‘or to services’’ for ‘‘or to other than services’’ after ‘‘(if not an employee of the hospice program)’’. 1982—Subsec. (a)(2). Pub. L. 97–248, § 123(a), redesig- nated existing provisions as subpar. (A) and added sub- par. (B). Subsec. (a)(4). Pub. L. 97–248, § 122(b)(1), added par. (4). Subsec. (d). Pub. L. 97–248, § 122(b)(2), added subsec. (d). Subsecs. (f), (g). Pub. L. 97–248, § 123(b), added subsec. (f) and redesignated former subsec. (f) as (g). 1981—Subsec. (a). Pub. L. 97–35 struck out par. (4) which related to alcohol detoxification facility serv- ices. 1980—Subsec. (a)(3). Pub. L. 96–499, § 930(b), sub- stituted ‘‘home health services’’ for ‘‘post-hospital home health services for up to 100 visits (during the one-year period described in section 1395x(n) of this title) after the beginning of one spell of illness and be- fore the beginning of the next’’. Subsec. (a)(4). Pub. L. 96–499, § 931(a), added par. (4). Subsec. (d). Pub. L. 96–499, § 930(c), struck out subsec. (d) which authorized payment for post-hospital home health services furnished an individual only during the one year period described in section 1395x(n) of this title following his most recent hospital discharge which met the requirements of such section and only for the first 100 visits in such period. Subsec. (e). Pub. L. 96–499, § 930(d), substituted ‘‘sub- sections (b) and (c)’’ for ‘‘subsections (b), (c), and (d)’’ and ‘‘and post-hospital extended care services’’ for ‘‘post-hospital extended care services, and post-hospital home health services’’. 1968—Subsec. (a). Pub. L. 90–248, § 143(b), inserted ‘‘or, in the case of payments referred to in section 1395f(d)(2) of this title to him’’ after ‘‘on his behalf’’ in text pre- ceding par. (1). Subsec. (a)(1). Pub. L. 90–248, § 137(a)(1), increased the maximum duration of benefits from 90 to 150 days minus 1 day for each day of inpatient hospital services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he speci- fies that he does not desire to have such payment made). Subsec. (a)(4). Pub. L. 90–248, § 129(c)(2), struck out par. (4) which provided for payment for outpatient hos- pital diagnostic services. Page 2934 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395d Subsec. (b)(1). Pub. L. 90–248, § 137(a)(2), changed the limitation on payments from 90 to 150 days minus 1 day for each day of inpatient hospital services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such serv- ices made under this part unless he specifies that he does not desire to have such payment made). Subsec. (c). Pub. L. 90–248, § 138(a), increased the limit from 90 to 150 days so that if an individual was an inpa- tient of a psychiatric or tuberculosis hospital on the first day of the first month for which he is entitled to benefits, the days he was an inpatient in the 150-day pe- riod immediately before such first day are included in determining the limit under subsec. (b)(1) insofar as such limit applies to (1) inpatient psychiatric hospital services and inpatient tuberculosis hospital services, or (2) inpatient hospital services for an individual who is an inpatient primarily for the diagnosis or treatment of mental illness or tuberculosis (but are not included in determining such limit as it applies to other inpa- tient hospital services or in determining the 190-day limit under subsec. (b)(3)). Pub. L. 90–248, § 146(a), provided that the limitation of allowable days of inpatient hospital services will not apply to services provided to an inpatient of a tuber- culosis hospital. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2003 AMENDMENT Pub. L. 108–173, title V, § 512(d), Dec. 8, 2003, 117 Stat. 2300, provided that: ‘‘The amendments made by this section [amending this section and sections 1395f and 1395x of this title] shall apply to services provided by a hospice program on or after January 1, 2005.’’ EFFECTIVE DATE OF 1999 AMENDMENT Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 321(m)], Nov. 29, 1999, 113 Stat. 1536, 1501A–368, provided that: ‘‘Except as otherwise provided, the amendments made by this section [amending this section and sections 1395i, 1395i–4, 1395l, 1395m, 1395u, 1395w–3, 1395w–4, 1395w–21, 1395w–22, 1395w–24, 1395x, 1395y, 1395cc, 1395ss, 1395ww, 1395yy, and 1395fff of this title, repealing sec- tion 1320b–5 of this title, and amending provisions set out as notes under sections 1395f and 1395ww of this title] shall take effect as if included in the enactment of BBA [Balanced Budget Act of 1997, Pub. L. 105–33].’’ EFFECTIVE DATE OF 1997 AMENDMENT Amendment by section 4201(c)(1) of Pub. L. 105–33 ap- plicable to services furnished on or after Oct. 1, 1997, see section 4201(d) of Pub. L. 105–33, set out as a note under section 1395f of this title. Pub. L. 105–33, title IV, § 4449, Aug. 5, 1997, 111 Stat. 424, provided that: ‘‘Except as otherwise provided in this chapter [chapter 4 (§§ 4441–4449) of subtitle E of title IV of Pub. L. 105–33, amending this section and sections 1395f, 1395x, and 1395pp of this title and enact- ing provisions set out as notes under section 1395f and 1395x of this title], the amendments made by this chap- ter apply to benefits provided on or after the date of the enactment of this chapter [Aug. 5, 1997], regardless of whether or not an individual has made an election under section 1812(d) of the Social Security Act (42 U.S.C. 1395d(d)) before such date.’’ Pub. L. 105–33, title IV, § 4611(f), Aug. 5, 1997, 111 Stat. 474, provided that: ‘‘The amendments made by this sec- tion [amending this section and sections 1395u, 1395x, and 1395ff of this title] apply to services furnished on or after January 1, 1998. For purpose of applying such amendments, any home health spell of illness that began, but not [sic] did not end, before such date shall be considered to have begun as of such date.’’ EFFECTIVE DATE OF 1994 AMENDMENT Pub. L. 103–432, title I, § 102(i), Oct. 31, 1994, 108 Stat. 4404, provided that: ‘‘The amendments made by this section [amending this section and sections 1395e, 1395f, 1395i–4, 1395m, 1395x, and 1395ww of this title] shall take effect on the date of the enactment of this Act [Oct. 31, 1994].’’ EFFECTIVE DATE OF 1990 AMENDMENT Pub. L. 101–508, title IV, § 4006(c), Nov. 5, 1990, 104 Stat. 1388–43, provided that: ‘‘The amendments made by this section [amending this section and section 1395f of this title] shall apply with respect to care and services furnished on or after January 1, 1990.’’ EFFECTIVE DATE OF 1989 AMENDMENT Amendment by Pub. L. 101–234 effective Jan. 1, 1990, see section 101(d) of Pub. L. 101–234, set out as a note under section 1395c of this title. EFFECTIVE DATE OF 1988 AMENDMENT Pub. L. 100–360, title I, § 104(a), July 1, 1988, 102 Stat. 687, as amended by Pub. L. 100–485, title VI, § 608(d)(3)(A), Oct. 13, 1988, 102 Stat. 2413, provided that: ‘‘(1) IN GENERAL.—Except as provided in paragraph (2) and subsection (b), the amendments made by this sub- title [subtitle A (§§ 101–104) of title I of Pub. L. 100–360, amending this section and sections 1395c, 1395e, 1395f, 1395i–2, 1395k, 1395x, 1395cc, and 1395tt of this title] shall take effect on January 1, 1989, and shall apply— ‘‘(A) to the inpatient hospital deductible for 1989 and succeeding years, ‘‘(B) to care and services furnished on or after Jan- uary 1, 1989, ‘‘(C) to premiums for January 1989 and succeeding months, and ‘‘(D) to blood or blood cells furnished on or after January 1, 1989. ‘‘(2) ELIMINATION OF POST-HOSPITAL REQUIREMENT FOR EXTENDED CARE SERVICES.—The amendments made by this subtitle, insofar as they eliminate the requirement (under section 1812(a)(2) of the Social Security Act [42 U.S.C. 1395d(a)(2)]) that extended care services are only covered under title XVIII of such Act [42 U.S.C. 1395 et seq.] if they are post-hospital extended care services, shall only apply to extended care services furnished pursuant to an admission to a skilled nursing facility occurring on or after January 1, 1989.’’ EFFECTIVE DATE OF 1983 AMENDMENT Amendment by Pub. L. 97–448 effective as if originally included as a part of this section as this section was amended by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248, see section 309(c)(2) of Pub. L. 97–448, set out as a note under section 426–1 of this title. EFFECTIVE DATE OF 1982 AMENDMENT Amendment by section 122(b) of Pub. L. 97–248 appli- cable to hospice care provided on or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 97–248, as amended, set out as a note under section 1395c of this title. EFFECTIVE DATE OF 1981 AMENDMENT Pub. L. 97–35, title XXI, § 2121(i), Aug. 13, 1981, 95 Stat. 796, provided that: ‘‘The amendments made by this sec- tion [amending this section and sections 1320c–3, 1320c–4, 1320c–7, 1395f, and 1395x of this title] (other than by subsection (h) [repealing provisions set out as a note under section 1395ll of this title]) shall apply to services furnished in detoxification facilities for inpatient stays beginning on or after the tenth day after the date of the enactment of this Act [Aug. 13, 1981].’’ EFFECTIVE DATE OF 1980 AMENDMENT Amendment by section 930(b)–(d) of Pub. L. 96–499 ef- fective with respect to services furnished on or after July 1, 1981, see section 930(s)(1) of Pub. L. 96–499, set out as a note under section 1395x of this title. Pub. L. 96–499, title IX, § 931(e), Dec. 5, 1980, 94 Stat. 2634, provided that: ‘‘The amendments made by sub- sections (a) through (d) of this section [amending this Page 2935 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395d section and sections 1395f and 1395x of this title] shall become effective on April 1, 1981.’’ EFFECTIVE DATE OF 1968 AMENDMENT Pub. L. 90–248, title I, § 129(d), Jan. 2, 1968, 81 Stat. 849, provided that: ‘‘The amendments made by this section [amending this section and sections 426, 1395e, 1395f, 1395k, 1395l, 1395n, 1395x, and 1395cc of this title and sec- tion 228s–2 of Title 45, Railroads] shall apply with re- spect to services furnished after March 31, 1968, except that subsection (c)(5) of such section [amending section 1395f of this title] shall become effective with respect to services furnished after the date of enactment of this Act [Jan. 2, 1968].’’ Pub. L. 90–248, title I, § 137(c), Jan. 2, 1968, 81 Stat. 854, provided that: ‘‘The amendments made by subsections (a) and (b) [amending this section and section 1395e of this title] shall apply with respect to services furnished after December 31, 1967.’’ Pub. L. 90–248, title I, § 138(b), Jan. 2, 1968, 81 Stat. 854, provided that: ‘‘The amendments made by subsection (a) [amending this section] shall apply with respect to payment for services furnished after December 31, 1967.’’ Pub. L. 90–248, title I, § 143(d), Jan. 2, 1968, 81 Stat. 858, provided that: ‘‘The provisions made by subsection (a) of this section [amending section 1395x of this title] shall become effective as of July 1, 1966, and the provi- sions made by subsections (b) and (c) of this section [amending this section and section 1395f of this title] shall apply to services furnished with respect to admis- sions occurring after December 31, 1967, and to out- patient hospital diagnostic services furnished after De- cember 31, 1967, and before April 1, 1968.’’ Pub. L. 90–248, title I, § 146(b), Jan. 2, 1968, 81 Stat. 859, provided that: ‘‘The amendment made by subsection (a) [amending this section] shall apply with respect to pay- ment for services furnished after December 31, 1967.’’ MEDICARE HOSPICE CONCURRENT CARE DEMONSTRATION PROGRAM Pub. L. 111–148, title III, § 3140, Mar. 23, 2010, 124 Stat. 440, provided that: ‘‘(a) ESTABLISHMENT.— ‘‘(1) IN GENERAL.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall establish a Medicare Hospice Con- current Care demonstration program at participating hospice programs under which Medicare beneficiaries are furnished, during the same period, hospice care and any other items or services covered under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) from funds otherwise paid under such title to such hospice programs. ‘‘(2) DURATION.—The demonstration program under this section shall be conducted for a 3-year period. ‘‘(3) SITES.—The Secretary shall select not more than 15 hospice programs at which the demonstration program under this section shall be conducted. Such hospice programs shall be located in urban and rural areas. ‘‘(b) INDEPENDENT EVALUATION AND REPORTS.— ‘‘(1) INDEPENDENT EVALUATION.—The Secretary shall provide for the conduct of an independent evaluation of the demonstration program under this section. Such independent evaluation shall determine wheth- er the demonstration program has improved patient care, quality of life, and cost-effectiveness for Medi- care beneficiaries participating in the demonstration program. ‘‘(2) REPORTS.—The Secretary shall submit to Con- gress a report containing the results of the evalua- tion conducted under paragraph (1), together with such recommendations as the Secretary determines appropriate. ‘‘(c) BUDGET NEUTRALITY.—With respect to the 3-year period of the demonstration program under this sec- tion, the Secretary shall ensure that the aggregate ex- penditures under title XVIII [42 U.S.C. 1395 et seq.] for such period shall not exceed the aggregate expenditures that would have been expended under such title if the demonstration program under this section had not been implemented.’’ PROTECTING HOME HEALTH BENEFITS Pub. L. 111–148, title III, § 3143, Mar. 23, 2010, 124 Stat. 442, provided that: ‘‘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 the reduction of guaranteed home health benefits under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].’’ RURAL HOSPICE DEMONSTRATION PROJECT Pub. L. 108–173, title IV, § 409, Dec. 8, 2003, 117 Stat. 2271, provided that: ‘‘(a) IN GENERAL.—The Secretary [of Health and Human Services] shall conduct a demonstration project for the delivery of hospice care to medicare bene- ficiaries in rural areas. Under the project medicare beneficiaries who are unable to receive hospice care in the facility for lack of an appropriate caregiver are provided such care in a facility of 20 or fewer beds which offers, within its walls, the full range of services provided by hospice programs under section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)). ‘‘(b) SCOPE OF PROJECT.—The Secretary shall conduct the project under this section with respect to no more than 3 hospice programs over a period of not longer than 5 years each. ‘‘(c) COMPLIANCE WITH CONDITIONS.—Under the dem- onstration project— ‘‘(1) the hospice program shall comply with other- wise applicable requirements, except that it shall not be required to offer services outside of the home or to meet the requirements of section 1861(dd)(2)(A)(iii) of the Social Security Act [42 U.S.C. 1395x(dd)(2)(A)(iii)]; and ‘‘(2) payments for hospice care shall be made at the rates otherwise applicable to such care under title XVIII of such Act [42 U.S.C. 1395 et seq.]. The Secretary may require the program to comply with such additional quality assurance standards for its pro- vision of services in its facility as the Secretary deems appropriate. ‘‘(d) REPORT.—Upon completion of the project, the Secretary shall submit a report to Congress on the project and shall include in the report recommenda- tions regarding extension of such project to hospice programs serving rural areas.’’ OIG REPORT ON NOTICES RELATING TO USE OF HOSPITAL LIFETIME RESERVE DAYS Pub. L. 108–173, title IX, § 953(d), Dec. 8, 2003, 117 Stat. 2428, provided that: ‘‘Not later than 1 year after the date of the enactment of this Act [Dec. 8, 2003], the In- spector General of the Department of Health and Human Services shall submit a report to Congress on— ‘‘(1) the extent to which hospitals provide notice to medicare beneficiaries in accordance with applicable requirements before they use the 60 lifetime reserve days described in section 1812(a)(1) of the Social Secu- rity Act (42 U.S.C. 1395d(a)(1)); and ‘‘(2) the appropriateness and feasibility of hospitals providing a notice to such beneficiaries before they completely exhaust such lifetime reserve days.’’ MEDPAC REPORT ON ACCESS TO, AND USE OF, HOSPICE BENEFIT Pub. L. 106–554, § 1(a)(6) [title III, § 323], Dec. 21, 2000, 114 Stat. 2763, 2763A–501, required a study on the factors affecting the use of hospice benefits under the medicare program and a report on the study no later than 18 months after Dec. 21, 2000. TRANSITION Pub. L. 105–33, title IV, § 4611(e), Aug. 5, 1997, 111 Stat. 473, provided that: Page 2936 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395e ‘‘(1) IN GENERAL.—Notwithstanding any provision of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], the Secretary of Health and Human Services shall establish a transition for the aggregate amount of ex- penditures that are transferred from part A, to part B, of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.], as a result of the amendments made by this section [amending this section and sec- tions 1395u, 1395x, and 1395ff of this title], during each of the years during the period beginning with 1998 and ending with 2002 according to this subsection. Under the transition for each such year, the Secretary shall effect such transfer, between the trust funds under such parts, as will result in only the proportion (specified in paragraph (2)) of such aggregate expenditures for the year being transferred from such part A to such part B. ‘‘(2) PROPORTION SPECIFIED.—The proportion specified in this paragraph for— ‘‘(A) 1998 is 1⁄6, ‘‘(B) 1999 is 1⁄3, ‘‘(C) 2000 is 1⁄2, ‘‘(D) 2001 is 2⁄3, and ‘‘(E) 2002 is 5⁄6. ‘‘(3) APPLICATION IN ESTABLISHING MONTHLY PREMIUMS FOR 1998 THROUGH 2003.— ‘‘(A) IN GENERAL.—For purposes only of computing the monthly premium under section 1839 of the Social Security Act (42 U.S.C. 1395r), the monthly actuarial rate for enrollees age 65 and over shall be computed as though any reference in paragraph (1) of this sub- section to 2002 were a reference to 2003 and as if the following proportions were substituted for the pro- portions specified in paragraph (2): ‘‘(i) For 1998, 1⁄7. ‘‘(ii) For 1999, 2⁄7. ‘‘(iii) For 2000, 3⁄7. ‘‘(iv) For 2001, 4⁄7. ‘‘(v) For 2002, 5⁄7. ‘‘(vi) For 2003, 6⁄7. ‘‘(B) NO IMPACT ON GOVERNMENT CONTRIBUTION.— Subparagraph (A) does not apply in determining the amount of the Government contribution under sec- tion 1844 of the Social Security Act (42 U.S.C. 1395w).’’ REPEAL OF 1988 EXPANSION OF MEDICARE PART A BENEFITS For provisions repealing amendment by section 101 of Pub. L. 100–360, restoring or reviving this section as if section 101 of Pub. L. 100–360 had not been enacted, and providing a transition period for medicare beneficiaries with respect to inpatient hospital services and ex- tended care services provided on or after Jan. 1, 1990, and providing an exception to such restoration for cer- tain hospice care, see section 101(a)–(b)(2) of Pub. L. 101–234, set out as a note under section 1395e of this title. § 1395e. Deductibles and coinsurance (a) Inpatient hospital services; outpatient hos- pital diagnostic services; blood; post-hospital extended care services (1) The amount payable for inpatient hospital services or inpatient critical access hospital services furnished an individual during any spell of illness shall be reduced by a deduction equal to the inpatient hospital deductible or, if less, the charges imposed with respect to such indi- vidual for such services, except that, if the cus- tomary charges for such services are greater than the charges so imposed, such customary charges shall be considered to be the charges so imposed. Such amount shall be further reduced by a coinsurance amount equal to— (A) one-fourth of the inpatient hospital de- ductible for each day (before the 91st day) on which such individual is furnished such serv- ices during such spell of illness after such services have been furnished to him for 60 days during such spell; and (B) one-half of the inpatient hospital deduct- ible for each day (before the day following the last day for which such individual is entitled under section 1395d(a)(1) of this title to have payment made on his behalf for inpatient hos- pital services or inpatient critical access hos- pital services during such spell of illness) on which such individual is furnished such serv- ices during such spell of illness after such services have been furnished to him for 90 days during such spell; except that the reduction under this sentence for any day shall not exceed the charges im- posed for that day with respect to such indi- vidual for such services (and for this purpose, if the customary charges for such services are greater than the charges so imposed, such cus- tomary charges shall be considered to be the charges so imposed). (2)(A) The amount payable to any provider of services under this part for services furnished an individual shall be further reduced by a deduc- tion equal to the expenses incurred for the first three pints of whole blood (or equivalent quan- tities of packed red blood cells, as defined under regulations) furnished to the individual during each calendar year, except that such deductible for such blood shall in accordance with regula- tions be appropriately reduced to the extent that there has been a replacement of such blood (or equivalent quantities of packed red blood cells, as so defined); and for such purposes blood (or equivalent quantities of packed red blood cells, as so defined) furnished such individual shall be deemed replaced when the institution or other person furnishing such blood (or such equivalent quantities of packed red blood cells, as so defined) is given one pint of blood for each pint of blood (or equivalent quantities of packed red blood cells, as so defined) furnished such in- dividual with respect to which a deduction is made under this sentence. (B) The deductible under subparagraph (A) for blood or blood cells furnished an individual in a year shall be reduced to the extent that a de- ductible has been imposed under section 1395l(b) of this title to blood or blood cells furnished the individual in the year. (3) The amount payable for post-hospital ex- tended care services furnished an individual dur- ing any spell of illness shall be reduced by a co- insurance amount equal to one-eighth of the in- patient hospital deductible for each day (before the 101st day) on which he is furnished such services after such services have been furnished to him for 20 days during such spell. (4)(A) The amount payable for hospice care shall be reduced— (i) in the case of drugs and biologicals pro- vided on an outpatient basis by (or under ar- rangements made by) the hospice program, by a coinsurance amount equal to an amount (not to exceed $5 per prescription) determined in accordance with a drug copayment schedule (established by the hospice program) which is related to, and approximates 5 percent of, the cost of the drug or biological to the program, and