42 USC 1395 - Scope of benefits

Editorial Notes

Amendments

2003—Subsec. (a)(3). Puspan. L. 108–173, § 736(c)(1), substituted “in the case of individuals not” for “for individuals not” and “in the case of individuals so” for “for individuals so”.

Subsec. (a)(5). Puspan. L. 108–173, § 512(a), added par. (5).

1999—Subsec. (span). Puspan. L. 106–113 inserted “during” after “100 visits” in concluding provisions.

1997—Subsec. (a)(1). Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (a)(3). Puspan. L. 105–33, § 4611(a)(1), substituted “for individuals not enrolled in part B, home health services, and for individuals so enrolled, post-institutional 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). Puspan. 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. (span). Puspan. L. 105–33, § 4611(a)(2), inserted closing provisions.

Subsec. (d)(1). Puspan. 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). Puspan. L. 105–33, § 4443(span)(1), substituted “90-day period or a subsequent 60-day period” for “90- or 30-day period or a subsequent extension period”.

1994—Subsec. (a)(1). Puspan. L. 103–432 substituted “inpatient hospital services or inpatient rural primary care hospital services” for “inpatient hospital services” before “for up to 150 days” and “such services” for “inpatient 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). Puspan. L. 101–508, § 4006(a)(1), substituted “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). Puspan. L. 101–508, § 4006(a)(2)(A), substituted “90 days each, a subsequent period of 30 days, and a subsequent extension period during the individual’s lifetime” for “90 days each and one subsequent period of 30 days during the individual’s lifetime”.

Subsec. (d)(2)(B). Puspan. L. 101–508, § 4006(a)(2)(B), substituted “a 90- or 30-day period or a subsequent extension period” for “a 90- or 30-day period”.

1989—Subsec. (a). Puspan. L. 101–234 repealed Puspan. L. 100–360, § 101(1), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

Subsec. (a)(1). Puspan. L. 101–239 inserted “and inpatient rural primary care hospital services” before semicolon at end.

Subsecs. (span) to (d)(1), (2)(B), (e) to (g). Puspan. L. 101–234 repealed Puspan. L. 100–360, § 101(2)–(6), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.

1988—Subsec. (a). Puspan. 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. (span). Puspan. L. 100–360, § 101(2), amended subsec. (span) generally, striking out par. (1) and renumbering and amending pars. (2) and (3) as (1) and (2), respectively.

Subsec. (c). Puspan. L. 100–360, § 101(3), amended subsec. (c) generally, substituting pars. (1) to (4) limiting periods for inpatients of psychiatric hospitals for former single paragraph.

Subsec. (d)(1). Puspan. L. 100–360, § 101(4)(A), substituted “, a subsequent period of 30 days, and a subsequent extension period” for “and one subsequent period of 30 days”.

Subsec. (d)(2)(B). Puspan. L. 100–360, § 101(4)(B), inserted “or a subsequent extension period” after “30-day period” in introductory provisions.

Subsec. (e). Puspan. L. 100–360, § 101(5), struck out “post-hospital” before “extended care services”.

Subsec. (f). Puspan. L. 100–360, § 101(6), struck out subsec. (f) which provided coverage of extended care services without regard to three-day prior hospitalization requirement.

Subsec. (g). Puspan. 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). Puspan. 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). Puspan. L. 97–248, § 123(a), redesignated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (a)(4). Puspan. L. 97–248, § 122(span)(1), added par. (4).

Subsec. (d). Puspan. L. 97–248, § 122(span)(2), added subsec. (d).

Subsecs. (f), (g). Puspan. L. 97–248, § 123(span), added subsec. (f) and redesignated former subsec. (f) as (g).

1981—Subsec. (a). Puspan. L. 97–35 struck out par. (4) which related to alcohol detoxification facility services.

1980—Subsec. (a)(3). Puspan. L. 96–499, § 930(span), substituted “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 before the beginning of the next”.

Subsec. (a)(4). Puspan. L. 96–499, § 931(a), added par. (4).

Subsec. (d). Puspan. 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). Puspan. L. 96–499, § 930(d), substituted “subsections (span) and (c)” for “subsections (span), (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). Puspan. L. 90–248, § 143(span), 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 preceding par. (1).

Subsec. (a)(1). Puspan. 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 specifies that he does not desire to have such payment made).

Subsec. (a)(4). Puspan. L. 90–248, § 129(c)(2), struck out par. (4) which provided for payment for outpatient hospital diagnostic services.

Subsec. (span)(1). Puspan. 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 services made under this part unless he specifies that he does not desire to have such payment made).

Subsec. (c). Puspan. L. 90–248, § 138(a), increased the limit from 90 to 150 days so that if an individual was an inpatient 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 period immediately before such first day are included in determining the limit under subsec. (span)(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 inpatient hospital services or in determining the 190-day limit under subsec. (span)(3)).

Puspan. 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 tuberculosis hospital.

Statutory Notes and Related Subsidiaries

Effective Date of 2003 Amendment

Puspan. 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

Puspan. 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 section 1320span–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, Puspan. L. 105–33].”

Effective Date of 1997 Amendment

Amendment by section 4201(c)(1) of Puspan. L. 105–33 applicable to services furnished on or after Oct. 1, 1997, see section 4201(d) of Puspan. L. 105–33, set out as a note under section 1395f of this title.

Puspan. 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 Puspan. L. 105–33, amending this section and sections 1395f, 1395x, and 1395pp of this title and enacting provisions set out as notes under section 1395f and 1395x of this title], the amendments made by this chapter 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.”

Puspan. L. 105–33, title IV, § 4611(f), Aug. 5, 1997, 111 Stat. 474, provided that: “The amendments made by this section [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

Puspan. 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

Puspan. 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 Puspan. L. 101–234 effective Jan. 1, 1990, see section 101(d) of Puspan. L. 101–234, set out as a note under section 1395c of this title.

Effective Date of 1988 Amendment

Puspan. L. 100–360, title I, § 104(a), July 1, 1988, 102 Stat. 687, as amended by Puspan. 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 (span), the amendments made by this subtitle [subtitle A (§§ 101–104) of title I of Puspan. 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 January 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 Puspan. 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, Puspan. L. 97–248, see section 309(c)(2) of Puspan. L. 97–448, set out as a note under section 426–1 of this title.

Effective Date of 1982 Amendment

Amendment by section 122(span) of Puspan. L. 97–248 applicable to hospice care provided on or after Nov. 1, 1983, see section 122(h)(1) of Puspan. L. 97–248, as amended, set out as a note under section 1395c of this title.

Effective Date of 1981 Amendment

Puspan. L. 97–35, title XXI, § 2121(i), Aug. 13, 1981, 95 Stat. 796, provided that: “The amendments made by this section [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(span)–(d) of Puspan. L. 96–499 effective with respect to services furnished on or after July 1, 1981, see section 930(s)(1) of Puspan. L. 96–499, set out as a note under section 1395x of this title.

Puspan. L. 96–499, title IX, § 931(e), Dec. 5, 1980, 94 Stat. 2634, provided that: “The amendments made by subsections (a) through (d) of this section [amending this section and sections 1395f and 1395x of this title] shall become effective on April 1, 1981.”

Effective Date of 1968 Amendment

Puspan. 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 section 228s–2 of Title 45, Railroads] shall apply with respect 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].”

Puspan. L. 90–248, title I, § 137(c), Jan. 2, 1968, 81 Stat. 854, provided that: “The amendments made by subsections (a) and (span) [amending this section and section 1395e of this title] shall apply with respect to services furnished after December 31, 1967.”

Puspan. L. 90–248, title I, § 138(span), 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.”

Puspan. 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 provisions made by subsections (span) and (c) of this section [amending this section and section 1395f of this title] shall apply to services furnished with respect to admissions occurring after December 31, 1967, and to outpatient hospital diagnostic services furnished after December 31, 1967, and before April 1, 1968.”

Puspan. L. 90–248, title I, § 146(span), Jan. 2, 1968, 81 Stat. 859, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to payment for services furnished after December 31, 1967.”

Medicare Hospice Concurrent Care Demonstration Program

Puspan. 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 Concurrent 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.

“(span)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 whether the demonstration program has improved patient care, quality of life, and cost-effectiveness for Medicare beneficiaries participating in the demonstration program.

“(2)Reports.—The Secretary shall submit to Congress a report containing the results of the evaluation 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 section, the Secretary shall ensure that the aggregate expenditures 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

Puspan. 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

Puspan. 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 beneficiaries 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)).

“(span)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 demonstration project—

“(1) the hospice program shall comply with otherwise 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 provision 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 recommendations regarding extension of such project to hospice programs serving rural areas.”

OIG Report on Notices Relating to Use of Hospital Lifetime Reserve Days

Puspan. 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 Inspector 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 Security 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

Puspan. 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

Puspan. L. 105–33, title IV, § 4611(e), Aug. 5, 1997, 111 Stat. 473, provided that:

“(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 expenditures 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 sections 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 ⅙,

“(B) 1999 is ⅓,

“(D) 2001 is ⅔, and

“(E) 2002 is ⅚.

“(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 subsection to 2002 were a reference to 2003 and as if the following proportions were substituted for the proportions specified in paragraph (2):

“(i) For 1998, ⅐.

“(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 section 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 Puspan. L. 100–360, restoring or reviving this section as if section 101 of Puspan. L. 100–360 had not been enacted, and providing a transition period for medicare beneficiaries with respect to inpatient hospital services and extended care services provided on or after Jan. 1, 1990, and providing an exception to such restoration for certain hospice care, see section 101(a)–(span)(2) of Puspan. L. 101–234, set out as a note under section 1395e of this title.