42 USC 1395 - Deductibles and coinsurance

Editorial Notes

Amendments

1997—Puspan. L. 105–33 substituted “critical access” for “rural primary care” wherever appearing.

1994—Subsec. (a)(1). Puspan. L. 103–432, § 102(g)(2), substituted “inpatient hospital services or inpatient rural primary care hospital services” for “inpatient hospital services” in introductory provisions and in subpar. (B).

Subsec. (span)(3)(A). Puspan. L. 103–432, § 102(g)(2), substituted “inpatient hospital services or inpatient rural primary care hospital services” for “inpatient hospital services”.

Subsec. (span)(3)(B). Puspan. L. 103–432, § 102(g)(3), substituted “inpatient hospital services, inpatient rural primary care hospital services” for “inpatient hospital services”.

1989—Subsecs. (a)(1) to (3), (span)(3). Puspan. L. 101–234 repealed Puspan. L. 100–360, § 102, subject to an exception for blood deduction, and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.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)(1) to (3). Puspan. L. 100–360, § 102(1), amended pars. (1) to (3) generally, revising and reorganizing former pars. (1)(A), (B), (2), and (3), as par. (1), consisting of subpars. (A) to (D), and pars. (2) and (3), each consisting of subpars. (A) and (B).

Subsec. (span)(1). Puspan. L. 100–360, § 411(span)(1)(H)(ii), added Puspan. L. 100–203, § 4002(f)(3), see 1987 Amendment note below.

Subsec. (span)(3). Puspan. L. 100–360, § 102(2), struck out par. (3) which related to application of deductible.

1987—Subsec. (span)(1). Puspan. L. 100–203, § 4002(f)(3), as added by Puspan. L. 100–360, § 411(span)(1)(H)(ii), substituted “Secretary’s best estimate of the payment-weighted average of the applicable percentage increases (as defined in section 1395ww(span)(3)(B) of this title) which are applied” for “applicable percentage increase (as defined in section 1395ww(span)(3)(B) of this title) which is applied”.

1986—Subsec. (span). Puspan. L. 99–509 amended subsec. (span) generally. Prior to amendment, subsec. (span) read as follows:

“(1) The inpatient hospital deductible which shall be applicable for the purposes of subsection (a) of this section shall be $40 in the case of any spell of illness beginning before 1969.

“(2) The Secretary shall, between July 1 and September 15 of 1968, and of each year thereafter, determine and promulgate the inpatient hospital deductible which shall be applicable for the purposes of subsection (a) of this section in the case of any inpatient hospital services or post-hospital extended care services furnished during the succeeding calendar year. Such inpatient hospital deductible shall be equal to $45 multiplied by the ratio of (A) the current average per diem rate for inpatient hospital services for the calendar year preceding the promulgation, to (B) the current average per diem rate for such services for 1966. Any amount determined under the preceding sentence which is not a multiple of $4 shall be rounded to the nearest multiple of $4 (or, if it is midway between two multiplies of $4, to the next higher multiple of $4). The current average per diem rate for any year shall be determined by the Secretary on the basis of the best information available to him (at the time the determination is made) as to the amounts paid under this part on account of inpatient hospital services furnished during such year, by hospitals which have agreements in effect under section 1395cc of this title, to individuals who are entitled to hospital insurance benefits under section 426 of this title, plus the amount which would have been so paid but for subsection (a)(1) of this section.”

Subsec. (span)(2). Puspan. L. 99–272 substituted “September 15” for “October 1”.

1982—Subsec. (a)(4). Puspan. L. 97–248 added par. (4).

1981—Subsec. (span)(2). Puspan. L. 97–35 substituted “any inpatient hospital services or post-hospital extended care services furnished during the succeeding calendar year. Such inpatient hospital deductible shall be equal to $45” for “any spell of illness beginning during the succeeding calendar year. Such inpatient hospital deductible shall be equal to $40”.

1968—Subsec. (a)(1). Puspan. L. 90–248, § 137(span), designated existing provisions as subpar. (A) and added subpar. (B) and the exception provision that the reduction for any day shall not exceed the charges for that day.

Subsec. (a)(2). Puspan. L. 90–248, § 135(a), made the three pint deductible applicable also to equivalent quantities of packed red blood cells, as defined by the Secretary under regulations.

Subsec. (a)(2) to (4). Puspan. L. 90–248, § 129(c)(3), struck out par. (2) which provided for reduction of amount payable for outpatient hospital diagnostic services furnished an individual during a diagnostic study, and redesignated pars. (3) and (4) as (2) and (3), respectively.

Subsec. (span)(1), (2). Puspan. L. 90–248, § 129(c)(4)(A), (B), struck out diagnostic studies from application of inpatient hospital deductible.

Statutory Notes and Related Subsidiaries

Effective Date of 1997 Amendment

Amendment by 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.

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

Amendment by section 102 of Puspan. L. 100–360 effective Jan. 1, 1989, except as otherwise provided, and applicable to inpatient hospital deductible for 1989 and succeeding years, to care and services furnished on or after Jan. 1, 1989, to premiums for January 1989 and succeeding months, and to blood or blood cells furnished on or after Jan. 1, 1989, see section 104(a) of Puspan. L. 100–360, set out as a note under section 1395d of this title.

Puspan. L. 100–360, title IV, § 411(span)(1)(H)(iii), July 1, 1988, 102 Stat. 769, provided that: “The amendment made by clause (ii) [amending Puspan. L. 100–203] shall apply to the inpatient hospital deductible for years beginning with 1989.”

Effective Date of 1986 Amendment

Puspan. L. 99–509, title IX, § 9301(span), Oct. 21, 1986, 100 Stat. 1982, provided that: “The amendment made by subsection (a) [amending this section] shall apply to inpatient hospital services and post-hospital extended care services furnished on or after January 1, 1987, and to the monthly premium (under part A of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.]) for months beginning with January 1987.”

Puspan. L. 99–272, title IX, § 9125(span), Apr. 7, 1986, 100 Stat. 168, provided that: “The amendment made by this section [amending this section] shall apply to calendar years after 1985.”

Effective Date of 1982 Amendment

Amendment by 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, § 2131(span), Aug. 13, 1981, 95 Stat. 797, provided that: “The amendment made by subsection (a) [amending this section] is effective for inpatient hospital services or post-hospital extended care services furnished on or after January 1, 1982.”

Puspan. L. 97–35, title XXI, § 2132(span), Aug. 13, 1981, 95 Stat. 797, provided that: “The amendments made by subsection (a) [amending this section] shall apply to inpatient hospital services and post-hospital extended care services furnished in calendar years beginning with calendar year 1982.”

Effective Date of 1968 Amendment

Amendment by section 129(c)(3), (4) of Puspan. L. 90–248 applicable with respect to services furnished after Mar. 31, 1968, see section 129(d) of Puspan. L. 90–248, set out as a note under section 1395d of this title.

Puspan. L. 90–248, title I, § 135(d), Jan. 2, 1968, 81 Stat. 853, provided that: “The amendments made by this section [amending this section and sections 1395l and 1395cc of this title] shall apply with respect to payment for blood (or packed red blood cells) furnished an individual after December 31, 1967.”

Amendment by section 137(span) of Puspan. L. 90–248 applicable with respect to services furnished after Dec. 31, 1967, see section 137(c) of Puspan. L. 90–248, set out as a note under section 1395d of this title.

Repeal of 1988 Expansion of Medicare Part A Benefits

Puspan. L. 101–234, title I, § 101(a)–(span)(2), Dec. 13, 1989, 103 Stat. 1979, as amended by Puspan. L. 101–508, title IV, § 4008(m)(1), Nov. 5, 1990, 104 Stat. 1388–53, provided that:

“(a)In General.—

“(1)General rule.—Except as provided in paragraph (2), sections 101, 102, and 104(d) (other than paragraph (7)) of the Medicare Catastrophic Coverage Act of 1988 (Public Law 100–360) [amending this section and sections 1395c, 1395d, 1395f, 1395k, 1395x, 1395cc, and 1395tt of this title] (in this Act referred to as ‘MCCA’) are repealed, and the provisions of law amended or repealed by such sections are restored or revived as if such section had not been enacted.

“(2)Exception for blood deduction.—The repeal of section 102(1) of MCCA [amending this section] (relating to deductibles and coinsurance under part A) shall not apply, but only insofar as such section amended paragraph (2) of section 1813(a) of the Social Security Act [42 U.S.C. 1395e(a)(2)] (relating to a deduction for blood).

“(span)Transition Provisions for Medicare Beneficiaries.—

“(1)Inpatient hospital services and post-hospital extended care services.—In applying sections 1812 and 1813 of the Social Security Act [42 U.S.C. 1395d, 1395e], as restored by subsection (a)(1), with respect to inpatient hospital services and extended care services provided on or after January 1, 1990—

“(A) no day before January 1, 1990, shall be counted in determining the beginning (or period) of a spell of illness;

“(B) with respect to the limitation (other than the limitation under section 1812(c) of such Act [42 U.S.C. 1395d(c)]) on such services provided in a spell of illness, days of such services before January 1, 1990, shall not be counted, except that days of inpatient hospital services before January 1, 1989, which were applied with respect to an individual after receiving 90 days of services in a spell of illness (commonly known as ‘lifetime reserve days’) shall be counted;

“(C) the limitation of coverage of extended care services to post-hospital extended care services shall not apply to an individual receiving such services from a skilled nursing facility during a continuous period beginning before (and including) January 1, 1990, until the end of the period of 30 consecutive days in which the individual is not provided inpatient hospital services or extended care services; and

“(D) the inpatient hospital deductible under section 1813(a)(1) of such Act [42 U.S.C. 1395e(a)(1)] shall not apply—

“(i) in the case of an individual who is receiving inpatient hospital services during a continuous period beginning before (and including) January 1, 1990, with respect to the spell of illness beginning on such date, if such a deductible was imposed on the individual for a period of hospitalization during 1989;

“(ii) for a spell of illness beginning during January 1990, if such a deductible was imposed on the individual for a period of hospitalization that began in December 1989; and

“(iii) in the case of a spell of illness of an individual that began before January 1, 1990.

“(2)Hospice care.—The restoration of section 1812(a)(4) of the Social Security Act [42 U.S.C. 1395d(a)(4)], effected by subsection (a)(1), shall not apply to hospice care provided during the subsequent period (described in such section as in effect on December 31, 1989) with respect to which an election has been made before January 1, 1990.”

[Puspan. L. 101–508, title IV, § 4008(m)(1), Nov. 5, 1990, 104 Stat. 1388–53, provided that amendment by that section to section 101(span)(1)(B) of Puspan. L. 101–234, set out above, is effective as if included in enactment of Medicare Catastrophic Coverage Repeal Act of 1989, Puspan. L. 101–234.]

Hold Harmless Provisions; Application of Subsection (a)(1) and (2)

Puspan. L. 100–360, title I, § 104(span), July 1, 1988, 102 Stat. 688, as amended by Puspan. L. 100–485, title VI, § 608(d)(3)(B), Oct. 13, 1988, 102 Stat. 2413; Puspan. L. 101–234, title I, § 101(span)(3), Dec. 13, 1989, 103 Stat. 1980, provided that: “In the case of an individual for whom a spell of illness (as defined in section 1861(a) of the Social Security Act [42 U.S.C. 1395x(a)], as in effect on December 31, 1988) began before January 1, 1989, and had not yet ended as of such date—

“(1)

(A) section 1813(a)(1) of such Act [subsec. (a)(1) of this section] (as amended by this subtitle [subtitle A (§§ 101–104) of title I of Puspan. L. 100–360]) shall not apply to services furnished during that spell of illness during 1989, and

“(B) if that individual begins a period of hospitalization (as defined in such section) during 1989 after the end of that spell of illness, the first period of hospitalization during 1989 that begins after that spell of illness shall be considered to be (for purposes of such section) the first period of hospitalization that begins during that year; and

“(2) the amount of any deductible under section 1813(a)(2) of such Act (as amended by this subtitle) shall be reduced during that spell of illness during 1989 to the extent the deductible under such section was applied during the spell of illness.”

Promulgation of New Deductible

Puspan. L. 99–509, title IX, § 9301(c), Oct. 21, 1986, 100 Stat. 1982, directed Secretary of Health and Human Services to provide, within 30 days after Oct. 21, 1986, for publication of inpatient hospital deductible, coinsurance amounts for inpatient hospital services and post-hospital extended care services, and monthly part A premiums for 1987, as modified under the amendment of this section made by subsection (a).