The Omnibus Budget Reconciliation Act of 1990, referred to in subsec. (span)(14)(A)(ii), is Puspan. L. 101–508, Nov. 5, 1990, 104 Stat. 1388. For complete classification of this Act to the Code, see Tables.

Section 303 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to in subsec. (o)(5)(B), is section 303 of Puspan. L. 108–173, which enacted sections 1395w–3a and 1395w–3span of this title, amended this section and sections 1395l, 1395w–4, 1395x, 1395y, and 1396r–8 of this title, enacted provisions set out as notes under this section and sections 1395w–3a, 1395w–3span, and 1395w–4 of this title, and repealed provisions set out as a note under this section.

Section 101 of the Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act of 2012, referred to in subsec. (o)(8), is section 101 of Puspan. L. 112–242, which is set out as a note under section 1395l of this title.

2022—Subsec. (span)(18)(C)(vii), (viii). Puspan. L. 117–328, § 4121(a)(5), added cls. (vii) and (viii).

Subsec. (o)(8). Puspan. L. 117–328, § 4134(span), added par. (8).

2020—Subsec. (span)(6)(C). Puspan. L. 116–260 inserted “for such services furnished before January 1, 2022,” after “section 1395x(s)(2)(K) of this title,”.

2018—Subsec. (span)(6)(I). Puspan. L. 115–123 inserted “or, in the case of items and services described in clause (i) of section 1395m(u)(7)(A) of this title furnished to an individual during the period described in clause (ii) of such section, payment shall be made to the eligible home infusion therapy supplier” after “payment shall be made to the qualified home infusion therapy supplier”.

2016—Subsec. (span)(6)(I). Puspan. L. 114–255, § 5012(c)(2), added subpar. (I).

Subsec. (span)(6)(J). Puspan. L. 114–255, § 16006(a), added subpar. (J).

Subsec. (o)(1)(C). Puspan. L. 114–255, § 5004(a)(1), inserted “(and including a drug or biological described in subparagraph (D)(i) furnished on or after January 1, 2017)” after “2005”.

Subsec. (o)(1)(D)(i). Puspan. L. 114–255, § 5004(a)(2), substituted “infusion drugs or biologicals” for “infusion drugs” and “2004, and before January 1, 2017” for “2004” and struck out “for such drug” after “average wholesale price”.

Subsec. (o)(1)(D)(ii). Puspan. L. 114–255, § 5004(a)(2)(A), (span)(2), substituted “infusion drugs or biologicals” for “infusion drugs” and “2007, and before December 13, 2016.” for “2007”.

Subsec. (s)(3)(B). Puspan. L. 114–255, § 16008(span)(2), substituted “subject to section 1395m(a)(1)(G) of this title, the Secretary” for “the Secretary”.

2012—Subsec. (t). Puspan. L. 112–96 designated existing provisions as par. (1) and added par. (2).

2011—Subsec. (l)(1)(A)(iii)(I), (2). Puspan. L. 112–40 substituted “quality improvement organization” for “peer review organization”.

2010—Subsec. (span)(3). Puspan. L. 111–148, § 6404(a)(2)(A)(ii), at end of concluding provisions, inserted “In applying subparagraph (B), the Secretary may specify exceptions to the 1 calendar year period specified in such subparagraph.”

Subsec. (span)(3)(B). Puspan. L. 111–148, § 6404(a)(2)(A)(i), substituted “period ending 1 calendar year after the date of service” for “close of the calendar year following the year in which such service is furnished (deeming any service furnished in the last 3 months of any calendar year to have been furnished in the succeeding calendar year)” in concluding provisions.

Subsec. (h)(9). Puspan. L. 111–148, § 6406(a), added par. (9).

Subsec. (s)(1). Puspan. L. 111–148, § 3401(o), designated existing provisions as subpar. (A), added subpar. (B) and concluding provisions, and struck out former second sentence, which read as follows: “Any fee schedule established under this paragraph for such item or service shall be updated each year by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, except that for items and services described in paragraph (2)(D)—

“(A) for 2009 section 1395m(a)(14)(J)(i) of this title shall apply under this paragraph instead of the percentage increase otherwise applicable; and

“(B) for 2014, if subparagraph (A) is applied to the items and services and there has not been a payment adjustment under paragraph (3)(B) for the items and services for any previous year, the percentage increase computed under section 1395m(a)(14)(L)(i) of this title shall apply instead of the percentage increase otherwise applicable.”

2008—Subsec. (span)(6)(D)(iii). Puspan. L. 110–275, § 137, struck out “(before July 1, 2008)” after “or are provided”.

Subsec. (s)(1). Puspan. L. 110–275, § 154(a)(2)(B), substituted “except that for items and services described in paragraph (2)(D)—” for “except that in no event shall a fee schedule for an item described in paragraph (2)(D) be updated before 2003.” and added subpars. (A) and (B).

2007—Subsec. (span)(6)(D)(iii). Puspan. L. 110–173 substituted “July 1, 2008” for “January 1, 2008”.

Puspan. L. 110–54 inserted “or are provided (before January 1, 2008) over a longer continuous period during all of which the first physician has been called or ordered to active duty as a member of a reserve component of the Armed Forces” after “of more than 60 days”.

2006—Subsec. (span)(6)(H). Puspan. L. 109–432, §§ 205(span)(2), 405(c)(2)(A)(i), amended directory language of Puspan. L. 109–171, § 5114(a)(2), identically, making technical correction. See below.

Puspan. L. 109–171, § 5114(a)(2), as amended by Puspan. L. 109–432, §§ 205(span)(2), 405(c)(2)(A)(i), added subpar. (H).

Subsec. (c)(3)(B)(ii). Puspan. L. 109–171, § 5202(a)(2), substituted “28 days” for “26 days”.

Subsec. (u). Puspan. L. 109–432, § 110(a), added subsec. (u).

2003—Puspan. L. 108–173, § 911(c)(1), substituted “Provisions relating to the administration of part B” for “Use of carriers for administration of benefits” in section catchline.

Subsec. (a). Puspan. L. 108–173, § 911(c)(2), amended subsec. (a) generally. Prior to amendment, subsec. (a) authorized the Secretary to enter into contracts with carriers for the administration of benefits under this part.

Subsec. (span)(1). Puspan. L. 108–173, § 911(c)(3)(A), struck out par. (1), which provided that contracts with carriers under subsection (a) could be entered into without regard to section 5 of title 41 or any other provision of law requiring competitive bidding.

Subsec. (span)(2)(A), (B). Puspan. L. 108–173, § 911(c)(3)(B)(i), struck out subpars. (A) and (B), which conditioned entering into contract on Secretary’s finding that carrier would perform obligations efficiently and effectively, provided for establishment and publication of standards and criteria for efficient and effective performance, and directed Secretary to establish standards for evaluating carriers’ performance of reviews of initial carrier determinations and of fair hearings under former paragraph (3)(C).

Subsec. (span)(2)(C). Puspan. L. 108–173, § 911(c)(3)(B)(ii), substituted “medicare administrative contractors” for “carriers”.

Subsec. (span)(2)(D), (E). Puspan. L. 108–173, § 911(c)(3)(B)(iii), struck out subpars. (D) and (E), which directed that carrier be subject to standards and criteria relating to the carrier’s success in recovering payments for items or services for which payment has been or could be made under a primary plan and that Secretary could continue administration of claims for certain home health services through fiscal intermediaries under section 1395h of this title.

Subsec. (span)(3). Puspan. L. 108–173, § 911(c)(3)(C)(ix), inserted “medicare administrative contractor,” after “carrier,” in seventh sentence in concluding provisions.

Puspan. L. 108–173, § 911(c)(3)(C)(viii), struck out “and shall contain such other terms and conditions not inconsistent with this section as the Secretary may find necessary or appropriate.” before “In determining” in concluding provisions.

Puspan. L. 108–173, § 911(c)(3)(C)(i), substituted “The Secretary” for “Each such contract shall provide that the carrier” in introductory provisions.

Subsec. (span)(3)(A). Puspan. L. 108–173, § 911(c)(3)(C)(ii), substituted “shall take such action” for “will take such action”.

Subsec. (span)(3)(B). Puspan. L. 108–173, § 911(c)(3)(C)(iii), substituted “to the policyholders and subscribers of the medicare administrative contractor” for “to the policyholders and subscribers of the carrier” in introductory provisions.

Puspan. L. 108–173, § 911(c)(3)(C)(ii), substituted “shall take such action” for “will take such action” in introductory provisions.

Subsec. (span)(3)(C) to (E). Puspan. L. 108–173, § 911(c)(3)(C)(iv), struck out subpars. (C) to (E), which directed that each contract provide that the carrier would establish and maintain procedures for a fair hearing in any case where the amount in controversy was between $100 and $500, that the carrier would furnish to the Secretary such information and reports as he would find necessary in performing his functions under this part, and that the carrier would maintain such records and afford such access thereto as the Secretary would find necessary to assure the correctness and verification of the information and reports under former subpar. (D) and otherwise to carry out the purposes of this part.

Subsec. (span)(3)(F). Puspan. L. 108–173, § 911(c)(3)(C)(ii), substituted “shall take such action” for “will take such action”.

Subsec. (span)(3)(G). Puspan. L. 108–173, § 911(c)(3)(C)(ii), substituted “shall, for a service” for “will, for a service” in introductory provisions.

Subsec. (span)(3)(H). Puspan. L. 108–173, § 911(c)(3)(C)(v)(I), struck out “if it makes determinations or payments with respect to physicians’ services,” before “shall implement” in introductory provisions.

Puspan. L. 108–173, § 911(c)(3)(C)(ii), substituted “shall implement” for “will implement” in introductory provisions.

Subsec. (span)(3)(H)(i). Puspan. L. 108–173, § 911(c)(3)(C)(v)(II), substituted “medicare administrative contractor” for “carrier”.

Subsec. (span)(3)(I). Puspan. L. 108–173, § 911(c)(3)(C)(vi), struck out subpar. (I), which directed that each contract would require the carrier to submit annual reports to the Secretary describing steps taken to recover payments made under this part for items or services for which payment had been or could have been made under a primary plan.

Subsec. (span)(3)(L). Puspan. L. 108–173, § 911(c)(3)(C)(vii), substituted period for semicolon at end.

Puspan. L. 108–173, § 911(c)(3)(C)(ii), substituted “shall monitor” for “will monitor”.

Subsec. (span)(5). Puspan. L. 108–173, § 911(c)(3)(D), struck out par. (5), which provided that each contract under this section would be for a term of at least one year and could be made automatically renewable and authorized Secretary to terminate any contract where carrier had failed substantially to carry out the contract or was carrying out the contract in a manner inconsistent with the efficient and effective administration of the insurance program established by this part.

Subsec. (span)(6). Puspan. L. 108–173, § 952(span), substituted “except to an employer or entity as described in subparagraph (A)” for “except to an employer or facility as described in clause (A)” in second sentence.

Subsec. (span)(6)(A)(ii). Puspan. L. 108–173, § 952(a), added cl. (ii) and struck out former cl. (ii) which read as follows: “(where the service was provided in a hospital, critical access hospital, clinic, or other facility) to the facility in which the service was provided if there is a contractual arrangement between such physician or other person and such facility under which such facility submits the bill for such service,”.

Subsec. (span)(6)(D)(iv). Puspan. L. 108–173, § 911(c)(3)(E), substituted “medicare administrative contractor” for “carrier”.

Subsec. (span)(7). Puspan. L. 108–173, § 911(c)(3)(F), substituted “the Secretary” for “the carrier” in introductory provisions of subpar. (A), before “shall take into account” in subpar. (B)(i), in introductory provisions of subpar. (B)(ii), and before “shall provide” in subpar. (C).

Subsec. (c)(1). Puspan. L. 108–173, § 911(c)(4)(A), struck out par. (1), which provided that any contract entered into with a carrier under this section would provide for advances of funds for the making of payments and for payment for necessary and proper cost of administration, and directed the Secretary to cause to have published in the Federal Register, by not later than Sept. 1 each year, data, standards, and methodology to be used to establish budgets for carriers and to cause to be published in the Federal Register for public comment, at least 90 days before Sept. 1, the data, standards, and methodology proposed to be used.

Subsec. (c)(2)(A). Puspan. L. 108–173, § 911(c)(4)(B), substituted “contract under section 1395kk–1 of this title that provides for making payments under this part” for “contract under this section which provides for the disbursement of funds, as described in subsection (a)(1)(B) of this section,” in introductory provisions.

Subsec. (c)(2)(B)(ii)(III). Puspan. L. 108–173, § 736(span)(8)(A), struck out “and” at end.

Subsec. (c)(2)(B)(ii)(IV). Puspan. L. 108–173, § 736(span)(8)(B), substituted “, and” for period at end.

Subsec. (c)(3)(A). Puspan. L. 108–173, § 911(c)(4)(C), substituted “section 1395kk–1(a)(3)(B) of this title” for “subsection (a)(1)(B) of this section”.

Subsec. (c)(4). Puspan. L. 108–173, § 911(c)(4)(D), substituted “medicare administrative contractor” for “carrier” in introductory provisions.

Subsec. (c)(5), (6). Puspan. L. 108–173, § 911(c)(4)(E), struck out pars. (5) and (6), which provided that each contract would require the carrier to meet criteria to measure the timeliness of responses to requests for payment of items described in section 1395m(a)(15)(C) of this title and prohibited any carrier from carrying out any activity pursuant to a contract under the Medicare Integrity Program under section 1395ddd of this title.

Subsec. (d) to (f). Puspan. L. 108–173, § 911(c)(5), struck out subsecs. (d) to (f), which provided that contracts under this section could require surety bonds and that certifying or disbursing officers or carriers would not be liable with respect to payments in the absence of gross negligence or intent to defraud and defined “carrier” for purposes of this part.

Subsec. (g). Puspan. L. 108–173, § 911(c)(6), substituted “medicare administrative contractor or contractors” for “carrier or carriers”.

Subsec. (h)(2). Puspan. L. 108–173, § 911(c)(7)(A), substituted “The Secretary” for “Each carrier having an agreement with the Secretary under subsection (a) of this section” in first sentence and for “Each such carrier” in last sentence.

Subsec. (h)(3)(A). Puspan. L. 108–173, § 911(c)(7)(B)(ii), which directed substitution of “such contractor” for “such carrier”, was executed by making the substitution in two places to reflect the probable intent of Congress.

Puspan. L. 108–173, § 911(c)(7)(B)(i), substituted “medicare administrative contractor having a contract under section 1395kk–1 of this title that provides for making payments under this part” for “a carrier having an agreement with the Secretary under subsection (a) of this section”.

Subsec. (h)(3)(B). Puspan. L. 108–173, § 911(c)(7)(C), substituted “a medicare administrative contractor” for “a carrier” in two places and “the contractor” for “the carrier” in two places.

Subsec. (h)(5)(A), (B)(iii). Puspan. L. 108–173, § 911(c)(7)(D), substituted “medicare administrative contractors” for “carriers”.

Subsec. (i)(2). Puspan. L. 108–173, § 736(span)(9), substituted “services, to a physician” for “services, a physician”.

Subsec. (l)(1)(A)(iii), (2). Puspan. L. 108–173, § 911(c)(8), substituted “medicare administrative contractor” for “carrier”.

Subsec. (o)(1). Puspan. L. 108–173, § 303(span)(1), substituted “equal to the following:” for “equal to 95 percent of the average wholesale price.” and added subpars. (A) to (G).

Subsec. (o)(1)(G). Puspan. L. 108–173, § 305(a), amended subpar. (G) generally. Prior to amendment, subpar. (G) read as follows: “The provisions of subparagraphs (A) through (F) of this paragraph shall not apply to an inhalation drug or biological furnished through durable medical equipment covered under section 1395x(n) of this title.”

Subsec. (o)(2). Puspan. L. 108–173, § 303(i)(1), inserted at end “This paragraph shall not apply in the case of payment under paragraph (1)(C).”

Subsec. (o)(4). Puspan. L. 108–173, § 303(span)(2), added par. (4).

Subsec. (o)(5), (6). Puspan. L. 108–173, § 303(e), added pars. (5) and (6).

Subsec. (o)(7). Puspan. L. 108–173, § 303(g)(1), added par. (7).

Subsec. (p)(3)(A). Puspan. L. 108–173, § 911(c)(9), substituted “medicare administrative contractor” for “carrier”.

Subsec. (q)(1)(A). Puspan. L. 108–173, § 911(c)(10), struck out “carrier” before “localities”.

Subsec. (s)(1). Puspan. L. 108–173, § 302(d)(3)(A), substituted “Subject to paragraph (3), the Secretary” for “The Secretary”.

Subsec. (s)(2)(C). Puspan. L. 108–173, § 627(span)(2), struck out subpar. (C) which read as follows: “Therapeutic shoes.”

Subsec. (s)(3). Puspan. L. 108–173, § 302(d)(3)(B), added par. (3).

2000—Subsec. (span)(6)(C). Puspan. L. 106–554, § 1(a)(6) [title II, § 222(a)], struck out “for such services provided before January 1, 2003,” before “payment may be made” and substituted comma for semicolon at end.

Subsec. (span)(6)(E). Puspan. L. 106–554, § 1(a)(6) [title III, § 313(span)(1)], inserted “by, or under arrangements made by, a skilled nursing facility” before “to an individual who” and struck out “or of a part of a facility that includes a skilled nursing facility (as determined under regulations)” before “, payment shall be made” and “(without regard to whether or not the item or service was furnished by the facility, by others under arrangement with them made by the facility, under any other contracting or consulting arrangement, or otherwise)” after “to the facility”.

Subsec. (span)(6)(G). Puspan. L. 106–554, § 1(a)(6) [title IV, § 432(span)(2)], added subpar. (G).

Subsec. (span)(18)(C)(vi). Puspan. L. 106–554, § 1(a)(6) [title I, § 105(d)], added cl. (vi).

Subsec. (o)(3). Puspan. L. 106–554, § 1(a)(6) [title I, § 114(a)], added par. (3).

Subsec. (t). Puspan. L. 106–554, § 1(a)(6) [title III, § 313(span)(2)], struck out “by a physician” before “to an individual” and “or of a part of a facility that includes a skilled nursing facility (as determined under regulations),” before “for which payment may be made”.

1999—Subsec. (span)(6)(F). Puspan. L. 106–113, § 1000(a)(6) [title III, § 305(a)], inserted “(including medical supplies described in section 1395x(m)(5) of this title, but excluding durable medical equipment to the extent provided for in such section)” after “home health services”.

Subsec. (span)(8)(A)(i)(I). Puspan. L. 106–113, § 1000(a)(6) [title II, § 223(c)], substituted “the application of this subchapter to payment under this part” for “the application of this part”.

Subsec. (s)(2)(E). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(4)], inserted period at end.

1997—Subsec. (span)(2)(E). Puspan. L. 105–33, § 4611(d), added subpar. (E).

Subsec. (span)(6). Puspan. L. 105–33, § 4512(c), inserted at end “For purposes of subparagraph (C) of the first sentence of this paragraph, an employment relationship may include any independent contractor arrangement, and employer status shall be determined in accordance with the law of the State in which the services described in such clause are performed.”

Subsec. (span)(6)(A)(ii). Puspan. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.

Subsec. (span)(6)(C). Puspan. L. 105–33, § 4205(d)(3)(B), amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: “in the case of services described in clauses (i), (ii), or (iv) of section 1395x(s)(2)(K) of this title payment shall be made to the employer of the physician assistant or nurse practitioner involved, and”.

Subsec. (span)(6)(E). Puspan. L. 105–33, § 4432(span)(2), added subpar. (E).

Subsec. (span)(6)(F). Puspan. L. 105–33, § 4603(c)(2)(B)(i), added subpar. (F).

Subsec. (span)(8), (9). Puspan. L. 105–33, § 4316(a), amended pars. (8) and (9) generally. Prior to amendment, par. (8) related to determination of reasonable charges for physician services, including factors to be considered, provision for increase or decrease of charge, consideration of resource costs, accounting for regional differences in prevailing charges, and impact of changes in reasonable charges, and par. (9) related to notice of proposed reasonable charges to be published in Federal Register, provision for comments on proposed changes, and publication of final determinations with respect to change in reasonable charges.

Subsec. (span)(12). Puspan. L. 105–33, § 4512(span)(2), struck out par. (12) which read as follows:

“(12)(A) With respect to services described in clauses (i), (ii), or (iv) of section 1395x(s)(2)(K) of this title (relating to a physician assistants and nurse practitioners)—

“(i) payment under this part may only be made on an assignment-related basis; and

“(ii) the prevailing charges determined under paragraph (3) shall not exceed—

“(I) in the case of services performed as an assistant at surgery, 65 percent of the amount that would otherwise be recognized if performed by a physician who is serving as an assistant at surgery, or

“(II) in other cases, the applicable percentage (as defined in subparagraph (B)) of the prevailing charge rate determined for such services (or, for services furnished on or after January 1, 1992, the fee schedule amount specified in section 1395w–4 of this title) performed by physicians who are not specialists.

“(B) In subparagraph (A)(ii)(II), the term ‘applicable percentage’ means—

“(i) 75 percent in the case of services performed (other than as an assistant at surgery) in a hospital, and

“(ii) 85 percent in the case of other services.”

Subsec. (span)(19). Puspan. L. 105–33, § 4531(a)(2), added par. (19).

Subsec. (h)(8). Puspan. L. 105–33, § 4302(span), added par. (8).

Subsec. (o). Puspan. L. 105–33, § 4556(a), added subsec. (o).

Subsec. (p)(1), (2). Puspan. L. 105–33, § 4317(a), inserted “or practitioner specified in subsection (span)(18)(C)” after “by a physician”.

Subsec. (p)(4). Puspan. L. 105–33, § 4317(span), added par. (4).

Subsec. (s). Puspan. L. 105–33, § 4315(a), added subsec. (s).

Subsec. (t). Puspan. L. 105–33, § 4432(span)(4), added subsec. (t).

1996—Subsec. (c)(6). Puspan. L. 104–191, § 202(span)(2), added par. (6).

Subsec. (r). Puspan. L. 104–191, § 221(span), inserted at end “Under such system, the Secretary may impose appropriate fees on such physicians to cover the costs of investigation and recertification activities with respect to the issuance of the identifiers.”

1994—Subsec. (span)(2)(A). Puspan. L. 103–432, § 126(g)(9), made technical amendment to directory language of Puspan. L. 101–508, § 4118(j)(2). See 1990 Amendment note below.

Subsec. (span)(2)(D). Puspan. L. 103–432, § 151(span)(2)(B), added subpar. (D).

Subsec. (span)(3)(G). Puspan. L. 103–432, § 151(span)(1)(B)(i), which directed striking out “and” at end of subpar. (G), could not be executed because “and” did not appear at end of subpar. (G) subsequent to amendment by Puspan. L. 103–432, § 123(c)(2). See below.

Puspan. L. 103–432, § 123(c)(2), amended subpar. (G) generally. Prior to amendment, subpar. (G) read as follows: “will provide to each nonparticipating physician, at the beginning of each year, a list of the physician’s limiting charges established under section 1395w–4(g)(2) of this title for the year for the physicians’ services mostly commonly furnished by that physician; and”.

Subsec. (span)(3)(H). Puspan. L. 103–432, § 151(span)(1)(B)(ii), which directed striking out “and” at end of subpar. (H), could not be executed because “and” does not appear at end.

Subsec. (span)(3)(I). Puspan. L. 103–432, § 151(span)(1)(B)(iii), added subpar. (I).

Subsec. (span)(6)(D). Puspan. L. 103–432, § 125(span)(1), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: “payment may be made to a physician who arranges for visit services (including emergency visits and related services) to be provided to an individual by a second physician on an occasional, reciprocal basis if (i) the first physician is unavailable to provide the visit services, (ii) the individual has arranged or seeks to receive the visit services from the first physician, (iii) the claim form submitted to the carrier includes the second physician’s unique identifier (provided under the system established under subsection (r) of this section) and indicates that the claim is for such a ‘covered visit service (and related services)’, and (iv) the visit services are not provided by the second physician over a continuous period of longer than 60 days.”

Subsec. (span)(12)(C). Puspan. L. 103–432, § 123(span)(2)(B), struck out subpar. (C). Prior to amendment, subpar. (C) read as follows: “Except for deductible and coinsurance amounts applicable under section 1395l of this title, any person who knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services described in clauses (i), (ii), or (iv) of section 1395x(s)(2)(K) of this title in violation of subparagraph (A)(i) is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (span)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

Subsec. (span)(16)(B)(iii). Puspan. L. 103–432, § 126(a)(1), struck out “, simple and subcutaneous” after “Partial”, substituted “injections and small joint” for “injections; small joint” and “femoral fracture and” for “femoral fracture treatments;”, struck out “lobectomy;” after “thoracostomy;” and “enterectomy; colectomy; cholecystectomy;” after “aneurysm repair;”, substituted “fulguration and resection” for “fulguration; transurerethral resection”, and struck out “sacral laminectomy;” before “tympanoplasty”.

Subsec. (span)(17). Puspan. L. 103–432, § 126(e), redesignated par. (18), relating to payment for technical component of diagnostic tests, as (17) and inserted “, tests specified in paragraph (14)(C)(i),” after “diagnostic laboratory tests”.

Subsec. (span)(18). Puspan. L. 103–432, § 126(e), redesignated par. (18), relating to payment for technical component of diagnostic tests, as (17).

Puspan. L. 103–432, § 123(span)(1), added par. (18), relating to payment for service furnished by a practitioner described in subpar. (C).

Subsec. (c)(1). Puspan. L. 103–432, § 126(h)(2), struck out subpar. (A) designation before “Any contract entered” and struck out subpar. (B) which read as follows: “Of the amounts appropriated for administrative activities to carry out this part, the Secretary shall provide payments, totaling 1 percent of the total payments to carriers for claims processing in any fiscal year, to carriers under this section, to reward carriers for their success in increasing the proportion of physicians in the carrier’s service area who are participating physicians or in increasing the proportion of total payments for physicians’ services which are payments for such services rendered by participating physicians.”

Subsec. (c)(4). Puspan. L. 103–432, § 125(a), added par. (4).

Subsec. (c)(5). Puspan. L. 103–432, § 135(span)(2), added par. (5).

Subsec. (h)(7)(C). Puspan. L. 103–432, § 123(c)(1)(B), struck out “shall include” before cl. (i).

Subsec. (h)(7)(D). Puspan. L. 103–432, § 123(c)(1)(A), (C), (D), added subpar. (D).

Subsec. (q)(1). Puspan. L. 103–432, § 126(c)(1), made technical amendment to Puspan. L. 101–508, § 4103(a). See 1990 Amendment note below.

Subsec. (q)(1)(B). Puspan. L. 103–432, § 126(c)(2)(A), substituted “shall, subject to clause (iv), be reduced to the adjusted prevailing charge conversion factor for the locality determined as follows:” for “shall be determined as follows:” in introductory provisions.

Subsec. (q)(1)(B)(iii). Puspan. L. 103–432, § 126(c)(2)(B), substituted “The adjusted prevailing charge conversion factor for” for “Subject to clause (iv), the prevailing charge conversion factor to be applied in”.

1993—Subsec. (span)(4)(F). Puspan. L. 103–66, § 13515(a)(2), struck out subpar. (F) which related to prevailing charge or fee schedule amount in case of professional services of health care practitioner (other than primary care services and other than services furnished in rural area designated as health professional shortage area) furnished during practitioner’s first through fourth years of practice.

Subsec. (span)(13)(A). Puspan. L. 103–66, § 13516(a)(2)(A), added subpar. (A) and struck out former subpar. (A) which read as follows: “In determining the reasonable charge under paragraph (3) of a physician for medical direction of two or more nurse anesthetists performing, on or after April 1, 1988, and before January 1, 1996, anesthesia services in whole or in part concurrently, the number of base units which may be recognized with respect to such medical direction for each concurrent procedure (other than cataract surgery or an iridectomy) shall be reduced by—

“(i) 10 percent, in the case of medical direction of 2 nurse anesthetists concurrently,

“(ii) 25 percent, in the case of medical direction of 3 nurse anesthetists concurrently, and

“(iii) 40 percent, in the case of medical direction of 4 nurse anesthetists concurrently.”

Subsec. (span)(13)(B), (C). Puspan. L. 103–66, § 13516(a)(2), redesignated subpar. (C) as (B), substituted “subparagraph (A)” for “subparagraph (A) or (B)”, and struck out former subpar. (B) which read as follows: “In determining the reasonable charge under paragraph (3) of a physician for medical direction of two or more nurse anesthetists performing, on or after January 1, 1989, and before January 1, 1996, anesthesia services in whole or in part concurrently, the number of base units which may be recognized with respect to such medical direction for each concurrent cataract surgery or iridectomy procedure shall be reduced by 10 percent.”

Subsec. (c)(2)(B)(ii). Puspan. L. 103–66, § 13568(span), substituted “period ending on or before September 30, 1993” for “period” in subcl. (IV) and added subcl. (V).

Subsec. (c)(3)(B). Puspan. L. 103–66, § 13568(a), added cls. (i) and (ii) and struck out former cls. (i) and (ii) which read as follows:

“(i) with respect to claims received in the 3-month period beginning July 1, 1988, 10 days, and

“(ii) with respect to claims received in the 12-month period beginning October 1, 1988, 14 days.”

Subsec. (i)(2). Puspan. L. 103–66, § 13517(span), substituted “; the term” for “, and the term” and inserted before period at end “; and the term ‘nonparticipating supplier or other person’ means a supplier or other person (excluding a provider of services) that is not a participating physician or supplier (as defined in subsection (h)(1))”.

1990—Subsec. (span)(2)(A). Puspan. L. 101–508, § 4118(j)(2), as amended by Puspan. L. 103–432, § 126(g)(9), substituted “section 1395w–1(e)(2)” for “section 1395w–1(f)(2)”.

Subsec. (span)(3)(G). Puspan. L. 101–508, § 4118(f)(2)(B), substituted “section 1395w–4(g)(2) of this title” for “subsection (j)(1)(C) of this section”.

Subsec. (span)(4)(A)(vi). Puspan. L. 101–508, § 4105(span)(1), substituted “60 percent” for “50 percent”.

Subsec. (span)(4)(B)(iv). Puspan. L. 101–508, § 4105(a)(2), added cl. (iv).

Subsec. (span)(4)(E)(iv)(I). Puspan. L. 101–508, § 4118(a)(2), substituted “the list referred to in paragraph (14)(C)(i)” for “Table #2 in the Joint Explanatory Statement of the Committee of Conference submitted with the Conference Report to accompany H.R. 3299 (the ‘Omnibus Budget Reconciliation Act of 1989’), 101st Congress”.

Subsec. (span)(4)(E)(v). Puspan. L. 101–508, § 4105(a)(1), added cl. (v).

Subsec. (span)(4)(F). Puspan. L. 101–508, § 4106(a)(1), amended subpar. (F) generally. Prior to amendment, subpar. (F) read as follows: “In determining the customary charges for physicians’ services furnished during a calendar year (other than primary care services and other than services furnished in a rural area (as defined in section 1395ww(d)(2)(D) of this title) that is designated, under section 254e(a)(1)(A) of this title, as a health manpower shortage area) for which adequate actual charge data are not available because a physician has not yet been in practice for a sufficient period of time, the Secretary shall set a customary charge at a level no higher than 80 percent of the prevailing charge for a service. For the first calendar year during which the preceding sentence no longer applies, the Secretary shall set the customary charge at a level no higher than 85 percent of the prevailing charge for the service.”

Subsec. (span)(4)(F)(i). Puspan. L. 101–597 substituted “health professional shortage area” for “health manpower shortage area”.

Puspan. L. 101–508, § 4106(span)(2)(A), (B), substituted “professional services” for “physicians’ services and professional services” and “practitioner’s first” for “physician’s or practitioner’s first”.

Subsec. (span)(4)(F)(ii)(II). Puspan. L. 101–508, § 4106(span)(2)(C), substituted “practitioner” for “physician or practitioner” in two places.

Subsec. (span)(6)(C). Puspan. L. 101–508, § 4155(c), substituted “clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)” for “section 1395x(s)(2)(K)”.

Subsec. (span)(6)(D). Puspan. L. 101–508, § 4110(a), added subpar. (D).

Subsec. (span)(12)(A). Puspan. L. 101–508, § 4155(c), substituted “clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)” for “section 1395x(s)(2)(K)” in introductory provisions.

Subsec. (span)(12)(A)(ii)(II). Puspan. L. 101–508, § 4118(f)(2)(C), struck out “, as the case may be” after “section 1395w–4 of this title”.

Puspan. L. 101–508, § 4118(f)(2)(A), made technical correction to Puspan. L. 101–239, § 6102(e)(4). See 1989 Amendment note below.

Subsec. (span)(12)(C). Puspan. L. 101–508, § 4155(c), substituted “clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)” for “section 1395x(s)(2)(K)”.

Subsec. (span)(13)(A), (B). Puspan. L. 101–508, § 4103(span), substituted “1996” for “1991”.

Subsec. (span)(14)(A). Puspan. L. 101–508, § 4101(a), designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (span)(14)(B)(iii)(I). Puspan. L. 101–508, § 4118(a)(1)(A), which directed amendment of subcl. (I) by substituting “practice expense component (percent), divided by 100, specified in appendix A (pages 187 through 194) of the Report of the Medicare and Medicaid Health Budget Reconciliation Amendments of 1989, prepared by the Subcommittee on Health and the Environment of the Committee on Energy and Commerce, House of Representatives, (Committee Print 101–M, 101st Congress, 1st Session) for the service” for “practice expense ratio for the service (specified in table #1 in the Joint Explanatory Statement referred to in subparagraph (C)(i))”, was executed by making the substitution for “practice expense ratio for the service (specified in Table #1 in the Joint Explanatory Statement referred to in subparagraph (C)(i))” to reflect the probable intent of Congress.

Subsec. (span)(14)(B)(iii)(II). Puspan. L. 101–508, § 4118(a)(1)(B), substituted “practice expense component (percent), divided by 100” for “practice expense ratio”.

Subsec. (span)(14)(C)(i). Puspan. L. 101–508, § 4118(a)(1)(C), substituted “procedures specified (by code and description) in the Overvalued Procedures List for Finance Committee, Revised September 20, 1989, prepared by the Physician Payment Review Commission” for “physicians’ services specified in Table #2 in the Joint Explanatory Statement of the Committee of Conference submitted with the Conference Report to accompany H.R. 3299 (the ‘Omnibus Budget Reconciliation Act of 1989’), 101st Congress,”.

Subsec. (span)(14)(C)(iii). Puspan. L. 101–508, § 4118(a)(1)(D), which directed amendment of cl. (iii) by substituting “The ‘percentage change’ specified in this clause, for a physicians’ service specified in clause (i), is the percent difference (but expressed as a positive number) specified for the service in the list” for “The ‘percent change’ specified in this clause, for a physicians’ service specified in clause (i), is the percent change specified for the service in table #2 in the Joint Explanatory Statement”, was executed by making the substitution for “The ‘percent change’ specified in this clause, for a physicians’ service specified in clause (i), is the percent change specified for the service in Table #2 in the Joint Explanatory Statement” to reflect the probable intent of Congress.

Subsec. (span)(14)(C)(iv). Puspan. L. 101–508, § 4118(a)(1)(E), which directed amendment of cl. (iv) by substituting “the Geographic Overhead Costs Index specified for the locality in table 1 of the September 1989 Supplement to the Geographic Medicare Economic Index: Alternative Approaches (prepared by the Urban Institute and the Center for Health Economics Research)” for “such value specified for the locality in table #3 in the Joint Explanatory Statement referred to in clause (i)”, was executed by making the substitution for “such value specified for the locality in Table #3 in the Joint Explanatory Statement referred to in clause (i)” to reflect the probable intent of Congress.

Subsec. (span)(16). Puspan. L. 101–508, § 4101(span), added par. (16).

Subsec. (span)(18). Puspan. L. 101–508, § 4108(a), added par. (18).

Subsec. (q)(1). Puspan. L. 101–508, § 4103(a), as amended by Puspan. L. 103–432, § 126(c)(1), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (r). Puspan. L. 101–508, § 4118(i)(1), added subsec. (r).

1989—Subsec. (span)(2)(A). Puspan. L. 101–239, § 6202(d)(2), inserted at end “The Secretary may not require, as a condition of entering into or renewing a contract under this section or under section 1395hh of this title, that a carrier match data obtained other than in its activities under this part with data used in the administration of this part for purposes of identifying situations in which section 1395y(span) of this title may apply.”

Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 202(e)(3)(C), 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. (span)(2)(C). Puspan. L. 101–239, § 6114(c)(2), added subpar. (C).

Subsec. (span)(3)(G). Puspan. L. 101–239, § 6102(e)(2), substituted “limiting charges established under subsection (j)(1)(C) of this section” for “maximum allowable actual charges (established under subsection (j)(1)(C) of this section)”.

Subsec. (span)(3)(I) to (K). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, §§ 201(c), 202(e)(2), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.

Subsec. (span)(3)(L). Puspan. L. 101–239, § 6102(span), added subpar. (L).

Subsec. (span)(4)(A)(iv). Puspan. L. 101–239, § 6102(e)(3), inserted “and before January 1, 1992,” after “January 1, 1987,”.

Subsec. (span)(4)(E)(iv). Puspan. L. 101–239, § 6107(span), added cl. (iv).

Subsec. (span)(4)(F). Puspan. L. 101–239, § 6108(a)(1), inserted “furnished during a calendar year” after “physicians’ services” and inserted at end “For the first calendar year during which the preceding sentence no longer applies, the Secretary shall set the customary charge at a level no higher than 85 percent of the prevailing charge for the service.”

Subsec. (span)(6)(A)(ii). Puspan. L. 101–239, § 6003(g)(3)(D)(ix), inserted “rural primary care hospital,” after “hospital,”.

Subsec. (span)(6)(C). Puspan. L. 101–239, § 6114(c)(1), inserted “or nurse practitioner” after “physician assistant”.

Subsec. (span)(12)(A). Puspan. L. 101–239, § 6114(span), substituted “physician assistants and nurse practitioners” for “physician assistant acting under the supervision of a physician” in introductory provisions.

Subsec. (span)(12)(A)(ii)(II). Puspan. L. 101–239, § 6102(e)(4), as amended by Puspan. L. 101–508, § 4118(f)(2)(A), inserted “(or, for services furnished on or after January 1, 1992, the fee schedule amount specified in section 1395w–4 of this title, as the case may be)” after “prevailing charge rate determined for such services”.

Subsec. (span)(14). Puspan. L. 101–239, § 6104(a), added par. (14).

Subsec. (span)(15). Puspan. L. 101–239, § 6108(span)(1), added par. (15).

Subsecs. (c)(1)(A), (2)(A), (3)(A), (4), (f)(3), (h)(1), (2), (4). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 202(c)(1)(A), (B), (e)(1), (3)(A), (4)(A), (5), 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.

Subsec. (j)(1)(B)(ii). Puspan. L. 101–239, § 6102(e)(9), substituted “December 31, 1990.” for “the earlier of (I) December 31, 1990, or (II) one-year after the date the Secretary reports to Congress, under section 1395w–1(e)(3) of this title, on the development of the relative value scale under section 1395w–1 of this title.”

Subsec. (j)(1)(C)(vii). Puspan. L. 101–234, § 301(span)(2), (c)(2), amended cl. (vii) identically, substituting “according” for “accordingly”.

Subsec. (j)(1)(D)(ii)(II). Puspan. L. 101–239, § 6104(span)(1), inserted “or (span)(14)(A)” after “(span)(10)(A)”.

Subsec. (j)(1)(D)(ii)(IV). Puspan. L. 101–239, § 6108(span)(2)(A), inserted “or (span)(15)(A)” after “subsection (span)(11)(C)(i)”.

Subsec. (j)(1)(D)(iii)(II). Puspan. L. 101–239, § 6108(span)(2)(B), substituted “(span)(14)(A), or (span)(15)(A)” for “or (span)(14)(A)”.

Puspan. L. 101–239, § 6104(span)(2), substituted “(span)(11)(C)(i), or (span)(14)(A)” for “or (span)(11)(C)(i)”.

Subsec. (j)(1)(D)(v). Puspan. L. 101–239, § 6102(e)(9), substituted “December 31, 1990.” for “the earlier of (I) December 31, 1990, or (II) one-year after the date the Secretary reports to Congress, under section 1395w–1(e)(3) of this title, on the development of the relative value scale under section 1395w–1 of this title.”

Subsec. (j)(2). Puspan. L. 101–234, § 301(span)(6), (d)(3), which directed identical amendments to subsec. (j)(2) by substituting “subsections” for “paragraphs” in subpar. (B) as amended by section 8(c)(2)(A) of the Medicare and Medicaid Fraud and Abuse Patient Protection Act of 1987 [probably meaning section 8(c)(2)(A) of Puspan. L. 100–93, the Medicare and Medicaid Patient and Program Protection Act of 1987, which amended subpar. (A) of subsec. (j)(2), generally] could not be executed because the word “paragraphs” did not appear.

Subsec. (o). Puspan. L. 101–234, § 201(a), repealed Puspan. L. 100–360, § 202(c)(1)(C), 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. (q). Puspan. L. 101–239, § 6106(a), added subsec. (q).

1988—Subsec. (span)(2). Puspan. L. 100–360, § 411(i)(2), amended Puspan. L. 100–203, § 4082(c), see 1987 Amendment note below.

Subsec. (span)(2)(A). Puspan. L. 100–485, § 608(d)(5)(G), inserted “, including claims processing functions” after “and related functions” in last sentence.

Puspan. L. 100–360, § 411(f)(1)(B), inserted reference to section 1395w–1(f)(2) of this title in third sentence.

Puspan. L. 100–360, § 202(e)(3)(C), as amended by Puspan. L. 100–485, § 608(d)(5)(F), inserted at end “With respect to activities relating to implementation and operation (and related functions) of the electronic system established under subsection (o)(4) of this section, the Secretary may enter into contracts with carriers under this section to perform such activities on a regional basis.”

Subsec. (span)(3). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(24), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(f)(4)(B)(ii), added Puspan. L. 100–203, § 4045(c)(2)(D), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(f)(11)(A), (14), renumbered and amended Puspan. L. 100–203, § 4053(a), see 1987 Amendment note below.

Subsec. (span)(3)(B)(ii). Puspan. L. 100–360, § 411(j)(4)(A), made technical correction to directory language of Puspan. L. 100–203, § 4096(a)(1)(A), see 1987 Amendment note below.

Subsec. (span)(3)(I). Puspan. L. 100–360, § 201(c), added subpar. (I) requiring notice that an individual has reached the part B catastrophic limit on out-of-pocket cost sharing for the year.

Subsec. (span)(3)(J). Puspan. L. 100–360, § 202(e)(2), added subpar. (J) relating to requirements for determinations or payments with respect to covered outpatient drugs, to receive information and respond to requests by participating pharmacies.

Subsec. (span)(3)(K). Puspan. L. 100–485, § 608(d)(5)(C), inserted “, including claims processing functions,” after “and for related functions”.

Puspan. L. 100–360, § 202(e)(2), added subpar. (K) requiring contracts with organizations described in subsection (f)(3) of this section to implement and operate the electronic system established under subsection (o)(4) of this section for covered outpatient drugs.

Subsec. (span)(4)(A)(iv). Puspan. L. 100–360, § 411(f)(2)(F)(i), as amended by Puspan. L. 100–485, § 608(d)(21)(B), redesignated and amended Puspan. L. 100–203, § 4042(c)(1), see 1987 Amendment note below.

Subsec. (span)(4)(A)(iv)(II). Puspan. L. 100–360, § 411(f)(2)(E), substituted “before January 1, 1989” for “before January 1, 1988”.

Subsec. (span)(4)(A)(vi). Puspan. L. 100–360, § 411(f)(3)(A), made technical amendment to directory language of Puspan. L. 100–203, § 4044(a), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(f)(3)(B), substituted “subsection (i)(4)” for “subparagraph (E)(iii)” and “the estimated average prevailing charge levels based on the best available data” for “the average of the prevailing charge levels” and struck out “for participating physicians” before “under the third”.

Subsec. (span)(4)(A)(vii). Puspan. L. 100–360, § 411(f)(2)(D), added Puspan. L. 100–203, § 4042(span)(2)(A), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(f)(3)(A), made technical amendment to directory language of Puspan. L. 100–203, § 4044(a), see 1987 Amendment note below.

Subsec. (span)(4)(E). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(C), (D), see 1987 Amendment notes below.

Subsec. (span)(4)(F). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(D), see 1987 Amendment note below.

Subsec. (span)(4)(F)(ii)(I). Puspan. L. 100–360, § 411(f)(2)(B), substituted “subsection (i)(4)” for “subparagraph (E)(iii)”.

Subsec. (span)(4)(F)(iii). Puspan. L. 100–360, § 411(f)(2)(A), substituted “services,” for “services;” in subcl. (I) and “physicians’ ” for “physician’s” in subcl. (II).

Subsec. (span)(4)(G). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(D), see 1987 Amendment note below.

Puspan. L. 100–360, § 411(f)(6)(B), substituted “other than primary care services” for “other primary care services” and struck out “(as determined under the third and fourth sentences of paragraph (3) and under paragraph (4))” after “the prevailing charge”.

Subsec. (span)(7)(B)(iii). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(22)(C), see 1987 Amendment note below.

Subsec. (span)(10)(A)(i). Puspan. L. 100–360, § 411(f)(4)(A)(i), struck out “under paragraph (3)” after “reasonable charge”, substituted “subparagraph (B)” for “subparagraph (C)”, and struck out “for participating and nonparticipating physicians” after “charge for such procedure”.

Subsec. (span)(10)(A)(iii). Puspan. L. 100–360, § 411(f)(4)(A)(ii), substituted “clause (i)(I)” for “clause (i)(II)”.

Subsec. (span)(10)(B). Puspan. L. 100–360, § 411(f)(4)(A)(iii), inserted “(including subsequent insertion of an intraocular lens)” after “cataract surgery”.

Subsec. (span)(10)(D). Puspan. L. 100–360, § 411(f)(4)(A)(iv), substituted “under section 1395ff” for “section 1395ff”.

Subsec. (span)(11)(B)(i). Puspan. L. 100–360, § 411(f)(4)(B)(i), amended Puspan. L. 100–203, § 4045(c)(2)(B), see 1987 Amendment note below.

Subsec. (span)(11)(C)(i). Puspan. L. 100–360, § 411(f)(5)(A), substituted “insertion” for “implantation”.

Subsec. (span)(11)(C)(ii). Puspan. L. 100–360, § 411(g)(2)(A), substituted “inserted during or subsequent to” for “implanted during”.

Subsec. (span)(12)(C). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(25), see 1987 Amendment note below.

Subsec. (span)(13), (14). Puspan. L. 100–360, § 411(f)(7)(A), redesignated par. (14) as (13).

Subsec. (c)(1)(A). Puspan. L. 100–360, § 202(e)(3)(A), designated existing provisions as cl. (i), inserted “, except as provided in clause (ii),” after “under this part, and” and added cl. (ii) relating to payment for implementation and operation of the electronic system for covered outpatient drugs.

Subsec. (c)(1)(A)(ii). Puspan. L. 100–485, § 608(d)(5)(D), inserted “, including claims processing functions” after “and related functions”.

Subsec. (c)(2)(A), (3)(A). Puspan. L. 100–360, § 202(e)(5)(A), as amended by Puspan. L. 100–485, § 608(d)(5)(H), substituted “Except as provided in paragraph (4), each” for “Each”.

Subsec. (c)(4). Puspan. L. 100–360, § 202(e)(5)(B), added par. (4) requiring contracts for the disbursement of funds with respect to claims for payment for covered outpatient drugs to provide for a payment cycle, and requiring interest if such requirements are not met.

Subsec. (f)(3). Puspan. L. 100–485, § 608(d)(5)(B), inserted “, including claims processing functions” after “and related functions”.

Puspan. L. 100–360, § 202(e)(1), added par. (3) which read as follows: “with respect to implementation and operation (and related functions) of the electronic system established under subsection (o)(4) of this section, a voluntary association, corporation, partnership, or other nongovernmental organization, which the Secretary determines to be qualified to conduct such activities.”

Subsec. (h)(1). Puspan. L. 100–360, § 202(c)(1)(A), inserted “, except that, with respect to a supplier of covered outpatient drugs, the term ‘participating supplier’ means a participating pharmacy (as defined in subsection (o)(1) of this section)” after “part during such year”.

Subsec. (h)(2). Puspan. L. 100–360, § 202(e)(4)(A), inserted “(other than a carrier described in subsection (f)(3) of this section)” after “Each carrier”.

Subsec. (h)(3)(B). Puspan. L. 100–360, § 411(i)(1)(A), substituted “payment determination” for “claims determination”, “shall include an explanation of benefits and any additional information that the Secretary may determine to be appropriate in order” for “including such information as the Secretary determines is generally provided”, “enter into agreements” for “enter into arrangements”, and “under this subparagraph by a carrier” for “under this subparagraph” and inserted “, and such user fees shall be collected and retained by the carrier”.

Subsec. (h)(4). Puspan. L. 100–360, § 202(c)(1)(B), inserted at end “In publishing directories under this paragraph, the Secretary shall provide for separate directories (wherever appropriate) for participating pharmacies.”

Subsec. (h)(5). Puspan. L. 100–360, § 223(span), designated existing provisions as subpar. (A), inserted “through an annual mailing”, struck out at end “The Secretary shall include such notice in the mailing of appropriate benefit checks provided under subchapter II of this chapter.”, and added subpar. (B).

Subsec. (h)(7). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(A), see 1987 Amendment note below.

Puspan. L. 100–360, § 223(c), in subpar. (A) inserted “prominent” before “reminder” and substituted “and a clear statement of any amounts charged for the particular items or services on the claim involved above the amount recognized under this part),” for “7E), and” and added subpar. (C).

Subsec. (h)(8). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(B), see 1987 Amendment note below.

Subsec. (i). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(B), see 1987 Amendment note below.

Subsec. (i)(2), (3). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(C), see 1987 Amendment note below.

Subsec. (i)(3). Puspan. L. 100–485, § 608(d)(21)(A), substituted “subsection (span)(3)” for “paragraph (3)”.

Subsec. (i)(4). Puspan. L. 100–360, § 411(f)(2)(C), added Puspan. L. 100–203, § 4042(span)(1)(E), see 1987 Amendment note below.

Subsec. (j)(1)(C)(i). Puspan. L. 100–360, § 411(f)(2)(F)(ii), added Puspan. L. 100–203, § 4042(c)(2), see 1987 Amendment note below.

Subsec. (j)(1)(C)(viii). Puspan. L. 100–360, § 411(f)(1)(A), amended Puspan. L. 100–203, § 4041(a)(1)(B), see 1987 Amendment note below.

Subsec. (j)(1)(C)(ix). Puspan. L. 100–360, § 411(f)(7)(B), added Puspan. L. 100–203, § 4048(e), see 1987 Amendment note below.

Subsec. (j)(1)(D)(ii)(IV). Puspan. L. 100–360, § 411(f)(5)(B), struck out “is” after “limit”.

Subsec. (j)(1)(D)(ii)(V). Puspan. L. 100–360, § 411(g)(2)(B), redesignated subcl. (IV) as (V) and struck out “is” after “limit”.

Subsec. (j)(1)(D)(iii). Puspan. L. 100–360, § 411(g)(2)(C), amended Puspan. L. 100–203, § 4063(a)(2)(B), see 1987 Amendment note below.

Subsec. (j)(1)(D)(iv). Puspan. L. 100–360, § 411(f)(4)(C), substituted “bills” for “imposes a charge”.

Subsec. (j)(2). Puspan. L. 100–360, § 411(i)(4)(C)(vi), as amended by Puspan. L. 100–485, § 608(d)(24)(B), added Puspan. L. 100–203, § 4085(i)(26), see 1987 Amendment note below.

Subsec. (l)(1)(C)(i). Puspan. L. 100–360, § 411(i)(4)(C)(vi), added Puspan. L. 100–203, § 4085(i)(27), see 1987 Amendment note below.

Subsec. (n)(1). Puspan. L. 100–360, § 411(f)(9)(A), in introductory provisions, struck out “to a patient” after “includes a charge”, inserted “the bill or request for” after “for which”, and substituted “shares a practice” for “shares his practice” and “supervised the performance of the test, the” for “supervised the test, the”.

Subsec. (n)(1)(A). Puspan. L. 100–485, § 608(d)(17), substituted “the supplier’s” for “the the supplier’s”.

Puspan. L. 100–360, § 411(f)(9)(B), as amended by Puspan. L. 100–485, § 608(d)(21)(D), substituted “(or other applicable limit)” for “to individuals enrolled under this part”.

Puspan. L. 100–360, § 411(a)(3)(A), (C)(i), clarified that illegible matter after “or, if lower, the” was “the supplier’s reasonable charge to individuals enrolled under this part for the test”.

Subsec. (n)(2)(A). Puspan. L. 100–360, § 411(f)(9)(C), inserted “the payment amount specified in paragraph (1)(A) and” after “other than”.

Subsec. (n)(3). Puspan. L. 100–360, § 411(f)(9)(D), struck out “or supplier” after “such physician”.

Subsec. (o). Puspan. L. 100–360, § 202(c)(1)(C), added subsec. (o) relating to “participating pharmacies” as entities authorized under State law to dispense covered outpatient drugs which had entered into agreements with Secretary to participate in catastrophic coverage program.

Subsec. (o)(1)(A)(i). Puspan. L. 100–485, § 608(d)(5)(A)(i), substituted “paragraph (4)” for “subparagraph (D)(i)”.

Subsec. (o)(1)(B)(ii). Puspan. L. 100–485, § 608(d)(5)(A)(ii), substituted “an eligible organization” for “eligible organization”.

Subsec. (p). Puspan. L. 100–360, § 202(g), added subsec. (p).

1987—Subsec. (span)(2). Puspan. L. 100–203, § 4082(c), as amended by Puspan. L. 100–360, § 411(i)(2), designated existing provisions as subpar. (A) and added subpar. (B).

Puspan. L. 100–203, § 4041(a)(3)(A)(i), inserted at end “In establishing such standards and criteria, the Secretary shall provide a system to measure a carrier’s performance of responsibilities described in paragraph (3)(H) and subsection (h) of this section.”

Subsec. (span)(3). Puspan. L. 100–203, § 4085(i)(24), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), substituted “In the case of physicians’ services” for “In the case of physician services” and “(with respect to physicians’ services” for “(with respect to physicians services” in fourth sentence.

Puspan. L. 100–203, § 4045(c)(2)(D), as added by Puspan. L. 100–360, § 411(f)(4)(B)(ii), inserted “(or under any other provision of law affecting the prevailing charge level)” in fourth sentence.

Puspan. L. 100–203, § 4053(a), formerly § 4052(a), as renumbered and amended by Puspan. L. 100–360, § 411(f)(11)(A), (14), inserted “, and shall remain at such prevailing charge level until the prevailing charge for a year (as adjusted by economic index data) equals or exceeds such prevailing charge level” before period at end of penultimate sentence.

Subsec. (span)(3)(B)(ii). Puspan. L. 100–203, § 4096(a)(1)(A), as amended by Puspan. L. 100–360, § 411(j)(4)(A), added subcl. (II), redesignated former subcl. (II) as (III), and inserted “(and to refund amounts already collected)”.

Subsec. (span)(3)(C). Puspan. L. 100–203, § 4085(i)(5), substituted “less than $500” for “not more than $500”.

Subsec. (span)(4)(A)(iv). Puspan. L. 100–203, § 4042(c)(1), formerly § 4042(c), as redesignated and amended by Puspan. L. 100–360, § 411(f)(2)(F)(i), and by Puspan. L. 100–485, § 608(d)(21)(B), amended cl. (iv) generally. Prior to amendment, cl. (iv) read as follows: “In determining the prevailing charge level under the third and fourth sentences of paragraph (3) for a physicians’ service furnished on or after January 1, 1987, by a nonparticipating physician, the Secretary shall set the level at 96 percent of the prevailing charge levels established under such sentences with respect to such service furnished by participating physicians.”

Subsec. (span)(4)(A)(v). Puspan. L. 100–203, § 4041(a)(1)(A)(i), added cl. (v). Former cl. (v) redesignated (vi).

Subsec. (span)(4)(A)(vi). Puspan. L. 100–203, § 4044(a), as amended by Puspan. L. 100–360, § 411(f)(3)(A), added cl. (vi). Former cl. (vi) redesignated (vii).

Puspan. L. 100–203, § 4041(a)(1)(A)(i), redesignated former cl. (v) as (vi).

Subsec. (span)(4)(A)(vii). Puspan. L. 100–203, § 4042(span)(2)(A), as added by Puspan. L. 100–360, § 411(f)(2)(D), substituted “subsection (i)(3)” for “subparagraph (E)(ii)”.

Puspan. L. 100–203, § 4044(a), as amended by Puspan. L. 100–360, § 411(f)(3)(A), redesignated former cl. (vi) as (vii).

Subsec. (span)(4)(B)(iii). Puspan. L. 100–203, § 4041(a)(1)(A)(ii), added cl. (iii).

Subsec. (span)(4)(E). Puspan. L. 100–203, § 4042(span)(1)(D), as added by Puspan. L. 100–360, § 411(f)(2)(C), redesignated subpar. (F) as (E). Former subpar. (E) transferred to subsec. (i).

Puspan. L. 100–203, § 4042(span)(1)(C), as added by Puspan. L. 100–360, § 411(f)(2)(C), struck out “(E) In this section:” before cl. (i), redesignated cls. (i) and (ii) as pars. (2) and (3), respectively, and transferred those pars. to subsec. (i).

Subsec. (span)(4)(F). Puspan. L. 100–203, § 4042(span)(1)(D), as added by Puspan. L. 100–360, § 411(f)(2)(C), redesignated subpar. (G) as (F). Former subpar. (F) redesignated (E).

Puspan. L. 100–203, § 4042(a), added subpar. (F).

Subsec. (span)(4)(G). Puspan. L. 100–203, § 4042(span)(1)(D), as added by Puspan. L. 100–360, § 411(f)(2)(C), redesignated subpar. (G) as (F).

Puspan. L. 100–203, § 4047(a), added subpar. (G).

Subsec. (span)(7)(B)(iii). Puspan. L. 100–203, § 4085(i)(22)(C), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), substituted “an assignment-related basis” for “the basis of an assignment described in paragraph (3)(B)(ii) or under the procedure described in section 1395gg(f)(1) of this title”.

Subsec. (span)(10). Puspan. L. 100–203, § 4045(a), amended par. (10) generally, revising and restating as subpars. (A) to (D) provisions of former subpars. (A) to (C).

Subsec. (span)(11)(B)(i). Puspan. L. 100–203, § 4045(c)(2)(B), as amended by Puspan. L. 100–360, § 411(f)(4)(B)(i), struck out “and shall be further reduced by 2 percent with respect to procedures performed in 1988” after “in 1987” and struck out second sentence which read as follows: “A reduced prevailing charge under this subparagraph shall become the prevailing charge level for subsequent years for purposes of applying the economic index under the fourth sentence of paragraph (3).”

Subsec. (span)(11)(C). Puspan. L. 100–203, § 4063(a)(1)(A), designated existing provisions as cl. (i) and added cl. (ii).

Puspan. L. 100–203, § 4046(a)(1)(B), (C), added subpar. (C) and redesignated former subpar. (C) as (D).

Puspan. L. 100–203, § 4045(c)(1)(A), struck out former cl. (i) designation before “In the case of” and substituted “, the physician’s actual charge is subject to a limit under subsection (j)(1)(D).” for “(subject to clause (iv)), the physician may not charge the individual more than the limiting charge (as defined in clause (ii)) plus (for services furnished during the 12-month period beginning on the effective date of the reduction) ½ of the amount by which the physician’s actual charges for the service for the previous 12-month period exceeds the limiting charge.”, and struck out former cls. (ii) to (iv) which read as follows:

“(ii) In clause (i), the term ‘limiting charge’ means, with respect to a service, 125 percent of the prevailing charge for the service after the reduction referred to in clause (i).

“(iii) If a physician knowingly and willfully imposes charges in violation of clause (i), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2) of this section.

“(iv) This subparagraph shall not apply to services furnished after the earlier of (I) December 31, 1990, or (II) one-year after the date the Secretary reports to Congress, under section 1395w–1(e)(3) of this title, on the development of the relative value scale under section 1395w–1 of this title.”

Subsec. (span)(11)(D). Puspan. L. 100–203, § 4063(a)(1)(B), which directed that subpar. (D) be amended by inserting “or item” after “service” or “services” each place either appears, was executed by inserting “or item” after “service” wherever appearing. The word “services” does not appear because of a prior amendment by section 4045(c)(1)(A) of Puspan. L. 100–203 to subpar. (D), formerly (C), see above.

Puspan. L. 100–203, § 4046(a)(1)(A), (B), redesignated former subpar. (C) as (D) and substituted “subparagraph (B) or (C)” for “subparagraph (B)”.

Subsec. (span)(12)(C). Puspan. L. 100–203, § 4085(i)(25), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), substituted “money penalty” for “monetary penalty” and amended second sentence generally. Prior to amendment, second sentence read as follows: “Such a penalty shall be imposed in the same manner as civil monetary penalties are imposed under section 1320a–7a of this title with respect to actions described in subsection (a) of that section.”

Subsec. (span)(14). Puspan. L. 100–203, § 4048(a), added par. (14).

Subsec. (c)(1). Puspan. L. 100–203, § 4041(a)(3)(A)(ii), designated existing provisions as subpar. (A) and added subpar. (B).

Puspan. L. 100–203, § 4035(a)(2), inserted at end “The Secretary shall cause to have published in the Federal Register, by not later than September 1 before each fiscal year, data, standards, and methodology to be used to establish budgets for carriers under this section for that fiscal year, and shall cause to be published in the Federal Register for public comment, at least 90 days before such data, standards, and methodology are published, the data, standards, and methodology proposed to be used.”

Subsec. (c)(3). Puspan. L. 100–203, § 4031(a)(2), added par. (3).

Subsec. (h)(3). Puspan. L. 100–203, § 4081(a), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (h)(5). Puspan. L. 100–203, § 4085(i)(6), substituted “the participation program” for “the the participation program”.

Subsec. (h)(7). Puspan. L. 100–203, § 4042(span)(1)(A), as added by Puspan. L. 100–360, § 411(f)(2)(C), struck out “, described in paragraph (8)” after “assignment-related basis” in introductory provisions.

Subsec. (h)(8). Puspan. L. 100–203, § 4042(span)(1)(B), as added by Puspan. L. 100–360, § 411(f)(2)(C), substituted “(1) A” for “(8) For purposes of this subchapter, a”, indented such par. 2 ems, and inserted subsec. (i) designation and “For purposes of this subchapter:”, effectively transferring former subsec. (h)(8) to subsec. (i).

Subsec. (i). Puspan. L. 100–203, § 4042(span)(1)(B), as added by Puspan. L. 100–360, § 411(f)(2)(C), transferred introductory provisions and par. (1) from former subsec. (h)(8).

Subsec. (i)(2), (3). Puspan. L. 100–203, § 4042(span)(1)(C), as added by Puspan. L. 100–360, § 411(f)(2)(C), transferred pars. (2) and (3) from subsec. (span)(4)(E).

Subsec. (i)(4). Puspan. L. 100–203, § 4042(span)(1)(E), as added by Puspan. L. 100–360, § 411(f)(2)(C), added par. (4).

Subsec. (j)(1)(B)(i). Puspan. L. 100–203, § 4054(a)(1), (2), formerly § 4053(a)(1), (2), as renumbered by Puspan. L. 100–360, § 411(f)(14), substituted “the actual charges of each such physician” for “each such physician’s actual charges” and “on a repeated basis for such a service an actual charge” for “for such a service a physician’s actual charge (as defined in subparagraph (C)(vi)”.

Subsec. (j)(1)(C)(i). Puspan. L. 100–203, § 4085(i)(7)(A), inserted “maximum allowable” after “If the physician’s”.

Puspan. L. 100–203, § 4042(c)(2), as added by Puspan. L. 100–360, § 411(f)(2)(F)(ii), substituted “applicable percent (as defined in subsection (span)(4)(A)(iv)) of the prevailing charge for the year and service involved” for “prevailing charge for the year involved for such service furnished by nonparticipating physicians” in subcls. (I) and (II).

Subsec. (j)(1)(C)(v). Puspan. L. 100–203, § 4085(i)(7)(B), substituted “1986” for “1987”.

Subsec. (j)(1)(C)(vi). Puspan. L. 100–203, § 4054(a)(3), formerly § 4053(a)(3), as renumbered by Puspan. L. 100–360, § 411(f)(14), struck out “and subparagraph (B)” after “purposes of this subparagraph”.

Subsec. (j)(1)(C)(vii). Puspan. L. 100–203, § 4085(i)(7)(C), added cl. (vii).

Subsec. (j)(1)(C)(viii). Puspan. L. 100–203, § 4041(a)(1)(B), as amended by Puspan. L. 100–360, § 411(f)(1)(A), added cl. (viii).

Subsec. (j)(1)(C)(ix). Puspan. L. 100–203, § 4048(e), as added by Puspan. L. 100–360, § 411(f)(7)(B), added cl. (ix).

Subsec. (j)(1)(D). Puspan. L. 100–203, § 4045(c)(1)(B), added subpar. (D).

Subsec. (j)(1)(D)(ii)(IV). Puspan. L. 100–203, § 4063(a)(2)(A), added subcl. (IV) relating to establishment of reasonable charge limit under subsec. (span)(11)(C)(ii) of this section.

Puspan. L. 100–203, § 4046(a)(2)(A), added subcl. (IV) relating to establishment of prevailing charge limit under subsec. (span)(11)(C)(i) of this section. Former subcl. (IV) redesignated (V).

Subsec. (j)(1)(D)(ii)(V), (VI). Puspan. L. 100–203, § 4063(a)(2)(A), redesignated former subcl. (V) as (VI).

Puspan. L. 100–203, § 4046(a)(2)(A), redesignated former subcl. (IV) as (V).

Subsec. (j)(1)(D)(iii). Puspan. L. 100–203, § 4063(a)(2)(B), as amended by Puspan. L. 100–360, § 411(g)(2)(C), struck out “or” at end of subcl. (I), substituted “; or” for period at end of subcl. (II), and added subcl. (III).

Puspan. L. 100–203, § 4046(a)(2)(B), substituted “, (span)(11)(B), or (span)(11)(C)(i)” for “or (span)(11)(B)” in subcl. (II).

Subsec. (j)(2). Puspan. L. 100–203, § 4085(i)(26), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), and amended by Puspan. L. 100–485, § 608(d)(24)(B), substituted “chapter” for “subchapter” in subpar. (A), struck out “the imposition of” before “civil monetary penalties” and inserted “and assessments” in subpar. (B), substituted “chapter” for “subchapter” in two places in last sentence, and amended last sentence generally. Prior to amendment, last sentence read as follows: “No payment may be made under this chapter with respect to any item or service furnished by a physician during the period when he is excluded from participation in the programs under this chapter pursuant to this subsection.”

Puspan. L. 100–93, § 8(c)(2)(A), amended subpar. (A) generally and substituted “excluded from participation in the programs” for “barred from participation in the program” in last sentence. Prior to amendment, subpar. (A) read as follows: “barring a physician from participation under the program under this subchapter for a period not to exceed 5 years, in accordance with the procedures of paragraphs (2) and (3) of section 1395y(d) of this title, or”.

Subsec. (j)(3)(A). Puspan. L. 100–93, § 8(c)(2)(B), substituted “exclude” for “bar”.

Subsec. (k)(1), (2). Puspan. L. 100–203, § 4085(g)(1), substituted “subsection (j)(2) in the case of surgery performed on or after March 1, 1987” for “subsection (j)(2)”.

Subsec. (l)(1)(A)(iii). Puspan. L. 100–203, § 4096(a)(1)(B), designated existing provisions as subcl. (I) and added subcl. (II).

Subsec. (l)(1)(C). Puspan. L. 100–203, § 4096(a)(1)(C), inserted “in the case described in subparagraph (A)(iii)(I)” after “to an individual” in introductory provisions.

Subsec. (l)(1)(C)(i). Puspan. L. 100–203, § 4085(i)(27), as added by Puspan. L. 100–360, § 411(i)(4)(C)(vi), inserted “the physician establishes that” after “(i)”.

Subsec. (n). Puspan. L. 100–203, § 4051(a), added subsec. (n).

1986—Subsec. (span)(3). Puspan. L. 99–509, § 9331(c)(3)(A), inserted “or (with respect to physicians services furnished in a year after 1987) the level determined under this sentence for the previous year” after “ending June 30, 1973,” and “year-to-year” before “economic changes” in fourth sentence.

Puspan. L. 99–272, § 9301(d)(1)(B), (C), substituted “June 30 last preceding the start of the calendar year” for “March 31 last preceding the start of the twelve-month period (beginning October 1 of each year)” in third sentence, and struck out “the twelve-month period beginning on October 1 in” before “any calendar year after 1974” in eighth sentence.

Subsec. (span)(3)(C). Puspan. L. 99–509, § 9341(a)(2), substituted “at least $100, but not more than $500” for “$100 or more”.

Subsec. (span)(3)(F). Puspan. L. 99–272, § 9301(d)(1)(A), struck out “(ending on September 30)” after “before the year”.

Subsec. (span)(3)(G). Puspan. L. 99–509, § 9331(span)(2), added subpar. (G).

Subsec. (span)(3)(H). Puspan. L. 99–509, § 9332(a)(1), added subpar. (H).

Subsec. (span)(4)(A)(i), (ii). Puspan. L. 99–272, § 9301(span)(1)(A), designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (span)(4)(A)(iii). Puspan. L. 99–509, § 9331(a)(1), added cl. (iii) and struck out former cl. (iii) which read as follows: “In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians’ services furnished during a 12-month period beginning on or after January 1, 1987, by a physician who is not a participating physician (as defined in subsection (h)(1) of this section) at the time of furnishing the services, the Secretary shall not set any level higher than the same level as was set for services furnished during the previous calendar year (without regard to clause (ii)(II)) for physicians who were participating physicians during that year.”

Puspan. L. 99–272, § 9301(span)(1)(A)(ii), added cl. (iii).

Subsec. (span)(4)(A)(iv), (v). Puspan. L. 99–509, § 9331(a)(1), added cls. (iv) and (v).

Subsec. (span)(4)(B). Puspan. L. 99–272, § 9301(span)(1)(B), designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (span)(4)(C). Puspan. L. 99–509, § 9331(a)(2), directed amendment of subpar. (C) by striking out “(i)” after “(C)” and striking out cl. (ii), applicable to services furnished on or after Jan. 1, 1987, which is identical to amendment by Puspan. L. 99–514, § 1895(span)(14)(A), as amended, effective as if included in enactment of Puspan. L. 99–272.

Puspan. L. 99–514, § 1895(span)(14)(A), as amended by Puspan. L. 99–509, § 9307(c)(2)(A), struck out cl. (i) designation, and struck out cl. (ii) which read as follows: “In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians’ services furnished during the periods beginning after December 31, 1986, by a physician who was not a participating physician on that date, the Secretary shall treat the level as set under subparagraph (A)(ii) as having fully provided for the economic changes which would have been taken into account but for the limitations contained in subparagraph (A)(ii).”

Puspan. L. 99–272, § 9301(span)(1)(C), designated existing provisions as cl. (i), substituted “subparagraph (A)(i)” for “subparagraph (A)” wherever appearing, and added cl. (ii).

Subsec. (span)(4)(D)(i) to (iii). Puspan. L. 99–272, § 9301(span)(1)(D), designated existing provisions as cl. (i), substituted “In determining the customary charges for physicians’ services furnished during the 8-month period beginning May 1, 1986, or the 12-month period beginning January 1, 1987, by a physician who was not a participating physician (as defined in subsection (h)(1)) on September 30, 1985” for “In determining the customary charges for physicians’ services furnished during the 12-month period beginning October 1, 1985, or October 1, 1986, by a physician who at no time for any services furnished during the 12-month period beginning October 1, 1984, was a participating physician (as defined in subsection (h)(1))”, and added cls. (ii) and (iii).

Subsec. (span)(4)(D)(iv). Puspan. L. 99–509, § 9331(span)(3), added cl. (iv).

Subsec. (span)(4)(E). Puspan. L. 99–509, § 9331(a)(3), added subpar. (E).

Subsec. (span)(6). Puspan. L. 99–509, § 9338(c), substituted “except that (A) payment may be made (i)” for “except that payment may be made (A)(i)”, substituted “(B) payment may be made” for “or (B)”, and inserted before the period at end “, and (C) in the case of services described in section 1395x(s)(2)(K) of this title payment shall be made to the employer of the physician assistant involved”.

Subsec. (span)(7)(B)(ii)(III). Puspan. L. 99–272, § 9219(span)(1)(A), realigned margin of subcl. (III).

Subsec. (span)(7)(B)(iii). Puspan. L. 99–272, § 9219(span)(2)(A), realigned margin of cl. (iii).

Subsec. (span)(8). Puspan. L. 99–509, § 9333(a), designated existing provisions as subpar. (A), redesignated former subpars. (A) and (B) as cls. (i) and (ii), respectively, and added subpars. (B) and (C).

Puspan. L. 99–272, § 9304(a), added par. (8).

Subsec. (span)(9). Puspan. L. 99–509, § 9333(span), added par. (9). Former par. (9) redesignated (11).

Puspan. L. 99–272, § 9306(a), added par. (9).

Subsec. (span)(10). Puspan. L. 99–509, § 9333(span), added par. (10).

Subsec. (span)(11). Puspan. L. 99–509, § 9334(a), designated existing provisions as subpar. (A), redesignated former subpars. (A) and (B) as cls. (i) and (ii), respectively, and added subpars. (B) and (C).

Puspan. L. 99–509, § 9333(span), redesignated former par. (9) as (11).

Subsec. (span)(12). Puspan. L. 99–509, § 9338(span), added par. (12).

Subsec. (c). Puspan. L. 99–509, § 9311(c), designated existing provisions as par. (1) and added par. (2).

Subsec. (h)(1). Puspan. L. 99–272, § 9301(d)(2), substituted “before the beginning of any year beginning with 1984” for “before October 1 of any year beginning with 1984”, “on an assignment-related basis” for “on the basis of an assignment described in subsection (span)(3)(B)(ii) of this section, in accordance with subsection (span)(6)(B) of this section, or under the procedure described in section 1395gg(f)(1) of this title”, “during such year” for “during the 12-month period beginning on October 1 of such year”, “after the beginning of a year” for “after October 1 of a year”, and “during the remainder of the year” for “during the remainder of the 12-month period beginning on such October 1”.

Subsec. (h)(2). Puspan. L. 99–509, § 9332(span)(1)(A), struck out period at end and substituted “and may request a copy of an appropriate directory published under paragraph (4). Each such carrier shall, without charge, mail a copy of such directory upon such a request.”

Subsec. (h)(4). Puspan. L. 99–509, § 9332(span)(2), inserted at end “Each participating physician directory for an area shall provide an alphabetical listing of all participating physicians practicing in the area and an alphabetical listing by locality and specialty of such physicians.”

Puspan. L. 99–272, § 9301(c)(3)(D), redesignated par. (2) of subsec. (i) as par. (4) of this subsection.

Subsec. (h)(5). Puspan. L. 99–509, § 9332(span)(1)(B), substituted “the participation program under this subsection and the publication and availability of the directories” for “publication of the directories” and inserted at end “The Secretary shall include such notice in the mailing of appropriate benefit checks provided under subchapter II of this chapter.”

Puspan. L. 99–514, § 1895(span)(15)(A), struck out “such” before “the directories” and before “the appropriate area directory”.

Puspan. L. 99–272, § 9301(c)(3)(D), redesignated par. (3) of subsec. (i) as par. (5) of this subsection.

Subsec. (h)(6). Puspan. L. 99–509, § 9332(span)(1)(C), inserted before period at end of second sentence “and that an appropriate number of copies of each such directory is sent to hospitals located in the area” and inserted at end “Such copies shall be sent free of charge.”

Puspan. L. 99–514, § 1895(span)(15)(B), substituted “the” for “the the” before “directories”.

Puspan. L. 99–272, § 9301(c)(3)(D), redesignated par. (4) of subsec. (i) as par. (6) of this subsection.

Subsec. (h)(7), (8). Puspan. L. 99–272, § 9301(c)(4), added pars. (7) and (8).

Subsec. (i)(1). Puspan. L. 99–272, § 9301(c)(3)(A), struck out par. (1) which required the Secretary to publish a list containing the span, address, specialty, and percent of claims submitted with respect to each physician and supplier during preceding year that were paid on the basis of an assignment described in subsec. (span)(3)(B)(ii) of this section, in accordance with subsec. (span)(6)(B) of this section, or under procedure described in section 1395gg(f)(1) of this title.

Subsec. (i)(2). Puspan. L. 99–272, § 9301(c)(3)(D), redesignated par. (2) of this subsection as par. (4) of subsec. (h).

Puspan. L. 99–272, § 9301(d)(3), substituted “year” for “fiscal year”, wherever appearing.

Puspan. L. 99–272, § 9301(c)(2)(A), (B), (3)(B), substituted “shall publish directories (for appropriate local geographic areas)” for “shall publish a directory”, inserted “for that area” before “for that fiscal year”, substituted “Each directory shall” for “The directory shall”, and substituted “paragraph (1)” for “subsection (h)(1) of this section”.

Subsec. (i)(3). Puspan. L. 99–272, § 9301(c)(3)(D), redesignated par. (3) of this subsection as par. (5) of subsec. (h).

Puspan. L. 99–272, § 9301(c)(2)(C), (3)(C), struck out “directory” first place it appeared and inserted in lieu “the directories”, struck out “directory” second place it appeared and inserted in lieu “the appropriate area directory or directories”, and struck out “list and” wherever appearing.

Subsec. (i)(4). Puspan. L. 99–272, § 9301(c)(3)(D), redesignated par. (4) of this subsection as par. (6) of subsec. (h).

Puspan. L. 99–272, § 9301(c)(2)(D), (3)(C), struck out “list and” after “The Secretary shall provide that the” in first sentence, substituted “the directories shall” for “directory shall”, and inserted provision requiring the Secretary to provide that each appropriate area directory be sent to each participating physician located in that area.

Subsec. (j)(1). Puspan. L. 99–509, § 9331(span)(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).

Puspan. L. 99–272, § 9301(span)(2), amended first sentence generally. Prior to amendment, first sentence read as follows: “In the case of a physician who is not a participating physician, the Secretary shall monitor each such physician’s actual charges to individuals enrolled under this part for physicians’ services furnished during the 15-month period beginning July 1, 1984.”

Subsec. (j)(2). Puspan. L. 99–509, § 9320(e)(3), substituted “this paragraph” for “paragraph (1) or subsection (k) of this section” in introductory text.

Puspan. L. 99–272, § 9307(c)(1), inserted reference to subsec. (k) of this section in introductory text.

Subsec. (k). Puspan. L. 99–514, § 1895(span)(16)(A), inserted “presents or causes to be presented a claim or” in pars. (1) and (2).

Puspan. L. 99–272, § 9307(c)(2), added subsec. (k).

Subsec. (l). Puspan. L. 99–509, § 9332(c)(1), added subsec. (l).

Subsec. (m). Puspan. L. 99–509, § 9332(d)(1), added subsec. (m).

1984—Subsec. (span)(2). Puspan. L. 98–369, § 2326(c)(2), inserted at end provision that the Secretary publish in the Federal Register standards and criteria for efficient and effective performance of contract obligations under this section and provide an opportunity for public comment prior to implementation.

Subsec. (span)(3). Puspan. L. 98–369, § 2306(span)(1)(B), (C), substituted “during the 12-month period ending on the March 31 last preceding” for “during the last preceding calendar year elapsing prior to” in third sentence and substituted “October 1” for “July 1” wherever appearing in third and eighth sentences.

Puspan. L. 98–369, § 2354(span)(14), substituted “(I)” and “(II)” for “(i)” and “(ii)”, respectively in concluding provisions.

Puspan. L. 98–369, § 2663(j)(2)(F)(iv), substituted “Health and Human Services” for “Health, Education, and Welfare” in concluding provisions.

Subsec. (span)(3)(B)(ii)(II). Puspan. L. 98–369, § 2354(span)(13), struck out the period after “subchapter”.

Subsec. (span)(3)(F). Puspan. L. 98–369, § 2306(span)(1)(A), substituted “September 30” for “June 30”.

Subsec. (span)(4), (5). Puspan. L. 98–369, § 2306(a), added par. (4) and redesignated former pars. (4) and (5) as (5) and (6), respectively.

Subsec. (span)(6). Puspan. L. 98–369, § 2339, redesignated cl. (A) as cl. (A)(i) and former cl. (B) as cl. (A)(ii), added a new cl. (B), and in the provisions after cl. (B), substituted “clause (A) of such sentence” for “clause (A) or (B) of such sentence”.

Puspan. L. 98–369, § 2306(a), redesignated par. (5) as (6). Former par. (6) redesignated (7).

Subsec. (span)(7). Puspan. L. 98–369, § 2306(a), redesignated par. (6) as (7).

Subsec. (span)(7)(A). Puspan. L. 98–617, § 3(span)(5)(B), struck out at end “If all the teaching physicians in a hospital agree to have payment made for all of their physicians’ services under this part furnished patients in the hospital on the basis of an assignment described in paragraph (3)(B)(ii) or under the procedure described in section 1395gg(f)(1) of this title, notwithstanding clause (ii) of this subparagraph, the carrier shall provide for payment in an amount equal to 90 percent of the prevailing charges paid for similar services in the same locality.”

Puspan. L. 98–369, § 2307(a)(1), as amended by Puspan. L. 98–617, § 3(a)(1), inserted “If all the teaching physicians in a hospital agree to have payment made for all of their physicians’ services under this part furnished patients in the hospital on the basis of an assignment described in paragraph (3)(B)(ii) or under the procedure described in section 1395gg(f)(1) of this title, notwithstanding clause (ii) of this subparagraph, the carrier shall provide for payment in an amount equal to 90 percent of the prevailing charges paid for similar services in the same locality.” at the end.

Subsec. (span)(7)(A)(ii). Puspan. L. 98–617, § 3(span)(5)(A), substituted “the payment is based upon a reasonable charge for the services in excess of the customary charge as determined in accordance with subparagraph (B)” for “the amount of the payment exceeds the reasonable charge for the services (with the customary charge determined consistent with subparagraph (B))”.

Subsec. (span)(7)(B)(i). Puspan. L. 98–369, § 2307(a)(2)(A), (B), substituted “physician who is not a teaching physician (as defined by the Secretary)” for “physician who has a substantial practice outside the teaching setting” and “practice outside the teaching setting” for “outside practice”.

Subsec. (span)(7)(B)(ii). Puspan. L. 98–369, § 2307(a)(2)(C), (D), substituted “In the case of a teaching physician” for “In the case of a physician who does not have a practice described in clause (i)” and “greatest” for “greater”.

Subsec. (span)(7)(B)(ii)(III). Puspan. L. 98–369, § 2307(a)(2)(E)–(G), added subcl. (III).

Subsec. (span)(7)(B)(iii). Puspan. L. 98–617, § 3(span)(6), added cl. (iii).

Subsec. (c). Puspan. L. 98–369, § 2326(d)(2), inserted provision that the Secretary, in determining a carrier’s necessary and proper cost of administration with respect to each contract, take into account the amount that is reasonable and adequate to meet the costs which must be incurred by an efficiently and economically operated carrier in carrying out the terms of its contract.

Subsec. (h). Puspan. L. 98–369, § 2306(c), added subsec. (h).

Puspan. L. 98–369, § 2303(e), struck out subsec. (h) providing for payment for laboratory tests.

Subsecs. (i), (j). Puspan. L. 98–369, § 2306(c), added subsecs. (i) and (j).

1982—Subsec. (span)(3)(B)(ii)(II). Puspan. L. 97–248, § 128(d)(1), substituted “section 1395y(a)” for “section 1395y”.

Subsec. (span)(3). Puspan. L. 97–248, § 104(a), in provisions following subpar. (F), inserted provisions that in determining the reasonable charge for outpatient services, the Secretary may limit such reasonable charge to a percentage of the amount of the prevailing charge for similar services furnished in a physician’s office, taking into account the extent to which overhead costs associated with such outpatient services have been included in the reasonable cost or charge of the facility.

Subsec. (span)(6)(D). Puspan. L. 97–248, § 113(a), added subpar. (D).

1981—Subsec. (span)(3). Puspan. L. 97–35 inserted provision that the amount of any charges for outpatient services which shall be considered reasonable shall be subject to the limitations established by regulations issued by the Secretary pursuant to section 1395x(v)(1)(K) of this title.

1980—Subsec. (span)(3). Puspan. L. 96–499, § 946(a), in provisions following subpar. (F), substituted “service is rendered” for “bill is submitted or the request for payment is made”.

Subsec. (span)(3)(F). Puspan. L. 96–499, § 946(span), added subpar. (F).

Subsec. (span)(6). Puspan. L. 96–499, § 948(span), added par. (6).

Subsec. (h). Puspan. L. 96–499, § 918(a)(1), added subsec. (h).

1977—Subsec. (span)(3). Puspan. L. 95–216 provided that, with respect to power-operated wheelchairs for which payment may be made in accordance with section 1395x(s)(6) of this title, charges determined to be reasonable may not exceed the lowest charge at which power-operated wheelchairs are available in the locality.

Subsec. (span)(5). Puspan. L. 95–142 inserted provisions relating to payments under a reassignment or power of attorney in cases other than direct payments to physicians or service providers.

1976—Subsec. (span)(3). Puspan. L. 94–368 substituted “for the twelve-month period beginning on July 1 in any calendar year after 1974” for “for the fiscal year beginning July 1, 1975,”, “prior to the start of the twelve-month period (beginning July 1, of each year) in which the bill is submitted or the request for payment is made” for “prior to the start of the fiscal year in which the bill is submitted or the request for payment is made”, and “for any twelve-month period (beginning after June 30, 1973) specified in clause (ii) of such sentence” for “for any fiscal year beginning after June 30, 1973,”.

1975—Subsec. (span)(3). Puspan. L. 94–182 inserted provisions relating to raising for fiscal year beginning July 1, 1975 inadequate prevailing charge levels for services of physicians in certain localities.

1974—Subsec. (g). Puspan. L. 93–445 substituted “section 231f(d) of title 45” for “section 228s–2(span) of title 45”.

1972—Subsec. (a). Puspan. L. 92–603, § 227(e)(3), substituted “which involve payments for physicians’ services on a reasonable charge basis” for “which involve payments for physicians’ services”.

Subsec. (span)(3). Puspan. L. 92–603, §§ 244(a), 258(a), inserted provisions relating to determination of reasonableness of physician charges, medical services, supplies, and equipment and for the extension of time for filing claims for supplementary medical insurance benefits where the delay is due to administrative error, at end thereof.

Subsec. (span)(3)(B)(ii). Puspan. L. 92–603, §§ 211(c)(3), 281(d), designated existing provisions as subcl. (I), added subcl. II, inserted exception in the case of services furnished as described in section 1395y(a)(4) of this title, other than for purposes of section 1395gg(f) of this title.

Subsec. (span)(3)(C). Puspan. L. 92–603, § 262(a), inserted provisions setting a $100 minimum amount on claims to establish entitlement to a hearing.

Subsec. (span)(5). Puspan. L. 92–603, § 236(a), added par. (5).

Subsec. (g). Puspan. L. 92–603, § 263(d)(5), added subsec. (g).

1968—Subsec. (span)(3)(B). Puspan. L. 90–248 provided that payment be made on the basis of an itemized bill instead of a receipted bill as formerly required, and established a time limit within which payment may be requested, and inserted “(except as otherwise provided in section 1395gg(f) of this title)” after “payment will”.

Committee on Energy and Commerce of House of Representatives treated as referring to Committee on Commerce of House of Representatives by section 1(a) of Puspan. L. 104–14, set out as a note preceding section 21 of Title 2, The Congress. Committee on Commerce of House of Representatives changed to Committee on Energy and Commerce of House of Representatives, and jurisdiction over matters relating to securities and exchanges and insurance generally transferred to Committee on Financial Services of House of Representatives by House Resolution No. 5, One Hundred Seventh Congress, Jan. 3, 2001.

Amendment by section 4121(a)(5) of Puspan. L. 117–328 applicable with respect to services furnished on or after Jan. 1, 2024, see section 4121(c) of Puspan. L. 117–328, set out as a note under section 1395l of this title.

Amendment by section 5012(c)(2) of Puspan. L. 114–255 applicable to items and services furnished on or after Jan. 1, 2019, see section 5012(d) of Puspan. L. 114–255, set out as a note under section 1395l of this title.

Puspan. L. 114–255, div. C, title XVI, § 16006(span), Dec. 13, 2016, 130 Stat. 1328, provided that:

Amendment by Puspan. L. 112–40 applicable to contracts entered into or renewed on or after Jan. 1, 2012, see section 261(e) of Puspan. L. 112–40, set out as a note under section 1320c of this title.

Amendment by section 6404(a)(2)(A) of Puspan. L. 111–148 applicable to services furnished on or after Jan. 1, 2010, and in case of services furnished before Jan. 1, 2010, a bill or request for payment under 42 U.S.C. 1395u(span)(3)(B) to be filed not later than Dec. 31, 2010, see section 6404(span) of Puspan. L. 111–148, set out as a note under section 1395f of this title.

Amendment by section 6406(a) of Puspan. L. 111–148 applicable to orders, certifications, and referrals made on or after Jan. 1, 2010, see section 6406(d) of Puspan. L. 111–148, set out as a note under section 1320a–7 of this title.

Amendment by section 154(a)(2)(B) of Puspan. L. 110–275 effective June 30, 2008, see section 154(e) of Puspan. L. 110–275, set out as a note under section 1395m of this title.

Puspan. L. 110–54, § 1(span), Aug. 3, 2007, 121 Stat. 551, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after the date of the enactment of this section [Aug. 3, 2007].”

Puspan. L. 109–432, div. B, title I, § 110(span), Dec. 20, 2006, 120 Stat. 2985, provided that: “The amendment made by subsection (a) [amending this section] shall apply to drugs furnished on or after January 1, 2008. The Secretary of Health and Human Services shall address the implementation of such amendment in the rulemaking process under section 1848 of the Social Security Act (42 U.S.C. 1395w–4) for payment for physicians’ services for 2008, consistent with the previous sentence.”

Puspan. L. 109–432, div. B, title II, § 205(c), Dec. 20, 2006, 120 Stat. 2990, provided that: “The amendments made by this section [amending this section, section 1395ww of this title, and provisions set out as a note under section 1395eee of this title] shall take effect as if included in the enactment of the Deficit Reduction Act of 2005 (Public Law 109–171).”

Puspan. L. 109–432, div. B, title IV, § 405(c)(2)(A), Dec. 20, 2006, 120 Stat. 2999, provided that the amendment made by section 405(c)(2)(A) is effective as if included in the enactment of the Deficit Reduction Act of 2005 (Public Law 109–171).

Puspan. L. 109–171, title V, § 5114(c), Fespan. 8, 2006, 120 Stat. 45, provided that: “The amendments made by this section [amending this section and section 1395x of this title] shall apply to services furnished on or after January 1, 2006.”

Amendment by section 5202(a)(2) of Puspan. L. 109–171 applicable to claims submitted on or after Jan. 1, 2006, see section 5202(span) of Puspan. L. 109–171, set out as a note under section 1395h of this title.

Amendment by section 627(span)(2) of Puspan. L. 108–173 applicable to items furnished on or after Jan. 1, 2005, see section 627(c) of Puspan. L. 108–173, set out as a note under section 1395l of this title.

Amendment by section 911(c) of Puspan. L. 108–173 effective Oct. 1, 2005, except as otherwise provided, with transition rules authorizing Secretary of Health and Human Services to continue to enter into contracts under this section prior to such date, and provisions authorizing continuation of Medicare Integrity Program functions during the period that begins on Dec. 8, 2003, and ends on Oct. 1, 2011, see section 911(d) of Puspan. L. 108–173, set out as an Effective Date; Transition Rule note under section 1395kk–1 of this title.

Puspan. L. 108–173, title IX, § 952(c), Dec. 8, 2003, 117 Stat. 2427, provided that: “The amendments made by this section [amending this section] shall apply to payments made on or after the date of the enactment of this Act [Dec. 8, 2003].”

Amendment by section 1(a)(6) [title I, § 105(d)] of Puspan. L. 106–554 applicable to services furnished on or after Jan. 1, 2002, see section 1(a)(6) [title I, § 105(e)] of Puspan. L. 106–554, set out as a note under section 1395l of this title.

Puspan. L. 106–554, § 1(a)(6) [title I, § 114(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–474, provided that: “The amendment made by subsection (a) [amending this section] shall apply to items furnished on or after January 1, 2001.”

Puspan. L. 106–554, § 1(a)(6) [title II, § 222(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–487, provided that: “The amendments made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Dec. 21, 2000].”

Puspan. L. 106–554, § 1(a)(6) [title III, § 313(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–499, provided that: “The amendments made by subsections (a) and (span) [amending this section and sections 1395y and 1395cc of this title] shall apply to services furnished on or after January 1, 2001.”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 432(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–526, provided that: “The amendments made by this section [amending this section and sections 1395y and 1395qq of this title] shall apply to services furnished on or after July 1, 2001.”

Puspan. L. 106–113, div. B, § 1000(a)(6) [title III, § 305(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–362, provided that: “The amendments made by this section [amending this section and section 1395y of this title] shall apply to payments for services provided on or after the date of enactment of this Act [Nov. 29, 1999].”

Amendment by section 1000(a)(6) [title III, § 321(k)(4)] of Puspan. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Puspan. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Puspan. L. 106–113, set out as a note under section 1395d of this title.

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.

Amendment by section 4205(d)(3)(B) of Puspan. L. 105–33 effective Aug. 5, 1997, see section 4205(d)(4) of Puspan. L. 105–33, set out as a note under section 1395x of this title.

Puspan. L. 105–33, title IV, § 4302(c), Aug. 5, 1997, 111 Stat. 382, provided that: “The amendments made by this section [amending this section and section 1395cc of this title] shall take effect on the date of the enactment of this Act [Aug. 5, 1997] and apply to the entry and renewal of contracts on or after such date.”

Amendment by section 4315(a) of Puspan. L. 105–33, to the extent such amendment substitutes fee schedules for reasonable charges, applicable to particular services as of date specified by the Secretary of Health and Human Services, see section 4315(c) of Puspan. L. 105–33, set out as a note under section 1395l of this title.

Amendment by section 4316(a) of Puspan. L. 105–33 effective Aug. 5, 1997, see section 4316(c) of Puspan. L. 105–33, set out as a note under section 1395m of this title.

Puspan. L. 105–33, title IV, § 4317(c), Aug. 5, 1997, 111 Stat. 392, provided that: “The amendments made by this section [amending this section] shall apply to items and services furnished on or after January 1, 1998.”

Amendment by section 4432(span)(2), (4) of Puspan. L. 105–33 applicable to items and services furnished on or after July 1, 1998, see section 4432(d) of Puspan. L. 105–33, set out as a note under section 1395i–3 of this title.

Amendment by section 4512(span)(2), (c) of Puspan. L. 105–33 applicable with respect to services furnished and supplies provided on and after Jan. 1, 1998, see section 4512(d) of Puspan. L. 105–33, set out as a note under section 1395l of this title.

Amendment by section 4556(a) of Puspan. L. 105–33 applicable to drugs and biologicals furnished on or after Jan. 1, 1998, see section 4556(d) of Puspan. L. 105–33, set out as a note under section 1395l of this title.

Amendment by section 4603(c)(2)(B)(i) of Puspan. L. 105–33 applicable to cost reporting periods beginning on or after Oct. 1, 1999, except as otherwise provided, see section 4603(d) of Puspan. L. 105–33, set out as an Effective Date note under section 1395fff of this title.

Amendment by section 4611(d) of Puspan. L. 105–33 applicable to services furnished on or after Jan. 1, 1998, and for purposes of applying such amendment, any home health spell of illness that began, but did not end, before such date, to be considered to have begun as of such date, see section 4611(f) of Puspan. L. 105–33, set out as a note under section 1395d of this title.

Amendment by section 123(span)(1), (2)(B) of Puspan. L. 103–432 applicable to services furnished on or after Jan. 1, 1995, see section 123(f)(2) of Puspan. L. 103–432, set out as a note under section 1395l of this title.

Puspan. L. 103–432, title I, § 123(f)(3), (4), Oct. 31, 1994, 108 Stat. 4413, provided that:

Puspan. L. 103–432, title I, § 125(span)(2), Oct. 31, 1994, 108 Stat. 4414, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to services furnished on or after the first day of the first month beginning more than 60 days after the date of the enactment of this Act [Oct. 31, 1994].”

Amendment by section 126(a)(1), (c), (e), (g)(9) of Puspan. L. 103–432 effective as if included in the enactment of Puspan. L. 101–508, see section 126(i) of Puspan. L. 103–432, set out as a note under section 1395m of this title.

Puspan. L. 103–432, title I, § 126(h)(2), Oct. 31, 1994, 108 Stat. 4416, provided that the amendment made by that section is effective for payments for fiscal years beginning with fiscal year 1994.

Puspan. L. 103–432, title I, § 135(span)(2), Oct. 31, 1994, 108 Stat. 4423, provided that the amendment made by that section is effective for standards applied for contract years beginning after Oct. 31, 1994.

Amendment by section 151(span)(1)(B), (2)(B) of Puspan. L. 103–432 applicable to contracts with fiscal intermediaries and carriers under this subchapter for contract years beginning with 1995, see section 151(span)(4) of Puspan. L. 103–432, set out as a note under section 1395h of this title.

Puspan. L. 103–66, title XIII, § 13515(d), Aug. 10, 1993, 107 Stat. 583, provided that: “The amendments made by subsection (a) [amending this section and section 1395w–4 of this title] shall apply to services furnished on or after January 1, 1994.”

Amendment by section 13568(a), (span) of Puspan. L. 103–66 applicable to claims received on or after Oct. 1, 1993, see section 13568(c) of Puspan. L. 103–66, set out as a note under section 1395h of this title.

Puspan. L. 101–508, title IV, § 4105(span)(3), Nov. 5, 1990, 104 Stat. 1388–60, as amended by Puspan. L. 103–432, title I, § 126(g)(2)(A)(ii), Oct. 31, 1994, 108 Stat. 4415, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to services furnished on or after January 1, 1991.”

Puspan. L. 101–508, title IV, § 4106(d), Nov. 5, 1990, 104 Stat. 1388–62, provided that:

Puspan. L. 101–508, title IV, § 4108(span), Nov. 5, 1990, 104 Stat. 1388–63, provided that: “The amendment made by subsection (a) [amending this section] shall apply to tests and services furnished on or after January 1, 1991.”

Puspan. L. 101–508, title IV, § 4110(span), Nov. 5, 1990, 104 Stat. 1388–64, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after the first day of the first month beginning more than 60 days after the date of the enactment of this Act [Nov. 5, 1990].”

Puspan. L. 101–508, title IV, § 4118(a)(3), Nov. 5, 1990, 104 Stat. 1388–67, provided that: “The amendments made by paragraphs (1) and (2) [amending this section] apply to services furnished after March 1990.”

Puspan. L. 101–508, title IV, § 4118(f)(2)(A), Nov. 5, 1990, 104 Stat. 1388–69, provided that the amendment by that section is effective as if included in the Omnibus Budget Reconciliation Act of 1989, Puspan. L. 101–239.

Puspan. L. 101–508, title IV, § 4118(f)(2)(B), Nov. 5, 1990, 104 Stat. 1388–69, provided that the amendment by that section is effective Jan. 1, 1991.

Amendment by section 4155(c) of Puspan. L. 101–508 applicable to services furnished on or after Jan. 1, 1991, see section 4155(e) of Puspan. L. 101–508, set out as a note under section 1395k of this title.

Puspan. L. 101–239, title VI, § 6102(e)(3), Dec. 19, 1989, 103 Stat. 2187, provided that the amendment made by that section is effective for physicians’ services furnished on or after Jan. 1, 1992.

Puspan. L. 101–239, title VI, § 6106(span), Dec. 19, 1989, 103 Stat. 2210, provided that: “The amendment made by subsection (a) [amending this section] shall apply to services furnished on or after April 1, 1990.”

Puspan. L. 101–239, title VI, § 6108(a)(2), Dec. 19, 1989, 103 Stat. 2212, as amended by Puspan. L. 101–508, title IV, § 4106(a)(2), Nov. 5, 1990, 104 Stat. 1388–61, provided that:

Puspan. L. 101–239, title VI, § 6108(span)(3), Dec. 19, 1989, 103 Stat. 2213, provided that: “The amendments made by this subsection [amending this section] apply to procedures performed after March 31, 1990.”

Puspan. L. 101–239, title VI, § 6114(f), Dec. 19, 1989, 103 Stat. 2218, provided that: “The amendments made by this section [amending this section and section 1395x of this title] shall apply to services furnished on or after April 1, 1990.”

Amendment by section 6202(d)(2) of Puspan. L. 101–239 applicable to agreements and contracts entered into or renewed on or after Dec. 19, 1989, see section 6202(d)(3) of Puspan. L. 101–239, set out as a note under section 1395h of this title.

Amendment by section 201(a) of Puspan. L. 101–234 effective Jan. 1, 1990, see section 201(c) of Puspan. L. 101–234, set out as a note under section 1320a–7a of this title.

Puspan. L. 101–234, title III, § 301(e), Dec. 13, 1989, 103 Stat. 1986, provided that: “The provisions of this section [amending this section and sections 1395m, 1395cc, 1395ll, and 1395ww of this title, enacting provisions set out as notes under section 1395m of this title, and repealing provisions set out as notes under sections 1395span, 1395span–1, 1395span–2, and 1395h of this title and section 8902 of Title 5, Government Organization and Employees] (other than subsections (c) and (d) [amending this section and sections 1395m, 1395cc, 1395ll, and 1395ww of this title and enacting provisions set out as a note under section 1395m of this title]) shall take effect January 1, 1990, except that—

Amendment by Puspan. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Puspan. L. 100–360, see section 608(g)(1) of Puspan. L. 100–485, set out as a note under section 704 of this title.

Puspan. L. 100–360, title II, § 202(m), July 1, 1988, 102 Stat. 721, as amended by Puspan. L. 101–234, title II, § 201(a), Dec. 13, 1989, 103 Stat. 1981, provided that:

[Amendment of section 202(m) of Puspan. L. 100–360, set out above, effective Jan. 1, 1990, see section 201(c) of Puspan. L. 101–234, set out as an Effective Date of 1989 Amendment note under section 1320a–7a of this title.]

Puspan. L. 100–360, title II, § 223(d)(2), (3), July 1, 1988, 102 Stat. 748, provided that:

Except as specifically provided in section 411 of Puspan. L. 100–360, amendment by section 411(a)(3)(A), (C)(i), (f)(1)(A), (B), (2)–(4)(C), (5), (6)(B), (7), (9), (11)(A), (14), (g)(2)(A)–(C), (i)(1)(A), (2), (4)(C)(vi), and (j)(4)(A) of Puspan. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, effective as if included in the enactment of that provision in Puspan. L. 100–203, see section 411(a) of Puspan. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

Amendment by section 4031(a)(2) of Puspan. L. 100–203 applicable to claims received on or after July 1, 1988, see section 4031(a)(3)(A) of Puspan. L. 100–203, set out as a note under section 1395h of this title.

Amendment by section 4035(a)(2) of Puspan. L. 100–203 effective Dec. 22, 1987, and applicable to budgets for fiscal years beginning with fiscal year 1989, see section 4035(a)(3) of Puspan. L. 100–203, set out as a note under section 1395h of this title.

Puspan. L. 100–203, title IV, § 4044(span), Dec. 22, 1987, 101 Stat. 1330–86, provided that: “The amendments made by subsection (a) [amending this section] shall apply to payment for physicians’ services furnished on or after January 1, 1989.”

Puspan. L. 100–203, title IV, § 4045(d), Dec. 22, 1987, 101 Stat. 1330–88, provided that: “The amendments made by this section [amending this section and sections 1395l and 1395w–1 of this title and amending provisions set out below] shall apply to items and services furnished on or after April 1, 1988, except the amendment made by subsection (c)(2)(B) [amending this section] shall apply to services furnished on or after January 1, 1988.”

Puspan. L. 100–203, title IV, § 4046(span), Dec. 22, 1987, 101 Stat. 1330–89, provided that: “The amendments made by subsection (a) [amending this section] shall apply to services furnished on or after April 1, 1988.”

Puspan. L. 100–203, title IV, § 4047(span), Dec. 22, 1987, 101 Stat. 1330–89, as amended by Puspan. L. 100–360, title IV, § 411(f)(6)(C), July 1, 1988, 102 Stat. 779, provided that: “The amendment made by subsection (a) [amending this section] shall apply to physicians who first furnish services to medicare beneficiaries on or after April 1, 1988.”

Puspan. L. 100–203, title IV, § 4051(c), Dec. 22, 1987, 101 Stat. 1330–94, provided that:

Puspan. L. 100–203, title IV, § 4053(span), formerly § 4052(span), Dec. 22, 1987, 101 Stat. 1330–97, as renumbered and amended by Puspan. L. 100–360, title IV, § 411(f)(11)(B), (14), July 1, 1988, 102 Stat. 781, provided that: “The amendment made by subsection (a) [amending this section] shall apply to payment for services furnished on or after April 1, 1988.”

Puspan. L. 100–203, title IV, § 4054(c), formerly § 4053(c), Dec. 22, 1987, 101 Stat. 1330–97, as renumbered by Puspan. L. 100–360, title IV, § 411(f)(14), July 1, 1988, 102 Stat. 781, provided that: “The amendment made by subsection (a) [amending this section] shall apply to charges imposed for services furnished on or after April 1, 1988.”

Amendment by section 4063(a) of Puspan. L. 100–203 applicable to items furnished on or after July 1, 1988, see section 4063(c) of Puspan. L. 100–203, set out as a note under section 1395(l) of this title.

Puspan. L. 100–203, title IV, § 4081(c)(1), Dec. 22, 1987, 101 Stat. 1330–127, provided that: “The amendment made by subsection (a) [amending this section] shall apply to contracts with carriers for claims for items and services furnished by participating physicians and suppliers on or after January 1, 1989.”

Puspan. L. 100–203, title IV, § 4082(e)(3), Dec. 22, 1987, 101 Stat. 1330–129, provided that: “The amendments made by subsection (c) [amending this section] shall apply to evaluation of performance of carriers under contracts entered into or renewed on or after October 1, 1988.”

Puspan. L. 100–203, title IV, § 4085(g)(2), Dec. 22, 1987, 101 Stat. 1330–131, provided that: “The amendment made by paragraph (1) [amending this section] shall be effective as if included in section 9307(c) of the Consolidated Omnibus Budget Reconciliation Act of 1985 [Puspan. L. 99–272].”

Puspan. L. 100–203, title IV, § 4085(i)(7), Dec. 22, 1987, 101 Stat. 1330–132, provided that the amendment made by that section is effective as if included in the enactment of Puspan. L. 99–509.

Amendment by section 4096(a)(1) of Puspan. L. 100–203 applicable to services furnished on or after Jan. 1, 1988, see section 4096(d) of Puspan. L. 100–203, set out as a note under section 1320c–3 of this title.

Amendment by Puspan. L. 100–93 effective at end of fourteen-day period beginning Aug. 18, 1987, and inapplicable to administrative proceedings commenced before end of such period, see section 15(a) of Puspan. L. 100–93, set out as a note under section 1320a–7 of this title.

Puspan. L. 99–514, title XVIII, § 1895(span)(16)(B), Oct. 22, 1986, 100 Stat. 2934, provided that: “The amendment made by subparagraph (A) [amending this section] shall apply to claims presented after the date of the enactment of this Act [Oct. 22, 1986].”

Amendment by section 1895(span)(14)(A), (15) of Puspan. L. 99–514 effective, except as otherwise provided, as if included in enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985, Puspan. L. 99–272, see section 1895(e) of Puspan. L. 99–514, set out as a note under section 162 of Title 26, Internal Revenue Code.

Puspan. L. 99–509, title IX, § 9307(c)(2), Oct. 21, 1986, 100 Stat. 1995, provided that the amendment made by section 9307(c)(2)(A) of Puspan. L. 99–509 [amending directory language of section 1895(span)(14)(A)(ii) of Puspan. L. 99–514 which amended this section] is effective as if included in the enactment of the Tax Reform Act of 1986, Puspan. L. 99–514.

Amendment by section 9311(c) of Puspan. L. 99–509 applicable to claims received on or after Nov. 1, 1986, with subsec. (c)(2)(C) of this section applicable to claims received on or after Apr. 1, 1987, see section 9311(d) of Puspan. L. 99–509, set out as a note under section 1395h of this title.

Amendment by section 9320(e)(3) of Puspan. L. 99–509 applicable to services furnished on or after Jan. 1, 1989, with exceptions for hospitals located in rural areas which meet certain requirements related to certified registered nurse anesthetists, see section 9320(i), (k) of Puspan. L. 99–509, as amended, set out as notes under section 1395k of this title.

Puspan. L. 99–509, title IX, § 9331(a)(4), Oct. 21, 1986, 100 Stat. 2019, provided that: “The amendments made by this subsection [amending this section] shall apply to services furnished on or after January 1, 1987.”

Puspan. L. 99–509, title IX, § 9331(span)(4), Oct. 21, 1986, 100 Stat. 2020, provided that: “The amendments made by this subsection [amending this section] shall apply to services furnished on or after January 1, 1987.”

Puspan. L. 99–509, title IX, § 9331(c)(3)(B), Oct. 21, 1986, 100 Stat. 2021, provided that: “The amendments made by subparagraph (A) [amending this section] shall apply to physicians’ services furnished on or after January 1, 1988.”

Puspan. L. 99–509, title IX, § 9332(a)(4)(A), Oct. 21, 1986, 100 Stat. 2023, provided that: “The amendment made by paragraph (1) [amending this section] shall be effective for contracts under section 1842 of the Social Security Act [42 U.S.C. 1395u] as of October 1, 1987.”

Puspan. L. 99–509, title IX, § 9332(span)(3), Oct. 21, 1986, 100 Stat. 2023, provided that: “The amendments made by this paragraph [probably means ‘this subsection’ which amended this section] shall first apply to directories for 1987.”

Puspan. L. 99–509, title IX, § 9332(c)(2), Oct. 21, 1986, 100 Stat. 2024, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to services furnished on or after October 1, 1987.”

Puspan. L. 99–509, title IX, § 9332(d)(2), Oct. 21, 1986, 100 Stat. 2025, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to surgical procedures performed on or after October 1, 1987.”

Puspan. L. 99–509, title IX, § 9333(d), Oct. 21, 1986, 100 Stat. 2028, provided that: “The amendments made by this section [amending this section] shall take effect on the date of the enactment of this Act [Oct. 21, 1986].”

Puspan. L. 99–509, title IX, § 9334(c), Oct. 21, 1986, 100 Stat. 2029, provided that: “The amendments made by this section [amending this section] shall apply to services furnished on or after January 1, 1987.”

Amendment by section 9338(span), (c) of Puspan. L. 99–509 applicable to services furnished on or after Jan. 1, 1987, see section 9338(f) of Puspan. L. 99–509 set out as a note under section 1395x of this title.

Amendment by section 9341(a)(2) of Puspan. L. 99–509 applicable to items and services furnished on or after Jan. 1, 1987, see section 9341(span) of Puspan. L. 99–509, set out as a note under section 1395ff of this title.

Puspan. L. 99–272, title IX, § 9219(span)(1)(D), Apr. 7, 1986, 100 Stat. 183, provided that: “The amendments made by this paragraph [amending this section and sections 1395x and 1395yy of this title] shall be effective as if they had been originally included in the Deficit Reduction Act of 1984 [Puspan. L. 98–369].”

Puspan. L. 99–272, title IX, § 9219(span)(2)(B), Apr. 7, 1986, 100 Stat. 183, provided that: “The amendment made by subparagraph (A) [amending this section] shall be effective as if it had been originally included in Public Law 98–617.”

Puspan. L. 99–272, title IX, § 9301(span)(4), Apr. 7, 1986, 100 Stat. 186, provided that: “The amendments made by this subsection [amending this section and enacting provisions set out as a note under this section] shall apply to services furnished on or after May 1, 1986.”

Puspan. L. 99–272, title IX, § 9301(c)(5), Apr. 7, 1986, 100 Stat. 187, as amended by Puspan. L. 99–514, title XVIII, § 1895(span)(14)(B), Oct. 22, 1986, 100 Stat. 2934, provided that: “Section 1842(h)(7) of the Social Security Act [42 U.S.C. 1395u(h)(7)], as added by paragraph (4) of this subsection, shall apply to explanations of benefits provided on or after such date (not later than October 1, 1986) as the Secretary of Health and Human Services shall specify.”

Puspan. L. 99–272, title IX, § 9301(d)(4), Apr. 7, 1986, 100 Stat. 188, provided that: “The amendments made by this subsection [amending this section and enacting provisions set out as a note under this section] shall apply to items and services furnished on or after October 1, 1986.”

Puspan. L. 99–272, title IX, § 9306(span), Apr. 7, 1986, 100 Stat. 193, provided that: “The amendments made by this section [amending this section] shall apply to items and services furnished on or after April 1, 1986.”

Amendment by section 9307(c) of Puspan. L. 99–272 applicable to services performed on or after April 1, 1986, see section 9307(e) of Puspan. L. 99–272, set out as a note under section 1320c–3 of this title.

Amendment by Puspan. L. 98–617 effective as if originally included in the Deficit Reduction Act of 1984, Puspan. L. 98–369, see section 3(c) of Puspan. L. 98–617, set out as a note under section 1395f of this title.

Amendment by section 2303(e) of Puspan. L. 98–369 applicable to clinical diagnostic laboratory tests furnished on or after July 1, 1984, but not applicable to clinical diagnostic laboratory tests furnished to inpatients of a provider operating under a waiver granted pursuant to section 602(k) of Puspan. L. 98–21, set out as a note under section 1395y of this title, see section 2303(j)(1), (3) of Puspan. L. 98–369, set out as a note under section 1395l of this title.

Puspan. L. 98–369, div. B, title III, § 2306(span)(2), July 18, 1984, 98 Stat. 1071, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to items and services furnished on or after October 1, 1985.”

Puspan. L. 98–369, div. B, title III, § 2307(a)(3), July 18, 1984, 98 Stat. 1073, provided that: “The amendments made by this subsection [amending this section] shall apply to services furnished on or after July 1, 1984.”

Amendment by section 2326(d)(2) of Puspan. L. 98–369 applicable to agreements and contracts entered into or renewed after Sept. 30, 1984, see section 2326(d)(3) of Puspan. L. 98–369, set out as a note under section 1395h of this title.

Amendment by section 2354(span)(13), (14) of Puspan. L. 98–369 effective July 18, 1984, but not to be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2354(e)(1) of Puspan. L. 98–369, set out as a note under section 1320a–1 of this title.

Amendment by section 2663(j)(2)(F)(iv) of Puspan. L. 98–369 effective July 18, 1984, but not to be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2664(span) of Puspan. L. 98–369, set out as a note under section 401 of this title.

Puspan. L. 97–248, title I, § 104(span), Sept. 3, 1982, 96 Stat. 337, as amended by Puspan. L. 97–448, title III, § 309(a)(2), Jan. 12, 1983, 96 Stat. 2408, provided that: “The amendment made by subsection (a) [amending this section] shall be effective with respect to services furnished on or after October 1, 1982.”

Puspan. L. 97–248, title I, § 113(span)(1), Sept. 3, 1982, 96 Stat. 341, provided that: “The amendment made by subsection (a) [amending this section] is effective with respect to services performed on or after October 1, 1982.”

Amendment by section 128(d)(1) of Puspan. L. 97–248 effective Sept. 3, 1982, see section 128(e)(3) of Puspan. L. 97–248, set out as a note under section 1395x of this title.

Puspan. L. 96–499, title IX, § 918(a)(2), Dec. 5, 1980, 94 Stat. 2626, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to bills submitted and requests for payment made on or after such date (not later than April 1, 1981) as the Secretary of Health and Human Services prescribes by a notice published in the Federal Register.”

Puspan. L. 96–499, title IX, § 946(c), Dec. 5, 1980, 94 Stat. 2643, provided that: “The amendments made by subsections (a) and (span) [amending this section] shall become effective with respect to bills submitted or requests for payment made on or after July 1, 1981.”

Puspan. L. 96–499, title IX, § 948(c)(2), Dec. 5, 1980, 94 Stat. 2645, provided that: “The amendment made by subsection (span) [amending this section] shall apply with respect to cost accounting periods beginning on or after January 1, 1981.”

Amendment by Puspan. L. 95–216 effective in the case of items and services furnished after Dec. 20, 1977, see section 501(c) of Puspan. L. 95–216, set out as a note under section 1395x of this title.

Amendment by Puspan. L. 95–142 applicable with respect to care and services furnished on or after Oct. 25, 1977, see section 2(a)(4) of Puspan. L. 95–142, set out as a note under section 1395g of this title.

Puspan. L. 94–368, § 4, July 16, 1976, 90 Stat. 997, provided that: “The amendments made by sections 2 and 3 of this Act [amending this section and provisions set out as a note under section 390e of Title 7, Agriculture] shall be effective with respect to periods beginning after June 30, 1976; except that, for the twelve-month period beginning July 1, 1976, the amendments made by section 3 [amending this section and provisions set out as a note under section 390e of Title 7, Agriculture] shall be applicable with respect to claims filed under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] (after June 30, 1976, and before July 1, 1977) with a carrier designated pursuant to section 1842 of such Act [42 U.S.C. 1395u], and processed by such carrier after the appropriate changes were made pursuant to such section 3 in the prevailing charge levels for such twelve-month period under the third and fourth sentences of section 1842(span)(3) of the Social Security Act [42 U.S.C. 1395u(span)(3)].”

Amendment by Puspan. L. 93–445 effective Jan. 1, 1975, see section 603 of Puspan. L. 93–445, set out as a note under section 402 of this title.

Amendment by section 211(c)(3) of Puspan. L. 92–603 applicable to services furnished with respect to admissions occurring after Dec. 31, 1972, see section 211(d) of Puspan. L. 92–603, set out as a note under section 1395f of this title.

Amendment by section 227(e)(3) of Puspan. L. 92–603 applicable with respect to accounting periods beginning after June 30, 1973, see section 227(g) of Puspan. L. 92–603, set out as a note under section 1395x of this title.

Puspan. L. 92–603, title II, § 236(c), Oct. 30, 1972, 86 Stat. 1415, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to bills submitted and requests for payments made after the date of the enactment of this Act [Oct. 30, 1972]. The amendments made by subsection (span) [amending section 1396a of this title] shall be effective January 1, 1973 (or earlier if the State plan so provides).”

Puspan. L. 92–603, title II, § 258(span), Oct. 30, 1972, 86 Stat. 1447, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to bills submitted and requests for payment made after March 1968.”

Puspan. L. 92–603, title II, § 262(span), Oct. 30, 1972, 86 Stat. 1448, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to hearings requested (under the procedures established under section 1842(span)(3)(C) of the Social Security Act [42 U.S.C. 1395u(span)(3)(C)]) after the date of the enactment of this Act [Oct. 30, 1972].”

Amendment by section 263(d)(5) of Puspan. L. 92–603 with respect to collection of premiums applicable to premiums becoming due and payable after the fourth month following the month of enactment of Puspan. L. 92–603 which was approved on Oct. 30, 1972, see section 263(f) of Puspan. L. 92–603, set out as a note under section 1395s of this title.

Amendment by section 281(d) of Puspan. L. 92–603 to apply in the case of notices sent to individuals after 1968, see section 281(g) of Puspan. L. 92–603, set out as a note under section 1395gg of this title.

Puspan. L. 90–248, title I, § 125(span), Jan. 2, 1968, 81 Stat. 846, provided that: “The amendments made by subsection (a) [amending this section] shall apply with respect to claims on which a final determination has not been made on or before the date of enactment of this Act [Jan. 2, 1968].”

Physician Payment Review Commission (PPRC) was terminated and its assets and staff transferred to the Medicare Payment Advisory Commission (MedPAC) by section 4022(c)(2), (3) of Puspan. L. 105–33, set out as a note under section 1395span–6 of this title. Section 4022(c)(2), (3) further provided that MedPAC was to be responsible for preparation and submission of reports required by law to be submitted by PPRC, and that, for that purpose, any reference in law to PPRC was to be deemed, after the appointment of MedPAC, to refer to MedPAC.

Puspan. L. 116–159, div. C, title V, § 2501(a)(2), Oct. 1, 2020, 134 Stat. 735, provided that:

Puspan. L. 108–173, title III, § 303(f), Dec. 8, 2003, 117 Stat. 2253, provided that: “The Secretary [of Health and Human Services] shall not implement the revisions in payment amounts for drugs and biologicals administered by physicians as a result of the amendments made by subsection (span) [amending this section] with respect to 2004 unless the Secretary concurrently makes adjustments to the practice expense payment adjustment under the amendments made by subsection (a) [amending section 1395w–4 of this title].”

Puspan. L. 108–173, title III, § 303(h), Dec. 8, 2003, 117 Stat. 2253, provided that: “Nothing in the amendments made by this section [enacting sections 1395w–3a and 1395w–3span of this title, amending this section and sections 1395l, 1395w–4, 1395x, 1395y, and 1396r–8 of this title, and repealing provisions set out as a note under this section] shall be construed as changing the payment methodology under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for radiopharmaceuticals, including the use by carriers of invoice pricing methodology.”

Puspan. L. 108–173, title III, § 303(i)(5), Dec. 8, 2003, 117 Stat. 2255, provided that: “The provisions of chapter 8 of title 5, United States Code, shall not apply with respect to regulations implementing the amendments made by subsections (a), (span), and (e)(3) [sic] [amending this section and section 1395w–4 of this title], to regulations implementing section 304 [set out as a note under this section], and to regulations implementing the amendment made by section 305(a) [amending this section], insofar as such regulations apply in 2004.”

Puspan. L. 108–173, title III, § 303(j), Dec. 8, 2003, 117 Stat. 2255, provided that: “Insofar as the amendments made by this section [enacting sections 1395w–3a and 1395w–3span of this title, amending this section and sections 1395l, 1395w–4, 1395x, 1395y, and 1396r–8 of this title, and repealing provisions set out as a note under this section] apply to payments for drugs or biologicals and drug administration services furnished by physicians, such amendments shall only apply to physicians in the specialties of hematology, hematology/oncology, and medical oncology under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].”

Puspan. L. 108–173, title III, § 304, Dec. 8, 2003, 117 Stat. 2255, provided that: “Notwithstanding section 303(j) [set out above], the amendments made by section 303 [enacting sections 1395w–3a and 1395w–3span of this title, amending this section and sections 1395l, 1395w–4, 1395x, 1395y, and 1396r–8 of this title, and repealing provisions set out as a note under this section] shall also apply to payments for drugs or biologicals and drug administration services furnished by physicians in specialties other than the specialties of hematology, hematology/oncology, and medical oncology.”

Puspan. L. 108–173, title VII, § 731(c), Dec. 8, 2003, 117 Stat. 2351, provided that: “Not later than July 1, 2004, the Secretary [of Health and Human Services] shall implement revised procedures for the issuance of temporary national HCPCS codes under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.].”

Puspan. L. 106–554, § 1(a)(6) [title IV, § 429], Dec. 21, 2000, 114 Stat. 2763, 2763A–522, provided that:

Puspan. L. 106–113, div. B, § 1000(a)(6) [title II, § 223(a), (span)], Nov. 29, 1999, 113 Stat. 1536, 1501A–352, 1501A–353, provided that:

Puspan. L. 105–33, title IV, § 4315(d), Aug. 5, 1997, 111 Stat. 390, provided that: “The Secretary, in developing a fee schedule for particular services (under the amendments made by this section [amending this section and section 1395l of this title]), shall set amounts for the first year period to which the fee schedule applies at a level so that the total payments under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for those services for that year period shall be approximately equal to the estimated total payments if such fee schedule had not been implemented.”

Puspan. L. 105–33, title IV, § 4554, Aug. 5, 1997, 111 Stat. 460, provided that:

Puspan. L. 105–33, title IV, § 4556(c), Aug. 5, 1997, 111 Stat. 463, which directed the Secretary of Health and Human Services to study the effect on the average wholesale price of drugs and biologicals of the amendments to this section by section 4556(a) of Puspan. L. 105–33, and to report to Congress the result of such study not later than July 1, 1999, was repealed by Puspan. L. 108–173, title III, § 303(i)(6), Dec. 8, 2003, 117 Stat. 2255.

Puspan. L. 103–66, title XIII, § 13515(span), Aug. 10, 1993, 107 Stat. 583, provided that: “Notwithstanding any other provision of law, the Secretary of Health and Human Services shall reduce the following values and amounts for 1994 (to be applied for that year and subsequent years) by such uniform percentage as the Secretary determines to be required to assure that the amendments made by subsection (a) [amending this section and section 1395w–4 of this title] will not result in expenditures under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] in 1994 that exceed the amount of such expenditures that would have been made if such amendments had not been made:

Puspan. L. 101–508, title IV, § 4101(span)(2), Nov. 5, 1990, 104 Stat. 1388–55, as amended by Puspan. L. 103–432, title I, § 126(a)(2), Oct. 31, 1994, 108 Stat. 4414, provided that: “In applying section 1842(span)(16)(B) of the Social Security Act [42 U.S.C. 1395u(span)(16)(B)]:

Puspan. L. 101–508, title IV, § 4111, Nov. 5, 1990, 104 Stat. 1388–64, directed Secretary of Health and Human Services to conduct a study of effect of release of medicare prepayment medical review screen parameters on physician billings for services to which the parameters apply, such study to be based upon the release of the screen parameters at a minimum of six carriers, with Secretary to report results of study to Congress not later than Oct. 1, 1992.

Puspan. L. 103–66, title XIII, § 13541, Aug. 10, 1993, 107 Stat. 587, provided that: “In determining the amount of payment under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] with respect to parenteral and enteral nutrients, supplies, and equipment during 1994 and 1995, the charges determined to be reasonable with respect to such nutrients, supplies, and equipment may not exceed the charges determined to be reasonable with respect to such nutrients, supplies, and equipment during 1993.”

Puspan. L. 101–508, title IV, § 4152(d), Nov. 5, 1990, 104 Stat. 1388–79, provided that: “In determining the amount of payment under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for enteral and parenteral nutrients, supplies, and equipment furnished during 1991, the charges determined to be reasonable with respect to such nutrients, supplies, and equipment may not exceed the charges determined to be reasonable with respect to such items for 1990.”

Puspan. L. 101–508, title IV, § 4153(span)(1), Nov. 5, 1990, 104 Stat. 1388–84, provided that:

Puspan. L. 101–508, title IV, § 4164(c), Nov. 5, 1990, 104 Stat. 1388–102, as amended by Puspan. L. 103–432, title I, § 147(f)(7)(B), Oct. 31, 1994, 108 Stat. 4432, provided that: “Not later than March 31, 1991, the Secretary of Health and Human Services shall publish, and shall periodically update, a directory of the unique physician identification numbers of all physicians providing services for which payment may be made under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.], and shall include in such directory the names, provider numbers, and billing addressess [sic] of all listed physicians.”

Puspan. L. 101–239, title VI, § 6102(e)(10), Dec. 19, 1989, 103 Stat. 2188, provided that: “In applying section 1842(i)(4) of the Social Security Act [42 U.S.C. 1395u(i)(4)] for services furnished on or after January 1, 1990, intermediate and comprehensive office visits for eye examinations and treatments (codes 92002 and 92004) shall be considered to be primary care services.”

Puspan. L. 101–239, title VI, § 6107(a), Dec. 19, 1989, 103 Stat. 2211, provided that:

Puspan. L. 101–239, title VI, § 6114(e), Dec. 19, 1989, 103 Stat. 2218, provided that: “The Secretary of Health and Human Services shall provide for at least 1 demonstration project under which, in the application of section 1842(span)(2)(C) of the Social Security Act [42 U.S.C. 1395u(span)(2)(C)] (as added by subsection (c)(2) of this section) in one or more States, the limitation on the number of visits per month per resident would be applied on an average basis over the aggregate total of residents receiving services from members of the team.”

Puspan. L. 100–360, title II, § 202(e)(3)(B), July 1, 1988, 102 Stat. 717, as amended by Puspan. L. 100–485, title VI, § 608(d)(5)(E), Oct. 13, 1988, 102 Stat. 2414, which required Secretary of Health and Human Services, before entering into contracts under section 1395u of this title with respect to implementation and operation of electronic system for covered outpatient drugs, to establish standards with respect to performance with respect to such activities, was repealed by Puspan. L. 101–234, title II, § 201(a), Dec. 13, 1989, 103 Stat. 1981.

Puspan. L. 100–360, title II, § 202(e)(4)(B), July 1, 1988, 102 Stat. 717, which provided that the provisions of section 1395u(h)(3) of this title not apply to covered outpatient drugs (other than drugs described in section 1395x(s)(2)(J) of this title as of July 1, 1988) dispensed before January 1, 1993, was repealed by Puspan. L. 101–234, title II, § 201(a), Dec. 13, 1989, 103 Stat. 1981.

Puspan. L. 100–203, title IV, § 4041(a)(2), Dec. 22, 1987, 101 Stat. 1330–83, provided that:

Puspan. L. 100–203, title IV, § 4048(span), Dec. 22, 1987, 101 Stat. 1330–90, as amended by Puspan. L. 101–508, title IV, § 4118(h)(1), Nov. 5, 1990, 104 Stat. 1388–70, provided that: “The Secretary of Health and Human Services, in consultation with groups representing physicians who furnish anesthesia services, shall establish by regulation a relative value guide for use in all carrier localities in making payment for physician anesthesia services furnished under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] on and after March 1, 1989. Such guide shall be designed so as to result in expenditures under such title [42 U.S.C. 1395 et seq.] for such services in an amount that would not exceed the amount of such expenditures which would otherwise occur.”

[Puspan. L. 101–508, title IV, § 4118(h), Nov. 5, 1990, 104 Stat. 1388–70, provided that the amendment by that section to section 4048(span) of Puspan. L. 100–203, set out above, is effective as if included in enactment of Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203.]

Puspan. L. 100–203, title IV, § 4048(c), Dec. 22, 1987, 101 Stat. 1330–90, which required Secretary of Health and Human Services to study variations in conversion factors used by carriers under section 1395u(span) of this title to determine prevailing charge for anesthesia services and to report results of study and make recommendations for appropriate adjustments in such factors not later than Jan. 1, 1989, was repealed by Puspan. L. 101–508, title IV, § 4118(g)(2), Nov. 5, 1990, 104 Stat. 1388–70.

Puspan. L. 100–203, title IV, § 4048(d), Dec. 22, 1987, 101 Stat. 1330–90, provided that:

Puspan. L. 100–203, title IV, § 4051(span), Dec. 22, 1987, 101 Stat. 1330–94, provided that:

Puspan. L. 100–203, title IV, § 4054(span), formerly § 4053(span), Dec. 22, 1987, 101 Stat. 1330–97, as renumbered by Puspan. L. 100–360, title IV, § 411(f)(14), July 1, 1988, 102 Stat. 781, provided that: “In the case of a physician who did not have actual charges under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for a procedure in the calendar quarter beginning on April 1, 1984, but who establishes to the satisfaction of a carrier that he or she had actual charges (whether under such title or otherwise) for the procedure performed prior to June 30, 1984, the carrier shall compute the maximum allowable actual charge under section 1842(j) of the Social Security Act [42 U.S.C. 1395u(j)] for such procedure performed by such physician in 1988 based on such physician’s actual charges for the procedure.”

Puspan. L. 100–203, title IV, § 4056(a), formerly § 4055(a), Dec. 22, 1987, 101 Stat. 1330–98, as renumbered and amended by Puspan. L. 100–360, title IV, § 411(f)(13)(A), (14), July 1, 1988, 102 Stat. 781; Puspan. L. 101–508, title IV, § 4118(g)(4), Nov. 5, 1990, 104 Stat. 1388–70, provided that:

Puspan. L. 100–203, title IV, § 4062(a), Dec. 22, 1987, 101 Stat. 1330–100, provided that:

Puspan. L. 100–203, title IV, § 4063(d), Dec. 22, 1987, 101 Stat. 1330–110, provided that: “With respect to the establishment of a reasonable charge limit under section 1842(span)(11)(C)(ii) of the Social Security Act [42 U.S.C. 1395u(span)(11)(C)(ii)], in applying section 1842(j)(1)(D)(i) of such Act, the matter beginning with ‘plus’ shall be considered to have been deleted.”

Puspan. L. 100–203, title IV, § 4082(d), Dec. 22, 1987, 101 Stat. 1330–128, provided that: “The Comptroller General shall conduct a study concerning the cost effectiveness of requiring hearings with a carrier under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] before having a hearing before an administrative law judge respecting carrier determinations under that part. The Comptroller General shall report to the Congress on the results of such study by not later than June 30, 1989.”

Puspan. L. 100–203, title IV, § 4085(e), Dec. 22, 1987, 101 Stat. 1330–131, provided that: “The Secretary of Health and Human Services shall develop the capability to implement (for services furnished on or after January 1, 1989) geographic limits on charges and payments under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] for physicians’ services based on statewide, regional, or national average (or percentile in a distribution) of prevailing charges or payment amounts (weighted by frequency of services). Any such limits shall take into account adjustments for geographic differences in cost of practice and cost of living.”

Puspan. L. 101–508, title IV, § 4114, Nov. 5, 1990, 104 Stat. 1388–65, as amended by Puspan. L. 103–432, title I, § 126(g)(4), Oct. 31, 1994, 108 Stat. 4416, provided that: “Not later than 180 days after the date of the enactment of this Act [Nov. 5, 1990], the Secretary of Health and Human Services shall issue guidelines to assure a uniform level of review of physician visits to patients of a rehabilitation hospital or unit after the medical review screen parameter established under section 4085(h) of the Omnibus Budget Reconciliation Act of 1987 [Puspan. L. 100–203, set out below] has been exceeded.”

Puspan. L. 100–203, title IV, § 4085(h), Dec. 22, 1987, 101 Stat. 1330–131, provided that:

For provisions directing that if any amendments made by subtitle A or subtitle C of title XI [§§ 1101–1147 and 1171–1177] or title XVIII [§§ 1800–1899A] of Puspan. L. 99–514 require an amendment to any plan, such plan amendment shall not be required to be made before the first plan year beginning on or after Jan. 1, 1989, see section 1140 of Puspan. L. 99–514, as amended, set out as a note under section 401 of Title 26, Internal Revenue Code.

The Secretary of Health and Human Services to provide for such timely amendments to contracts under this section, and regulations, to such extent as may be necessary to implement Puspan. L. 99–509 on a timely basis, see section 9311(d)(3) of Puspan. L. 99–509, set out as an Effective Date of 1986 Amendment note under section 1395h of this title.

Puspan. L. 99–509, title IX, § 9331(c)(1), (2), (4)–(6), Oct. 21, 1986, 100 Stat. 2020, 2021, provided that:

“(4) Study.—The Secretary shall conduct a study of the extent to which the MEI appropriately and equitably reflects economic changes in the provision of the physicians’ services to medicare beneficiaries. In conducting such study the Secretary shall consult with appropriate experts.

“(5) Limitation on changes in mei methodology.—The Secretary shall not change the methodology (including the basis and elements) used in the MEI from that in effect as of October 1, 1985, until completion of the study under paragraph (4). After the completion of the study, the Secretary may not change such methodology except after providing notice in the Federal Register and opportunity for public comment.

“(6) MEI defined.—In this subsection, the term ‘MEI’ means the economic index referred to in the fourth sentence of section 1842(span)(3) of the Social Security Act [42 U.S.C. 1395u(span)(3)].”

Puspan. L. 99–509, title IX, § 9331(d), Oct. 21, 1986, 100 Stat. 2021, provided that:

Puspan. L. 99–509, title IX, § 9332(a)(2), (3), Oct. 21, 1986, 100 Stat. 2022, as amended by Puspan. L. 100–203, title IV, § 4085(i)(21)(B), Dec. 22, 1987, 101 Stat. 1330–133, which provided that the Secretary of Health and Human Services was to provide, in the standards and criteria established under section 1842(span)(2) of the Social Security Act [42 U.S.C. 1395u(span)(2)] for contracts under that section, a system to measure a carrier’s performance of the responsibilities described in sections 1842(span)(3)(H) and 1842(h) of such Act and that, of the amounts appropriated for administrative activities to carry out part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.], the Secretary of Health and Human Services was to provide payments, totaling 1 percent of the total payments to carriers for claims processing in any fiscal year, to carriers under section 1842 of such Act, to reward such carriers for their success in increasing the proportion of physicians in the carrier’s service area who were participating physicians or in increasing the proportion of total payments for physicians’ services which were payments for such services rendered by participating physicians, was repealed by Puspan. L. 100–203, title IV, § 4041(a)(3)(B)(i), Dec. 22, 1987, 101 Stat. 1330–84.

Puspan. L. 99–509, title IX, § 9332(a)(4)(B), (C), Oct. 21, 1986, 100 Stat. 2023, as amended by Puspan. L. 100–203, title IV, § 4041(a)(3)(B)(ii), (iii), Dec. 22, 1987, 101 Stat. 1330–84; Puspan. L. 100–360, title IV, § 411(f)(1)(C), July 1, 1988, 102 Stat. 776, provided that:

Puspan. L. 99–509, title IX, § 9333(c), Oct. 21, 1986, 100 Stat. 2028, provided that: “Not later than October 1, 1987, the Secretary of Health and Human Services shall review the inherent reasonableness of the reasonable charges for at least 10 of the most costly procedures with respect to which payment is made under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] (determined on the basis of the aggregate annual payments under such part with respect to each such procedure).”

Puspan. L. 99–509, title IX, § 9334(span), Oct. 21, 1986, 100 Stat. 2028, as amended by Puspan. L. 100–203, title IV, § 4045(c)(2)(C), Dec. 22, 1987, 101 Stat. 1330–88, provided that:

Puspan. L. 99–509, title IX, § 9340, Oct. 21, 1986, 100 Stat. 2037, provided that: “The Secretary of Health and Human Services shall apply the sixth sentence of section 1842(span)(3) of the Social Security Act [42 U.S.C. 1395u(span)(3)] to payment—

Puspan. L. 99–509, title IX, § 9343(g), Oct. 21, 1986, 100 Stat. 2041, provided that: “Not later than July 1, 1987, each fiscal intermediary which processes claims under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] shall require hospitals, as a condition of payment for outpatient hospital services under that part, to report claims for payment for such services under such part using a HCFA Common Procedure Coding System.”

Puspan. L. 99–272, title IX, § 9301(span)(3), Apr. 7, 1986, 100 Stat. 186, provided that: “The Secretary of Health and Human Services shall provide, during the month of April 1986, that physicians and suppliers may enter into an agreement under section 1842(h)(1) of the Social Security Act [42 U.S.C. 1395u(h)(1)] for the 8-month period beginning May 1, 1986, or terminate such an agreement previously entered into for fiscal year 1986. In the case of a physician or supplier who entered into such an agreement for fiscal year 1986, the physician or supplier shall be deemed to have entered into such agreement for such 8-month period and for each succeeding year unless the physician or supplier terminates such agreement before the beginning of the respective period. At the beginning of such 8-month period, the Secretary shall publish a new directory (described in section 1842(h)(4) of that Act [42 U.S.C. 1395u(h)(4)], as redesignated by subsection (c)(3)(D) of this section) of participating physicians and suppliers.”

Puspan. L. 99–272, title IX, § 9301(d)(5), Apr. 7, 1986, 100 Stat. 188, provided that: “Notwithstanding any other provision of law, for purposes of making payment under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.], customary and prevailing charges (and the lowest charges determined under the sixth sentence of section 1842(span)(3) of such Act [42 U.S.C. 1395u(span)(3)]) for items and services furnished during the period beginning on October 1, 1986, and ending on December 31, 1986, shall be determined on the same basis as for items and services furnished on September 30, 1986.”

Puspan. L. 99–272, title IX, § 9304(span), Apr. 7, 1986, 100 Stat. 190, provided that:

Period of 15 months referred to in subsec. (j)(1) of this section for monitoring the charges of nonparticipating physicians to be deemed to include the period Oct. 1, 1985, to Mar. 14, 1986, see section 5(span) of Puspan. L. 99–107, set out as a note under section 1395ww of this title.

Puspan. L. 98–369, div. B, title III, § 2303(h), July 18, 1984, 98 Stat. 1066, provided that: “The Secretary of Health and Human Services shall simplify the procedures under section 1842 of the Social Security Act [42 U.S.C. 1395u] with respect to claims and payments for clinical diagnostic laboratory tests so as to reduce unnecessary paperwork while assuring that sufficient information is supplied to identify instances of fraud and abuse.”

Puspan. L. 98–369, div. B, title III, § 2307(c), July 18, 1984, 98 Stat. 1074, directed Comptroller General to conduct a study of the amounts billed for physician services and paid by carriers under subsec. (span)(7) of this section to determine whether such payments were made only where the physician satisfied the requirements of subsec. (span)(7)(A)(i) of this section, and to submit to Congress a report on results of such study not later than 18 months after July 18, 1984.

For provision authorizing two agreements under section 1395h of this title and two contracts under this section for replacement of an agency, organization, or carrier in the lowest 20th percentile, see section 2326(a) of Puspan. L. 98–369, as amended, set out as a note under 1395h of this title.

Puspan. L. 97–248, title I, § 113(span)(2), Sept. 3, 1982, 96 Stat. 341, provided that: “The Secretary of Health and Human Services shall first issue such final regulations (whether on an interim or other basis) before October 1, 1982, as may be necessary to implement the amendment made by subsection (a) [amending this section] on a timely basis. If such regulations are promulgated on an interim final basis, the Secretary shall take such steps as may be necessary to provide opportunity for public comment, and appropriate revision based thereon, so as to provide that such regulations are not on an interim basis later than January 31, 1983.”

Puspan. L. 96–499, title IX, § 918(a)(3), Dec. 5, 1980, 94 Stat. 2626, provided that not later than 24 months after an effective date (not later than Apr. 1, 1981) which was to have been prescribed by the Secretary of Health and Human Services, the Secretary was to report to the Congress (A) the proportion of bills and requests for payment submitted (during the 18-month period beginning on such effective date) under this subchapter for laboratory tests which did not identify who performed the tests, (B) the proportion of bills and requests for payment submitted during such period for laboratory tests with respect to which the amount paid under this subchapter was less than the amount that would otherwise have been payable in the absence of subsec. (h) of this section, (C) with respect to requests for payment described in subparagraph (B) which were submitted by patients, the average additional cost per laboratory test to patients resulting from reductions in payment that would otherwise have been made for such tests in the absence of such subsec. (h), and (D) with respect to bills described in subparagraph (B) which were submitted by physicians, the average reduction in payment per laboratory test to physicians resulting from the application of such subsec. (h).

Puspan. L. 94–182, title I, § 101(span), Dec. 31, 1975, 89 Stat. 1051, provided that: “The amendment made by subsection (a) [amending subsec. (span)(3) of this section] shall be applicable with respect to claims filed under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] with a carrier designated pursuant to section 1842 of such Act [42 U.S.C. 1395u] and processed by such carrier after the appropriate changes were made in the prevailing charge levels for the fiscal year beginning July 1, 1975, on the basis of economic index data under the third and fourth sentences of section 1842(span)(3) of such Act [42 U.S.C. 1395u(span)(3)]; except that (1) if less than the correct amount was paid (after the application of subsection (a) of this section) on any claim processed prior to the enactment of this section [Dec. 31, 1975], the correct amount shall be paid by such carrier at such time (not exceeding 6 months after the date of the enactment of this section) [Dec. 31, 1975] as is administratively feasible, and (2) no such payment shall be made on any claim where the difference between the amount paid and the correct amount due is less than $1.”

Puspan. L. 92–603, title II, § 224(span), Oct. 30, 1972, 86 Stat. 1395, directed Health Insurance Benefits Advisory Council to conduct a study of methods of reimbursement for physicians’ services under Medicare with respect to fees, extent of assignments accepted by physicians, and share of physician-fee costs which Medicare program does not pay and submit such study to Congress by Jan. 1, 1973.

Ex. Ord. No. 13947, July 24, 2020, 85 F.R. 59171, which related to a payment model pursuant to which Medicare would pay, for certain high-cost prescription drugs and biological products covered by Medicare Part B, no more than the most-favored-nation price, was revoked by Ex. Ord. No. 13948, § 5, Sept. 13, 2020, 85 F.R. 59650, set out below.

Ex. Ord. No. 13948, Sept. 13, 2020, 85 F.R. 59649, provided:

By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:

Section 1. Purpose. Americans pay more per capita for prescription drugs than residents of any other developed country in the world. It is unacceptable that Americans pay more for the exact same drugs, often made in the exact same places. Other countries’ governments regulate drug prices by negotiating with drug manufacturers to secure bargain prices, leaving Americans to make up the difference—effectively subsidizing innovation and) [sic] lower-cost drugs for the rest of the world. The Council of Economic Advisers has found that Americans finance much of the biopharmaceutical innovation that the world depends on, allowing foreign governments, many of which are the sole healthcare payers in their respective countries, to enjoy bargain prices for such innovations. Americans should not bear extra burdens to compensate for the shortfalls that result from the nationalized public healthcare systems of wealthy countries abroad.

In addition to being unfair, high drug prices in the United States also have serious economic and health consequences for patients in need of treatment. High prices cause Americans to divert too much of their scarce resources to pharmaceutical treatments and away from other productive uses. High prices are also a reason many patients skip doses of their medications, take less than the recommended doses, or abandon treatment altogether. The consequences of these behaviors can be severe. For example, patients may develop acute conditions that result in poor clinical outcomes or that require drastic and expensive medical interventions.

In most markets, the largest buyers pay the lowest prices, but this has not been true for prescription drugs. The Federal Government is the largest payer for prescription drugs in the world, but it pays more than many smaller buyers, including other developed nations. When the Federal Government purchases a drug covered by Medicare—the cost of which is shared by American seniors who take the drug and American taxpayers—it should insist on, at a minimum, the lowest price at which the manufacturer sells that drug to any other developed nation.

Sec. 2. Policy. (a) It is the policy of the United States that the Medicare program should not pay more for costly Part B or Part D prescription drugs or biological products than the most-favored-nation price.

(span) The “most-favored-nation price” shall mean the lowest price, after adjusting for volume and differences in national gross domestic product, for a pharmaceutical product that the drug manufacturer sells in a member country of the Organisation for Economic Co-operation and Development (OECD) that has a comparable per-capita gross domestic product.

Sec. 3. Payment Model on the Most-Favored-Nation Price in Medicare Part B. To the extent consistent with law, the Secretary of Health and Human Services shall immediately take appropriate steps to implement his rulemaking plan to test a payment model pursuant to which Medicare would pay, for certain high-cost prescription drugs and biological products covered by Medicare Part B, no more than the most-favored-nation price. The model would test whether, for patients who require pharmaceutical treatment, paying no more than the most-favored-nation price would mitigate poor clinical outcomes and increased expenditures associated with high drug costs.

Sec. 4. Payment Model on the Most-Favored-Nation Price in Medicare Part D. To the extent consistent with law, the Secretary shall take appropriate steps to develop and implement a rulemaking plan, selecting for testing, consistent with section 1315a(span)(2)(A) of title 42, United States Code, a payment model pursuant to which Medicare would pay, for Part D prescription drugs or biological products where insufficient competition exists and seniors are faced with prices above those in OECD member countries that have a comparable per-capita gross domestic product to the United States, after adjusting for volume and differences in national gross domestic product, no more than the most-favored-nation price, to the extent feasible. The model should test whether, for patients who require pharmaceutical treatment, paying no more than the most-favored-nation price would mitigate poor clinical outcomes and increased expenditures associated with high drug costs.

Sec. 5. Revocation of Executive Order. The Executive Order of July 24, 2020 (Lowering Drug Prices by Putting America First) [Ex. Ord. No. 13947, formerly set out above], is revoked.

Sec. 6. General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect:

(i) the authority granted by law to an executive department or agency, or the head thereof; or

(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(span) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.