
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)[506]]
[CITE: 42USC1395bbb]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 1395bbb. Conditions of participation for home health 
        agencies; home health quality
        

(a) Conditions of participation; protection of individual rights; 
        notification of State entities; use of home health aides; 
        medical equipment; individual's plan of care; compliance with 
        Federal, State, and local laws and regulations

    The conditions of participation that a home health agency is 
required to meet under this subsection are as follows:
        (1) The agency protects and promotes the rights of each 
    individual under its care, including each of the following rights:
            (A) The right to be fully informed in advance about the care 
        and treatment to be provided by the agency, to be fully informed 
        in advance of any changes in the care or treatment to be 
        provided by the agency that may affect the individual's well-
        being, and (except with respect to an individual adjudged 
        incompetent) to participate in planning care and treatment or 
        changes in care or treatment.
            (B) The right to voice grievances with respect to treatment 
        or care that is (or fails to be) furnished without 
        discrimination or reprisal for voicing grievances.
            (C) The right to confidentiality of the clinical records 
        described in section 1395x(o)(3) of this title.
            (D) The right to have one's property treated with respect.
            (E) The right to be fully informed orally and in writing (in 
        advance of coming under the care of the agency) of--
                (i) all items and services furnished by (or under 
            arrangements with) the agency for which payment may be made 
            under this subchapter,
                (ii) the coverage available for such items and services 
            under this subchapter, subchapter XIX of this chapter, and 
            any other Federal program of which the agency is reasonably 
            aware,
                (iii) any charges for items and services not covered 
            under this subchapter and any charges the individual may 
            have to pay with respect to items and services furnished by 
            (or under arrangements with) the agency, and
                (iv) any changes in the charges or items and services 
            described in clause (i), (ii), or (iii).

            (F) The right to be fully informed in writing (in advance of 
        coming under the care of the agency) of the individual's rights 
        and obligations under this subchapter.
            (G) The right to be informed of the availability of the 
        State home health agency hot-line established under section 
        1395aa(a) of this title.

        (2) The agency notifies the State entity responsible for the 
    licensing or certification of the agency of a change in--
            (A) the persons with an ownership or control interest (as 
        defined in section 1320a-3(a)(3) of this title) in the agency,
            (B) the persons who are officers, directors, agents, or 
        managing employees (as defined in section 1320a-5(b) of this 
        title) of the agency, and
            (C) the corporation, association, or other company 
        responsible for the management of the agency.

    Such notice shall be given at the time of the change and shall 
    include the identity of each new person or company described in the 
    previous sentence.
        (3)(A) The agency must not use as a home health aide (on a full-
    time, temporary, per diem, or other basis), any individual to 
    provide items or services described in section 1395x(m) of this 
    title on or after January 1, 1990, unless the individual--
            (i) has completed a training and competency evaluation 
        program, or a competency evaluation program, that meets the 
        minimum standards established by the Secretary under 
        subparagraph (D), and
            (ii) is competent to provide such items and services.

    For purposes of clause (i), an individual is not considered to have 
    completed a training and competency evaluation program, or a 
    competency evaluation program if, since the individual's most recent 
    completion of such a program, there has been a continuous period of 
    24 consecutive months during none of which the individual provided 
    items and services described in section 1395x(m) of this title for 
    compensation.
        (B)(i) The agency must provide, with respect to individuals used 
    as a home health aide by the agency as of July 1, 1989, for a 
    competency evaluation program (as described in subparagraph (A)(i)) 
    and such preparation as may be necessary for the individual to 
    complete such a program by January 1, 1990.
        (ii) The agency must provide such regular performance review and 
    regular in-service education as assures that individuals used to 
    provide items and services described in section 1395x(m) of this 
    title are competent to provide those items and services.
        (C) The agency must not permit an individual, other than in a 
    training and competency evaluation program that meets the minimum 
    standards established by the Secretary under subparagraph (D), to 
    provide items or services of a type for which the individual has not 
    demonstrated competency.
        (D)(i) The Secretary shall establish minimum standards for the 
    programs described in subparagraph (A) by not later than October 1, 
    1988.
        (ii) Such standards shall include the content of the curriculum, 
    minimum hours of training, qualification of instructors, and 
    procedures for determination of competency.
        (iii) Such standards may permit approval of programs offered by 
    or in home health agencies, as well as outside agencies (including 
    employee organizations), and of programs in effect on December 22, 
    1987; except that they may not provide for the approval of a program 
    offered by or in a home health agency which, within the previous 2 
    years--
            (I) has been determined to be out of compliance with 
        subparagraph (A), (B), or (C);
            (II) has been subject to an extended (or partial extended) 
        survey under subsection (c)(2)(D) of this section;
            (III) has been assessed a civil money penalty described in 
        subsection (f)(2)(A)(i) of this section of not less than $5,000; 
        or
            (IV) has been subject to the remedies described in 
        subsection (e)(1) of this section or in clauses (ii) or (iii) of 
        subsection (f)(2)(A) of this section.

        (iv) Such standards shall permit a determination that an 
    individual who has completed (before July 1, 1989) a training and 
    competency evaluation program or a competency evaluation program 
    shall be deemed for purposes of subparagraph (A) to have completed a 
    program that is approved by the Secretary under the standards 
    established under this subparagraph if the Secretary determines 
    that, at the time the program was offered, the program met such 
    standards.
        (E) In this paragraph, the term ``home health aide'' means any 
    individual who provides the items and services described in section 
    1395x(m) of this title, but does not include an individual--
            (i) who is a licensed health professional (as defined in 
        subparagraph (F)), or
            (ii) who volunteers to provide such services without 
        monetary compensation.

        (F) In this paragraph, the term ``licensed health professional'' 
    means a physician, physician assistant, nurse practitioner, 
    physical, speech, or occupational therapist, physical or 
    occupational therapy assistant, registered professional nurse, 
    licensed practical nurse, or licensed or certified social worker.
        (4) The agency includes an individual's plan of care required 
    under section 1395x(m) of this title as part of the clinical records 
    described in section 1395x(o)(3) of this title.
        (5) The agency operates and provides services in compliance with 
    all applicable Federal, State, and local laws and regulations 
    (including the requirements of section 1320a-3 of this title) and 
    with accepted professional standards and principles which apply to 
    professionals providing items and services in such an agency.
        (6) The agency complies with the requirement of section 
    1395cc(f) of this title (relating to maintaining written policies 
    and procedures respecting advance directives).

(b) Duty of Secretary

    It is the duty and responsibility of the Secretary to assure that 
the conditions of participation and requirements specified in or 
pursuant to section 1395x(o) of this title and subsection (a) of this 
section and the enforcement of such conditions and requirements are 
adequate to protect the health and safety of individuals under the care 
of a home health agency and to promote the effective and efficient use 
of public moneys.

(c) Surveys of home health agencies

    (1) Any agreement entered into or renewed by the Secretary pursuant 
to section 1395aa of this title relating to home health agencies shall 
provide that the appropriate State or local agency shall conduct, 
without any prior notice, a standard survey of each home health agency. 
Any individual who notifies (or causes to be notified) a home health 
agency of the time or date on which such a survey is scheduled to be 
conducted is subject to a civil money penalty of not to exceed $2,000. 
The provisions of section 1320a-7a of this title (other than subsections 
(a) and (b)) shall apply to a civil money penalty under this paragraph 
in the same manner as such provisions apply to a penalty or proceeding 
under section 1320a-7a of this title. The Secretary shall review each 
State's or local agency's procedures for scheduling and conduct of 
standard surveys to assure that the State or agency has taken all 
reasonable steps to avoid giving notice of such a survey through the 
scheduling procedures and the conduct of the surveys themselves.
    (2)(A) Except as provided in subparagraph (B), each home health 
agency shall be subject to a standard survey not later than 36 months 
after the date of the previous standard survey conducted under this 
paragraph. The Secretary shall establish a frequency for surveys of home 
health agencies within this 36-month interval commensurate with the need 
to assure the delivery of quality home health services.
    (B) If not otherwise conducted under subparagraph (A), a standard 
survey (or an abbreviated standard survey) of an agency--
        (i) may be conducted within 2 months of any change of ownership, 
    administration, or management of the agency to determine whether the 
    change has resulted in any decline in the quality of care furnished 
    by the agency, and
        (ii) shall be conducted within 2 months of when a significant 
    number of complaints have been reported with respect to the agency 
    to the Secretary, the State, the entity responsible for the 
    licensing of the agency, the State or local agency responsible for 
    maintaining a toll-free hotline and investigative unit (under 
    section 1395aa(a) of this title), or any other appropriate Federal, 
    State, or local agency.

    (C) A standard survey conducted under this paragraph with respect to 
a home health agency--
        (i) shall include (to the extent practicable), for a case-mix 
    stratified sample of individuals furnished items or services by the 
    agency--
            (I) visits to the homes of such individuals, but only with 
        the consent of such individuals, for the purpose of evaluating 
        (in accordance with a standardized reproducible assessment 
        instrument (or instruments) approved by the Secretary under 
        subsection (d) of this section) the extent to which the quality 
        and scope of items and services furnished by the agency attained 
        and maintained the highest practicable functional capacity of 
        each such individual as reflected in such individual's written 
        plan of care required under section 1395x(m) of this title and 
        clinical records required under section 1395x(o)(3) of this 
        title; and
            (II) a survey of the quality of care and services furnished 
        by the agency as measured by indicators of medical, nursing, and 
        rehabilitative care;

        (ii) shall be based upon a protocol that is developed, tested, 
    and validated by the Secretary not later than January 1, 1989; and
        (iii) shall be conducted by an individual--
            (I) who meets minimum qualifications established by the 
        Secretary not later than July 1, 1989,
            (II) who is not serving (or has not served within the 
        previous 2 years) as a member of the staff of, or as a 
        consultant to, the home health agency surveyed respecting 
        compliance with the conditions of participation specified in or 
        pursuant to section 1395x(o) of this title or subsection (a) of 
        this section, and
            (III) who has no personal or familial financial interest in 
        the home health agency surveyed.

    (D) Each home health agency that is found, under a standard survey, 
to have provided substandard care shall be subject to an extended survey 
to review and identify the policies and procedures which produced such 
substandard care and to determine whether the agency has complied with 
the conditions of participation specified in or pursuant to section 
1395x(o) of this title or subsection (a) of this section. Any other 
agency may, at the Secretary's or State's discretion, be subject to such 
an extended survey (or a partial extended survey). The extended survey 
shall be conducted immediately after the standard survey (or, if not 
practical, not later than 2 weeks after the date of completion of the 
standard survey).
    (E) Nothing in this paragraph shall be construed as requiring an 
extended (or partial extended) survey as a prerequisite to imposing a 
sanction against an agency under subsection (e) of this section on the 
basis of the findings of a standard survey.

(d) Assessment process; reports to Congress

    (1) Not later than January 1, 1989, the Secretary shall designate an 
assessment instrument (or instruments) for use by an agency in complying 
with subsection (c)(2)(C)(I) \1\ of this section.
---------------------------------------------------------------------------
    \1\ So in original. Probably should be subsection 
``(c)(2)(C)(i)(I)''.
---------------------------------------------------------------------------
    (2)(A) Not later than January 1, 1992, the Secretary shall--
        (i) evaluate the assessment process,
        (ii) report to Congress on the results of such evaluation, and
        (iii) based on such evaluation, make such modifications in the 
    assessment process as the Secretary determines are appropriate.

    (B) The Secretary shall periodically update the evaluation conducted 
under subparagraph (A), report the results of such update to Congress, 
and, based on such update, make such modifications in the assessment 
process as the Secretary determines are appropriate.
    (3) The Secretary shall provide for the comprehensive training of 
State and Federal surveyors in matters relating to the performance of 
standard and extended surveys under this section, including the use of 
any assessment instrument (or instruments) designated under paragraph 
(1).

(e) Enforcement

    (1) If the Secretary determines on the basis of a standard, 
extended, or partial extended survey or otherwise, that a home health 
agency that is certified for participation under this subchapter is no 
longer in compliance with the requirements specified in or pursuant to 
section 1395x(o) of this title or subsection (a) of this section and 
determines that the deficiencies involved immediately jeopardize the 
health and safety of the individuals to whom the agency furnishes items 
and services, the Secretary shall take immediate action to remove the 
jeopardy and correct the deficiencies through the remedy specified in 
subsection (f)(2)(A)(iii) of this section or terminate the certification 
of the agency, and may provide, in addition, for 1 or more of the other 
remedies described in subsection (f)(2)(A) of this section.
    (2) If the Secretary determines on the basis of a standard, 
extended, or partial extended survey or otherwise, that a home health 
agency that is certified for participation under this subchapter is no 
longer in compliance with the requirements specified in or pursuant to 
section 1395x(o) of this title or subsection (a) of this section and 
determines that the deficiencies involved do not immediately jeopardize 
the health and safety of the individuals to whom the agency furnishes 
items and services, the Secretary may (for a period not to exceed 6 
months) impose intermediate sanctions developed pursuant to subsection 
(f) of this section, in lieu of terminating the certification of the 
agency. If, after such a period of intermediate sanctions, the agency is 
still no longer in compliance with the requirements specified in or 
pursuant to section 1395x(o) of this title or subsection (a) of this 
section, the Secretary shall terminate the certification of the agency.
    (3) If the Secretary determines that a home health agency that is 
certified for participation under this subchapter is in compliance with 
the requirements specified in or pursuant to section 1395x(o) of this 
title or subsection (a) of this section but, as of a previous period, 
did not meet such requirements, the Secretary may provide for a civil 
money penalty under subsection (f)(2)(A)(i) of this section for the days 
in which it finds that the agency was not in compliance with such 
requirements.
    (4) The Secretary may continue payments under this subchapter with 
respect to a home health agency not in compliance with the requirements 
specified in or pursuant to section 1395x(o) of this title or subsection 
(a) of this section over a period of not longer than 6 months, if--
        (A) the State or local survey agency finds that it is more 
    appropriate to take alternative action to assure compliance of the 
    agency with the requirements than to terminate the certification of 
    the agency,
        (B) the agency has submitted a plan and timetable for corrective 
    action to the Secretary for approval and the Secretary approves the 
    plan of corrective action, and
        (C) the agency agrees to repay to the Federal Government 
    payments received under this subparagraph if the corrective action 
    is not taken in accordance with the approved plan and timetable.

The Secretary shall establish guidelines for approval of corrective 
actions requested by home health agencies under this subparagraph.

(f) Intermediate sanctions

    (1) The Secretary shall develop and implement, by not later than 
April 1, 1989--
        (A) a range of intermediate sanctions to apply to home health 
    agencies under the conditions described in subsection (e) of this 
    section, and
        (B) appropriate procedures for appealing determinations relating 
    to the imposition of such sanctions.

    (2)(A) The intermediate sanctions developed under paragraph (1) 
shall include--
        (i) civil money penalties in an amount not to exceed $10,000 for 
    each day of noncompliance,
        (ii) suspension of all or part of the payments to which a home 
    health agency would otherwise be entitled under this subchapter with 
    respect to items and services furnished by a home health agency on 
    or after the date on which the Secretary determines that 
    intermediate sanctions should be imposed pursuant to subsection 
    (e)(2) of this section, and
        (iii) the appointment of temporary management to oversee the 
    operation of the home health agency and to protect and assure the 
    health and safety of the individuals under the care of the agency 
    while improvements are made in order to bring the agency into 
    compliance with all the requirements specified in or pursuant to 
    section 1395x(o) of this title or subsection (a) of this section.

The provisions of section 1320a-7a of this title (other than subsections 
(a) and (b)) shall apply to a civil money penalty under clause (i) in 
the same manner as such provisions apply to a penalty or proceeding 
under section 1320a-7a(a) of this title. The temporary management under 
clause (iii) shall not be terminated until the Secretary has determined 
that the agency has the management capability to ensure continued 
compliance with all the requirements referred to in that clause.
    (B) The sanctions specified in subparagraph (A) are in addition to 
sanctions otherwise available under State or Federal law and shall not 
be construed as limiting other remedies, including any remedy available 
to an individual at common law.
    (C) A finding to suspend payment under subparagraph (A)(ii) shall 
terminate when the Secretary finds that the home health agency is in 
substantial compliance with all the requirements specified in or 
pursuant to section 1395x(o) of this title and subsection (a) of this 
section.
    (3) The Secretary shall develop and implement, by not later than 
April 1, 1989, specific procedures with respect to the conditions under 
which each of the intermediate sanctions developed under paragraph (1) 
is to be applied, including the amount of any fines and the severity of 
each of these sanctions. Such procedures shall be designed so as to 
minimize the time between identification of deficiencies and imposition 
of these sanctions and shall provide for the imposition of incrementally 
more severe fines for repeated or uncorrected deficiencies.

(g) Payment on basis of location of service

    A home health agency shall submit claims for payment for home health 
services under this subchapter only on the basis of the geographic 
location at which the service is furnished, as determined by the 
Secretary.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1891, as added and amended 
Pub. L. 100-203, title IV, Secs. 4021(b), 4022(a), 4023(a), Dec. 22, 
1987, 101 Stat. 1330-67, 1330-69, 1330-71; Pub. L. 100-360, title IV, 
Sec. 411(d)(1)(A), (2)-(3)(B), July 1, 1988, 102 Stat. 773, 774; Pub. L. 
100-485, title VI, Sec. 608(d)(20)(A), Oct. 13, 1988, 102 Stat. 2419; 
Pub. L. 101-508, title IV, Secs. 4206(d)(2), 4207(i)(1), formerly 
4027(i)(1), Nov. 5, 1990, 104 Stat. 1388-116, 1388-123, renumbered Pub. 
L. 103-432, title I, Sec. 160(d)(4), Oct. 31, 1994, 108 Stat. 4444; Pub. 
L. 104-134, title I, Sec. 101(d) [title V, Sec. 516(a)], Apr. 26, 1996, 
110 Stat. 1321-211, 1321-246; renumbered title I, Pub. L. 104-140, 
Sec. 1(a), May 2, 1996, 110 Stat. 1327; Pub. L. 105-33, title IV, 
Sec. 4604(a), Aug. 5, 1997, 111 Stat. 472.)


                               Amendments

    1997--Subsec. (g). Pub. L. 105-33 added subsec. (g).
    1996--Subsec. (c)(2)(A). Pub. L. 104-134 substituted ``36 months'' 
for ``15 months'' in first sentence and amended last sentence generally. 
Prior to amendment, last sentence read as follows: ``The statewide 
average interval between standard surveys of any home health agency 
shall not exceed 12 months.''
    1990--Subsec. (a)(3)(D)(iii). Pub. L. 101-508, Sec. 4207(i)(1), 
formerly Sec. 4027(i)(1), as renumbered by Pub. L. 103-432, substituted 
``which, within the previous 2 years--'' and subcls. (I) to (IV) for 
``which has been determined to be out of compliance with the 
requirements specified in or pursuant to section 1395x(o) of this title 
or subsection (a) of this section within the previous 2 years.''
    Subsec. (a)(6). Pub. L. 101-508, Sec. 4206(d)(2), added par. (6).
    1988--Subsec. (a)(3)(A). Pub. L. 100-360, Sec. 411(d)(1)(A)(i), 
struck out ``who is not a licensed health care professional (as defined 
in subparagraph (F))'' after ``any individual'' in introductory 
provisions.
    Subsec. (a)(3)(F). Pub. L. 100-360, Sec. 411(d)(1)(A)(ii), inserted 
``physical or occupational therapy assistant,'' after ``occupational 
therapist''.
    Subsec. (a)(4) to (6). Pub. L. 100-360, Sec. 411(d)(1)(A)(iii), 
redesignated pars. (5) and (6) as (4) and (5), respectively, and struck 
out former par. (4) which read as follows: ``With respect to durable 
medical equipment furnished to individuals for whom the agency provides 
items and services, suppliers of such equipment do not use (on a full-
time, temporary, per diem, or other basis) any individual who does not 
meet minimum training standards (established by the Secretary by October 
1, 1988) for the demonstration and use of any such equipment furnished 
to individuals with respect to whom payments may be made under this 
subchapter.''
    Subsec. (c)(1). Pub. L. 100-360, Sec. 411(d)(2)(A), as amended by 
Pub. L. 100-485, Sec. 608(d)(20)(A), amended third sentence generally. 
Prior to amendment, third sentence read as follows: ``The Secretary 
shall provide for imposition of civil money penalties under this clause 
in a manner similar to that for the imposition of civil money penalties 
under section 1320a-7a of this title.''
    Subsec. (d)(2)(A). Pub. L. 100-360, Sec. 411(d)(2)(B), substituted 
``1992'' for ``1991'' in introductory provisions.
    Subsecs. (e), (f). Pub. L. 100-360, Sec. 411(d)(3)(A), made 
technical amendment to Pub. L. 100-203, Sec. 4023(a), see 1987 Amendment 
note below.
    Subsec. (f)(2)(A). Pub. L. 100-360, Sec. 411(d)(3)(B)(iii), inserted 
before last sentence ``The provisions of section 1320a-7a of this title 
(other than subsections (a) and (b)) shall apply to a civil money 
penalty under clause (i) in the same manner as such provisions apply to 
a penalty or proceeding under section 1320a-7a(a) of this title.''
    Pub. L. 100-360, Sec. 411(d)(3)(B)(i), realigned the margins of cls. 
(i) to (iii) and concluding provisions.
    Subsec. (f)(2)(A)(i). Pub. L. 100-360, Sec. 411(d)(3)(B)(ii), 
substituted ``in an amount not to exceed $10,000 for each day of 
noncompliance'' for ``for each day of noncompliance''.
    1987--Subsecs. (c), (d). Pub. L. 100-203, Sec. 4022(a), added 
subsecs. (c) and (d).
    Subsecs. (e), (f). Pub. L. 100-203, Sec. 4023(a), as amended by Pub. 
L. 100-360, Sec. 411(d)(3)(A), added subsecs. (e) and (f).


                    Effective Date of 1997 Amendment

    Amendment by Pub. L. 105-33 applicable to cost reporting periods 
beginning on or after Oct. 1, 1997, see section 4604(c) of Pub. L. 105-
33, set out as a note under section 1395x of this title.


                    Effective Date of 1990 Amendment

    Amendment by section 4206(d)(2) of Pub. L. 101-508 applicable with 
respect to services furnished on or after the first day of the first 
month beginning more than 1 year after Nov. 5, 1990, see section 
4206(e)(1) of Pub. L. 101-508, set out as a note under section 1395i-3 
of this title.
    Section 4207(i)(1), formerly 4027(i)(1), of Pub. L. 101-508, as 
renumbered by Pub. L. 103-432, title I, Sec. 160(d)(4), Oct. 31, 1994, 
108 Stat. 4444, provided that the amendment made by that section is 
effective as if included in the enactment of the Omnibus Budget 
Reconciliation Act of 1987, Pub. L. 100-203.
    Section 4207(i)(2), formerly 4027(i)(2), of Pub. L. 101-508, as 
renumbered and amended by Pub. L. 103-432, title I, Sec. 160(d)(4), 
(11), Oct. 31, 1994, 108 Stat. 4444, provided that: ``The amendments 
made by paragraph (1) [amending this section] shall take effect as if 
included in the enactment of the Omnibus Budget Reconciliation Act of 
1987 [Pub. L. 100-203], except that the Secretary may not permit 
approval of a training and competency evaluation program or a competency 
evaluation program offered by or in a home health agency which, pursuant 
to any Federal or State law within the 2-year period beginning on 
October 1, 1988--
        ``(i) had its participation terminated under title XVIII of the 
    Social Security Act [this subchapter];
        ``(ii) was assessed a civil money penalty not less than $5,000 
    for deficiencies in applicable quality standards for home health 
    agencies;
        ``(iii) was subject to suspension by the Secretary of all or 
    part of the payments to which it would otherwise be entitled under 
    such title;
        ``(iv) operated under a temporary management appointed to 
    oversee the operation of the agency and to ensure the health and 
    safety of the agency's patients; or
        ``(v) pursuant to State action, was closed or had its patients 
    transferred.''


                    Effective Date of 1988 Amendments

    Amendment by Pub. L. 100-485 effective as if included in the 
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note 
under section 704 of this title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by Pub. L. 100-360, as it relates to a provision in the 
Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, effective as 
if included in the enactment of that provision in Pub. L. 100-203, see 
section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA; 
Effective Date note under section 106 of Title 1, General Provisions.


                    Effective Date of 1987 Amendment

    Section 4022(b) of Pub. L. 100-203 provided that: ``Except as 
otherwise specifically provided in section 1891(d) of the Social 
Security Act [subsec. (d) of this section] (as added by subsection (a)), 
the amendment made by subsection (a) [amending this section] shall 
become effective on the first day of the 18th calendar month to begin 
after the date of the enactment of this Act [Dec. 22, 1987].''
    Section 4023(b) of Pub. L. 100-203, as amended by Pub. L. 100-360, 
title IV, Sec. 411(d)(3)(C), July 1, 1988, 102 Stat. 774, provided that: 
``Except as otherwise specifically provided in subsections (e) and (f) 
of section 1891 of the Social Security Act [subsecs. (e) and (f) of this 
section] (as added by subsection (a)), the amendment made by subsection 
(a) [amending this section] shall become effective on the first day of 
the 18th calendar month to begin after the date of the enactment of this 
Act [Dec. 22, 1987], and no intermediate sanction described in section 
1891(f)(2)(A) of such Act [subsec. (f)(2)(A) of this section] shall be 
imposed for violations occurring before such effective date.''


                             Effective Date

    Section applicable to home health agencies as of the first day of 
the 18th calendar month that begins after Dec. 22, 1987, except as 
otherwise provided, see section 4021(c) of Pub. L. 100-203, set out as 
an Effective Date of 1987 Amendment note under section 1395x of this 
title.

                  Section Referred to in Other Sections

    This section is referred to in sections 1395x, 1395cc of this title.
