
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395c]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
        Part A--Hospital Insurance Benefits for Aged and Disabled
 
Sec. 1395c. Description of program

    The insurance program for which entitlement is established by 
sections 426 and 426-1 of this title provides basic protection against 
the costs of hospital, related post-hospital, home health services, and 
hospice care in accordance with this part for (1) individuals who are 
age 65 or over and are eligible for retirement benefits under subchapter 
II of this chapter (or would be eligible for such benefits if certain 
government employment were covered employment under such subchapter) or 
under the railroad retirement system, (2) individuals under age 65 who 
have been entitled for not less than 24 months to benefits under 
subchapter II of this chapter (or would have been so entitled to such 
benefits if certain government employment were covered employment under 
such subchapter) or under the railroad retirement system on the basis of 
a disability, and (3) certain individuals who do not meet the conditions 
specified in either clause (1) or (2) but who are medically determined 
to have end stage renal disease.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1811, as added Pub. L. 89-97, 
title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended Pub. L. 92-
603, title II, Sec. 201(a)(2), Oct. 30, 1972, 86 Stat. 1371; Pub. L. 95-
292, Sec. 4(a), June 13, 1978, 92 Stat. 315; Pub. L. 96-265, title I, 
Sec. 103(a)(2), June 9, 1980, 94 Stat. 444; Pub. L. 96-473, Sec. 2(b), 
Oct. 19, 1980, 94 Stat. 2263; Pub. L. 96-499, title IX, Sec. 930(a), 
Dec. 5, 1980, 94 Stat. 2631; Pub. L. 97-248, title I, Sec. 122(a)(1), 
title II, Sec. 278(b)(3), Sept. 3, 1982, 96 Stat. 356, 561; Pub. L. 99-
272, title XIII, Sec. 13205(b)(2)(C)(i), Apr. 7, 1986, 100 Stat. 317; 
Pub. L. 100-360, title I, Sec. 104(d)(1), July 1, 1988, 102 Stat. 688; 
Pub. L. 101-234, title I, Sec. 101(a), Dec. 13, 1989, 103 Stat. 1979.)


                               Amendments

    1989--Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 104(d)(1), and 
provided that the provisions of law amended or repealed by such section 
are restored or revived as if such section had not been enacted, see 
1988 Amendment note below.
    1988--Pub. L. 100-360 substituted ``inpatient hospital services, 
extended care services'' for ``hospital, related post-hospital''.
    1986--Pub. L. 99-272 substituted ``government employment'' for 
``Federal employment'' in cls. (1) and (2).
    1982--Pub. L. 97-248, Sec. 122(a)(1), substituted ``home health 
services, and hospice care'' for ``and home health services''.
    Pub. L. 97-248, Sec. 278(b)(3), inserted ``(or would be eligible for 
such benefits if certain Federal employment were covered employment 
under such subchapter)'' after ``subchapter II of this chapter'' in cl. 
(1), and inserted ``(or would have been so entitled to such benefits if 
certain Federal employment were covered employment under such 
subchapter)'' after ``subchapter II of this chapter'' in cl. (2).
    1980--Pub. L. 96-499 substituted ``, related post-hospital, and home 
health services'' for ``and related post-hospital services''.
    Pub. L. 96-473 substituted ``are eligible for'' for ``are entitled 
to''.
    Pub. L. 96-265 substituted ``not less than 24 months'' for ``not 
less than 24 consecutive months''.
    1978--Pub. L. 95-292 inserted references to section 426-1 of this 
title and to individuals who do not meet the conditions specified in 
either clause (1) or (2) but who are medically determined to have end 
stage renal disease.
    1972--Pub. L. 92-603 designated existing provisions as cl. (1) and 
added cl. (2).


                    Effective Date of 1989 Amendment

    Section 101(d) of Pub. L. 101-234 provided that: ``The provisions of 
this section [amending this section and sections 1395d, 1395e, 1395f, 
1395k, 1395x, 1395cc, and 1395tt of this title, enacting provisions set 
out as notes under sections 1395e and 1395ww of this title, and amending 
provisions set out as notes under sections 1395e and 1395ww of this 
title] shall take effect January 1, 1990, except that the amendments 
made by subsection (c) [amending provisions set out as a note under 
section 1395ww of this title] shall be effective as if included in the 
enactment of MCCA [Pub. L. 100-360].''


                    Effective Date of 1988 Amendment

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


                    Effective Date of 1986 Amendment

    Amendment by Pub. L. 99-272 effective after Mar. 31, 1986, with no 
individual to be considered under disability for any period beginning 
before Apr. 1, 1986, for purposes of hospital insurance benefits, see 
section 13205(d)(2) of Pub. L. 99-272, set out as a note under section 
410 of this title.


                    Effective Date of 1982 Amendment

    Section 122(h)(1) of Pub. L. 97-248, as amended by Pub. L. 99-272, 
title IX, Sec. 9123(a), Apr. 7, 1986, 100 Stat. 168, provided that: 
``The amendments made by this section [amending this section and 
sections 1395d to 1395f, 1395h, and 1395x to 1395cc of this title and 
section 231f of Title 45, Railroads, and enacting provisions set out as 
notes under sections 1395b-1 and 1395f of this title] apply to hospice 
care provided on or after November 1, 1983.''
    Amendment by section 278(b)(3) of Pub. L. 97-248 effective on and 
after Jan. 1, 1983, and applicable to remuneration (for medicare 
qualified Federal employment) paid after Dec. 31, 1982, see section 
278(c)(2)(A) of Pub. L. 97-248, set out as a note under section 426 of 
this title.


                    Effective Date of 1980 Amendments

    Amendment by Pub. L. 96-499 effective with respect to services 
furnished on or after July 1, 1981, see section 930(s)(1) of Pub. L. 96-
499, set out as a note under section 1395x of this title.
    Amendment by Pub. L. 96-473 effective after second month beginning 
after Oct. 19, 1980, see section 2(d) of Pub. L. 96-473, set out as a 
note under section 426 of this title.
    Amendment by Pub. L. 96-265 applicable with respect to hospital 
insurance or supplementary medical insurance benefits for services 
provided on or after first day of sixth month which begins after June 9, 
1980, see section 103(c) of Pub. L. 96-265, set out as a note under 
section 426 of this title.


                    Effective Date of 1978 Amendment

    Amendment by Pub. L. 95-292 effective with respect to services, 
supplies, and equipment furnished after the third calendar month 
beginning after June 13, 1978, except that provisions for the 
implementation of an incentive reimbursement system for dialysis 
services furnished in facilities and providers to become effective with 
respect to a facility's or provider's first accounting period beginning 
after the last day of the twelfth month following the month of June 
1978, and except that provisions for reimbursement rates for home 
dialysis to become effective on Apr. 1, 1979, see section 6 of Pub. L. 
95-292, set out as a note under section 426 of this title.


  Advisory Council To Study Coverage of Disabled Under This Subchapter

    Pub. L. 90-248, title I, Sec. 140, Jan. 2, 1968, 81 Stat. 854, 
directed Secretary of Health, Education, and Welfare to appoint an 
Advisory Council to study need for coverage of disabled under the health 
insurance programs of this subchapter, directed Council to submit a 
report on such study to Secretary by Jan. 1, 1969, and directed 
Secretary in turn to transmit such report to Congress, resulting in 
termination of Council's existence.


Reimbursement of Charges Under Part A for Services to Patients Admitted 
                   Prior to 1968 to Certain Hospitals

    Pub. L. 90-248, title I, Sec. 142, Jan. 2, 1968, 81 Stat. 855, 
provided that:
    ``(a) Notwithstanding any provision of title XVIII of the Social 
Security Act [this subchapter] an individual who is entitled to hospital 
insurance benefits under section 226 of such Act [section 426 of this 
title] may, subject to subsections (b) and (c), receive, on the basis of 
an itemized bill, reimbursement for charges to him for inpatient 
hospital services (as defined in section 1861 of such Act [section 1395x 
of this title], but without regard to subsection (e) of such section) 
furnished by, or under arrangements (as defined in section 1861(w) of 
such Act [section 1395x(w) of this title] with, a hospital if--
        ``(1) the hospital did not have an agreement in effect under 
    section 1866 of such Act [section 1395cc of this title] but would 
    have been eligible for payment under part A of title XVIII of such 
    Act [this part] with respect to such services if at the time such 
    services were furnished the hospital had such an agreement in 
    effect;
        ``(2) the hospital (A) meets the requirements of paragraphs (5) 
    and (7) of section 1861(e) of such Act [section 1395x(e) of this 
    title], (B) is not primarily engaged in providing the services 
    described in section 1961(j)(1)(A) of such Act [section 
    1395x(j)(1)(A) of this title], and (C) is primarily engaged in 
    providing, by or under the supervision of individuals referred to in 
    paragraph (1) of section 1861(r) of such Act [section 1395x(r) of 
    this title], to inpatients (i) diagnostic services and therapeutic 
    services for medical diagnosis, treatment, and care of injured, 
    disabled, or sick persons, or (ii) rehabilitation services for the 
    rehabilitation of injured, disabled, or sick persons;
        ``(3) the hospital did not meet the requirements that must be 
    met to permit payment to the hospital under part A of title XVIII of 
    such Act [this part]; and
        ``(4) an application is filed (submitted in such form and manner 
    and by such person, and containing and supported by such 
    information, as the Secretary shall by regulations prescribe) for 
    reimbursement before January 1, 1969.
    ``(b) Payments under this section may not be made for inpatient 
hospital services (as described in subsection (a)) furnished to an 
individual--
        ``(1) prior to July 1, 1966,
        ``(2) after December 31, 1967, unless furnished with respect to 
    an admission to the hospital prior to January 1, 1968, and
        ``(3) for more than--
            ``(A) 90 days in any spell of illness, but only if (i) prior 
        to January 1, 1969, the hospital furnishing such services 
        entered into an agreement under section 1866 of the Social 
        Security Act [section 1395cc of this title] and (ii) the 
        hospital's plan for utilization review, as provided for in 
        section 1861(k) of such Act [section 1395x(k) of this title], 
        has, in accordance with section 1814 of such Act [section 1395f 
        of this title], been applied to the services furnished such 
        individual, or
            ``(B) 20 days in any spell of illness, if the hospital did 
        not meet the conditions of clauses (i) and (ii) of subparagraph 
        (A).
    ``(c)(1) The amounts payable in accordance with subsection (a) with 
respect to inpatient hospital services shall, subject to paragraph (2) 
of this subsection, be paid from the Federal Hospital Insurance Trust 
Fund in amounts equal to 60 percent of the hospital's reasonable charges 
for routine services furnished in the accommodations occupied by the 
individual or in semi-private accommodations (as defined in section 
1861(v)(4) of the Social Security Act [section 1395x(v)(4) of this 
title]) whichever is less, plus 80 percent of the hospital's reasonable 
charges for ancillary services. If separate charges for routine and 
ancillary services are not made by the hospital, reimbursement may be 
based on two-thirds of the hospital's reasonable charges for the 
services received but not to exceed the charges which would have been 
made if the patient had occupied semi-private accommodations (as so 
defined). For purposes of the preceding provisions of this paragraph, 
the term `routine services' shall mean the regular room, dietary, and 
nursing services, minor medical and surgical supplies and the use of 
equipment and facilities for which a separate charge is not customarily 
made; the term `ancillary services' shall mean those special services 
for which charges are customarily made in addition to routine services.
    ``(2) Before applying paragraph (1), payments made under this 
section shall be reduced to the extent provided for under section 1813 
of the Social Security Act [section 1395e of this title] in the case of 
benefits payable to providers of services under part A of title XVIII of 
such Act [this part].
    ``(d) For the purposes of this section--
        ``(1) the 90-day period, referred to in subsection (b)(3)(A), 
    shall be reduced by the number of days of inpatient hospital 
    services furnished to such individual during the spell of illness, 
    referred to therein, and with respect to which he was entitled to 
    have payment made under part A of title XVIII of the Social Security 
    Act [this part];
        ``(2) the 20-day period, referred to in subsection (b)(3)(B) 
    shall be reduced by the number of days in excess of 70 days of 
    inpatient hospital services furnished during the spell of illness, 
    referred to therein, and with respect to which such individual was 
    entitled to have payment made under such part A [this part];
        ``(3) the term `spell of illness' shall have the meaning 
    assigned to it by subsection (a) of section 1861 of such Act 
    [section 1395x(a) of this title] except that the term `inpatient 
    hospital services' as it appears in such subsection shall have the 
    meaning assigned to it by subsection (a) of this section.''

                  Section Referred to in Other Sections

    This section is referred to in title 26 section 220; title 38 
sections 1725, 1729.
