
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395ff]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 1395ff. Determinations of Secretary


(a) Entitlement to and amount of benefits

    The determination of whether an individual is entitled to benefits 
under part A or part B of this subchapter, and the determination of the 
amount of benefits under part A or part B of this subchapter, and any 
other determination with respect to a claim for benefits under part A of 
this subchapter or a claim for benefits with respect to home health 
services under part B of this subchapter shall be made by the Secretary 
in accordance with regulations prescribed by him.

(b) Appeal by individuals; provider representation of beneficiaries

    (1) Any individual dissatisfied with any determination under 
subsection (a) of this section as to--
        (A) whether he meets the conditions of section 426 or section 
    426a of this title, or
        (B) whether he is eligible to enroll and has enrolled pursuant 
    to the provisions of part B of this subchapter or section 1395i-2 of 
    this title,
        (C) the amount of benefits under part A or part B of this 
    subchapter (including a determination where such amount is 
    determined to be zero), or
        (D) any other denial (other than under part B of subchapter XI 
    of this chapter) of a claim for benefits under part A of this 
    subchapter or a claim for benefits with respect to home health 
    services under part B of this subchapter,

shall be entitled to a hearing thereon by the Secretary to the same 
extent as is provided in section 405(b) of this title and to judicial 
review of the Secretary's final decision after such hearing as is 
provided in section 405(g) of this title, except that, in so applying 
such sections and in applying section 405(l) of this title thereto, any 
reference therein to the Commissioner of Social Security or the Social 
Security Administration shall be considered a reference to the Secretary 
or the Department of Health and Human Services, respectively. Sections 
406(a), 1302, and 1395hh of this title shall not be construed as 
authorizing the Secretary to prohibit an individual from being 
represented under this subsection by a person that furnishes or supplies 
the individual, directly or indirectly, with services or items solely on 
the basis that the person furnishes or supplies the individual with such 
a service or item. Any person that furnishes services or items to an 
individual may not represent an individual under this subsection with 
respect to the issue described in section 1395pp(a)(2) of this title 
unless the person has waived any rights for payment from the beneficiary 
with respect to the services or items involved in the appeal. If a 
person furnishes services or items to an individual and represents the 
individual under this subsection, the person may not impose any 
financial liability on such individual in connection with such 
representation.
    (2) Notwithstanding paragraph (1)(C) and (1)(D), in the case of a 
claim arising--
        (A) under part A of this subchapter, a hearing shall not be 
    available to an individual under paragraph (1)(C) and (1)(D) if the 
    amount in controversy is less than $100 and judicial review shall 
    not be available to the individual under that paragraph if the 
    amount in controversy is less than $1,000; or
        (B) under part B of this subchapter, a hearing shall not be 
    available to an individual under paragraph (1)(C) and (1)(D) if the 
    amount in controversy is less than $500 (or $100 in the case of home 
    health services) and judicial review shall not be available to the 
    individual under that paragraph if the aggregate amount in 
    controversy is less than $1,000.

In determining the amount in controversy, the Secretary, under 
regulations, shall allow two or more claims to be aggregated if the 
claims involve the delivery of similar or related services to the same 
individual or involve common issues of law and fact arising from 
services furnished to two or more individuals.
    (3) Review of any national coverage determination under section 
1395y(a)(1) of this title respecting whether or not a particular type or 
class of items or services is covered under this subchapter shall be 
subject to the following limitations:
        (A) Such a determination shall not be reviewed by any 
    administrative law judge.
        (B) Such a determination shall not be held unlawful or set aside 
    on the ground that a requirement of section 553 of title 5 or 
    section 1395hh(b) of this title, relating to publication in the 
    Federal Register or opportunity for public comment, was not 
    satisfied.
        (C) In any case in which a court determines that the record is 
    incomplete or otherwise lacks adequate information to support the 
    validity of the determination, it shall remand the matter to the 
    Secretary for additional proceedings to supplement the record and 
    the court may not determine that an item or service is covered 
    except upon review of the supplemented record.

    (4) A regulation or instruction which relates to a method for 
determining the amount of payment under part B of this subchapter and 
which was initially issued before January 1, 1981, shall not be subject 
to judicial review.
    (5) In an administrative hearing pursuant to paragraph (1), where 
the moving party alleges that there are no material issues of fact in 
dispute, the administrative law judge shall make an expedited 
determination as to whether any such facts are in dispute and, if not, 
shall determine the case expeditiously.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1869, as added Pub. L. 89-97, 
title I, Sec. 102(a), July 30, 1965, 79 Stat. 330; amended Pub. L. 92-
603, title II, Sec. 299O(a), Oct. 30, 1972, 86 Stat. 1464; Pub. L. 98-
369, div. B, title III, Sec. 2354(b)(35), July 18, 1984, 98 Stat. 1102; 
Pub. L. 99-509, title IX, Secs. 9313(a)(1), (b)(1), 9341(a)(1), Oct. 21, 
1986, 100 Stat. 2002, 2037; Pub. L. 100-93, Sec. 8(e), Aug. 18, 1987, 
101 Stat. 694; Pub. L. 100-203, title IV, Secs. 4082(a), (b), 
4085(i)(18), (19), Dec. 22, 1987, 101 Stat. 1330-128, 1330-133; Pub. L. 
103-296, title I, Sec. 108(c)(5), Aug. 15, 1994, 108 Stat. 1485; Pub. L. 
105-33, title IV, Sec. 4611(c), Aug. 5, 1997, 111 Stat. 473.)

                       References in Text

    Parts A and B of this subchapter, referred to in subsecs. (a) and 
(b), are classified to sections 1395c et seq. and 1395j et seq., 
respectively, of this title.
    Part B of subchapter XI of this chapter, referred to in subsec. 
(b)(1)(D), is classified to section 1320c et seq. of this title.


                               Amendments

    1997--Subsec. (b)(2)(B). Pub. L. 105-33 inserted ``(or $100 in the 
case of home health services)'' after ``$500''.
    1994--Subsec. (b)(1). Pub. L. 103-296 inserted ``, except that, in 
so applying such sections and in applying section 405(l) of this title 
thereto, any reference therein to the Commissioner of Social Security or 
the Social Security Administration shall be considered a reference to 
the Secretary or the Department of Health and Human Services, 
respectively'' after ``section 405(g) of this title'' in closing 
provisions.
    1987--Subsec. (a). Pub. L. 100-203, Sec. 4085(i)(18), inserted ``or 
a claim for benefits with respect to home health services under part B 
of this subchapter'' before ``shall''.
    Subsec. (b)(2). Pub. L. 100-203, Sec. 4085(i)(19), inserted ``and 
(1)(D)'' after ``paragraph (1)(C)'' in two places.
    Subsec. (b)(3)(B). Pub. L. 100-203, Sec. 4082(a), substituted 
``section 553'' for ``chapter 5''.
    Subsec. (b)(5). Pub. L. 100-203, Sec. 4082(b), added par. (5).
    Subsec. (c). Pub. L. 100-93 struck out subsec. (c) which read as 
follows: ``Any institution or agency dissatisfied with any determination 
by the Secretary that it is not a provider of services, or with any 
determination described in section 1395cc(b)(2) of this title, shall be 
entitled to a hearing thereon by the Secretary (after reasonable notice 
and opportunity for hearing) to the same extent as is provided in 
section 405(b) of this title, and to judicial review of the Secretary's 
final decision after such hearing as is provided in section 405(g) of 
this title.''
    1986--Subsec. (a). Pub. L. 99-509, Sec. 9341(a)(1)(A), inserted ``or 
part B'' after ``amount of benefits under part A''.
    Pub. L. 99-509, Sec. 9313(b)(1)(A), inserted ``and any other 
determination with respect to a claim for benefits under part A of this 
subchapter'' before ``shall''.
    Subsec. (b)(1). Pub. L. 99-509, Sec. 9313(a)(1), in concluding 
provisions, inserted at end ``Sections 406(a), 1302, and 1395hh of this 
title shall not be construed as authorizing the Secretary to prohibit an 
individual from being represented under this subsection by a person that 
furnishes or supplies the individual, directly or indirectly, with 
services or items solely on the basis that the person furnishes or 
supplies the individual with such a service or item. Any person that 
furnishes services or items to an individual may not represent an 
individual under this subsection with respect to the issue described in 
section 1395pp(a)(2) of this title unless the person has waived any 
rights for payment from the beneficiary with respect to the services or 
items involved in the appeal. If a person furnishes services or items to 
an individual and represents the individual under this subsection, the 
person may not impose any financial liability on such individual in 
connection with such representation.''
    Subsec. (b)(1)(C). Pub. L. 99-509, Sec. 9341(a)(1)(B), inserted ``or 
part B''.
    Subsec. (b)(1)(D). Pub. L. 99-509, Sec. 9313(b)(1)(B), added subpar. 
(D).
    Subsec. (b)(2). Pub. L. 99-509, Sec. 9341(a)(1)(C), amended par. (2) 
generally. Prior to amendment, par. (2) read as follows: 
``Notwithstanding the provisions of subparagraph (C) of paragraph (1) of 
this subsection, a hearing shall not be available to an individual by 
reason of such subparagraph (C) if the amount in controversy is less 
than $100; nor shall judicial review be available to an individual by 
reason of such subparagraph (C) if the amount in controversy is less 
than $1,000.''
    Subsec. (b)(3), (4). Pub. L. 99-509, Sec. 9341(a)(1)(D), added pars. 
(3) and (4).
    1984--Subsec. (b)(1)(B). Pub. L. 98-369 struck out the comma before 
``or section 1395i-2'' and struck out ``, or section 1819'' after 
``section 1395i-2 of this title''.
    1972--Subsec. (b). Pub. L. 92-603 redesignated existing provisions 
as par. (1), generally amended conditions under which a dissatisfied 
individual shall be entitled to a hearing by Secretary and to judicial 
review of final decision of Secretary after such hearing, and added par. 
(2).


                    Effective Date of 1997 Amendment

    Amendment by Pub. 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 Pub. L. 105-33, set out as a note under section 1395d of this 
title.


                    Effective Date of 1994 Amendment

    Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section 
110(a) of Pub. L. 103-296, set out as a note under section 401 of this 
title.


                    Effective Date of 1987 Amendments

    Section 4082(e)(1), (2) of Pub. L. 100-203 provided that:
    ``(1) The amendment made by subsection (a) [amending this section] 
shall take effect on the date of the enactment of this Act [Dec. 22, 
1987].
    ``(2) The amendment made by subsection (b) [amending this section] 
shall apply to requests for hearings filed after the end of the 60-day 
period beginning on the date of the enactment of this Act.''
    Amendment by Pub. 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 Pub. L. 100-
93, set out as a note under section 1320a-7 of this title.


                    Effective Date of 1986 Amendment

    Section 9313(b)(2) of Pub. L. 99-509 provided that: ``The amendments 
made by this subsection [amending this section] take effect on the date 
of the enactment of this Act [Oct. 21, 1986].''
    Section 9341(b) of Pub. L. 99-509 provided that: ``The amendments 
made by subsection (a) [amending this section and sections 1395u and 
1395pp of this title] shall apply to items and services furnished on or 
after January 1, 1987.''


                    Effective Date of 1984 Amendment

    Amendment by Pub. 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 Pub. L. 98-369, set out as a 
note under section 1320a-1 of this title.


                    Effective Date of 1972 Amendment

    Section 299O(b) of Pub. L. 92-603 provided that:
    ``(1) The provisions of subparagraphs (A) and (B) of section 
1869(b)(1) of the Social Security Act [subsec. (b)(1)(A), (B) of this 
section], as amended by subsection (a) of this section, shall be 
effective on the date of enactment of this Act [Oct. 30, 1972].
    ``(2) The provisions of paragraph (2) and subparagraph (C) of 
paragraph (1) of section 1869(b) of the Social Security Act [subsec. 
(b)(1)(C) and (b)(2) of this section], as amended by subsection (a) of 
this section, shall be effective with respect to any claims under part A 
of title XVIII of such Act [part A of this subchapter], filed--
        ``(A) in or after the month in which this Act is enacted [Oct. 
    1972], or
        ``(B) before the month in which this Act is enacted [Oct. 1972], 
    but only if a civil action with respect to a final decision of the 
    Secretary of Health, Education, and Welfare on such claim has not 
    been commenced under such section 1869(b) [subsec. (b) of this 
    section] before such month.''


  Study of Aggregation Rule for Claims for Similar Physicians' Services

    Pub. L. 101-508, title IV, Sec. 4113, Nov. 5, 1990, 104 Stat. 1388-
64, directed Secretary of Health and Human Services to carry out a study 
of the effects of permitting the aggregation of claims that involve 
common issues of law and fact furnished in the same carrier area to two 
or more individuals by two or more physicians within the same 12-month 
period for purposes of appeals provided for under subsec. (b)(2) of this 
section, and to report on the results of such study and any 
recommendations to Congress by Dec. 31, 1992.


                      Medicare Hearings and Appeals

    Section 4037 of Pub. L. 100-203 provided that:
    ``(a) Maintaining Current System for Hearings and Appeals.--Any 
hearing conducted under section 1869(b)(1) of the Social Security Act 
[subsec. (b)(1) of this section] prior to the earliest of the date on 
which the Secretary of Health and Human Services submits the report 
required to be submitted by the Secretary under subsection (b)(1) or 
September 1 shall be conducted by Administrative Law Judges of the 
Office of Hearings and Appeals of the Social Security Administration in 
the same manner as are hearings conducted under section 205(b)(1) of 
such Act [section 405(b)(1) of this title].
    ``(b) Study and Report on Use of Telephone Hearings.--
        ``(1) The Secretary of Health and Human Services and the 
    Comptroller General of the United States shall each conduct a study 
    on holding hearings under section 1869(b)(1) of the Social Security 
    Act [subsec. (b)(1) of this section] by telephone and shall each 
    report the results of the study not later than 6 months after the 
    date of enactment of this Act [Dec. 22, 1987].
        ``(2) The studies under paragraph (1) shall focus on whether 
    telephone hearings allow for a full and fair evidentiary hearing, in 
    general, or with respect to any particular category of claims and 
    shall examine the possible improvements to the hearing process (such 
    as cost-effectiveness, convenience to the claimant, and reduction in 
    time under the process) resulting from the use of such hearings as 
    compared to the adoption of other changes to the process (such as 
    expansions in staff and resources).''

                  Section Referred to in Other Sections

    This section is referred to in sections 1395i-5, 1395l, 1395m, 
1395u, 1395x, 1395w-4, 1395pp, 1395ww, 1395yy, 1395fff of this title; 
title 45 section 231f.
