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[Laws in effect as of January 23, 2000]
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[CITE: 42USC1395m]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
 Part B--Supplementary Medical Insurance Benefits for Aged and Disabled
 
Sec. 1395m. Special payment rules for particular items and 
        services
        

(a) Payment for durable medical equipment

                    (1) General rule for payment

        (A) In general

            With respect to a covered item (as defined in paragraph 
        (13)) for which payment is determined under this subsection, 
        payment shall be made in the frequency specified in paragraphs 
        (2) through (7) and in an amount equal to 80 percent of the 
        payment basis described in subparagraph (B).

        (B) Payment basis

            The payment basis described in this subparagraph is the 
        lesser of--
                (i) the actual charge for the item, or
                (ii) the payment amount recognized under paragraphs (2) 
            through (7) of this subsection for the item;

        except that clause (i) shall not apply if the covered item is 
        furnished by a public home health agency (or by another home 
        health agency which demonstrates to the satisfaction of the 
        Secretary that a significant portion of its patients are low 
        income) free of charge or at nominal charges to the public.

        (C) Exclusive payment rule

            This subsection shall constitute the exclusive provision of 
        this subchapter for payment for covered items under this part or 
        under part A of this subchapter to a home health agency.

        (D) Reduction in fee schedules for certain items

            With respect to a seat-lift chair or transcutaneous 
        electrical nerve stimulator furnished on or after April 1, 1990, 
        the Secretary shall reduce the payment amount applied under 
        subparagraph (B)(ii) for such an item by 15 percent, and, in the 
        case of a transcutaneous electrical nerve stimulator furnished 
        on or after January 1, 1991, the Secretary shall further reduce 
        such payment amount (as previously reduced) by 45 percent.

     (2) Payment for inexpensive and other routinely purchased 
                          durable medical equipment

        (A) In general

            Payment for an item of durable medical equipment (as defined 
        in paragraph (13))--
                (i) the purchase price of which does not exceed $150,
                (ii) which the Secretary determines is acquired at least 
            75 percent of the time by purchase, or
                (iii) which is an accessory used in conjunction with a 
            nebulizer, aspirator, or a ventilator excluded under 
            paragraph (3)(A),

        shall be made on a rental basis or in a lump-sum amount for the 
        purchase of the item. The payment amount recognized for purchase 
        or rental of such equipment is the amount specified in 
        subparagraph (B) for purchase or rental, except that the total 
        amount of payments with respect to an item may not exceed the 
        payment amount specified in subparagraph (B) with respect to the 
        purchase of the item.

        (B) Payment amount

            For purposes of subparagraph (A), the amount specified in 
        this subparagraph, with respect to the purchase or rental of an 
        item furnished in a carrier service area--
                (i) in 1989 and in 1990 is the average reasonable charge 
            in the area for the purchase or rental, respectively, of the 
            item for the 12-month period ending on June 30, 1987, 
            increased by the percentage increase in the consumer price 
            index for all urban consumers (U.S. city average) for the 6-
            month period ending with December 1987;
                (ii) in 1991 is the sum of (I) 67 percent of the local 
            payment amount for the item or device computed under 
            subparagraph (C)(i)(I) for 1991, and (II) 33 percent of the 
            national limited payment amount for the item or device 
            computed under subparagraph (C)(ii) for 1991;
                (iii) in 1992 is the sum of (I) 33 percent of the local 
            payment amount for the item or device computed under 
            subparagraph (C)(i)(II) for 1992, and (II) 67 percent of the 
            national limited payment amount for the item or device 
            computed under subparagraph (C)(ii) for 1992; and
                (iv) in 1993 and each subsequent year is the national 
            limited payment amount for the item or device computed under 
            subparagraph (C)(ii) for that year (reduced by 10 percent, 
            in the case of a blood glucose testing strip furnished after 
            1997 for an individual with diabetes).

        (C) Computation of local payment amount and national limited 
                payment amount

            For purposes of subparagraph (B)--
                (i) the local payment amount for an item or device for a 
            year is equal to--
                    (I) for 1991, the amount specified in subparagraph 
                (B)(i) for 1990 increased by the covered item update for 
                1991, and
                    (II) for 1992, 1993, and 1994, the amount determined 
                under this clause for the preceding year increased by 
                the covered item update for the year; and

                (ii) the national limited payment amount for an item or 
            device for a year is equal to--
                    (I) for 1991, the local payment amount determined 
                under clause (i) for such item or device for that year, 
                except that the national limited payment amount may not 
                exceed 100 percent of the weighted average of all local 
                payment amounts determined under such clause for such 
                item for that year and may not be less than 85 percent 
                of the weighted average of all local payment amounts 
                determined under such clause for such item,
                    (II) for 1992 and 1993, the amount determined under 
                this clause for the preceding year increased by the 
                covered item update for such subsequent year,
                    (III) for 1994, the local payment amount determined 
                under clause (i) for such item or device for that year, 
                except that the national limited payment amount may not 
                exceed 100 percent of the median of all local payment 
                amounts determined under such clause for such item for 
                that year and may not be less than 85 percent of the 
                median of all local payment amounts determined under 
                such clause for such item or device for that year, and
                    (IV) for each subsequent year, the amount determined 
                under this clause for the preceding year increased by 
                the covered item update for such subsequent year.

      (3) Payment for items requiring frequent and substantial 
                                  servicing

        (A) In general

            Payment for a covered item (such as IPPB machines and 
        ventilators, excluding ventilators that are either continuous 
        airway pressure devices or intermittent assist devices with 
        continuous airway pressure devices) for which there must be 
        frequent and substantial servicing in order to avoid risk to the 
        patient's health shall be made on a monthly basis for the rental 
        of the item and the amount recognized is the amount specified in 
        subparagraph (B).

        (B) Payment amount

            For purposes of subparagraph (A), the amount specified in 
        this subparagraph, with respect to an item or device furnished 
        in a carrier service area--
                (i) in 1989 and in 1990 is the average reasonable charge 
            in the area for the rental of the item or device for the 12-
            month period ending with June 1987, increased by the 
            percentage increase in the consumer price index for all 
            urban consumers (U.S. city average) for the 6-month period 
            ending with December 1987;
                (ii) in 1991 is the sum of (I) 67 percent of the local 
            payment amount for the item or device computed under 
            subparagraph (C)(i)(I) for 1991, and (II) 33 percent of the 
            national limited payment amount for the item or device 
            computed under subparagraph (C)(ii) for 1991;
                (iii) in 1992 is the sum of (I) 33 percent of the local 
            payment amount for the item or device computed under 
            subparagraph (C)(i)(II) for 1992, and (II) 67 percent of the 
            national limited payment amount for the item or device 
            computed under subparagraph (C)(ii) for 1992; and
                (iv) in 1993 and each subsequent year is the national 
            limited payment amount for the item or device computed under 
            subparagraph (C)(ii) for that year.

        (C) Computation of local payment amount and national limited 
                payment amount

            For purposes of subparagraph (B)--
                (i) the local payment amount for an item or device for a 
            year is equal to--
                    (I) for 1991, the amount specified in subparagraph 
                (B)(i) for 1990 increased by the covered item update for 
                1991, and
                    (II) for 1992, 1993, and 1994, the amount determined 
                under this clause for the preceding year increased by 
                the covered item update for the year; and

                (ii) the national limited payment amount for an item or 
            device for a year is equal to--
                    (I) for 1991, the local payment amount determined 
                under clause (i) for such item or device for that year, 
                except that the national limited payment amount may not 
                exceed 100 percent of the weighted average of all local 
                payment amounts determined under such clause for such 
                item for that year and may not be less than 85 percent 
                of the weighted average of all local payment amounts 
                determined under such clause for such item,
                    (II) for 1992 and 1993, the amount determined under 
                this clause for the preceding year increased by the 
                covered item update for such subsequent year,
                    (III) for 1994, the local payment amount determined 
                under clause (i) for such item or device for that year, 
                except that the national limited payment amount may not 
                exceed 100 percent of the median of all local payment 
                amounts determined under such clause for such item for 
                that year and may not be less than 85 percent of the 
                median of all local payment amounts determined under 
                such clause for such item or device for that year, and
                    (IV) for each subsequent year, the amount determined 
                under this clause for the preceding year increased by 
                the covered item update for such subsequent year.

              (4) Payment for certain customized items

        Payment with respect to a covered item that is uniquely 
    constructed or substantially modified to meet the specific needs of 
    an individual patient, and for that reason cannot be grouped with 
    similar items for purposes of payment under this subchapter, shall 
    be made in a lump-sum amount (A) for the purchase of the item in a 
    payment amount based upon the carrier's individual consideration for 
    that item, and (B) for the reasonable and necessary maintenance and 
    servicing for parts and labor not covered by the supplier's or 
    manufacturer's warranty, when necessary during the period of medical 
    need, and the amount recognized for such maintenance and servicing 
    shall be paid on a lump-sum, as needed basis based upon the 
    carrier's individual consideration for that item.

             (5) Payment for oxygen and oxygen equipment

        (A) In general

            Payment for oxygen and oxygen equipment shall be made on a 
        monthly basis in the monthly payment amount recognized under 
        paragraph (9) for oxygen and oxygen equipment (other than 
        portable oxygen equipment), subject to subparagraphs (B), (C), 
        and (E).

        (B) Add-on for portable oxygen equipment

            When portable oxygen equipment is used, but subject to 
        subparagraph (D), the payment amount recognized under 
        subparagraph (A) shall be increased by the monthly payment 
        amount recognized under paragraph (9) for portable oxygen 
        equipment.

        (C) Volume adjustment

            When the attending physician prescribes an oxygen flow 
        rate--
                (i) exceeding 4 liters per minute, the payment amount 
            recognized under subparagraph (A), subject to subparagraph 
            (D), shall be increased by 50 percent, or
                (ii) of less than 1 liter per minute, the payment amount 
            recognized under subparagraph (A) shall be decreased by 50 
            percent.

        (D) Limit on adjustment

            When portable oxygen equipment is used and the attending 
        physician prescribes an oxygen flow rate exceeding 4 liters per 
        minute, there shall only be an increase under either 
        subparagraph (B) or (C), whichever increase is larger, and not 
        under both such subparagraphs.

        (E) Recertification for patients receiving home oxygen therapy

            In the case of a patient receiving home oxygen therapy 
        services who, at the time such services are initiated, has an 
        initial arterial blood gas value at or above a partial pressure 
        of 56 or an arterial oxygen saturation at or above 89 percent 
        (or such other values, pressures, or criteria as the Secretary 
        may specify) no payment may be made under this part for such 
        services after the expiration of the 90-day period that begins 
        on the date the patient first receives such services unless the 
        patient's attending physician certifies that, on the basis of a 
        follow-up test of the patient's arterial blood gas value or 
        arterial oxygen saturation conducted during the final 30 days of 
        such 90-day period, there is a medical need for the patient to 
        continue to receive such services.

      (6) Payment for other covered items (other than durable 
                             medical equipment)

        Payment for other covered items (other than durable medical 
    equipment and other covered items described in paragraph (3), (4), 
    or (5)) shall be made in a lump-sum amount for the purchase of the 
    item in the amount of the purchase price recognized under paragraph 
    (8).

      (7) Payment for other items of durable medical equipment

        (A) In general

            In the case of an item of durable medical equipment not 
        described in paragraphs (2) through (6)--
                (i) payment shall be made on a monthly basis for the 
            rental of such item during the period of medical need (but 
            payments under this clause may not extend over a period of 
            continuous use of longer than 15 months, or, in the case of 
            an item for which a purchase agreement has been entered into 
            under clause (iii), a period of continuous use of longer 
            than 13 months), and, subject to subparagraph (B), the 
            amount recognized for each of the first 3 months of such 
            period is 10 percent of the purchase price recognized under 
            paragraph (8) with respect to the item, and for each of the 
            remaining months of such period is 7.5 percent of such 
            purchase price;
                (ii) in the case of a power-driven wheelchair, at the 
            time the supplier furnishes the item, the supplier shall 
            offer the individual patient the option to purchase the 
            item, and payment for such item shall be made on a lump-sum 
            basis if the patient exercises such option;
                (iii) during the 10th continuous month during which 
            payment is made for the rental of an item under clause (i), 
            the supplier of such item shall offer the individual patient 
            the option to enter into a purchase agreement under which, 
            if the patient notifies the supplier not later than 1 month 
            after the supplier makes such offer that the patient agrees 
            to accept such offer and exercise such option--
                    (I) the supplier shall transfer title to the item to 
                the individual patient on the first day that begins 
                after the 13th continuous month during which payment is 
                made for the rental of the item under clause (i),
                    (II) after the supplier transfers title to the item 
                under subclause (I), maintenance and servicing payments 
                shall be made in accordance with clause (vi);

                (iv) in the case of an item for which a purchase 
            agreement has not been entered into under clause (ii) or 
            clause (iii), during the first 6-month period of medical 
            need that follows the period of medical need during which 
            payment is made under clause (i), no payment shall be made 
            for rental or maintenance and servicing of the item;
                (v) in the case of an item for which a purchase 
            agreement has not been entered into under clause (ii) or 
            clause (iii), during the first month of each succeeding 6-
            month period of medical need, a maintenance and servicing 
            payment may be made (for parts and labor not covered by the 
            supplier's or manufacturer's warranty, as determined by the 
            Secretary to be appropriate for the particular type of 
            durable medical equipment) and the amount recognized for 
            each such 6-month period is the lower of (I) a reasonable 
            and necessary maintenance and servicing fee or fees 
            established by the Secretary, or (II) 10 percent of the 
            total of the purchase price recognized under paragraph (8) 
            with respect to the item; and
                (vi) in the case of an item for which a purchase 
            agreement has been entered into under clause (ii) or clause 
            (iii), maintenance and servicing payments may be made (for 
            parts and labor not covered by the supplier's or 
            manufacturer's warranty, as determined by the Secretary to 
            be appropriate for the particular type of durable medical 
            equipment), and such payments shall be in an amount 
            established by the Secretary on the basis of reasonable 
            charges in the locality for maintenance and servicing.

        The Secretary shall determine the meaning of the term 
        ``continuous'' in subparagraph (A).

        (B) Range for rental amounts

            (i) For 1989

                For items furnished during 1989, the payment amount 
            recognized under subparagraph (A)(i) shall not be more than 
            115 percent, and shall not be less than 85 percent, of the 
            prevailing charge established for rental of the item in 
            January 1987, increased by the percentage increase in the 
            consumer price index for all urban consumers (U.S. city 
            average) for the 6-month period ending with December 1987.
            (ii) For 1990

                For items furnished during 1990, clause (i) shall apply 
            in the same manner as it applies to items furnished during 
            1989.

        (C) Replacement of items

            (i) Establishment of reasonable useful lifetime

                In accordance with clause (iii), the Secretary shall 
            determine and establish a reasonable useful lifetime for 
            items of durable medical equipment for which payment may be 
            made under this paragraph.
            (ii) Payment for replacement items

                If the reasonable lifetime of such an item, as so 
            established, has been reached during a continuous period of 
            medical need, or the carrier determines that the item is 
            lost or irreparably damaged, the patient may elect to have 
            payment for an item serving as a replacement for such item 
            made--
                    (I) on a monthly basis for the rental of the 
                replacement item in accordance with subparagraph (A); or
                    (II) in the case of an item for which a purchase 
                agreement has been entered into under subparagraph 
                (A)(ii) or (A)(iii), in a lump-sum amount for the 
                purchase of the item.
            (iii) Length of reasonable useful lifetime

                The reasonable useful lifetime of an item of durable 
            medical equipment under this subparagraph shall be equal to 
            5 years, except that, if the Secretary determines that, on 
            the basis of prior experience in making payments for such an 
            item under this subchapter, a reasonable useful lifetime of 
            5 years is not appropriate with respect to a particular 
            item, the Secretary shall establish an alternative 
            reasonable lifetime for such item.

    (8) Purchase price recognized for miscellaneous devices and 
                                    items

        For purposes of paragraphs (6) and (7), the amount that is 
    recognized under this paragraph as the purchase price for a covered 
    item is the amount described in subparagraph (C) of this paragraph, 
    determined as follows:

        (A) Computation of local purchase price

            Each carrier under section 1395u of this title shall compute 
        a base local purchase price for the item as follows:
                (i) The carrier shall compute a base local purchase 
            price, for each item described--
                    (I) in paragraph (6) equal to the average reasonable 
                charge in the locality for the purchase of the item for 
                the 12-month period ending with June 1987, or
                    (II) in paragraph (7) equal to the average of the 
                purchase prices on the claims submitted on an 
                assignment-related basis for the unused item supplied 
                during the 6-month period ending with December 1986.

                (ii) The carrier shall compute a local purchase price, 
            with respect to the furnishing of each particular item--
                    (I) in 1989 and 1990, equal to the base local 
                purchase price computed under clause (i) increased by 
                the percentage increase in the consumer price index for 
                all urban consumers (U.S. city average) for the 6-month 
                period ending with December 1987,
                    (II) in 1991, equal to the local purchase price 
                computed under this clause for the previous year, 
                increased by the covered item update for 1991, and 
                decreased by the percentage by which the average of the 
                reasonable charges for claims paid for all items 
                described in paragraph (7) is lower than the average of 
                the purchase prices submitted for such items during the 
                final 9 months of 1988; \1\ or
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    \1\ So in original. The semicolon probably should be a comma.
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                    (III) in 1992, 1993, and 1994, equal to the local 
                purchase price computed under this clause for the 
                previous year increased by the covered item update for 
                the year.

        (B) Computation of national limited purchase price

            With respect to the furnishing of a particular item in a 
        year, the Secretary shall compute a national limited purchase 
        price--
                (i) for 1991, equal to the local purchase price computed 
            under subparagraph (A)(ii) for the item for the year, except 
            that such national limited purchase price may not exceed 100 
            percent of the weighted average of all local purchase prices 
            for the item computed under such subparagraph for the year, 
            and may not be less than 85 percent of the weighted average 
            of all local purchase prices for the item computed under 
            such subparagraph for the year;
                (ii) for 1992 and 1993, the amount determined under this 
            subparagraph for the preceding year increased by the covered 
            item update for such subsequent year;
                (iii) for 1994, the local purchase price computed under 
            subparagraph (A)(ii) for the item for the year, except that 
            such national limited purchase price may not exceed 100 
            percent of the median of all local purchase prices computed 
            for the item under such subparagraph for the year and may 
            not be less than 85 percent of the median of all local 
            purchase prices computed under such subparagraph for the 
            item for the year; and
                (iv) for each subsequent year, equal to the amount 
            determined under this subparagraph for the preceding year 
            increased by the covered item update for such subsequent 
            year.

        (C) Purchase price recognized

            For purposes of paragraphs (6) and (7), the amount that is 
        recognized under this paragraph as the purchase price for each 
        item furnished--
                (i) in 1989 or 1990, is 100 percent of the local 
            purchase price computed under subparagraph (A)(ii)(I);
                (ii) in 1991, is the sum of (I) 67 percent of the local 
            purchase price computed under subparagraph (A)(ii)(II) for 
            1991, and (II) 33 percent of the national limited purchase 
            price computed under subparagraph (B) for 1991;
                (iii) in 1992, is the sum of (I) 33 percent of the local 
            purchase price computed under subparagraph (A)(ii)(III) for 
            1992, and (II) 67 percent of the national limited purchase 
            price computed under subparagraph (B) for 1992; and
                (iv) in 1993 or a subsequent year, is the national 
            limited purchase price computed under subparagraph (B) for 
            that year.

    (9) Monthly payment amount recognized with respect to oxygen 
                            and oxygen equipment

        For purposes of paragraph (5), the amount that is recognized 
    under this paragraph for payment for oxygen and oxygen equipment is 
    the monthly payment amount described in subparagraph (C) of this 
    paragraph. Such amount shall be computed separately (i) for all 
    items of oxygen and oxygen equipment (other than portable oxygen 
    equipment) and (ii) for portable oxygen equipment (each such group 
    referred to in this paragraph as an ``item'').

        (A) Computation of local monthly payment rate

            Each carrier under this section shall compute a base local 
        payment rate for each item as follows:
                (i) The carrier shall compute a base local average 
            monthly payment rate per beneficiary as an amount equal to 
            (I) the total reasonable charges for the item during the 12-
            month period ending with December 1986, divided by (II) the 
            total number of months for all beneficiaries receiving the 
            item in the area during the 12-month period for which the 
            carrier made payment for the item under this subchapter.
                (ii) The carrier shall compute a local average monthly 
            payment rate for the item applicable--
                    (I) to 1989 and 1990, equal to 95 percent of the 
                base local average monthly payment rate computed under 
                clause (i) for the item increased by the percentage 
                increase in the consumer price index for all urban 
                consumers (U.S. city average) for the 6-month period 
                ending with December 1987, or
                    (II) to 1991, 1992, 1993, and 1994, equal to the 
                local average monthly payment rate computed under this 
                clause for the item for the previous year increased by 
                the covered item increase for the year.

        (B) Computation of national limited monthly payment rate

            With respect to the furnishing of an item in a year, the 
        Secretary shall compute a national limited monthly payment rate 
        equal to--
                (i) for 1991, the local monthly payment rate computed 
            under subparagraph (A)(ii)(II) for the item for the year, 
            except that such national limited monthly payment rate may 
            not exceed 100 percent of the weighted average of all local 
            monthly payment rates computed for the item under such 
            subparagraph for the year, and may not be less than 85 
            percent of the weighted average of all local monthly payment 
            rates computed for the item under such subparagraph for the 
            year;
                (ii) for 1992 and 1993, the amount determined under this 
            subparagraph for the preceding year increased by the covered 
            item update for such subsequent year;
                (iii) for 1994, the local monthly payment rate computed 
            under subparagraph (A)(ii) for the item for the year, except 
            that such national limited monthly payment rate may not 
            exceed 100 percent of the median of all local monthly 
            payment rates computed for the item under such subparagraph 
            for the year and may not be less than 85 percent of the 
            median of all local monthly payment rates computed for the 
            item under such subparagraph for the year;
                (iv) for 1995, 1996, and 1997, equal to the amount 
            determined under this subparagraph for the preceding year 
            increased by the covered item update for such subsequent 
            year;
                (v) for 1998, 75 percent of the amount determined under 
            this subparagraph for 1997; and
                (vi) for 1999 and each subsequent year, 70 percent of 
            the amount determined under this subparagraph for 1997.

        (C) Monthly payment amount recognized

            For purposes of paragraph (5), the amount that is recognized 
        under this paragraph as the base monthly payment amount for each 
        item furnished--
                (i) in 1989 and in 1990, is 100 percent of the local 
            average monthly payment rate computed under subparagraph 
            (A)(ii) for the item;
                (ii) in 1991, is the sum of (I) 67 percent of the local 
            average monthly payment rate computed under subparagraph 
            (A)(ii)(II) for the item for 1991, and (II) 33 percent of 
            the national limited monthly payment rate computed under 
            subparagraph (B)(i) for the item for 1991;
                (iii) in 1992, is the sum of (I) 33 percent of the local 
            average monthly payment rate computed under subparagraph 
            (A)(ii)(II) for the item for 1992, and (II) 67 percent of 
            the national limited monthly payment rate computed under 
            subparagraph (B)(ii) for the item for 1992; and
                (iv) in a subsequent year, is the national limited 
            monthly payment rate computed under subparagraph (B) for the 
            item for that year.

        (D) Authority to create classes

            (i) In general

                Subject to clause (ii), the Secretary may establish 
            separate classes for any item of oxygen and oxygen equipment 
            and separate national limited monthly payment rates for each 
            of such classes.
            (ii) Budget neutrality

                The Secretary may take actions under clause (i) only to 
            the extent such actions do not result in expenditures for 
            any year to be more or less than the expenditures which 
            would have been made if such actions had not been taken.

                   (10) Exceptions and adjustments

        (A) Areas outside continental United States

            Exceptions to the amounts recognized under the previous 
        provisions of this subsection shall be made to take into account 
        the unique circumstances of covered items furnished in Alaska, 
        Hawaii, or Puerto Rico.

        (B) Adjustment for inherent reasonableness

            The Secretary is authorized to apply the provisions of 
        paragraphs (8) and (9) of section 1395u(b) of this title to 
        covered items and suppliers of such items and payments under 
        this subsection.

        (C) Transcutaneous electrical nerve stimulator (TENS)

            In order to permit an attending physician time to determine 
        whether the purchase of a transcutaneous electrical nerve 
        stimulator is medically appropriate for a particular patient, 
        the Secretary may determine an appropriate payment amount for 
        the initial rental of such item for a period of not more than 2 
        months. If such item is subsequently purchased, the payment 
        amount with respect to such purchase is the payment amount 
        determined under paragraph (2).

      (11) Improper billing and requirement of physician order

        (A) Improper billing for certain rental items

            Notwithstanding any other provision of this subchapter, a 
        supplier of a covered item for which payment is made under this 
        subsection and which is furnished on a rental basis shall 
        continue to supply the item without charge (other than a charge 
        provided under this subsection for the maintenance and servicing 
        of the item) after rental payments may no longer be made under 
        this subsection. If a supplier knowingly and willfully violates 
        the previous sentence, the Secretary may apply sanctions against 
        the supplier under section 1395u(j)(2) of this title in the same 
        manner such sanctions may apply with respect to a physician.

        (B) Requirement of physician order

            The Secretary is authorized to require, for specified 
        covered items, that payment may be made under this subsection 
        with respect to the item only if a physician has communicated to 
        the supplier, before delivery of the item, a written order for 
        the item.

                       (12) Regional carriers

        The Secretary may designate, by regulation under section 1395u 
    of this title, one carrier for one or more entire regions to process 
    all claims within the region for covered items under this section.

                    (13) ``Covered item'' defined

        In this subsection, the term ``covered item'' means durable 
    medical equipment (as defined in section 1395x(n) of this title), 
    including such equipment described in section 1395x(m)(5) of this 
    title, but not including implantable items for which payment may be 
    made under section 1395l(t) of this title.

                      (14) Covered item update

        In this subsection, the term ``covered item update'' means, with 
    respect to a year--
            (A) for 1991 and 1992, the percentage increase in the 
        consumer price index for all urban consumers (U.S. city average) 
        for the 12-month period ending with June of the previous year 
        reduced by 1 percentage point;
            (B) for 1993, 1994, 1995, 1996, and 1997, the percentage 
        increase in the consumer price index for all urban consumers 
        (U.S. city average) for the 12-month period ending with June of 
        the previous year;
            (C) for each of the years 1998 through 2002, 0 percentage 
        points; and
            (D) for a subsequent year, the percentage increase in the 
        consumer price index for all urban consumers (U.S. urban 
        average) for the 12-month period ending with June of the 
        previous year.

      (15) Advance determinations of coverage for certain items

        (A) Development of lists of items by Secretary

            The Secretary may develop and periodically update a list of 
        items for which payment may be made under this subsection that 
        the Secretary determines, on the basis of prior payment 
        experience, are frequently subject to unnecessary utilization 
        throughout a carrier's entire service area or a portion of such 
        area.

        (B) Development of lists of suppliers by Secretary

            The Secretary may develop and periodically update a list of 
        suppliers of items for which payment may be made under this 
        subsection with respect to whom--
                (i) the Secretary has found that a substantial number of 
            claims for payment under this part for items furnished by 
            the supplier have been denied on the basis of the 
            application of section 1395y(a)(1) of this title; or
                (ii) the Secretary has identified a pattern of 
            overutilization resulting from the business practice of the 
            supplier.

        (C) Determinations of coverage in advance

            A carrier shall determine in advance of delivery of an item 
        whether payment for the item may not be made because the item is 
        not covered or because of the application of section 1395y(a)(1) 
        of this title if--
                (i) the item is included on the list developed by the 
            Secretary under subparagraph (A);
                (ii) the item is furnished by a supplier included on the 
            list developed by the Secretary under subparagraph (B); or
                (iii) the item is a customized item (other than 
            inexpensive items specified by the Secretary) and the 
            patient to whom the item is to be furnished or the supplier 
            requests that such advance determination be made.

           (16) Disclosure of information and surety bond

        The Secretary shall not provide for the issuance (or renewal) of 
    a provider number for a supplier of durable medical equipment, for 
    purposes of payment under this part for durable medical equipment 
    furnished by the supplier, unless the supplier provides the 
    Secretary on a continuing basis--
            (A) with--
                (i) full and complete information as to the identity of 
            each person with an ownership or control interest (as 
            defined in section 1320a-3(a)(3) of this title) in the 
            supplier or in any subcontractor (as defined by the 
            Secretary in regulations) in which the supplier directly or 
            indirectly has a 5 percent or more ownership interest; and
                (ii) to the extent determined to be feasible under 
            regulations of the Secretary, the name of any disclosing 
            entity (as defined in section 1320a-3(a)(2) of this title) 
            with respect to which a person with such an ownership or 
            control interest in the supplier is a person with such an 
            ownership or control interest in the disclosing entity; and

            (B) with a surety bond in a form specified by the Secretary 
        and in an amount that is not less than $50,000.

    The Secretary may waive the requirement of a bond under subparagraph 
    (B) in the case of a supplier that provides a comparable surety bond 
    under State law. The Secretary, at the Secretary's discretion, may 
    impose the requirements of the first sentence with respect to some 
    or all providers of items or services under part A of this 
    subchapter or some or all suppliers or other persons (other than 
    physicians or other practitioners, as defined in section 
    1395u(b)(18)(C) of this title) who furnish items or services under 
    this part.

                   (17) \2\ Certain upgraded items
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    \2\ So in original. Two pars. (17) have been enacted.
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        (A) Individual's right to choose upgraded item

            Notwithstanding any other provision of this subchapter, the 
        Secretary may issue regulations under which an individual may 
        purchase or rent from a supplier an item of upgraded durable 
        medical equipment for which payment would be made under this 
        subsection if the item were a standard item.

        (B) Payments to supplier

            In the case of the purchase or rental of an upgraded item 
        under subparagraph (A)--
                (i) the supplier shall receive payment under this 
            subsection with respect to such item as if such item were a 
            standard item; and
                (ii) the individual purchasing or renting the item shall 
            pay the supplier an amount equal to the difference between 
            the supplier's charge and the amount under clause (i).

        In no event may the supplier's charge for an upgraded item 
        exceed the applicable fee schedule amount (if any) for such 
        item.

        (C) Consumer protection safeguards

            Any regulations under subparagraph (A) shall provide for 
        consumer protection standards with respect to the furnishing of 
        upgraded equipment under subparagraph (A). Such regulations 
        shall provide for--
                (i) determination of fair market prices with respect to 
            an upgraded item;
                (ii) full disclosure of the availability and price of 
            standard items and proof of receipt of such disclosure 
            information by the beneficiary before the furnishing of the 
            upgraded item;
                (iii) conditions of participation for suppliers in the 
            billing arrangement;
                (iv) sanctions of suppliers who are determined to engage 
            in coercive or abusive practices, including exclusion; and
                (v) such other safeguards as the Secretary determines 
            are necessary.

    (17) \2\ Prohibition against unsolicited telephone contacts 
                                by suppliers

        (A) In general

            A supplier of a covered item under this subsection may not 
        contact an individual enrolled under this part by telephone 
        regarding the furnishing of a covered item to the individual 
        unless 1 of the following applies:
                (i) The individual has given written permission to the 
            supplier to make contact by telephone regarding the 
            furnishing of a covered item.
                (ii) The supplier has furnished a covered item to the 
            individual and the supplier is contacting the individual 
            only regarding the furnishing of such covered item.
                (iii) If the contact is regarding the furnishing of a 
            covered item other than a covered item already furnished to 
            the individual, the supplier has furnished at least 1 
            covered item to the individual during the 15-month period 
            preceding the date on which the supplier makes such contact.

        (B) Prohibiting payment for items furnished subsequent to 
                unsolicited contacts

            If a supplier knowingly contacts an individual in violation 
        of subparagraph (A), no payment may be made under this part for 
        any item subsequently furnished to the individual by the 
        supplier.

        (C) Exclusion from program for suppliers engaging in pattern of 
                unsolicited contacts

            If a supplier knowingly contacts individuals in violation of 
        subparagraph (A) to such an extent that the supplier's conduct 
        establishes a pattern of contacts in violation of such 
        subparagraph, the Secretary shall exclude the supplier from 
        participation in the programs under this chapter, in accordance 
        with the procedures set forth in subsections (c), (f), and (g) 
        of section 1320a-7 of this title.

      (18) Refund of amounts collected for certain disallowed 
                                    items

        (A) In general

            If a nonparticipating supplier furnishes to an individual 
        enrolled under this part a covered item for which no payment may 
        be made under this part by reason of paragraph (17)(B), the 
        supplier shall refund on a timely basis to the patient (and 
        shall be liable to the patient for) any amounts collected from 
        the patient for the item, unless--
                (i) the supplier establishes that the supplier did not 
            know and could not reasonably have been expected to know 
            that payment may not be made for the item by reason of 
            paragraph (17)(B), or
                (ii) before the item was furnished, the patient was 
            informed that payment under this part may not be made for 
            that item and the patient has agreed to pay for that item.

        (B) Sanctions

            If a supplier knowingly and willfully fails to make refunds 
        in violation of subparagraph (A), the Secretary may apply 
        sanctions against the supplier in accordance with section 
        1395u(j)(2) of this title.

        (C) Notice

            Each carrier with a contract in effect under this part with 
        respect to suppliers of covered items shall send any notice of 
        denial of payment for covered items by reason of paragraph 
        (17)(B) and for which payment is not requested on an assignment-
        related basis to the supplier and the patient involved.

        (D) Timely basis defined

            A refund under subparagraph (A) is considered to be on a 
        timely basis only if--
                (i) in the case of a supplier who does not request 
            reconsideration or seek appeal on a timely basis, the refund 
            is made within 30 days after the date the supplier receives 
            a denial notice under subparagraph (C), or
                (ii) in the case in which such a reconsideration or 
            appeal is taken, the refund is made within 15 days after the 
            date the supplier receives notice of an adverse 
            determination on reconsideration or appeal.

(b) Fee schedules for radiologist services

                           (1) Development

        The Secretary shall develop--
            (A) a relative value scale to serve as the basis for the 
        payment for radiologist services under this part, and
            (B) using such scale and appropriate conversion factors and 
        subject to subsection (c)(1)(A) of this section, fee schedules 
        (on a regional, statewide, locality, or carrier service area 
        basis) for payment for radiologist services under this part, to 
        be implemented for such services furnished during 1989.

                          (2) Consultation

        In carrying out paragraph (1), the Secretary shall regularly 
    consult closely with the Physician Payment Review Commission, the 
    American College of Radiology, and other organizations representing 
    physicians or suppliers who furnish radiologist services and shall 
    share with them the data and data analysis being used to make the 
    determinations under paragraph (1), including data on variations in 
    current medicare payments by geographic area, and by service and 
    physician specialty.

                         (3) Considerations

        In developing the relative value scale and fee schedules under 
    paragraph (1), the Secretary--
            (A) shall take into consideration variations in the cost of 
        furnishing such services among geographic areas and among 
        different sites where services are furnished, and
            (B) may also take into consideration such other factors 
        respecting the manner in which physicians in different 
        specialties furnish such services as may be appropriate to 
        assure that payment amounts are equitable and designed to 
        promote effective and efficient provision of radiologist 
        services by physicians in the different specialties.

                             (4) Savings

        (A) Budget neutral fee schedules

            The Secretary shall develop preliminary fee schedules for 
        1989, which are designed to result in the same amount of 
        aggregate payments (net of any coinsurance and deductibles under 
        sections 1395l(a)(1)(J) and 1395l(b) of this title) for 
        radiologist services furnished in 1989 as would have been made 
        if this subsection had not been enacted.

        (B) Initial savings

            The fee schedules established for payment purposes under 
        this subsection for services furnished in 1989 shall be 97 
        percent of the amounts permitted under the preliminary fee 
        schedules developed under subparagraph (A).

        (C) 1990 fee schedules

            For radiologist services (other than portable X-ray 
        services) furnished under this part during 1990, after March 31 
        of such year, the conversion factors used under this subsection 
        shall be 96 percent of the conversion factors that applied under 
        this subsection as of December 31, 1989.

        (D) 1991 fee schedules

            For radiologist services (other than portable X-ray 
        services) furnished under this part during 1991, the conversion 
        factors used in a locality under this subsection shall, subject 
        to clause (vii), be reduced to the adjusted conversion factor 
        for the locality determined as follows:
            (i) National weighted average conversion factor

                The Secretary shall estimate the national weighted 
            average of the conversion factors used under this subsection 
            for services furnished during 1990 beginning on April 1, 
            using the best available data.
            (ii) Reduced national weighted average

                The national weighted average estimated under clause (i) 
            shall be reduced by 13 percent.
            (iii) Computation of 1990 locality index relative to 
                    national average

                The Secretary shall establish an index which reflects, 
            for each locality, the ratio of the conversion factor used 
            in the locality under this subsection to the national 
            weighted average estimated under clause (i).
            (iv) Adjusted conversion factor

                The adjusted conversion factor for the professional or 
            technical component of a service in a locality is the sum of 
            \1/2\ of the locally-adjusted amount determined under clause 
            (v) and \1/2\ of the GPCI-adjusted amount determined under 
            clauses \3\ (vi).
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    \3\ So in original. Probably should be ``clause''.
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            (v) Locally-adjusted amount

                For purposes of clause (iv), the locally adjusted amount 
            determined under this clause is the product of (I) the 
            national weighted average conversion factor computed under 
            clause (ii), and (II) the index value established under 
            clause (iii) for the locality.
            (vi) GPCI-adjusted amount

                For purposes of clause (iv), the GPCI-adjusted amount 
            determined under this clause is the sum of--
                    (I) the product of (a) the portion of the reduced 
                national weighted average conversion factor computed 
                under clause (ii) which is attributable to physician 
                work and (b) the geographic work index value for the 
                locality (specified in Addendum C to the Model Fee 
                Schedule for Physician Services (published on September 
                4, 1990, 55 Federal Register pp. 36238-36243)); and
                    (II) the product of (a) the remaining portion of the 
                reduced national weighted average conversion factor 
                computed under clause (ii), and (b) the geographic 
                practice cost index value specified in section 
                1395u(b)(14)(C)(iv) of this title for the locality.

          In applying this clause with respect to the professional 
            component of a service, 80 percent of the conversion factor 
            shall be considered to be attributable to physician work and 
            with respect to the technical component of the service, 0 
            percent shall be considered to be attributable to physician 
            work.
            (vii) Limits on conversion factor

                The conversion factor to be applied to a locality to the 
            professional or technical component of a service shall not 
            be reduced under this subparagraph by more than 9.5 percent 
            below the conversion factor applied in the locality under 
            subparagraph (C) to such component, but in no case shall the 
            conversion factor be less than 60 percent of the national 
            weighted average of the conversion factors (computed under 
            clause (i)).

        (E) Rule for certain scanning services

            In the case of the technical components of magnetic 
        resonance imaging (MRI) services and computer assisted 
        tomography (CAT) services furnished after December 31, 1990, the 
        amount otherwise payable shall be reduced by 10 percent.

        (F) Subsequent updating

            For radiologist services furnished in subsequent years, the 
        fee schedules shall be the schedules for the previous year 
        updated by the percentage increase in the MEI (as defined in 
        section 1395u(i)(3) of this title) for the year.

        (G) Nonparticipating physicians and suppliers

            Each fee schedule so established shall provide that the 
        payment rate recognized for nonparticipating physicians and 
        suppliers is equal to the appropriate percent (as defined in 
        section 1395u(b)(4)(A)(iv) of this title) of the payment rate 
        recognized for participating physicians and suppliers.

      (5) Limiting charges of nonparticipating physicians and 
                                  suppliers

        (A) In general

            In the case of radiologist services furnished after January 
        1, 1989, for which payment is made under a fee schedule under 
        this subsection, if a nonparticipating physician or supplier 
        furnishes the service to an individual entitled to benefits 
        under this part, the physician or supplier may not charge the 
        individual more than the limiting charge (as defined in 
        subparagraph (B)).

        (B) ``Limiting charge'' defined

            In subparagraph (A), the term ``limiting charge'' means, 
        with respect to a service furnished--
                (i) in 1989, 125 percent of the amount specified for the 
            service in the appropriate fee schedule established under 
            paragraph (1),
                (ii) in 1990, 120 percent of the amount specified for 
            the service in the appropriate fee schedule established 
            under paragraph (1), and
                (iii) after 1990, 115 percent of the amount specified 
            for the service in the appropriate fee schedule established 
            under paragraph (1).

        (C) Enforcement

            If a physician or supplier knowingly and willfully bills in 
        violation of subparagraph (A), the Secretary may apply sanctions 
        against such physician or supplier in accordance with section 
        1395u(j)(2) of this title in the same manner as such sanctions 
        may apply to a physician.

                (6) ``Radiologist services'' defined

        For the purposes of this subsection and section 1395l(a)(1)(J) 
    of this title, the term ``radiologist services'' only includes 
    radiology services performed by, or under the direction or 
    supervision of, a physician--
            (A) who is certified, or eligible to be certified, by the 
        American Board of Radiology, or
            (B) for whom radiology services account for at least 50 
        percent of the total amount of charges made under this part.

(c) Payments and standards for screening mammography

                           (1) In general

        Notwithstanding any other provision of this part, with respect 
    to expenses incurred for screening mammography (as defined in 
    section 1395x(jj) of this title)--
            (A) payment may be made only for screening mammography 
        conducted consistent with the frequency permitted under 
        paragraph (2);
            (B) payment may be made only if the screening mammography is 
        conducted by a facility that has a certificate (or provisional 
        certificate) issued under section 263b of this title; and
            (C) the amount of the payment under this part shall be equal 
        to 80 percent of the least of--
                (i) the actual charge for the screening,
                (ii) the fee schedule established under subsection (b) 
            of this section or the fee schedule established under 
            section 1395w-4 of this title, whichever is applicable, with 
            respect to both the professional and technical components of 
            the screening mammography, or
                (iii) the limit established under paragraph (3) for the 
            screening mammography.

                        (2) Frequency covered

        (A) In general

            Subject to revision by the Secretary under subparagraph 
        (B)--
                (i) No payment may be made under this part for screening 
            mammography performed on a woman under 35 years of age.
                (ii) Payment may be made under this part for only 1 
            screening mammography performed on a woman over 34 years of 
            age, but under 40 years of age.
                (iii) In the case of a woman over 39 years of age, 
            payment may not be made under this part for screening 
            mammography performed within 11 months following the month 
            in which a previous screening mammography was performed.

        (B) Revision of frequency

            (i) Review

                The Secretary, in consultation with the Director of the 
            National Cancer Institute, shall review periodically the 
            appropriate frequency for performing screening mammography, 
            based on age and such other factors as the Secretary 
            believes to be pertinent.
            (ii) Revision of frequency

                The Secretary, taking into consideration the review made 
            under clause (i), may revise from time to time the frequency 
            with which screening mammography may be paid for under this 
            subsection, but no such revision shall apply to screening 
            mammography performed before January 1, 1992.

                              (3) Limit

        (A) $55, indexed

            Except as provided by the Secretary under subparagraph (B), 
        the limit established under this paragraph--
                (i) for screening mammography performed in 1991, is $55, 
            and
                (ii) for screening mammography performed in a subsequent 
            year is the limit established under this paragraph for the 
            preceding year increased by the percentage increase in the 
            MEI for that subsequent year.

        (B) Reduction of limit

            The Secretary shall review from time to time the 
        appropriateness of the amount of the limit established under 
        this paragraph. The Secretary may, with respect to screening 
        mammography performed in a year after 1992, reduce the amount of 
        such limit as it applies nationally or in any area to the amount 
        that the Secretary estimates is required to assure that 
        screening mammography of an appropriate quality is readily and 
        conveniently available during the year.

        (C) Application of limit in hospital outpatient setting

            The Secretary shall provide for an appropriate allocation of 
        the limit established under this paragraph between professional 
        and technical components in the case of hospital outpatient 
        screening mammography (and comparable situations) where there is 
        a claim for professional services separate from the claim for 
        the radiologic procedure.

         (4) Limiting charges of nonparticipating physicians

        (A) In general

            In the case of mammography screening performed on or after 
        January 1, 1991, for which payment is made under this 
        subsection, if a nonparticipating physician or supplier provides 
        the screening to an individual entitled to benefits under this 
        part, the physician or supplier may not charge the individual 
        more than the limiting charge (as defined in subparagraph (B), 
        or if less, as defined in subsection (b)(5)(B) of this section 
        or as defined in section 1395w-4(g)(2) of this title).

        (B) ``Limiting charge'' defined

            In subparagraph (A), the term ``limiting charge'' means, 
        with respect to screening mammography performed--
                (i) in 1991, 125 percent of the limit established under 
            paragraph (4),
                (ii) in 1992, 120 percent of the limit established under 
            paragraph (4), or
                (iii) after 1992, 115 percent of the limit established 
            under paragraph (4).

        (C) Enforcement

            If a physician or supplier knowing \4\ and willfully imposes 
        a charge in violation of subparagraph (A), the Secretary may 
        apply sanctions against such physician or supplier in accordance 
        with section 1395u(j)(2) of this title.
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    \4\ So in original. Probably should be ``knowingly''.
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(d) Frequency limits and payment for colorectal cancer screening tests

               (1) Screening fecal-occult blood tests

        (A) Payment amount

            The payment amount for colorectal cancer screening tests 
        consisting of screening fecal-occult blood tests is equal to the 
        payment amount established for diagnostic fecal-occult blood 
        tests under section 1395l(h) of this title.

        (B) Frequency limit

            No payment may be made under this part for a colorectal 
        cancer screening test consisting of a screening fecal-occult 
        blood test--
                (i) if the individual is under 50 years of age; or
                (ii) if the test is performed within the 11 months after 
            a previous screening fecal-occult blood test.

               (2) Screening flexible sigmoidoscopies

        (A) Fee schedule

            With respect to colorectal cancer screening tests consisting 
        of screening flexible sigmoidoscopies, payment under section 
        1395w-4 of this title shall be consistent with payment under 
        such section for similar or related services.

        (B) Payment limit

            In the case of screening flexible sigmoidoscopy services, 
        payment under this part shall not exceed such amount as the 
        Secretary specifies, based upon the rates recognized for 
        diagnostic flexible sigmoidoscopy services.

        (C) Facility payment limit

            (i) In general

                Notwithstanding subsections (i)(2)(A) and (t) of section 
            1395l of this title, in the case of screening flexible 
            sigmoidoscopy services furnished on or after January 1, 
            1999, that--
                    (I) in accordance with regulations, may be performed 
                in an ambulatory surgical center and for which the 
                Secretary permits ambulatory surgical center payments 
                under this part, and
                    (II) are performed in an ambulatory surgical center 
                or hospital outpatient department,

          payment under this part shall be based on the lesser of the 
            amount under the fee schedule that would apply to such 
            services if they were performed in a hospital outpatient 
            department in an area or the amount under the fee schedule 
            that would apply to such services if they were performed in 
            an ambulatory surgical center in the same area.
            (ii) Limitation on deductible and coinsurance

                Notwithstanding any other provision of this subchapter, 
            in the case of a beneficiary who receives the services 
            described in clause (i)--
                    (I) in computing the amount of any applicable 
                deductible or copayment, the computation of such 
                deductible or coinsurance shall be based upon the fee 
                schedule under which payment is made for the services, 
                and
                    (II) the amount of such coinsurance is equal to 25 
                percent of the payment amount under the fee schedule 
                described in subclause (I).

        (D) Special rule for detected lesions

            If during the course of such screening flexible 
        sigmoidoscopy, a lesion or growth is detected which results in a 
        biopsy or removal of the lesion or growth, payment under this 
        part shall not be made for the screening flexible sigmoidoscopy 
        but shall be made for the procedure classified as a flexible 
        sigmoidoscopy with such biopsy or removal.

        (E) Frequency limit

            No payment may be made under this part for a colorectal 
        cancer screening test consisting of a screening flexible 
        sigmoidoscopy--
                (i) if the individual is under 50 years of age; or
                (ii) if the procedure is performed within the 47 months 
            after a previous screening flexible sigmoidoscopy.

     (3) Screening colonoscopy for individuals at high risk for 
                              colorectal cancer

        (A) Fee schedule

            With respect to colorectal cancer screening test consisting 
        of a screening colonoscopy for individuals at high risk for 
        colorectal cancer (as defined in section 1395x(pp)(2) of this 
        title), payment under section 1395w-4 of this title shall be 
        consistent with payment amounts under such section for similar 
        or related services.

        (B) Payment limit

            In the case of screening colonoscopy services, payment under 
        this part shall not exceed such amount as the Secretary 
        specifies, based upon the rates recognized for diagnostic 
        colonoscopy services.

        (C) Facility payment limit

            (i) In general

                Notwithstanding subsections (i)(2)(A) and (t) of section 
            1395l of this title, in the case of screening colonoscopy 
            services furnished on or after January 1, 1999, that are 
            performed in an ambulatory surgical center or a hospital 
            outpatient department, payment under this part shall be 
            based on the lesser of the amount under the fee schedule 
            that would apply to such services if they were performed in 
            a hospital outpatient department in an area or the amount 
            under the fee schedule that would apply to such services if 
            they were performed in an ambulatory surgical center in the 
            same area.
            (ii) Limitation on deductible and coinsurance

                Notwithstanding any other provision of this subchapter, 
            in the case of a beneficiary who receives the services 
            described in clause (i)--
                    (I) in computing the amount of any applicable 
                deductible or coinsurance, the computation of such 
                deductible or coinsurance shall be based upon the fee 
                schedule under which payment is made for the services, 
                and
                    (II) the amount of such coinsurance is equal to 25 
                percent of the payment amount under the fee schedule 
                described in subclause (I).

        (D) Special rule for detected lesions

            If during the course of such screening colonoscopy, a lesion 
        or growth is detected which results in a biopsy or removal of 
        the lesion or growth, payment under this part shall not be made 
        for the screening colonoscopy but shall be made for the 
        procedure classified as a colonoscopy with such biopsy or 
        removal.

        (E) Frequency limit

            No payment may be made under this part for a colorectal 
        cancer screening test consisting of a screening colonoscopy for 
        individuals at high risk for colorectal cancer if the procedure 
        is performed within the 23 months after a previous screening 
        colonoscopy.

(e) Repealed. Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 
        Stat. 1981

(f) Reduction in payments for physician pathology services during 1991

                           (1) In general

        For physician pathology services furnished under this part 
    during 1991, the prevailing charges used in a locality under this 
    part shall be 7 percent below the prevailing charges used in the 
    locality under this part in 1990 after March 31.

                           (2) Limitation

        The prevailing charge for the technical and professional 
    components of an \5\ physician pathology service furnished by a 
    physician through an independent laboratory shall not be reduced 
    pursuant to paragraph (1) to the extent that such reduction would 
    reduce such prevailing charge below 115 percent of the prevailing 
    charge for the professional component of such service when furnished 
    by a hospital-based physician in the same locality. For purposes of 
    the preceding sentence, an independent laboratory is a laboratory 
    that is independent of a hospital and separate from the attending or 
    consulting physicians' office.
---------------------------------------------------------------------------
    \5\ So in original. Probably should be ``a''.
---------------------------------------------------------------------------

(g) Payment for outpatient critical access hospital services

                           (1) In general

        The amount of payment for outpatient critical access hospital 
    services of a critical access hospital is the reasonable costs of 
    the hospital in providing such services, unless the hospital makes 
    the election under paragraph (2).

       (2) Election of cost-based hospital outpatient service 
             payment plus fee schedule for professional services

        A critical access hospital may elect to be paid for outpatient 
    critical access hospital services amounts equal to the sum of the 
    following, less the amount that such hospital may charge as 
    described in section 1395cc(a)(2)(A) of this title:

        (A) Facility fee

            With respect to facility services, not including any 
        services for which payment may be made under subparagraph (B), 
        the reasonable costs of the critical access hospital in 
        providing such services.

        (B) Fee schedule for professional services

            With respect to professional services otherwise included 
        within outpatient critical access hospital services, such 
        amounts as would otherwise be paid under this part if such 
        services were not included in outpatient critical access 
        hospital services.

                      (3) Disregarding charges

        The payment amounts under this subsection shall be determined 
    without regard to the amount of the customary or other charge.

(h) Payment for prosthetic devices and orthotics and prosthetics

                    (1) General rule for payment

        (A) In general

            Payment under this subsection for prosthetic devices and 
        orthotics and prosthetics shall be made in a lump-sum amount for 
        the purchase of the item in an amount equal to 80 percent of the 
        payment basis described in subparagraph (B).

        (B) Payment basis

            Except as provided in subparagraphs (C) and (E), the payment 
        basis described in this subparagraph is the lesser of--
                (i) the actual charge for the item; or
                (ii) the amount recognized under paragraph (2) as the 
            purchase price for the item.

        (C) Exception for certain public home health agencies

            Subparagraph (B)(i) shall not apply to an item furnished by 
        a public home health agency (or by another home health agency 
        which demonstrates to the satisfaction of the Secretary that a 
        significant portion of its patients are low income) free of 
        charge or at nominal charges to the public.

        (D) Exclusive payment rule

            This subsection shall constitute the exclusive provision of 
        this subchapter for payment for prosthetic devices, orthotics, 
        and prosthetics under this part or under part A of this 
        subchapter to a home health agency.

        (E) Exception for certain items

            Payment for ostomy supplies, tracheostomy supplies, and 
        urologicals shall be made in accordance with subparagraphs (B) 
        and (C) of subsection (a)(2) of this section.

                    (2) Purchase price recognized

        For purposes of paragraph (1), the amount that is recognized 
    under this paragraph as the purchase price for prosthetic devices, 
    orthotics, and prosthetics is the amount described in subparagraph 
    (C) of this paragraph, determined as follows:

        (A) Computation of local purchase price

            Each carrier under section 1395u of this title shall compute 
        a base local purchase price for the item as follows:
                (i) The carrier shall compute a base local purchase 
            price for each item equal to the average reasonable charge 
            in the locality for the purchase of the item for the 12-
            month period ending with June 1987.
                (ii) The carrier shall compute a local purchase price, 
            with respect to the furnishing of each particular item--
                    (I) in 1989 and 1990, equal to the base local 
                purchase price computed under clause (i) increased by 
                the percentage increase in the consumer price index for 
                all urban consumers (United States city average) for the 
                6-month period ending with December 1987, or
                    (II) in 1991, 1992 or 1993, equal to the local 
                purchase price computed under this clause for the 
                previous year increased by the applicable percentage 
                increase for the year.

        (B) Computation of regional purchase price

            With respect to the furnishing of a particular item in each 
        region (as defined by the Secretary), the Secretary shall 
        compute a regional purchase price--
                (i) for 1992, equal to the average (weighted by relative 
            volume of all claims among carriers) of the local purchase 
            prices for the carriers in the region computed under 
            subparagraph (A)(ii)(II) for the year, and
                (ii) for each subsequent year, equal to the regional 
            purchase price computed under this subparagraph for the 
            previous year increased by the applicable percentage 
            increase for the year.

        (C) Purchase price recognized

            For purposes of paragraph (1) and subject to subparagraph 
        (D), the amount that is recognized under this paragraph as the 
        purchase price for each item furnished--
                (i) in 1989, 1990, or 1991, is 100 percent of the local 
            purchase price computed under subparagraph (A)(ii);
                (ii) in 1992, is the sum of (I) 75 percent of the local 
            purchase price computed under subparagraph (A)(ii)(II) for 
            1992, and (II) 25 percent of the regional purchase price 
            computed under subparagraph (B) for 1992;
                (iii) in 1993, is the sum of (I) 50 percent of the local 
            purchase price computed under subparagraph (A)(ii)(II) for 
            1993, and (II) 50 percent of the regional purchase price 
            computed under subparagraph (B) for 1993; and
                (iv) in 1994 or a subsequent year, is the regional 
            purchase price computed under subparagraph (B) for that 
            year.

        (D) Range on amount recognized

            The amount that is recognized under subparagraph (C) as the 
        purchase price for an item furnished--
                (i) in 1992, may not exceed 125 percent, and may not be 
            lower than 85 percent, of the average of the purchase prices 
            recognized under such subparagraph for all the carrier 
            service areas in the United States in that year; and
                (ii) in a subsequent year, may not exceed 120 percent, 
            and may not be lower than 90 percent, of the average of the 
            purchase prices recognized under such subparagraph for all 
            the carrier service areas in the United States in that year.

    (3) Applicability of certain provisions relating to durable 
                              medical equipment

        Paragraphs (12), (15), and (17) and subparagraphs (A) and (B) of 
    paragraph (10) and paragraph (11) of subsection (a) of this section 
    shall apply to prosthetic devices, orthotics, and prosthetics in the 
    same manner as such provisions apply to covered items under such 
    subsection.

                           (4) Definitions

        In this subsection--
            (A) the term ``applicable percentage increase'' means--
                (i) for 1991, 0 percent;
                (ii) for 1992 and 1993, 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 previous year;
                (iii) for 1994 and 1995, 0 percent;
                (iv) for 1996 and 1997, 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 previous year;
                (v) for each of the years 1998 through 2002, 1 percent; 
            and
                (vi) for a subsequent year, 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 previous year;

            (B) the term ``prosthetic devices'' has the meaning given 
        such term in section 1395x(s)(8) of this title, except that such 
        term does not include parenteral and enteral nutrition 
        nutrients, supplies, and equipment and does not include an 
        implantable item for which payment may be made under section 
        1395l(t) of this title; and
            (C) the term ``orthotics and prosthetics'' has the meaning 
        given such term in section 1395x(s)(9) of this title, but does 
        not include intraocular lenses or medical supplies (including 
        catheters, catheter supplies, ostomy bags, and supplies related 
        to ostomy care) furnished by a home health agency under section 
        1395x(m)(5) of this title.

(i) Payment for surgical dressings

                           (1) In general

        Payment under this subsection for surgical dressings (described 
    in section 1395x(s)(5) of this title) shall be made in a lump sum 
    amount for the purchase of the item in an amount equal to 80 percent 
    of the lesser of--
            (A) the actual charge for the item; or
            (B) a payment amount determined in accordance with the 
        methodology described in subparagraphs (B) and (C) of subsection 
        (a)(2) of this section (except that in applying such 
        methodology, the national limited payment amount referred to in 
        such subparagraphs shall be initially computed based on local 
        payment amounts using average reasonable charges for the 12-
        month period ending December 31, 1992, increased by the covered 
        item updates described in such subsection for 1993 and 1994).

                           (2) Exceptions

        Paragraph (1) shall not apply to surgical dressings that are--
            (A) furnished as an incident to a physician's professional 
        service; or
            (B) furnished by a home health agency.

(j) Requirements for suppliers of medical equipment and supplies

             (1) Issuance and renewal of supplier number

        (A) Payment

            Except as provided in subparagraph (C), no payment may be 
        made under this part after October 31, 1994, for items furnished 
        by a supplier of medical equipment and supplies unless such 
        supplier obtains (and renews at such intervals as the Secretary 
        may require) a supplier number.

        (B) Standards for possessing a supplier number

            A supplier may not obtain a supplier number unless--
                (i) for medical equipment and supplies furnished on or 
            after October 31, 1994, and before January 1, 1996, the 
            supplier meets standards prescribed by the Secretary in 
            regulations issued on June 18, 1992; and
                (ii) for medical equipment and supplies furnished on or 
            after January 1, 1996, the supplier meets revised standards 
            prescribed by the Secretary (in consultation with 
            representatives of suppliers of medical equipment and 
            supplies, carriers, and consumers) that shall include 
            requirements that the supplier--
                    (I) comply with all applicable State and Federal 
                licensure and regulatory requirements;
                    (II) maintain a physical facility on an appropriate 
                site;
                    (III) have proof of appropriate liability insurance; 
                and
                    (IV) meet such other requirements as the Secretary 
                may specify.

        (C) Exception for items furnished as incident to a physician's 
                service

            Subparagraph (A) shall not apply with respect to medical 
        equipment and supplies furnished incident to a physician's 
        service.

        (D) Prohibition against multiple supplier numbers

            The Secretary may not issue more than one supplier number to 
        any supplier of medical equipment and supplies unless the 
        issuance of more than one number is appropriate to identify 
        subsidiary or regional entities under the supplier's ownership 
        or control.

        (E) Prohibition against delegation of supplier determinations

            The Secretary may not delegate (other than by contract under 
        section 1395u of this title) the responsibility to determine 
        whether suppliers meet the standards necessary to obtain a 
        supplier number.

                (2) Certificates of medical necessity

        (A) Limitation on information provided by suppliers on 
                certificates of medical necessity

            (i) In general

                Effective 60 days after October 31, 1994, a supplier of 
            medical equipment and supplies may distribute to physicians, 
            or to individuals entitled to benefits under this part, a 
            certificate of medical necessity for commercial purposes 
            which contains no more than the following information 
            completed by the supplier:
                    (I) An identification of the supplier and the 
                beneficiary to whom such medical equipment and supplies 
                are furnished.
                    (II) A description of such medical equipment and 
                supplies.
                    (III) Any product code identifying such medical 
                equipment and supplies.
                    (IV) Any other administrative information (other 
                than information relating to the beneficiary's medical 
                condition) identified by the Secretary.
            (ii) Information on payment amount and charges

                If a supplier distributes a certificate of medical 
            necessity containing any of the information permitted to be 
            supplied under clause (i), the supplier shall also list on 
            the certificate of medical necessity the fee schedule amount 
            and the supplier's charge for the medical equipment or 
            supplies being furnished prior to distribution of such 
            certificate to the physician.
            (iii) Penalty

                Any supplier of medical equipment and supplies who 
            knowingly and willfully distributes a certificate of medical 
            necessity in violation of clause (i) or fails to provide the 
            information required under clause (ii) is subject to a civil 
            money penalty in an amount not to exceed $1,000 for each 
            such certificate of medical necessity so distributed. The 
            provisions of section 1320a-7a of this title (other than 
            subsections (a) and (b)) shall apply to civil money 
            penalties under this subparagraph in the same manner as they 
            apply to a penalty or proceeding under section 1320a-7a(a) 
            of this title.

        (B) ``Certificate of medical necessity'' defined

            For purposes of this paragraph, the term ``certificate of 
        medical necessity'' means a form or other document containing 
        information required by the carrier to be submitted to show that 
        an item is reasonable and necessary for the diagnosis or 
        treatment of illness or injury or to improve the functioning of 
        a malformed body member.

                  (3) Coverage and review criteria

        The Secretary shall annually review the coverage and utilization 
    of items of medical equipment and supplies to determine whether such 
    items should be made subject to coverage and utilization review 
    criteria, and if appropriate, shall develop and apply such criteria 
    to such items.

                 (4) Limitation on patient liability

        If a supplier of medical equipment and supplies (as defined in 
    paragraph (5))--
            (A) furnishes an item or service to a beneficiary for which 
        no payment may be made by reason of paragraph (1);
            (B) furnishes an item or service to a beneficiary for which 
        payment is denied in advance under subsection (a)(15) of this 
        section; or
            (C) furnishes an item or service to a beneficiary for which 
        payment is denied under section 1395y(a)(1) of this title;

    any expenses incurred for items and services furnished to an 
    individual by such a supplier not on an assigned basis shall be the 
    responsibility of such supplier. The individual shall have no 
    financial responsibility for such expenses and the supplier shall 
    refund on a timely basis to the individual (and shall be liable to 
    the individual for) any amounts collected from the individual for 
    such items or services. The provisions of subsection (a)(18) of this 
    section shall apply to refunds required under the previous sentence 
    in the same manner as such provisions apply to refunds under such 
    subsection.

           (5) ``Medical equipment and supplies'' defined

        The term ``medical equipment and supplies'' means--
            (A) durable medical equipment (as defined in section 
        1395x(n) of this title);
            (B) prosthetic devices (as described in section 1395x(s)(8) 
        of this title);
            (C) orthotics and prosthetics (as described in section 
        1395x(s)(9) of this title);
            (D) surgical dressings (as described in section 1395x(s)(5) 
        of this title);
            (E) such other items as the Secretary may determine; and
            (F) for purposes of paragraphs (1) and (3)--
                (i) home dialysis supplies and equipment (as described 
            in section 1395x(s)(2)(F) of this title),
                (ii) immunosuppressive drugs (as described in section 
            1395x(s)(2)(J) of this title),
                (iii) therapeutic shoes for diabetics (as described in 
            section 1395x(s)(12) of this title),
                (iv) oral drugs prescribed for use as an anticancer 
            therapeutic agent (as described in section 1395x(s)(2)(Q) of 
            this title), and
                (v) self-administered erythropoetin (as described in 
            section 1395x(s)(2)(P) of this title).

(k) Payment for outpatient therapy services and comprehensive outpatient 
        rehabilitation services

                           (1) In general

        With respect to services described in section 1395l(a)(8) or 
    1395l(a)(9) of this title for which payment is determined under this 
    subsection, the payment basis shall be--
            (A) for services furnished during 1998, the amount 
        determined under paragraph (2); or
            (B) for services furnished during a subsequent year, 80 
        percent of the lesser of--
                (i) the actual charge for the services, or
                (ii) the applicable fee schedule amount (as defined in 
            paragraph (3)) for the services.

      (2) Payment in 1998 based upon adjusted reasonable costs

        The amount under this paragraph for services is the lesser of--
            (A) the charges imposed for the services, or
            (B) the adjusted reasonable costs (as defined in paragraph 
        (4)) for the services,

    less 20 percent of the amount of the charges imposed for such 
    services.

                 (3) Applicable fee schedule amount

        In this subsection, the term ``applicable fee schedule amount'' 
    means, with respect to services furnished in a year, the amount 
    determined under the fee schedule established under section 1395w-4 
    of this title for such services furnished during the year or, if 
    there is no such fee schedule established for such services, the 
    amount determined under the fee schedule established for such 
    comparable services as the Secretary specifies.

                    (4) Adjusted reasonable costs

        In paragraph (2), the term ``adjusted reasonable costs'' means, 
    with respect to any services, reasonable costs determined for such 
    services, reduced by 10 percent. The 10-percent reduction shall not 
    apply to services described in section 1395l(a)(8)(B) of this title 
    (relating to services provided by hospitals).

                         (5) Uniform coding

        For claims for services submitted on or after April 1, 1998, for 
    which the amount of payment is determined under this subsection, the 
    claim shall include a code (or codes) under a uniform coding system 
    specified by the Secretary that identifies the services furnished.

                      (6) Restraint on billing

        The provisions of subparagraphs (A) and (B) of section 
    1395u(b)(18) of this title shall apply to therapy services for which 
    payment is made under this subsection in the same manner as they 
    apply to services provided by a practitioner described in section 
    1395u(b)(18)(C) of this title.

(l) Establishment of fee schedule for ambulance services

                           (1) In general

        The Secretary shall establish a fee schedule for payment for 
    ambulance services whether provided directly by a supplier or 
    provider or under arrangement with a provider under this part 
    through a negotiated rulemaking process described in title 5 and in 
    accordance with the requirements of this subsection.

                         (2) Considerations

        In establishing such fee schedule, the Secretary shall--
            (A) establish mechanisms to control increases in 
        expenditures for ambulance services under this part;
            (B) establish definitions for ambulance services which link 
        payments to the type of services provided;
            (C) consider appropriate regional and operational 
        differences;
            (D) consider adjustments to payment rates to account for 
        inflation and other relevant factors; and
            (E) phase in the application of the payment rates under the 
        fee schedule in an efficient and fair manner.

                             (3) Savings

        In establishing such fee schedule, the Secretary shall--
            (A) ensure that the aggregate amount of payments made for 
        ambulance services under this part during 2000 does not exceed 
        the aggregate amount of payments which would have been made for 
        such services under this part during such year if the amendments 
        made by section 4531(a) of the Balanced Budget Act of 1997 
        continued in effect, except that in making such determination 
        the Secretary shall assume an update in such payments for 2002 
        equal to percentage increase in the consumer price index for all 
        urban consumers (U.S. city average) for the 12-month period 
        ending with June of the previous year reduced in the case of 
        2001 and 2002 by 1.0 percentage points; and
            (B) set the payment amounts provided under the fee schedule 
        for services furnished in 2001 and each subsequent year at 
        amounts equal to the payment amounts under the fee schedule for 
        services furnished during the previous year, increased by the 
        percentage increase in the consumer price index for all urban 
        consumers (U.S. city average) for the 12-month period ending 
        with June of the previous year reduced in the case of 2001 and 
        2002 by 1.0 percentage points.

                          (4) Consultation

        In establishing the fee schedule for ambulance services under 
    this subsection, the Secretary shall consult with various national 
    organizations representing individuals and entities who furnish and 
    regulate ambulance services and share with such organizations 
    relevant data in establishing such schedule.

                      (5) Limitation on review

        There shall be no administrative or judicial review under 
    section 1395ff of this title or otherwise of the amounts established 
    under the fee schedule for ambulance services under this subsection, 
    including matters described in paragraph (2).

                      (6) Restraint on billing

        The provisions of subparagraphs (A) and (B) of section 
    1395u(b)(18) of this title shall apply to ambulance services for 
    which payment is made under this subsection in the same manner as 
    they apply to services provided by a practitioner described in 
    section 1395u(b)(18)(C) of this title.

                          (7) Coding system

        The Secretary may require the claim for any services for which 
    the amount of payment is determined under this subsection to include 
    a code (or codes) under a uniform coding system specified by the 
    Secretary that identifies the services furnished.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1834, as added and amended 
Pub. L. 100-203, title IV, Secs. 4049(a)(2), 4062(b), Dec. 22, 1987, 101 
Stat. 1330-91, 1330-100; Pub. L. 100-360, title II, Secs. 202(b)(4), 
203(c)(1)(F), 204(b), title IV, Sec. 411(a)(3)(A), (B)(ii), (C)(ii), 
(f)(8)(A), (B)(ii), (D), (g)(1)(A), (B), July 1, 1988, 102 Stat. 704, 
722, 726, 768, 779, 781; Pub. L. 100-485, title VI, Sec. 608(d)(21)(C), 
(22)(A), Oct. 13, 1988, 102 Stat. 2420; Pub. L. 101-234, title II, 
Sec. 201(a), title III, Sec. 301(b)(1), (c)(1), Dec. 13, 1989, 103 Stat. 
1981, 1985; Pub. L. 101-239, title VI, Secs. 6102(f)(1), 6105(a), 
6112(a), (c), (d)(1), (e)(2), 6116(b)(2), 6140, Dec. 19, 1989, 103 Stat. 
2188, 2210, 2214-2216, 2220, 2224; Pub. L. 101-508, title IV, 
Secs. 4102(a), (d), (f), 4104(a), 4152(a)(1), (b), (c)(1)-(4)(B)(i), 
(e), (f)(1), (g)(1), 4153(a)(1), (2)(D), 4163(b), Nov. 5, 1990, 104 
Stat. 1388-55, 1388-57, 1388-59, 1388-74, 1388-77 to 1388-81, 1388-83, 
1388-97; Pub. L. 103-66, title XIII, Secs. 13542(a), 13543(a), (b), 
13544(a)(1), (2), (b)(1), 13545(a), 13546, Aug. 10, 1993, 107 Stat. 587, 
589, 590; Pub. L. 103-432, title I, Secs. 102(e), 126(b)(1), (2), (4), 
(5), (g)(1), (10)(B), 131(a), 132(a), (b), 133(a)(1), 134(a)(1), 
135(a)(1), (b)(1), (3), (d)(1), (e)(2)-(5), 145(a), 156(a)(2)(C), Oct. 
31, 1994, 108 Stat. 4403, 4414-4416, 4419, 4421, 4424, 4427, 4440; Pub. 
L. 105-33, title IV, Secs. 4101(a), (c), 4104(b)(1), 4105(b)(2), 
4201(c)(5), 4312(a), (c), 4316(b), 4531(b)(2), 4541(a)(2), 4551(a), 
(c)(1), 4552(a), (b), Aug. 5, 1997, 111 Stat. 360, 363, 367, 374, 386, 
387, 392, 451, 455, 457-459; Pub. L. 106-113, div. B, Sec. 1000(a)(6) 
[title II, Sec. 201(e)(2), title III, Sec. 321(k)(3), title IV, 
Sec. 403(d)(1)], Nov. 29, 1999, 113 Stat. 1536, 1501A-340, 1501A-366, 
1501A-371.)

                       References in Text

    Part A of this subchapter, referred to in subsecs. (a)(1)(C), (16) 
and (h)(1)(D), is classified to section 1395c et seq. of this title.
    Section 4531(a) of the Balanced Budget Act of 1997, referred to in 
subsec. (l)(3)(A), is section 4531(a) of Pub. L. 105-33, which amended 
sections 1395u and 1395x of this title.

                          Codification

    Amendment of subsec. (a)(4) by Pub. L. 101-508, 
Sec. 4152(c)(4)(B)(i), did not become effective pursuant to Pub. L. 101-
508, Sec. 4152(c)(4)(B)(ii), because of action of Secretary in 
developing specific criteria for the treatment of wheelchairs as 
customized items for purposes of subsec. (a)(4). See Effective Date of 
1990 Amendment note below.


                            Prior Provisions

    A prior section 1395m, act Aug. 14, 1935, ch. 531, title XVIII, 
Sec. 1834, as added July 30, 1965, Pub. L. 89-97, title I, Sec. 102(a), 
79 Stat. 303, prescribed limitations on payments for home health 
services, prior to repeal by Pub. L. 96-499, title IX, Sec. 930(i), Dec. 
5, 1980, 94 Stat. 2631, effective with respect to services furnished on 
or after July 1, 1981.


                               Amendments

    1999--Subsec. (a)(13). Pub. L. 106-113, Sec. 1000(a)(6) [title II, 
Sec. 201(e)(2)(A)], substituted ``1395x(m)(5) of this title, but not 
including implantable items for which payment may be made under section 
1395l(t) of this title'' for ``1395x(m)(5) of this title)''.
    Subsec. (g). Pub. L. 106-113, Sec. 1000(a)(6) [title IV, 
Sec. 403(d)(1)], amended heading and text of subsec. (g) generally. 
Prior to amendment, text read as follows: ``The amount of payment under 
this part for outpatient critical access hospital services is the 
reasonable costs of the critical access hospital in providing such 
services.''
    Subsec. (h)(4)(A)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(3)(A)], substituted semicolon for comma at end.
    Subsec. (h)(4)(A)(v). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(3)(B)], substituted ``; and'' for ``, and'' at end.
    Subsec. (h)(4)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title II, 
Sec. 201(e)(2)(B)], inserted ``and does not include an implantable item 
for which payment may be made under section 1395l(t) of this title'' 
before the semicolon.
    1997--Subsec. (a)(2)(B)(iv). Pub. L. 105-33, Sec. 4105(b)(2), 
inserted before period at end ``(reduced by 10 percent, in the case of a 
blood glucose testing strip furnished after 1997 for an individual with 
diabetes)''.
    Subsec. (a)(9)(B)(iv). Pub. L. 105-33, Sec. 4552(a)(2)(A), 
substituted ``1995, 1996, and 1997'' for ``each subsequent year''.
    Subsec. (a)(9)(B)(v), (vi). Pub. L. 105-33, Sec. 4552(a)(1), (2)(B), 
(3), added cls. (v) and (vi).
    Subsec. (a)(9)(D). Pub. L. 105-33, Sec. 4552(b), which directed 
amendment of section 1848(a)(9) (42 U.S.C. 1395m(a)(9)) by adding 
subpar. (D) at end, was executed by adding subpar. (D) at end of subsec. 
(a)(9) of this section, to reflect the probable intent of Congress.
    Subsec. (a)(10)(B). Pub. L. 105-33, Sec. 4316(b), substituted ``The 
Secretary'' for ``For covered items furnished on or after January 1, 
1991, the Secretary'' and struck out ``(other than subparagraph (D))'' 
before ``of section 1395u(b) of this title'' and ``as such provisions 
would otherwise apply to physicians' services and physicians and a 
reasonable charge under section 1395u(b) of this title but for the 
application of section 1395w-4(i)(3) of this title. In applying such 
provisions to payments for an item under this subsection, the Secretary 
shall make adjustments to the payment basis for the item described in 
paragraph (1)(B) if the Secretary determines (in accordance with such 
provisions and on the basis of prices and costs applicable at the time 
the item is furnished) that such payment basis is not inherently 
reasonable'' before period at end.
    Subsec. (a)(14)(B). Pub. L. 105-33, Sec. 4551(a)(1)(B)(i), 
substituted ``1993, 1994, 1995, 1996, and 1997'' for ``a subsequent 
year''.
    Subsec. (a)(14)(C), (D). Pub. L. 105-33, Sec. 4551(a)(1)(A), 
(B)(ii), (C), added subpars. (C) and (D).
    Subsec. (a)(16). Pub. L. 105-33, Sec. 4312(c), inserted at end ``The 
Secretary, at the Secretary's discretion, may impose the requirements of 
the first sentence with respect to some or all providers of items or 
services under part A of this subchapter or some or all suppliers or 
other persons (other than physicians or other practitioners, as defined 
in section 1395u(b)(18)(C) of this title) who furnish items or services 
under this part.''
    Pub. L. 105-33, Sec. 4312(a), added par. (16).
    Subsec. (a)(17). Pub. L. 105-33, Sec. 4551(c)(1), added par. (17) 
relating to certain upgraded items.
    Subsec. (c)(1)(C). Pub. L. 105-33, Sec. 4101(c), in introductory 
provisions, struck out ``, subject to the deductible established under 
section 1395l(b) of this title,'' before ``be equal to 80''.
    Subsec. (c)(2)(A)(iii). Pub. L. 105-33, Sec. 4101(a)(1), amended cl. 
(iii) generally. Prior to amendment, cl. (iii) read as follows: ``In the 
case of a woman over 39 years of age, but under 50 years of age, who--
        ``(I) is at a high risk of developing breast cancer (as 
    determined pursuant to factors identified by the Secretary), payment 
    may not be made under this part for a screening mammography 
    performed within the 11 months following the month in which a 
    previous screening mammography was performed, or
        ``(II) is not at a high risk of developing breast cancer, 
    payment may not be made under this part for a screening mammography 
    performed within the 23 months following the month in which a 
    previous screening mammography was performed.''
    Subsec. (c)(2)(A)(iv), (v). Pub. L. 105-33, Sec. 4101(a)(2), struck 
out cls. (iv) and (v), which read as follows:
    ``(iv) In the case of a woman over 49 years of age, but under 65 
years of age, payment may not be made under this part for screening 
mammography performed within 11 months following the month in which a 
previous screening mammography was performed.
    ``(v) In the case of a woman over 64 years of age, payment may not 
be made for screening mammography performed within 23 months following 
the month in which a previous screening mammography was performed.''
    Subsec. (d). Pub. L. 105-33, Sec. 4104(b)(1), added subsec. (d).
    Subsec. (g). Pub. L. 105-33, Sec. 4201(c)(5), amended heading and 
text of subsec. (g) generally. Prior to amendment, text related to 
payment for outpatient rural primary care hospital services as 
determined, in par. (1), by either the cost-based facility fee plus 
professional charges method or the all-inclusive rate method and, in 
par. (2), by the prospective payment system.
    Subsec. (h)(4)(A)(iv). Pub. L. 105-33, Sec. 4551(a)(2)(B), 
substituted ``1996 and 1997'' for ``a subsequent year''.
    Subsec. (h)(4)(A)(v), (vi). Pub. L. 105-33, Sec. 4551(a)(2)(A), (C), 
added cls. (v) and (vi).
    Subsec. (k). Pub. L. 105-33, Sec. 4541(a)(2), added subsec. (k).
    Subsec. (l). Pub. L. 105-33, Sec. 4531(b)(2), added subsec. (l).
    1994--Subsec. (a)(3)(D). Pub. L. 103-432, Sec. 135(e)(5), struck out 
heading and text of subpar. (D). Text read as follows: ``If the 
reasonable useful lifetime of such an item, as established under 
paragraph (7)(C), has been reached during a continuous period of medical 
need, or the Secretary determines on the basis of investigation by the 
carrier that the item is lost or irreparably damaged, payment for an 
item serving as a replacement for such item shall be made on a monthly 
basis for the rental of the replacement item in accordance with 
subparagraph (A).''
    Subsec. (a)(5)(E). Pub. L. 103-432, Sec. 135(d)(1), substituted 
``pressure of 56'' for ``pressure of 55''.
    Subsec. (a)(7). Pub. L. 103-432, Sec. 135(e)(2), made technical 
amendment to directory language of Pub. L. 101-508, Sec. 4152(c)(2). See 
1990 Amendment note below.
    Subsec. (a)(7)(A)(iii)(II). Pub. L. 103-432, Sec. 135(e)(3), 
substituted ``clause (vi)'' for ``clause (v)''.
    Subsec. (a)(7)(C)(i). Pub. L. 103-432, Sec. 135(e)(4), substituted 
``this paragraph'' for ``this paragraph or paragraph (3)''.
    Subsec. (a)(10)(B). Pub. L. 103-432, Sec. 134(a)(1), inserted at end 
``In applying such provisions to payments for an item under this 
subsection, the Secretary shall make adjustments to the payment basis 
for the item described in paragraph (1)(B) if the Secretary determines 
(in accordance with such provisions and on the basis of prices and costs 
applicable at the time the item is furnished) that such payment basis is 
not inherently reasonable.''
    Pub. L. 103-432, Sec. 126(g)(10)(B), substituted ``would otherwise 
apply to physicians' services'' for ``apply to physicians' services'' 
and inserted before period at end ``but for the application of section 
1395w-4(i)(3) of this title''.
    Subsec. (a)(14)(A). Pub. L. 103-432, Sec. 135(a)(1), amended subpar. 
(A) generally. Prior to amendment, subpar. (A) read as follows: ``for 
1991 and 1992, reduction of 1 percentage point; and''.
    Subsec. (a)(15). Pub. L. 103-432, Sec. 135(b)(1), amended heading 
and text of par. (15) generally. Prior to amendment, text read as 
follows:
    ``(A) Development of list of items by secretary.--The Secretary 
shall develop and periodically update a list of items for which payment 
may be made under this subsection that the Secretary determines, on the 
basis of prior payment experience, are frequently subject to unnecessary 
utilization, and shall include in such list seat-lift mechanisms, 
transcutaneous electrical nerve stimulators, and motorized scooters.
    ``(B) Determinations of coverage in advance.--A carrier shall 
determine in advance whether payment for an item included on the list 
developed by the Secretary under subparagraph (A) may not be made 
because of the application of section 1395y(a)(1) of this title.''
    Subsec. (a)(16). Pub. L. 103-432, Sec. 131(a)(2), struck out heading 
and text of par. (16). Text read as follows:
    ``(A) In general.--A supplier of a covered item under this 
subsection may not distribute to physicians or to individuals entitled 
to benefits under this part for commercial purposes any completed or 
partially completed forms or other documents required by the Secretary 
to be submitted to show that a covered item is reasonable and necessary 
for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member.
    ``(B) Penalty.--Any supplier of a covered item who knowingly and 
willfully distributes a form or other document in violation of 
subparagraph (A) is subject to a civil money penalty in an amount not to 
exceed $1,000 for each such form or document so distributed. The 
provisions of section 1320a-7a of this title (other than subsections (a) 
and (b)) shall apply to civil money penalties under this subparagraph in 
the same manner as they apply to a penalty or proceeding under section 
1320a-7a(a) of this title.''
    Subsec. (a)(17), (18). Pub. L. 103-432, Sec. 132(a)(1), (2), added 
pars. (17) and (18).
    Subsec. (b)(4)(D). Pub. L. 103-432, Sec. 126(b)(2)(A), in 
introductory provisions substituted ``shall, subject to clause (vii), be 
reduced to the adjusted conversion factor for the locality determined as 
follows:'' for ``shall be determined as follows:''.
    Subsec. (b)(4)(D)(iv). Pub. L. 103-432, Sec. 126(b)(2)(B), 
substituted ``Adjusted conversion factor'' for ``Local adjustment'' in 
heading and ``The adjusted conversion factor for'' for ``Subject to 
clause (vii), the conversion factor to be applied to'' in text.
    Subsec. (b)(4)(D)(vii). Pub. L. 103-432, Sec. 126(b)(2)(C), (D), 
struck out ``under this subparagraph'' after ``applied to a locality'' 
and inserted ``reduced under this subparagraph by'' before ``more than 
9.5 percent''.
    Subsec. (b)(4)(E). Pub. L. 103-432, Sec. 126(b)(5), inserted heading 
``Rule for certain scanning services''.
    Pub. L. 103-432, Sec. 126(b)(4), made technical amendment to 
directory language of Pub. L. 101-508, Sec. 4102(d). See 1990 Amendment 
note below.
    Pub. L. 103-432, Sec. 126(b)(1), redesignated subpar. (E), relating 
to subsequent updating, as (F).
    Subsec. (b)(4)(F), (G). Pub. L. 103-432, Sec. 126(b)(1), 
redesignated subpars. (E), relating to subsequent updating, and (F) as 
(F) and (G), respectively.
    Subsec. (c)(1)(B). Pub. L. 103-432, Sec. 145(a)(1), substituted ``is 
conducted by a facility that has a certificate (or provisional 
certificate) issued under section 263b of this title'' for ``meets the 
quality standards established under paragraph (3)''.
    Subsec. (c)(1)(C)(iii). Pub. L. 103-432, Sec. 145(a)(2), substituted 
``paragraph (3)'' for ``paragraph (4)''.
    Subsec. (c)(3) to (5). Pub. L. 103-432, Sec. 145(a)(3), (4), 
redesignated pars. (4) and (5) as (3) and (4), respectively, and struck 
out former par. (3) which directed Secretary to establish standards to 
assure the safety and accuracy of screening mammography performed under 
this part.
    Subsec. (f). Pub. L. 103-432, Sec. 126(g)(1), substituted ``during 
1991'' for ``during fiscal year 1991'' in heading.
    Subsec. (g)(1). Pub. L. 103-432, Sec. 102(e)(1)(A), (2), substituted 
in introductory provisions ``during a year before the prospective 
payment system described in paragraph (2) is in effect'' for ``during a 
year before 1993'' and inserted at end ``The amount of payment shall be 
determined under either method without regard to the amount of the 
customary or other charge.''
    Subsec. (g)(1)(B). Pub. L. 103-432, Sec. 156(a)(2)(C), struck out 
``and for items and services furnished in connection with obtaining a 
second opinion required under section 1320c-13(c)(2) of this title, or a 
third opinion, if the second opinion was in disagreement with the first 
opinion'' after ``section 1395x(s)(10)(A) of this title''.
    Subsec. (g)(2). Pub. L. 103-432, Sec. 102(e)(1)(B), substituted 
``January 1, 1996'' for ``January 1, 1993''.
    Subsec. (h)(3). Pub. L. 103-432, Sec. 135(b)(3), substituted 
``Paragraphs (12), (15), and (17)'' for ``Paragraphs (12) and (17)''.
    Pub. L. 103-432, Sec. 132(b), substituted ``Paragraphs (12) and 
(17)'' for ``Paragraph (12)''.
    Subsec. (j). Pub. L. 103-432, Sec. 131(a)(1), added subsec. (j).
    Subsec. (j)(4), (5). Pub. L. 103-432, Sec. 133(a)(1), added par. (4) 
and redesignated former par. (4) as (5).
    1993--Subsec. (a)(1)(D). Pub. L. 103-66, Sec. 13545(a), substituted 
``45 percent'' for ``15 percent'' after ``(as previously reduced) by''.
    Subsec. (a)(2)(A)(iii). Pub. L. 103-66, Sec. 13543(b), added cl. 
(iii).
    Subsec. (a)(2)(C). Pub. L. 103-66, Sec. 13542(a)(1), in cl. (i)(II), 
substituted ``for 1992, 1993, and 1994'' for ``for 1992'' and ``update 
for the year'' for ``update for 1992'', and in cl. (ii), struck out 
``and'' at end of subcl. (I), added subcls. (II) and (III), and 
redesignated former subcl. (II) as (IV).
    Subsec. (a)(3)(A). Pub. L. 103-66, Sec. 13543(a), substituted ``IPPB 
machines and ventilators, excluding ventilators that are either 
continuous airway pressure devices or intermittent assist devices with 
continuous airway pressure devices'' for ``ventilators, aspirators, IPPB 
machines, and nebulizers''.
    Subsec. (a)(3)(C). Pub. L. 103-66, Sec. 13542(a)(1), in cl. (i)(II), 
substituted ``for 1992, 1993, and 1994'' for ``for 1992'' and ``update 
for the year'' for ``update for 1992'', and in cl. (ii), struck out 
``and'' at end of subcl. (I), added subcls. (II) and (III), and 
redesignated former subcl. (II) as (IV).
    Subsec. (a)(8)(A)(ii)(III). Pub. L. 103-66, Sec. 13542(a)(2)(A), 
substituted ``1992, 1993, and 1994'' for ``1992''.
    Subsec. (a)(8)(B)(ii) to (iv). Pub. L. 103-66, Sec. 13542(a)(2)(B), 
added cls. (ii) and (iii) and redesignated former cl. (ii) as (iv).
    Subsec. (a)(9)(A)(ii)(II). Pub. L. 103-66, Sec. 13542(a)(3)(A), 
substituted ``1991, 1992, 1993, and 1994'' for ``1991 and 1992''.
    Subsec. (a)(9)(B)(ii) to (iv). Pub. L. 103-66, Sec. 13542(a)(3)(B), 
added cls. (ii) and (iii) and redesignated former cl. (ii) as (iv).
    Subsec. (h)(1)(B). Pub. L. 103-66, Sec. 13544(a)(2), substituted 
``subparagraphs (C) and (E)'' for ``subparagraph (C)'' in introductory 
provisions.
    Subsec. (h)(1)(E). Pub. L. 103-66, Sec. 13544(a)(1), added subpar. 
(E).
    Subsec. (h)(4)(A). Pub. L. 103-66, Sec. 13546, struck out ``and'' at 
end of cl. (i), substituted ``1992 and 1993'' for ``a subsequent year'' 
in cl. (ii), and added cls. (iii) and (iv).
    Subsec. (i). Pub. L. 103-66, Sec. 13544(b)(1), added subsec. (i).
    1990--Subsec. (a). Pub. L. 101-508, Sec. 4153(a)(2)(D)(i), struck 
out ``, prosthetic devices, orthotics, and prosthetics'' after ``medical 
equipment'' in heading.
    Subsec. (a)(1)(D). Pub. L. 101-508, Sec. 4152(a)(1), inserted before 
period at end ``, and, in the case of a transcutaneous electrical nerve 
stimulator furnished on or after January 1, 1991, the Secretary shall 
further reduce such payment amount (as previously reduced) by 15 
percent''.
    Subsec. (a)(2)(A). Pub. L. 101-508, Sec. 4153(a)(2)(D)(ii), 
substituted ``(13)'' for ``(13)(A)''.
    Pub. L. 101-508, Sec. 4152(c)(4)(A), inserted ``or'' after ``$150,'' 
in cl. (i), struck out ``or'' after ``purchase,'' in cl. (ii), and 
struck out cl. (iii) which read as follows: ``which is a power-driven 
wheelchair (other than a customized wheelchair that is classified as a 
customized item under paragraph (4) pursuant to criteria specified by 
the Secretary),''.
    Subsec. (a)(2)(B). Pub. L. 101-508, Sec. 4152(b)(1)(A), (B), struck 
out ``or'' after ``1987;'' in cl. (i), added cls. (ii) to (iv), and 
struck out former cl. (ii) which read as follows: ``in a subsequent 
year, is the amount specified in this subparagraph for the preceding 
year increased by the percentage increase in the consumer price index 
for all urban consumers (U.S. city average) for the 12-month period 
ending with June of that preceding year.''
    Subsec. (a)(2)(C). Pub. L. 101-508, Sec. 4152(b)(1)(C), added 
subpar. (C).
    Subsec. (a)(3)(B). Pub. L. 101-508, Sec. 4152(b)(1)(A), (B), struck 
out ``or'' after ``1987;'' in cl. (i), added cls. (ii) to (iv), and 
struck out former cl. (ii) which read as follows: ``in a subsequent 
year, is the amount specified in this subparagraph for the preceding 
year increased by the percentage increase in the consumer price index 
for all urban consumers (U.S. city average) for the 12-month period 
ending with June of that preceding year.''
    Subsec. (a)(3)(C). Pub. L. 101-508, Sec. 4152(b)(1)(C), added 
subpar. (C).
    Subsec. (a)(3)(D). Pub. L. 101-508, Sec. 4152(c)(3), added subpar. 
(D).
    Subsec. (a)(4). Pub. L. 101-508, Sec. 4152(c)(4)(B)(i), directed 
amendment of par. (4) by inserting at end ``In the case of a wheelchair 
furnished on or after January 1, 1992, the wheelchair shall be treated 
as a customized item for purposes of this paragraph if the wheelchair 
has been measured, fitted, or adapted in consideration of the patient's 
body size, disability, period of need, or intended use, and has been 
assembled by a supplier or ordered from a manufacturer who makes 
available customized features, modifications, or components for 
wheelchairs that are intended for an individual patient's use in 
accordance with instructions from the patient's physician.'' The 
amendment did not become effective pursuant to Pub. L. 101-508, 
Sec. 4152(c)(4)(B)(ii). See Effective Date of 1990 Amendment note below.
    Subsec. (a)(5)(A). Pub. L. 101-508, Sec. 4152(g)(1)(A), substituted 
``(B), (C), and (E)'' for ``(B) and (C)''.
    Subsec. (a)(5)(E). Pub. L. 101-508, Sec. 4152(g)(1)(B), added 
subpar. (E).
    Subsec. (a)(7)(A)(i). Pub. L. 101-508, Sec. 4152(c)(2)(A), as 
amended by Pub. L. 103-432, Sec. 135(e)(2), substituted ``15 months, or, 
in the case of an item for which a purchase agreement has been entered 
into under clause (iii), a period of continuous use of longer than 13 
months'' for ``15 months''.
    Pub. L. 101-508, Sec. 4152(c)(1), substituted ``for each of the 
first 3 months of such period'' for ``for each such month'' and ``, and 
for each of the remaining months of such period is 7.5 percent of such 
purchase price;'' for semicolon at end.
    Subsec. (a)(7)(A)(ii), (iii). Pub. L. 101-508, Sec. 4152(c)(2)(D), 
as amended by Pub. L. 103-432, Sec. 135(e)(2), added cls. (ii) and 
(iii). Former cls. (ii) and (iii) redesignated (iv) and (v), 
respectively.
    Subsec. (a)(7)(A)(iv). Pub. L. 101-508, Sec. 4152(c)(2)(B), as 
amended by Pub. L. 103-432, Sec. 135(e)(2), redesignated cl. (ii) as 
(iv), substituted ``in the case of an item for which a purchase 
agreement has not been entered into under clause (ii) or clause (iii), 
during the first 6-month period of medical need that follows the period 
of medical need during which payment is made under clause (i),'' for 
``during the succeeding 6-month period of medical need,'' and struck out 
``and'' at end.
    Subsec. (a)(7)(A)(v). Pub. L. 101-508, Sec. 4152(c)(2)(C), as 
amended by Pub. L. 103-432, Sec. 135(e)(2), redesignated cl. (iii) as 
(v), inserted at beginning ``in the case of an item for which a purchase 
agreement has not been entered into under clause (ii) or clause 
(iii),'', and substituted ``; and'' for period at end.
    Subsec. (a)(7)(A)(vi). Pub. L. 101-508, Sec. 4152(c)(2)(E), as 
amended by Pub. L. 103-432, Sec. 135(e)(2), added cl. (vi).
    Subsec. (a)(7)(C). Pub. L. 101-508, Sec. 4152(c)(2)(F), as amended 
by Pub. L. 103-432, Sec. 135(e)(2), added subpar. (C).
    Subsec. (a)(8)(A)(ii). Pub. L. 101-508, Sec. 4152(b)(2)(A), added 
subcl. (II), redesignated former subcl. (II) as (III), struck out ``1991 
or'' before ``1992'', and substituted ``the covered item update for the 
year'' for ``the percentage increase in the consumer price index for all 
urban consumers (U.S. city average) for the 12-month period ending with 
June of the previous year''.
    Subsec. (a)(8)(B). Pub. L. 101-508, Sec. 4152(b)(2)(B), amended 
subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: 
``With respect to the furnishing of a particular item in each region (as 
defined by the Secretary), the Secretary shall compute a regional 
purchase price--
        ``(i) for 1991 and for 1992, equal to the average (weighted by 
    relative volume of all claims among carriers) of the local purchase 
    prices for the carriers in the region computed under subparagraph 
    (A)(ii)(II) for the year, and
        ``(ii) for each subsequent year, equal to the regional purchase 
    price computed under this subparagraph for the previous year 
    increased by the percentage increase in the consumer price index for 
    all urban consumers (U.S. city average) for the 12-month period 
    ending with June of the previous year.''
    Subsec. (a)(8)(C). Pub. L. 101-508, Sec. 4152(b)(2)(C)(ii), struck 
out ``and subject to subparagraph (D)'' after ``and (7)'' in 
introductory provisions.
    Subsec. (a)(8)(C)(ii). Pub. L. 101-508, Sec. 4152(b)(2)(C)(i), 
(iii), in subcl. (I) substituted ``67 percent'' for ``75 percent'' and 
in subcl. (II) substituted ``33 percent'' for ``25 percent'' and 
``national limited purchase price'' for ``regional purchase price''.
    Subsec. (a)(8)(C)(iii). Pub. L. 101-508, Sec. 4152(b)(2)(C)(i), 
(iv), in subcl. (I) substituted ``33 percent'' for ``50 percent'' and 
``subparagraph (A)(ii)(III)'' for ``subparagraph (A)(ii)(II)'' and in 
subcl. (II) substituted ``67 percent'' for ``50 percent'' and ``national 
limited purchase price'' for ``regional purchase price''.
    Subsec. (a)(8)(C)(iv). Pub. L. 101-508, Sec. 4152(b)(2)(C)(i), 
substituted ``national limited purchase price'' for ``regional purchase 
price''.
    Subsec. (a)(8)(D). Pub. L. 101-508, Sec. 4152(b)(2)(D), struck out 
subpar. (D) which read as follows: ``The amount that is recognized under 
subparagraph (C) as the purchase price for an item furnished--
        ``(i) in 1991, may not exceed 125 percent, and may not be lower 
    than 85 percent, of the average of the purchase prices recognized 
    under such subparagraph for all the carrier service areas in the 
    United States in that year; and
        ``(ii) in a subsequent year, may not exceed 120 percent, and may 
    not be lower than 90 percent, of the average of the purchase prices 
    recognized under such subparagraph for all the carrier service areas 
    in the United States in that year.''
    Subsec. (a)(9)(A)(ii)(II). Pub. L. 101-508, Sec. 4152(b)(3)(A), 
substituted ``the covered item increase for the year'' for ``the 
percentage increase in the consumer price index for all urban consumers 
(U.S. city average) for the 12-month period ending with June of the 
previous year''.
    Subsec. (a)(9)(B). Pub. L. 101-508, Sec. 4152(b)(3)(B), amended 
subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: 
``With respect to the furnishing of an item in each region (as defined 
by the Secretary), the Secretary shall compute a regional monthly 
payment rate--
        ``(i) for 1991 and 1992, equal to the average (weighted by 
    relative volume of all claims among carriers) of the local monthly 
    payment rates for the carriers in the region computed under 
    subparagraph (A)(ii)(II) for the year, and
        ``(ii) for each subsequent year, equal to the regional monthly 
    payment rates computed under this subparagraph for the previous year 
    increased by the percentage increase in the consumer price index for 
    all urban consumers (U.S. city average) for the 12-month period 
    ending with June of the previous year.''
    Subsec. (a)(9)(C)(ii). Pub. L. 101-508, Sec. 4152(b)(3)(C)(i), (ii), 
in subcl. (I) substituted ``67 percent'' for ``75 percent'' and in 
subcl. (II) substituted ``33 percent'' for ``25 percent'' and ``national 
limited monthly payment rate'' for ``regional monthly payment rate''.
    Subsec. (a)(9)(C)(iii). Pub. L. 101-508, Sec. 4152(b)(3)(C)(i), 
(iii), in subcl. (I) substituted ``33 percent'' for ``50 percent'' and 
in subcl. (II) substituted ``67 percent'' for ``50 percent'', ``national 
limited monthly payment rate'' for ``regional monthly payment rate'', 
and ``subparagraph (B)(ii)'' for ``subparagraph (B)(i)''.
    Subsec. (a)(9)(C)(iv). Pub. L. 101-508, Sec. 4152(b)(3)(C)(i), 
substituted ``national limited monthly payment rate'' for ``regional 
monthly payment rate''.
    Subsec. (a)(9)(D). Pub. L. 101-508, Sec. 4152(b)(3)(D), struck out 
subpar. (D) which read as follows: ``The amount that is recognized under 
subparagraph (C) as the base monthly payment amount for an item 
furnished--
        ``(i) in 1991, may not exceed 125 percent, and may not be lower 
    than 85 percent, of the average of the base monthly payment amounts 
    recognized under such subparagraph for all the carrier service areas 
    in the United States in that year; and
        ``(ii) in a subsequent year, may not exceed 120 percent, and may 
    not be lower than 90 percent, of the average of the base monthly 
    payment amounts recognized under such subparagraph for all the 
    carrier service areas in the United States in that year.''
    Subsec. (a)(12). Pub. L. 101-508, Sec. 4152(b)(5), struck out 
``defined for purposes of paragraphs (8)(B) and (9)(B)'' after ``one or 
more entire regions''.
    Subsec. (a)(13). Pub. L. 101-508, Sec. 4153(a)(2)(D)(iii), 
substituted ``means durable medical equipment (as defined in section 
1395x(n) of this title), including such equipment described in section 
1395x(m)(5) of this title).'' for ``means--
        ``(A) durable medical equipment (as defined in section 1395x(n) 
    of this title), including such equipment described in section 
    1395x(m)(5) of this title;
        ``(B) prosthetic devices (described in section 1395x(s)(8) of 
    this title), but not including parenteral and enteral nutrition 
    nutrients, supplies, and equipment; and
        ``(C) orthotics and prosthetics (described in section 
    1395x(s)(9) of this title);
but does not include intraocular lenses or medical supplies (including 
catheters, catheter supplies, ostomy bags, and supplies related to 
ostomy care) furnished by a home health agency under section 1395x(m)(5) 
of this title.''
    Subsec. (a)(14). Pub. L. 101-508, Sec. 4152(b)(4), added par. (14).
    Subsec. (a)(15). Pub. L. 101-508, Sec. 4152(e), added par. (15).
    Subsec. (a)(16). Pub. L. 101-508, Sec. 4152(f)(1), added par. (16).
    Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4163(b)(1), inserted ``and 
subject to subsection (c)(1)(A) of this section'' after ``conversion 
factors''.
    Pub. L. 101-508, Sec. 4102(f), inserted ``locality,'' after 
``statewide,''.
    Subsec. (b)(4)(D). Pub. L. 101-508, Sec. 4102(a)(2), added subpar. 
(D). Former subpar. (D) redesignated (E) relating to subsequent 
updating.
    Subsec. (b)(4)(E). Pub. L. 101-508, Sec. 4102(d), as amended by Pub. 
L. 103-432, Sec. 126(b)(4), added subpar. (E) relating to rule for 
certain scanning services.
    Pub. L. 101-508, Sec. 4102(a)(1), redesignated subpar. (D), relating 
to subsequent updating, as (E). Former subpar. (E) redesignated (F).
    Subsec. (b)(4)(F). Pub. L. 101-508, Sec. 4102(a)(1), redesignated 
subpar. (E) as (F).
    Subsec. (c). Pub. L. 101-508, Sec. 4163(b)(2), added subsec. (c).
    Subsec. (f). Pub. L. 101-508, Sec. 4104(a), amended subsec. (f) 
generally, substituting provisions relating to reduction in payments for 
physician pathology services during 1991 for provisions directing 
Secretary to provide for application of a fee schedule with respect to 
such services.
    Subsec. (h). Pub. L. 101-508, Sec. 4153(a)(1), added subsec. (h).
    1989--Subsec. (a)(1)(D). Pub. L. 101-239, Sec. 6112(c), added 
subpar. (D).
    Subsec. (a)(2)(A)(iii). Pub. L. 101-239, Sec. 6112(d)(1), added cl. 
(iii).
    Subsec. (a)(2)(B)(i), (3)(B)(i). Pub. L. 101-239, Sec. 6112(a)(1), 
inserted ``and in 1990'' after ``1989''.
    Subsec. (a)(7)(A)(i). Pub. L. 101-239, Sec. 6112(a)(4)(A), 
substituted ``this clause'' for ``this subparagraph''.
    Subsec. (a)(7)(B)(i). Pub. L. 101-239, Sec. 6112(a)(4)(B), inserted 
``in'' after ``rental of the item''.
    Subsec. (a)(7)(B)(ii). Pub. L. 101-239, Sec. 6112(a)(4)(C), 
substituted ``clause (i) shall apply in the same manner as it applies to 
items furnished during 1989'' for ``the payment amount recognized under 
subparagraph (A)(i) shall not be more than the maximum amount 
established under clause (i), and shall not be less than the minimum 
amount established under such clause, for 1989, each such amount 
increased by the percentage increase in the consumer price index for all 
urban consumers (U.S. city average) for the 12-month period ending with 
June 1989''.
    Subsec. (a)(8)(A)(ii)(I). Pub. L. 101-239, Sec. 6112(a)(2)(A), 
inserted ``and 1990'' after ``1989''.
    Subsec. (a)(8)(A)(ii)(II). Pub. L. 101-239, Sec. 6112(a)(2)(B), 
substituted ``1991 or 1992'' for ``1990, 1991, or 1992''.
    Subsec. (a)(8)(D)(i). Pub. L. 101-239, Sec. 6140(1), substituted 
``1991, may not exceed 125 percent, and may not be lower than 85 
percent'' for ``1991, may not exceed 130 percent, and may not be lower 
than 80 percent''.
    Subsec. (a)(8)(D)(ii). Pub. L. 101-239, Sec. 6140(2), substituted 
``120 percent, and may not be lower than 90 percent'' for ``125 percent, 
and may not be lower than 85 percent''.
    Subsec. (a)(9)(A)(ii)(I). Pub. L. 101-239, Sec. 6112(a)(3)(A), 
inserted ``and 1990'' after ``1989''.
    Subsec. (a)(9)(A)(ii)(II). Pub. L. 101-239, Sec. 6112(a)(3)(B), 
substituted ``1991 and 1992'' for ``1990, 1991, and 1992''.
    Subsec. (a)(9)(D)(i). Pub. L. 101-239, Sec. 6140(1), substituted 
``1991, may not exceed 125 percent, and may not be lower than 85 
percent'' for ``1991, may not exceed 130 percent, and may not be lower 
than 80 percent''.
    Subsec. (a)(9)(D)(ii). Pub. L. 101-239, Sec. 6140(2), substituted 
``120 percent, and may not be lower than 90 percent'' for ``125 percent, 
and may not be lower than 85 percent''.
    Subsec. (a)(13). Pub. L. 101-239, Sec. 6112(e)(2), inserted before 
period at end ``or medical supplies (including catheters, catheter 
supplies, ostomy bags, and supplies related to ostomy care) furnished by 
a home health agency under section 1395x(m)(5) of this title''.
    Subsec. (b)(1)(B). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 
100-360, Sec. 204(b)(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.
    Subsec. (b)(4)(A). Pub. L. 101-234, Sec. 301(b)(1), (c)(1), amended 
subpar. (A) identically, substituting ``coinsurance and deductibles 
under sections 1395l(a)(1)(J)'' for ``insurance and deductibles under 
section 1395n(a)(1)(I)''.
    Subsec. (b)(4)(C) to (E). Pub. L. 101-239, Sec. 6105(a), added 
subpar. (C) and redesignated former subpars. (C) and (D) as (D) and (E), 
respectively.
    Subsecs. (c) to (e). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 
100-360, Secs. 202(b)(4), 203(c)(1)(F), 204(b)(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. (f). Pub. L. 101-239, Sec. 6102(f)(1), added subsec. (f).
    Subsec. (g). Pub. L. 101-239, Sec. 6116(b)(2), added subsec. (g).
    1988--Pub. L. 100-360, Sec. 411(g)(1)(A), inserted ``items and'' in 
section catchline.
    Subsec. (a)(1)(C). Pub. L. 100-360, Sec. 411(g)(1)(B)(i), inserted 
``or under part A of this subchapter to a home health agency'' before 
period at end.
    Subsec. (a)(2)(A). Pub. L. 100-360, Sec. 411(g)(1)(B)(iii), struck 
out ``rental'' before ``payments'' in concluding provisions.
    Subsec. (a)(2)(B)(i). Pub. L. 100-360, Sec. 411(g)(1) (B)(iii), 
substituted ``reasonable'' for ``allowed''.
    Subsec. (a)(3)(A). Pub. L. 100-360, Sec. 411(g)(1)(B)(iv), struck 
out the extra space appearing in text of original act after 
``ventilators''.
    Subsec. (a)(3)(B)(i). Pub. L. 100-360, Sec. 411(g)(1) (B)(iii), 
substituted ``reasonable'' for ``allowable''.
    Subsec. (a)(4). Pub. L. 100-360, Sec. 411(g)(1) (B)(v)-(vii), 
inserted ``, and for that reason cannot be grouped with similar items 
for purposes of payment under this subchapter,'' after ``individual 
patient'', inserted cl. (A) and (B) designations, and in cl. (B), 
substituted ``servicing'' for ``service'' in two places.
    Subsec. (a)(7)(A)(ii). Pub. L. 100-360, Sec. 411(g)(1) (B)(vii), 
inserted ``maintenance and'' before ``servicing''.
    Subsec. (a)(7)(A)(iii). Pub. L. 100-360, Sec. 411(g)(1) (B)(vii), 
(viii), substituted ``maintenance and servicing'' for ``service and 
maintenance'', and in subcl. (I) substituted ``fee or fees established 
by the Secretary'' for ``fee established by the carrier''.
    Subsec. (a)(7)(B)(i). Pub. L. 100-360, Sec. 411(a)(3)(A), (C)(ii), 
provided that subsec. (a)(7)(B)(i) of this section, as inserted by 
section 4062(b) of Pub. L. 100-203, is deemed to have a reference to 
``1987'' immediately after ``December''.
    Subsec. (a)(8)(A)(i)(I). Pub. L. 100-360, Sec. 411(g)(1) (B)(iii), 
substituted ``reasonable'' for ``allowable''.
    Subsec. (a)(8)(B). Pub. L. 100-360, Sec. 411(g)(1)(B)(xi), as 
amended Pub. L. 100-485, Sec. 608(d)(22)(A)(i), substituted ``(as 
defined by the Secretary)'' for ``(as defined in section 1395ww(d)(2)(D) 
of this title)'', and in cl. (i) struck out the comma after ``1991''.
    Subsec. (a)(9)(A)(ii)(I). Pub. L. 100-360, Sec. 411(g)(1) (B)(ix), 
substituted ``6-month'' for ``12-month''.
    Subsec. (a)(9)(A)(ii)(II). Pub. L. 100-360, Sec. 411(g)(1) (B)(x), 
substituted ``, 1991, and 1992'' for ``and to 1991''.
    Subsec. (a)(9)(B). Pub. L. 100-360, Sec. 411(g)(1)(B)(xi), as 
amended by Pub. L. 100-485, Sec. 608(d)(22)(A)(i), substituted ``(as 
defined by the Secretary)'' for ``(as defined in section 1395ww(d)(2)(D) 
of this title)'', and in cl. (i) struck out the comma after ``1991''.
    Subsec. (a)(9)(C)(i). Pub. L. 100-360, Sec. 411(g)(1) (B)(xii), 
substituted ``subparagraph (A)(ii)'' for ``subparagraph (A)(ii)(I)''.
    Subsec. (a)(10)(B). Pub. L. 100-360, Sec. 411(g)(1) (B)(xiii), 
inserted before period at end ``and payments under this subsection as 
such provisions apply to physicians' services and physicians and a 
reasonable charge under section 1395u(b) of this title''.
    Subsec. (a)(11)(A). Pub. L. 100-360, Sec. 411(g)(1) (B)(vii), (xiv), 
inserted ``maintenance and'' before ``servicing'' and substituted 
``section 1395u(j)(2) of this title'' for ``subsection (j)(2) of this 
section''.
    Subsec. (a)(12). Pub. L. 100-360, Sec. 411(g)(1)(B)(xv), as amended 
by Pub. L. 100-485, Sec. 608(d)(22)(A)(ii), substituted ``one or more 
entire regions defined for purposes of paragraphs (8)(B) and (9)(B)'' 
for ``each region (as defined in section 1395ww(d)(2)(D) of this 
title)''.
    Subsec. (a)(14). Pub. L. 100-360, Sec. 411(g)(1)(B)(xvi), struck out 
par. (14) which read as follows: ``In this subsection, any reference to 
the term `carrier' includes a reference, with respect to durable medical 
equipment furnished by a home health agency as part of home health 
services, to a fiscal intermediary.''
    Subsec. (b). Pub. L. 100-360, Sec. 411(a)(3)(A), (B)(ii), 
(f)(8)(B)(ii), amended Pub. L. 100-203, Sec. 4049(a)(2), see 1987 
Amendment note below.
    Subsec. (b)(1)(B). Pub. L. 100-360, Sec. 204(b)(1), inserted ``and 
subject to subsection (e)(1)(A) of this section'' after ``conversion 
factors''.
    Subsec. (b)(4)(C). Pub. L. 100-360, Sec. 411(f)(8)(D)(ii), as added 
by Pub. L. 100-485, Sec. 608(d)(21)(C), substituted ``For radiologist'' 
for ``Radiologist'' and ``1395u(i)(3) of this title'' for 
``1395u(b)(4)(E)(ii) of this title''.
    Subsec. (b)(4)(D), (5). Pub. L. 100-360, Sec. 411(f)(8)(D)(i), 
inserted ``and suppliers'' after ``physicians'' in heading.
    Subsec. (b)(5)(C). Pub. L. 100-360, Sec. 411(f)(8)(D)(iii), (iv), 
formerly (ii), (iii), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(21)(C), substituted ``bills'' for ``imposes a charge'' and 
inserted ``in the same manner as such sanctions may apply to a 
physician'' before period at end.
    Subsec. (b)(6). Pub. L. 100-360, Sec. 411(f)(8)(D)(v), formerly 
(iv), as redesignated by Pub. L. 100-485, Sec. 608(d)(21)(C), 
substituted ``and section 1395l(a)(1)(J) of this title'' for ``, section 
1395l(a)(1)(I) of this title, and section 1395u(h)(1)(B) of this 
title''.
    Pub. L. 100-360, Sec. 411(f)(8)(A), substituted ``radiology'' for 
``radiologic''.
    Subsec. (b)(6)(B). Pub. L. 100-360, Sec. 411(f)(8)(D)(vi), formerly 
(v), as redesignated by Pub. L. 100-485, Sec. 608(d)(21)(C), substituted 
``the total amount of charges'' for ``billings''.
    Pub. L. 100-360, Sec. 411(f)(8)(A), substituted ``radiology'' for 
``radiologic''.
    Subsec. (c). Pub. L. 100-360, Sec. 202(b)(4), added subsec. (c) 
relating to payment for covered outpatient drugs.
    Subsec. (d). Pub. L. 100-360, Sec. 203(c)(1)(F), added subsec. (d) 
relating to home intravenous drug therapy services.
    Subsec. (e). Pub. L. 100-360, Sec. 204(b)(2), added subsec. (e) 
relating to payments and standards for screening mammography.
    1987--Subsec. (b). Pub. L. 100-203, Sec. 4049(a)(2), as amended by 
Pub. L. 100-360, Sec. 411(a)(3)(A), (B)(ii), (f)(8)(B)(ii), added 
subsec. (b).


                    Effective Date of 1999 Amendment

    Amendment by section 1000(a)(6) [title II, Sec. 201(e)(2)] of Pub. 
L. 106-113 effective as if included in enactment of the Balanced Budget 
Act of 1997, Pub. L. 105-33, except as otherwise provided, see 
Sec. 1000(a)(6) [title II, Sec. 201(m)] of Pub. L. 106-113, set out as a 
note under section 1395l of this title.
    Amendment by section 1000(a)(6) [title III, Sec. 321(k)(3)] of Pub. 
L. 106-113 effective as if included in the enactment of the Balanced 
Budget Act of 1997, Pub. L. 105-33, except as otherwise provided, see 
section 1000(a)(6) [title III, Sec. 321(m)] of Pub. L. 106-113, set out 
as a note under section 1395d of this title.
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV, Sec. 403(d)(2)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-371, provided that: ``The amendment 
made by subsection (a) [probably should be ``paragraph (1)'', amending 
this section] shall apply for cost reporting periods beginning on or 
after October 1, 2000.''


                    Effective Date of 1997 Amendment

    Amendment by section 4101(a), (c) of Pub. L. 105-33 applicable to 
items and services furnished on or after Jan. 1, 1998, see section 
4101(d) of Pub. L. 105-33, set out as a note under section 1395l of this 
title.
    Amendment by section 4104(b)(1) of Pub. L. 105-33 applicable to 
items and services furnished on or after Jan. 1, 1998, see section 
4104(e) of Pub. L. 105-33, set out as a note under section 1395l of this 
title.
    Section 4105(d) of Pub. L. 105-33 provided that:
    ``(1) In general.--Except as provided in paragraph (2), the 
amendments made by this section [amending this section and sections 
1395w-4 and 1395x of this title] shall apply to items and services 
furnished on or after July 1, 1998.
    ``(2) Testing strips.--The amendment made by subsection (b)(2) 
[amending this section] shall apply with respect to blood glucose 
testing strips furnished on or after January 1, 1998.''
    Amendment by section 4201(c)(5) of Pub. L. 105-33 applicable to 
services furnished on or after Oct. 1, 1997, see section 4201(d) of Pub. 
L. 105-33, set out as a note under section 1395f of this title.
    Section 4312(f)(1) of Pub. L. 105-33 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to suppliers 
of durable medical equipment with respect to such equipment furnished on 
or after January 1, 1998.''
    Section 4312(f)(3) of Pub. L. 105-33 provided that: ``The amendments 
made by subsections (c) through (e) [amending this section and section 
1395x of this title] shall take effect on the date of the enactment of 
this Act [Aug. 5, 1997] and may be applied with respect to items and 
services furnished on or after January 1, 1998.''
    Section 4316(c) of Pub. L. 105-33 provided that: ``The amendments 
made by this section [amending this section and section 1395u of this 
title] shall take effect on the date of the enactment of this Act [Aug. 
5, 1997].''
    Amendment by section 4531(b)(2) of Pub. L. 105-33 applicable to 
services furnished on or after Jan. 1, 2000, see section 4531(b)(3) of 
Pub. L. 105-33, set out as a note under section 1395l of this title.
    Amendment by section 4541(a)(2) of Pub. L. 105-33 applicable to 
services furnished on or after Jan. 1, 1998, including portions of cost 
reporting periods occurring on or after such date, except that subsec. 
(k) of this section inapplicable to services described in section 
1395l(a)(8)(B) of this title that are furnished during 1998, see section 
4541(e) of Pub. L. 105-33, set out as a note under section 1395l of this 
title.
    Section 4551(c)(2) of Pub. L. 105-33 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to purchases 
or rentals after the effective date of any regulations issued pursuant 
to such amendment.''
    Section 4552(e) of Pub. L. 105-33 provided that:
    ``(1) Oxygen.--The amendments made by subsection (a) [amending this 
section] shall apply to items furnished on and after January 1, 1998.
    ``(2) Other provisions.--The amendments made by this section other 
than subsection (a) [amending this section] shall take effect on the 
date of the enactment of this Act [Aug. 5, 1997].''


                    Effective Date of 1994 Amendment

    Section 126(i) of Pub. L. 103-432 provided that: ``Except as 
provided in subsection (h) [amending section 1395u of this title, 
enacting provisions set out as notes under sections 1395u and 1395w-4 of 
this title, and amending provisions set out as a note under section 
1395w-4 of this title], the amendments made by this section and the 
provisions of this section [amending this section and sections 1395u, 
1395w-1, and 1395w-4 of this title, enacting provisions set out as notes 
under sections 1395u and 1395w-4 of this title, and amending provisions 
set out as notes under this section and sections 1395u and 1395w-4 of 
this title] shall take effect as if included in the enactment of OBRA-
1990 [Pub. L. 101-508].''
    Section 131(a)(2) of Pub. L. 103-432 provided that the amendment 
made by that section is effective 60 days after Oct. 31, 1994.
    Section 132(c) of Pub. L. 103-432 provided that: ``The amendments 
made by subsections (a) and (b) [amending this section] shall apply to 
items furnished after the expiration of the 60-day period that begins on 
the date of the enactment of this Act [Oct. 31, 1994].''
    Section 133(c) of Pub. L. 103-432 provided that: ``The amendments 
made by this section [amending this section and sections 1395m and 
1395pp of this title] shall apply to items or services furnished on or 
after January 1, 1995.''
    Section 134(a)(2) of Pub. L. 103-432 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall take effect on the 
date of the enactment of this Act [Oct. 31, 1994].''
    Section 135(a)(2) of Pub. L. 103-432 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective on the 
date of the enactment of this Act [Oct. 31, 1994].''
    Section 135(b)(1) of Pub. L. 103-432 provided that the amendment 
made by that section is effective Oct. 31, 1994.
    Section 135(b)(3) of Pub. L. 103-432 provided that the amendment 
made by that section is effective Oct. 31, 1994.
    Section 135(d)(2) of Pub. L. 103-432 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective on the 
date of the enactment of this Act [Oct. 31, 1994].''
    Section 135(e)(8) of Pub. L. 103-432 provided that: ``The amendments 
made by this subsection [amending this section and provisions set out as 
notes under this section and section 1395cc of this title] shall take 
effect as if included in the enactment of OBRA-1990 [Pub. L. 101-508].''
    Section 145(d) of Pub. L. 103-432 provided that: ``The amendments 
made by this section [amending this section and sections 1395x to 1395bb 
of this title] shall apply to mammography furnished by a facility on and 
after the first date that the certificate requirements of section 354(b) 
of the Public Health Service Act [section 263b(b) of this title] apply 
to such mammography conducted by such facility.''
    Amendment by section 156(a)(2)(C) of Pub. L. 103-432 applicable to 
services provided on or after Oct. 31, 1994, see section 156(a)(3) of 
Pub. L. 103-432, set out as a note under section 1320c-3 of this title.


                    Effective Date of 1993 Amendment

    Section 13542(b) of Pub. L. 103-66 provided that: ``The amendments 
made by this section [amending this section] shall apply to items 
furnished on or after January 1, 1994.''
    Section 13543(c) of Pub. L. 103-66 provided that: ``The amendments 
made by this section [amending this section] shall apply to items 
furnished on or after January 1, 1994.''
    Section 13544(a)(3) of Pub. L. 103-66 provided that: ``The 
amendments made by this subsection [amending this section] shall apply 
to items furnished on or after January 1, 1994.''
    Amendment by section 13544(b)(1) of Pub. L. 103-66 applicable to 
items furnished on or after Jan. 1, 1994, see section 13544(b)(3) of 
Pub. L. 103-66, set out as a note under section 1395l of this title.
    Section 13545(b) of Pub. L. 103-66 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to items 
furnished on or after January 1, 1994.''


                    Effective Date of 1990 Amendment

    Section 4102(i) of Pub. L. 101-508 provided that:
    ``(1) Except as otherwise provided, the amendments made by this 
section [amending this section, section 1395w-4 of this title, and 
provisions set out as a note below] shall apply to services furnished on 
or after January 1, 1991.
    ``(2) The amendment made by subsection (f) [amending this section] 
shall be effective as if included in the enactment of the Omnibus Budget 
Reconciliation Act of 1987 [Pub. L. 100-203].''
    Amendment by section 4104(a) of Pub. L. 101-508 applicable to 
services furnished on or after Jan. 1, 1991, see section 4104(d) of Pub. 
L. 101-508, set out as a note under section 1395l of this title.
    Section 4152(a)(3) of Pub. L. 101-508, as amended by Pub. L. 103-
432, title I, Sec. 135(e)(1), Oct. 31, 1994, 108 Stat. 4424, provided 
that: ``The amendments made by this subsection [amending this section 
and section 1395x of this title] shall apply to items furnished on or 
after January 1, 1991.''
    Section 4152(c)(4)(B)(ii) of Pub. L. 101-508 provided that: ``The 
amendment made by clause (i) [amending this section] shall apply to 
items furnished on or after January 1, 1992, unless the Secretary 
develops specific criteria before that date for the treatment of 
wheelchairs as customized items for purposes of section 1834(a)(4) of 
the Social Security Act [subsec. (a)(4) of this section] (in which case 
the amendment made by such clause shall not become effective).'' 
[Criteria established by Secretary Nov. 1, 1991, see 56 F.R. 65995, Dec. 
20, 1991, 42 CFR Sec. 414.224.]
    Section 4152(f)(2) of Pub. L. 101-508 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to forms and 
documents distributed on or after January 1, 1991.''
    Section 4152(g)(2) of Pub. L. 101-508 provided that: ``The 
amendments made by paragraph (1) [amending this section] shall apply to 
patients who first receive home oxygen therapy services on or after 
January 1, 1991.''
    Section 4152(i) of Pub. L. 101-508 provided that: ``Except as 
otherwise provided, the amendments made by this section [amending this 
section, section 1395x of this title, and provisions set out as a note 
under section 1395f of this title] shall apply to items furnished on or 
after January 1, 1991.''
    Amendment by section 4153(a)(1), (2)(D) of Pub. L. 101-508 
applicable to items furnished on or after Jan. 1, 1991, see section 
4153(a)(3) of Pub. L. 101-508, set out as a note under section 1395k of 
this title.
    Amendment by section 4163(b) of Pub. L. 101-508 applicable to 
screening mammography performed on or after Jan. 1, 1991, see section 
4163(e) of Pub. L. 101-508, set out as a note under section 1395l of 
this title.


                    Effective Date of 1989 Amendments

    Amendment by section 6102(f)(1) of Pub. L. 101-239 applicable to 
services furnished on or after Jan. 1, 1991, see section 6102(f)(3) of 
Pub. L. 101-239, set out as a note under section 1395l of this title.
    Section 6112(e)(4) of Pub. L. 101-239 provided that: ``The 
amendments made by this subsection [amending this section and sections 
1395x and 1395cc of this title] shall apply with respect to items 
furnished on or after January 1, 1990.''
    Amendment by section 201(a) of Pub. L. 101-234 effective Jan. 1, 
1990, see section 201(c) of Pub. L. 101-234, set out as a note under 
section 1320a-7a of this title.
    Section 301(b)(1), (c)(1) of Pub. L. 101-234 provided that the 
amendments made by that section are effective as if included in the 
enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-
203.


                    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.
    Amendment by section 202(b)(4) of Pub. L. 100-360 applicable to 
items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub. 
L. 100-360, set out as a note under section 1395u of this title.
    Amendment by section 203(c)(1)(F) of Pub. L. 100-360 applicable to 
items and services furnished on or after Jan. 1, 1990, see section 
203(g) of Pub. L. 100-360, set out as a note under section 1320c-3 of 
this title.
    Section 204(e) of Pub. L. 100-360, which provided that the 
amendments made by section 204 of Pub. L. 100-360 [amending this section 
and sections 1395l, 1395x to 1395z, 1395aa, 1395bb, 1396a, and 1396n of 
this title] applied to screening mammography performed on or after 
January 1, 1990, and that subsec. (e)(5) of this section only applied 
until such time as the Secretary of Health and Human Services 
implemented the physician fee schedules based on relative value scale 
developed under section 1395w-1(e) of this title, was repealed by Pub. 
L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(a)(3)(A), (B)(ii), (C)(ii), (f)(8)(A), (B)(ii), 
(D), (g)(1)(A) and (B) of 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 4049(b)(2) of Pub. L. 100-203, as amended by Pub. L. 101-
239, title VI, Sec. 6102(e)(6)(B), Dec. 19, 1989, 103 Stat. 2188; Pub. 
L. 101-508, title IV, Sec. 4118(h)(2), Nov. 5, 1990, 104 Stat. 1388-70, 
provided that: ``The amendments made by this section [amending this 
section and section 1395l of this title] shall apply to services 
performed on or after April 1, 1989.''
    [Section 4118(h) of Pub. L. 101-508 provided that the amendment by 
that section to section 4049(b)(2) of Pub. L. 100-203, set out above, is 
effective as if included in enactment of Omnibus Budget Reconciliation 
Act of 1987, Pub. L. 100-203.]


                             Effective Date

    Subsection (a) of this section applicable to covered items (other 
than oxygen and oxygen equipment) furnished on or after Jan. 1, 1989, 
and to oxygen and oxygen equipment furnished on or after June 1, 1989, 
see section 4062(e) of Pub. L. 100-203, as amended, set out as an 
Effective Date of 1987 Amendment note under section 1395f of this title.

                          Transfer of Functions

    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 Pub. L. 105-33, set out as a note 
under section 1395b-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.


    Study of Delivery of Intravenous Immune Globulin (IVIG) Outside 
                    Hospitals and Physicians' Offices

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 201(n)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-341, provided that:
    ``(1) Study.--The Secretary of Health and Human Services shall 
conduct a study of the extent to which intravenous immune globulin 
(IVIG) could be delivered and reimbursed under the medicare program 
outside of a hospital or physician's office. In conducting the study, 
the Secretary shall--
        ``(A) consider the sites of service that other payors, including 
    Medicare+Choice plans, use for these drugs and biologicals;
        ``(B) determine whether covering the delivery of these drugs and 
    biologicals in a medicare patient's home raises any additional 
    safety and health concerns for the patient;
        ``(C) determine whether covering the delivery of these drugs and 
    biologicals in a patient's home can reduce overall spending under 
    the medicare program; and
        ``(D) determine whether changing the site of setting for these 
    services would affect beneficiary access to care.
    ``(2) Report.--The Secretary shall submit a report on such study to 
the Committees on Ways and Means and Commerce of the House of 
Representatives and the Committee on Finance of the Senate within 18 
months after the date of the enactment of this Act [Nov. 29, 1999]. The 
Secretary shall include in the report recommendations regarding the 
appropriate manner and settings under which the medicare program should 
pay for these drugs and biologicals delivered outside of a hospital or 
physician's office.''


 Temporary Increase in Payment Rates for Durable Medical Equipment and 
                                 Oxygen

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 228], Nov. 
29, 1999, 113 Stat. 1536, 1501A-356, provided that:
    ``(a) In General.--For purposes of payments under section 1834(a) of 
the Social Security Act (42 U.S.C. 1395m(a)) for covered items (as 
defined in paragraph (13) of that section) furnished during 2001 and 
2002, the Secretary of Health and Human Services shall increase the 
payment amount in effect (but for this section) for such items for--
        ``(1) 2001 by 0.3 percent, and
        ``(2) 2002 by 0.6 percent.
    ``(b) Limiting Application to Specified Years.--The payment amount 
increase--
        ``(1) under subsection (a)(1) shall not apply after 2001 and 
    shall not be taken into account in calculating the payment amounts 
    applicable for covered items furnished after such year; and
        ``(2) under subsection (a)(2) shall not apply after 2002 and 
    shall not be taken into account in calculating the payment amounts 
    applicable for covered items furnished after such year.''


 Demonstration of Coverage of Ambulance Services Under Medicare Through 
                Contracts With Units of Local Government

    Pub. L. 105-33, title IV, Sec. 4532, Aug. 5, 1997, 111 Stat. 453, as 
amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, 
Sec. 225], Nov. 29, 1999, 113 Stat. 1536, 1501A-353, provided that:
    ``(a) Demonstration Project Contracts with Local Governments.--The 
Secretary of Health and Human Services shall establish up to 3 
demonstration projects under which, at the request of a unit of local 
government, the Secretary enters into a contract with the unit of local 
government under which--
        ``(1) the unit of local government furnishes (or arranges for 
    the furnishing of) ambulance services for which payment may be made 
    under part B of title XVIII of the Social Security Act [this part] 
    for individuals residing in the unit of local government who are 
    enrolled under such part, except that the unit of local government 
    may not enter into the contract unless the contract covers at least 
    80 percent of the individuals residing in the unit of local 
    government who are enrolled under such part but not in a 
    Medicare+Choice plan;
        ``(2) any individual or entity furnishing ambulance services 
    under the contract meets the requirements otherwise applicable to 
    individuals and entities furnishing such services under such part; 
    and
        ``(3) for each month during which the contract is in effect, the 
    Secretary makes a capitated payment to the unit of local government 
    in accordance with subsection (b).
The projects may extend over a period of not to exceed 3 years each. Not 
later than July 1, 2000, the Secretary shall publish a request for 
proposals for such projects.
    ``(b) Amount of Payment.--
        ``(1) In general.--The amount of the monthly payment made for 
    months occurring during a calendar year to a unit of local 
    government under a demonstration project contract under subsection 
    (a) shall be equal to the product of--
            ``(A) the Secretary's estimate of the number of individuals 
        covered under the contract for the month; and
            ``(B) \1/12\ of the capitated payment rate for the year 
        established under paragraph (2).
        ``(2) Capitated payment rate defined.--In this subsection, the 
    term `capitated payment rate' means, with respect to a demonstration 
    project--
            ``(A) in its first year, a rate established for the project 
        by the Secretary, using the most current available data, in a 
        manner that ensures that aggregate payments under the project 
        will not exceed the aggregate payment that would have been made 
        for ambulance services under part B of title XVIII of the Social 
        Security Act [this part] in the local area of government's 
        jurisdiction; and
            ``(B) in a subsequent year, the capitated payment rate 
        established for the previous year increased by an appropriate 
        inflation adjustment factor.
    ``(c) Other Terms of Contract.--The Secretary and the unit of local 
government may include in a contract under this section such other terms 
as the parties consider appropriate, including--
        ``(1) covering individuals residing in additional units of local 
    government (under arrangements entered into between such units and 
    the unit of local government involved);
        ``(2) permitting the unit of local government to transport 
    individuals to non-hospital providers if such providers are able to 
    furnish quality services at a lower cost than hospital providers; or
        ``(3) implementing such other innovations as the unit of local 
    government may propose to improve the quality of ambulance services 
    and control the costs of such services.
    ``(d) Contract Payments in Lieu of Other Benefits.--Payments under a 
contract to a unit of local government under this section shall be 
instead of the amounts which (in the absence of the contract) would 
otherwise be payable under part B of title XVIII of the Social Security 
Act [this part] for the services covered under the contract which are 
furnished to individuals who reside in the unit of local government.
    ``(e) Report on Effects of Capitated Contracts.--
        ``(1) Study.--The Secretary shall evaluate the demonstration 
    projects conducted under this section. Such evaluation shall include 
    an analysis of the quality and cost-effectiveness of ambulance 
    services furnished under the projects.
        ``(2) Report.--Not later than January 1, 2000, the Secretary 
    shall submit a report to Congress on the study conducted under 
    paragraph (1), and shall include in the report such recommendations 
    as the Secretary considers appropriate, including recommendations 
    regarding modifications to the methodology used to determine the 
    amount of payments made under such contracts and extending or 
    expanding such projects.''
    [Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 225], Nov. 
29, 1999, 113 Stat. 1536, 1501A-353, provided that the amendment made by 
that section to section 4532 of Pub. L. 105-33, set out above, is 
effective as if included in the enactment of the Balanced Budget Act of 
1997, Pub. L. 105-33.]


   Payment Freeze for Parenteral and Enteral Nutrients, Supplies, and 
                                Equipment

    Section 4551(b) of Pub. L. 105-33 provided that: ``In determining 
the amount of payment under part B of title XVIII of the Social Security 
Act [this part] with respect to parenteral and enteral nutrients, 
supplies, and equipment during each of the years 1998 through 2002, 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 1995.''


     Service Standards for Providers of Oxygen and Oxygen Equipment

    Section 4552(c) of Pub. L. 105-33 provided that: ``The Secretary 
shall as soon as practicable establish service standards for persons 
seeking payment under part B of title XVIII of the Social Security Act 
[this part] for the providing of oxygen and oxygen equipment to 
beneficiaries within their homes.''


                     Access to Home Oxygen Equipment

    Section 4552(d) of Pub. L. 105-33 provided that:
    ``(1) Study.--The Comptroller General of the United States shall 
study issues relating to access to home oxygen equipment and shall, 
within 18 months after the date of the enactment of this Act [Aug. 5, 
1997], report to the Committees on Commerce and Ways and Means of the 
House of Representatives and the Committee on Finance of the Senate the 
results of the study, including recommendations (if any) for 
legislation.
    ``(2) Peer review evaluation.--The Secretary of Health and Human 
Services shall arrange for peer review organizations established under 
section 1154 of the Social Security Act [section 1320c-3 of this title] 
to evaluate access to, and quality of, home oxygen equipment.''


             Use of Covered Items by Disabled Beneficiaries

    Section 131(b) of Pub. L. 103-432 provided that:
    ``(1) In general.--The Secretary of Health and Human Services, in 
consultation with representatives of suppliers of durable medical 
equipment under part B of the medicare program [this part] and 
individuals entitled to benefits under such program on the basis of 
disability, shall conduct a study of the effects of the methodology for 
determining payments for items of such equipment under such part on the 
ability of such individuals to obtain items of such equipment, including 
customized items.
    ``(2) Report.--Not later than one year after the date of the 
enactment of this Act [Oct. 31, 1994], the Secretary shall submit a 
report to Congress on the study conducted under paragraph (1), and shall 
include in the report such recommendations as the Secretary considers 
appropriate to assure that disabled medicare beneficiaries have access 
to items of durable medical equipment.''


 Criteria for Treatment of Items as Prosthetic Devices or Orthotics and 
                               Prosthetics

    Section 131(c) of Pub. L. 103-432 provided that: ``Not later than 
one year after the date of the enactment of this Act [Oct. 31, 1994], 
the Secretary of Health and Human Services shall submit a report to the 
Committees on Ways and Means and Energy and Commerce [now Committee on 
Commerce] of the House of Representatives and the Committee on Finance 
of the Senate describing prosthetic devices or orthotics and prosthetics 
covered under part B of the medicare program [probably means this part] 
that do not require individualized or custom fitting and adjustment to 
be used by a patient. Such report shall include recommendations for an 
appropriate methodology for determining the amount of payment for such 
items under such program.''


                  Adjustment Required for Certain Items

    Section 134(b) of Pub. L. 103-432 provided that:
    ``(1) In general.--In accordance with section 1834(a)(10)(B) of the 
Social Security Act [subsec. (a)(10)(B) of this section] (as amended by 
subsection (a)), the Secretary of Health and Human Services shall 
determine whether the payment amounts for the items described in 
paragraph (2) are not inherently reasonable, and shall adjust such 
amounts in accordance with such section if the amounts are not 
inherently reasonable.
    ``(2) Items described.--The items referred to in paragraph (1) are 
decubitus care equipment, transcutaneous electrical nerve stimulators, 
and any other items considered appropriate by the Secretary.''


   Limitation on Prevailing Charge for Physicians' Radiology Services 
                    Furnished During 1991; Exceptions

    Section 4102(c) of Pub. L. 101-508, as amended by Pub. L. 103-432, 
title I, Sec. 126(b)(3), Oct. 31, 1994, 108 Stat. 4415, provided that:
    ``(1) In general.--In applying part B of title XVIII of the Social 
Security Act [this part], the prevailing charge for physicians' 
services, furnished during 1991, which are radiology services may not 
exceed the fee schedule amount established under section 1834(b) of such 
Act [subsec. (b) of this section] with respect to such services.
    ``(2) Exception.--Paragraph (1) shall not apply to nuclear medicine 
services.''


  Limitation on Carrier Adjustments for Radiologist Services Furnished 
                               During 1991

    Section 4102(e) of Pub. L. 101-508 provided that: ``For radiologist 
services furnished during 1991 for which payment is made under section 
1834(b) of the Social Security Act [subsec. (b) of this section]--
        ``(1) a carrier may not make any adjustment, under section 
    1842(b)(3)(B) of such Act [section 1395u(b)(3)(B) of this title], in 
    the payment amount for the service under section 1834(b) on the 
    basis that the payment amount is higher than the charge applicable, 
    for a comparable service and under comparable circumstances, to the 
    policyholders and subscribers of the carrier,
        ``(2) no payment adjustment may be made under section 1842(b)(8) 
    of such Act, and
        ``(3) section 1842(b)(9) of such Act shall not apply.''


  Study of Payments for Prosthetic Devices, Orthotics, and Prosthetics

    Section 4153(c) of Pub. L. 101-508, as amended by Pub. L. 103-432, 
title I, Sec. 135(e)(6), Oct. 31, 1994, 108 Stat. 4424, directed 
Comptroller General to conduct a study of feasibility and desirability 
of establishing a separate fee schedule for use in determining the 
amount of payments for covered items under subsec. (h) of this section 
with respect to suppliers of prosthetic devices, orthotics, and 
prosthetics who provide professional services that would take into 
account the costs to such providers of providing such services and, not 
later than 1 year after Nov. 5, 1990, submit a report on the study to 
Committees on Energy and Commerce and Ways and Means of House of 
Representatives and Committee on Finance of Senate, including any 
recommendations regarding payments for prosthetic devices, orthotics, 
and prosthetics under the medicare program.


              Special Rule for Nuclear Medicine Physicians

    Section 6105(b) of Pub. L. 101-239, as amended by Pub. L. 101-508, 
title IV, Sec. 4102(g)(1), Nov. 5, 1990, 104 Stat. 1388-57, provided 
that: ``In applying section 1834(b) of the Social Security Act [subsec. 
(b) of this section] with respect to nuclear medicine services furnished 
by a physician for whom nuclear medicine services account for at least 
80 percent of the total amount of charges made under part B of title 
XVIII of the Social Security Act [this part] beginning April 1, 1990, 
and ending December 31, 1991, there shall be substituted for the fee 
schedule otherwise applicable a fee schedule based \1/3\ on the fee 
schedule computed under such section (without regard to this subsection) 
and \2/3\ on 101 percent of the 1988 prevailing charge for such 
services.''


     Special Rule for Interventional Radiologists; ``Split Billing''

    Section 6105(c) of Pub. L. 101-239, as amended by Pub. L. 101-508, 
title IV, Sec. 4102(h), Nov. 5, 1990, 104 Stat. 1388-58, provided that: 
``In applying section 1834(b) of the Social Security Act [subsec. (b) of 
this section] to radiologist services furnished in 1990 or 1991, the 
exception for `split billing' set forth at section 5262J of the Medicare 
Carriers Manual shall apply to services furnished in 1990 or 1991 in the 
same manner and to the same extent as the exception applied to services 
furnished in 1989.''


            Rental Payments for Enteral and Parenteral Pumps

    Section 6112(b) of Pub. L. 101-239 provided that:
    ``(1) In general.--Except as provided in paragraph (2), the amount 
of any monthly rental payment under part B of title XVIII of the Social 
Security Act [this part] for an enteral or parenteral pump furnished on 
or after April 1, 1990, shall be determined in accordance with the 
methodology under which monthly rental payments for such pumps were 
determined during 1989.
    ``(2) Cap on Rental Payments, Servicing, and Repairs.--In the case 
of an enteral or parenteral pump described in paragraph (1) that is 
furnished on a rental basis during a period of medical need--
        ``(A) monthly rental payments shall not be made under part B of 
    title XVIII of the Social Security Act for more than 15 months 
    during such period, and
        ``(B) after monthly rental payments have been made for 15 months 
    during such period, payment under such part shall be made for 
    maintenance and servicing of the pump in such amounts as the 
    Secretary of Health and Human Services determines to be reasonable 
    and necessary to ensure the proper operation of the pump.''


        Treatment of Power-Driven Wheelchairs as Customized Items

    Section 6112(d)(2) of Pub. L. 101-239 provided that: ``The Secretary 
of Health and Human Services shall by regulation specify criteria to be 
used by carriers in making determinations on a case-by-case basis as 
whether to classify power-driven wheelchairs as a customized item (as 
described in section 1834(a)(4) of the Social Security Act [subsec. 
(a)(4) of this section]) for purposes of reimbursement under title XVIII 
of such Act [this subchapter].''


              Study of Payment for Portable X-Ray Services

    Section 6134 of Pub. L. 101-239 directed Secretary of Health and 
Human Services to conduct a study of costs of furnishing, and payments 
for, portable x-ray services under part B and, not later than 1 year 
after Dec. 19, 1989, report to Congress on results of such study 
including a recommendation respecting whether payment for such services 
should be made in the same manner as for radiologists' services or on 
the basis of a separate fee schedule.


   GAO Study of Standards for Use of and Payment for Items of Durable 
                            Medical Equipment

    Section 6139 of Pub. L. 101-239 directed Comptroller General to 
conduct a study of appropriate uses of items of durable medical 
equipment and of appropriate criteria for making determinations of 
medical necessity under this subchapter for such items, with particular 
emphasis on items (including seat-lift chairs) that may be subject to 
abusive billing practices, such study to include an analysis of 
appropriate use of forms in making medical necessity determinations for 
items of durable medical equipment under such title, and procedures for 
identifying items of durable medical equipment that should no longer be 
covered under this subchapter, and to be conducted with a panel convened 
by the Comptroller General consisting of specialists in the disciplines 
of orthopedic medicine, rehabilitation, arthritis, and geriatric 
medicine, representatives of consumer organizations, and representatives 
of carriers under the medicare program, with the Comptroller General to 
submit not later than Apr. 1, 1991, a report to Committees on Ways and 
Means and Energy and Commerce of House of Representatives and Committee 
on Finance of Senate on the study including recommendations.


              Reports on Medicare Beneficiary Drug Expenses

    Section 202(i) of Pub. L. 100-360, directed Secretary of Health and 
Human Services, by not later than Apr. 1, 1989, to report to Congress on 
expenses incurred by medicare beneficiaries for outpatient prescription 
drugs, and to provide Director of Congressional Budget Office with such 
data from that Survey as Director might request to make required 
estimates, prior to repeal by Pub. L. 101-234, title II, Sec. 201(a), 
Dec. 13, 1989, 103 Stat. 1981.


         Additional Studies by Secretary or Comptroller General

    Section 202(k) of Pub. L. 100-360 directed Secretary of Health and 
Human Services to conduct a study, and make a report to Congress by Jan. 
1, 1990, on possibility of including drugs which have not yet been 
approved under section 355 or 357 of Title 21, Food and Drugs, and 
biological products which have not been licensed under section 262 of 
this title but which are commonly used in the treatment of cancer or in 
immunosuppressive therapy and other experimental drugs and biological 
products as covered outpatient drugs under medicare program, to conduct 
a study, and report to Congress by Jan. 1, 1990, evaluating potential to 
use mail service pharmacies to reduce costs to medicare program and to 
medicare beneficiaries, to conduct a study, and report to Congress by 
Jan. 1, 1993, on methods to improve utilization review of covered 
outpatient drugs, and to conduct a longitudinal study, and report to 
Congress by Jan. 1, 1993, on use of outpatient prescription drugs by 
medicare beneficiaries with respect to medical necessity, potential for 
adverse drug interactions, cost (including whether lower cost drugs 
could have been used), and patient stockpiling or wastage, and which 
further directed Comptroller General to conduct studies, and report to 
Congress by not later than May 1, 1991, on comparing average wholesale 
prices with actual pharmacy acquisition costs by type of pharmacy, on 
determining the overhead costs of retail pharmacies, and on discounts 
given by pharmacies to other third-party insurers, prior to repeal by 
Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.


              Development of Standard Medicare Claims Forms

    Section 202(l) of Pub. L. 100-360 directed Secretary of Health and 
Human Services to develop, in consultation with representatives of 
pharmacies and other interested individuals, a standard claims form (and 
a standard electronic claims format) to be used in requests for payment 
for covered outpatient drugs under medicare program and other third-
party payors, prior to repeal by Pub. L. 101-234, title II, Sec. 201(a), 
Dec. 13, 1989, 103 Stat. 1981.


              Studies and Reports on Screening Mammography

    Section 204(f) of Pub. L. 100-360 directed Physician Payment Review 
Commission to study and report, by July 1, 1989, to Committees on Ways 
and Means and Energy and Commerce of the House of Representatives and 
Committee on Finance of the Senate concerning the cost of providing 
screening mammography in a variety of settings and at different volume 
levels, prior to repeal by Pub. L. 101-234, title II, Sec. 201(a), Dec. 
13, 1989, 103 Stat. 1981.


 Deadline for Establishment of Fee Schedules for Radiologist Services; 
                           Report to Congress

    Section 4049(b)(1) of Pub. L. 100-203, as amended by Pub. L. 100-
360, title IV, Sec. 411(f)(8)(E), July 1, 1988, 102 Stat. 780; Pub. L. 
101-508, title IV, Sec. 4118(g)(3), Nov. 5, 1990, 104 Stat. 1388-70, 
directed Secretary of Health and Human Services to propose the relative 
value scale and fee schedules for radiologist services (under subsec. 
(b) of this section) by not later than Aug. 1, 1988.


                          Study and Evaluation

    Section 4062(c) of Pub. L. 100-203, as amended by Pub. L. 100-360, 
title IV, Sec. 411(g)(1)(C), July 1, 1988, 102 Stat. 782, provided that:
    ``(1) The Secretary of Health and Human Services shall monitor the 
impact of the amendments made by this section [enacting this section, 
amending sections 1395f, 1395k, 1395l, and 1395cc of this title, and 
repealing section 1395zz of this title] on the availability of covered 
items and shall evaluate the appropriateness of the volume adjustment 
for oxygen and oxygen equipment under section 1834(a)(5)(C) of the 
Social Security Act [subsec. (a)(5)(C) of this section] (as amended by 
subsection (b) of this section). The Secretary shall report to Congress, 
by not later than January 1, 1991, on such impact and on the evaluation 
and shall include in such report recommendations for changes in payment 
methodology for covered items under section 1834(a) of such Act.
    ``(2) Before January 1, 1991, the Secretary may not conduct any 
demonstration project respecting alternative methods of payment for 
covered items under title XVIII of the Social Security Act [this 
subchapter].
    ``(3) In this subsection, the term `covered item' has the meaning 
given such term in section 1834(a)(13) of the Social Security Act 
[subsec. (a)(13) of this section] (as amended by subsection (b) of this 
section).
    ``(4) The Secretary shall, upon written request and payment of a 
reasonable copying fee which the Secretary may establish, provide the 
data and information used in determining the payment amounts for covered 
items under section 1834(a) of the Social Security Act [subsec. (a) of 
this section], but only in a form which does not permit identification 
of individual suppliers.
    ``(5) The Comptroller General shall conduct a study on the 
appropriateness of the level of payments allowed for covered items under 
the medicare program, and shall report to Congress on the results of 
such study (including recommendations on the transition to regional or 
national rates) by not later than January 1, 1991. Entities furnishing 
such items which fail to provide the Comptroller General with reasonable 
access to necessary records to carry out the study under this paragraph 
are subject to exclusion from the medicare program under section 1128(a) 
of the Social Security Act [section 1320a-7(a) of this title].''

                  Section Referred to in Other Sections

    This section is referred to in sections 1395f, 1395k, 1395l, 1395u, 
1395w-4, 1395y, 1395bb, 1395cc, 1395pp, 1395ddd, 1396a of this title.
