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[Laws in effect as of January 23, 2000]
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[Document affected by Public Law 106-554 Section 1(a)(6)[222(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[114(b)]]
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[CITE: 42USC1395u]

 
                 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. 1395u. Use of carriers for administration of benefits


(a) Authority of Secretary to enter into contracts with carriers

    In order to provide for the administration of the benefits under 
this part with maximum efficiency and convenience for individuals 
entitled to benefits under this part and for providers of services and 
other persons furnishing services to such individuals, and with a view 
to furthering coordination of the administration of the benefits under 
part A of this subchapter and under this part, the Secretary is 
authorized to enter into contracts with carriers, including carriers 
with which agreements under section 1395h of this title are in effect, 
which will perform some or all of the following functions (or, to the 
extent provided in such contracts, will secure performance thereof by 
other organizations); and, with respect to any of the following 
functions which involve payments for physicians' services on a 
reasonable charge basis, the Secretary shall to the extent possible 
enter into such contracts:
        (1)(A) make determinations of the rates and amounts of payments 
    required pursuant to this part to be made to providers of services 
    and other persons on a reasonable cost or reasonable charge basis 
    (as may be applicable);
        (B) receive, disburse, and account for funds in making such 
    payments; and
        (C) make such audits of the records of providers of services as 
    may be necessary to assure that proper payments are made under this 
    part;
        (2)(A) determine compliance with the requirements of section 
    1395x(k) of this title as to utilization review; and
        (B) assist providers of services and other persons who furnish 
    services for which payment may be made under this part in the 
    development of procedures relating to utilization practices, make 
    studies of the effectiveness of such procedures and methods for 
    their improvement, assist in the application of safeguards against 
    unnecessary utilization of services furnished by providers of 
    services and other persons to individuals entitled to benefits under 
    this part, and provide procedures for and assist in arranging, where 
    necessary, the establishment of groups outside hospitals (meeting 
    the requirements of section 1395x(k)(2) of this title) to make 
    reviews of utilization;
        (3) serve as a channel of communication of information relating 
    to the administration of this part; and
        (4) otherwise assist, in such manner as the contract may 
    provide, in discharging administrative duties necessary to carry out 
    the purposes of this part.

(b) Applicability of competitive bidding provisions; findings as to 
        financial responsibility, etc., of carrier; contractual duties 
        imposed by contract

    (1) Contracts with carriers under subsection (a) of this section may 
be entered into without regard to section 5 of title 41 or any other 
provision of law requiring competitive bidding.
    (2)(A) No such contract shall be entered into with any carrier 
unless the Secretary finds that such carrier will perform its 
obligations under the contract efficiently and effectively and will meet 
such requirements as to financial responsibility, legal authority, and 
other matters as he finds pertinent. The Secretary shall publish in the 
Federal Register standards and criteria for the efficient and effective 
performance of contract obligations under this section, and opportunity 
shall be provided for public comment prior to implementation. In 
establishing such standards and criteria, the Secretary shall provide a 
system to measure a carrier's performance of responsibilities described 
in paragraph (3)(H), subsection (h) of this section, and section 1395w-
1(e)(2) \1\ of this title. The Secretary may not require, as a condition 
of entering into or renewing a contract under this section or under 
section 1395hh of this title, that a carrier match data obtained other 
than in its activities under this part with data used in the 
administration of this part for purposes of identifying situations in 
which section 1395y(b) of this title may apply.
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    \1\ See References in Text note below.
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    (B) The Secretary shall establish standards for evaluating carriers' 
performance of reviews of initial carrier determinations and of fair 
hearings under paragraph (3)(C), under which a carrier is expected--
        (i) to complete such reviews, within 45 days after the date of a 
    request by an individual enrolled under this part for such a review, 
    in 95 percent of such requests, and
        (ii) to make a final determination, within 120 days after the 
    date of receipt of a request by an individual enrolled under this 
    part for a fair hearing under paragraph (3)(C), in 90 percent of 
    such cases.

    (C) In the case of residents of nursing facilities who receive 
services described in clause (i) or (ii) of section 1395x(s)(2)(K) of 
this title performed by a member of a team, the Secretary shall instruct 
carriers to develop mechanisms which permit routine payment under this 
part for up to 1.5 visits per month per resident. In the previous 
sentence, the term ``team'' refers to a physician and includes a 
physician assistant acting under the supervision of the physician or a 
nurse practitioner working in collaboration with that physician, or 
both.
    (D) In addition to any other standards and criteria established by 
the Secretary for evaluating carrier performance under this paragraph 
relating to avoiding erroneous payments, the carrier shall be subject to 
standards and criteria relating to the carrier's success in recovering 
payments made under this part for items or services for which payment 
has been or could be made under a primary plan (as defined in section 
1395y(b)(2)(A) of this title).
    (E) With respect to the payment of claims for home health services 
under this part that, but for the amendments made by section 4611 of the 
Balanced Budget Act of 1997, would be payable under part A of this 
subchapter instead of under this part, the Secretary shall continue 
administration of such claims through fiscal intermediaries under 
section 1395h of this title.
    (3) Each such contract shall provide that the carrier--
        (A) will take such action as may be necessary to assure that, 
    where payment under this part for a service is on a cost basis, the 
    cost is reasonable cost (as determined under section 1395x(v) of 
    this title);
        (B) will take such action as may be necessary to assure that, 
    where payment under this part for a service is on a charge basis, 
    such charge will be reasonable and not higher than the charge 
    applicable, for a comparable service and under comparable 
    circumstances, to the policyholders and subscribers of the carrier, 
    and such payment will (except as otherwise provided in section 
    1395gg(f) of this title) be made--
            (i) on the basis of an itemized bill; or
            (ii) on the basis of an assignment under the terms of which 
        (I) the reasonable charge is the full charge for the service, 
        (II) the physician or other person furnishing such service 
        agrees not to charge (and to refund amounts already collected) 
        for services for which payment under this subchapter is denied 
        under section 1320c-3(a)(2) of this title by reason of a 
        determination under section 1320c-3(a)(1)(B) of this title, and 
        (III) the physician or other person furnishing such service 
        agrees not to charge (and to refund amounts already collected) 
        for such service if payment may not be made therefor by reason 
        of the provisions of paragraph (1) of section 1395y(a) of this 
        title, and if the individual to whom such service was furnished 
        was without fault in incurring the expenses of such service, and 
        if the Secretary's determination that payment (pursuant to such 
        assignment) was incorrect and was made subsequent to the third 
        year following the year in which notice of such payment was sent 
        to such individual; except that the Secretary may reduce such 
        three-year period to not less than one year if he finds such 
        reduction is consistent with the objectives of this subchapter 
        (except in the case of physicians' services and ambulance 
        service furnished as described in section 1395y(a)(4) of this 
        title, other than for purposes of section 1395gg(f) of this 
        title);

    but (in the case of bills submitted, or requests for payment made, 
    after March 1968) only if the bill is submitted, or a written 
    request for payment is made in such other form as may be permitted 
    under regulations, no later than the close of the calendar year 
    following the year in which such service is furnished (deeming any 
    service furnished in the last 3 months of any calendar year to have 
    been furnished in the succeeding calendar year);
        (C) will establish and maintain procedures pursuant to which an 
    individual enrolled under this part will be granted an opportunity 
    for a fair hearing by the carrier, in any case where the amount in 
    controversy is at least $100, but less than $500, when requests for 
    payment under this part with respect to services furnished him are 
    denied or are not acted upon with reasonable promptness or when the 
    amount of such payment is in controversy;
        (D) will furnish to the Secretary such timely information and 
    reports as he may find necessary in performing his functions under 
    this part;
        (E) will maintain such records and afford such access thereto as 
    the Secretary finds necessary to assure the correctness and 
    verification of the information and reports under subparagraph (D) 
    and otherwise to carry out the purposes of this part;
        (F) will take such action as may be necessary to assure that 
    where payment under this part for a service rendered is on a charge 
    basis, such payment shall be determined on the basis of the charge 
    that is determined in accordance with this section on the basis of 
    customary and prevailing charge levels in effect at the time the 
    service was rendered or, in the case of services rendered more than 
    12 months before the year in which the bill is submitted or request 
    for payment is made, on the basis of such levels in effect for the 
    12-month period preceding such year;
        (G) will, for a service that is furnished with respect to an 
    individual enrolled under this part, that is not paid on an 
    assignment-related basis, and that is subject to a limiting charge 
    under section 1395w-4(g) of this title--
            (i) determine, prior to making payment, whether the amount 
        billed for such service exceeds the limiting charge applicable 
        under section 1395w-4(g)(2) of this title;
            (ii) notify the physician, supplier, or other person 
        periodically (but not less often than once every 30 days) of 
        determinations that amounts billed exceeded such applicable 
        limiting charges; and
            (iii) provide for prompt response to inquiries of 
        physicians, suppliers, and other persons concerning the accuracy 
        of such limiting charges for their services;

        (H) if it makes determinations or payments with respect to 
    physicians' services, will implement--
            (i) programs to recruit and retain physicians as 
        participating physicians in the area served by the carrier, 
        including educational and outreach activities and the use of 
        professional relations personnel to handle billing and other 
        problems relating to payment of claims of participating 
        physicians; and
            (ii) programs to familiarize beneficiaries with the 
        participating physician program and to assist such beneficiaries 
        in locating participating physicians;

        (I) will submit annual reports to the Secretary describing the 
    steps taken to recover payments made under this part for items or 
    services for which payment has been or could be made under a primary 
    plan (as defined in section 1395y(b)(2)(A) of this title); and
        (J), (K) Repealed. Pub. L. 101-234, title II, Sec. 201(a), Dec. 
    13, 1989, 103 Stat. 1981;
        (L) will monitor and profile physicians' billing patterns within 
    each area or locality and provide comparative data to physicians 
    whose utilization patterns vary significantly from other physicians 
    in the same payment area or locality;

and shall contain such other terms and conditions not inconsistent with 
this section as the Secretary may find necessary or appropriate. In 
determining the reasonable charge for services for purposes of this 
paragraph, there shall be taken into consideration the customary charges 
for similar services generally made by the physician or other person 
furnishing such services, as well as the prevailing charges in the 
locality for similar services. No charge may be determined to be 
reasonable in the case of bills submitted or requests for payment made 
under this part after December 31, 1970, if it exceeds the higher of (i) 
the prevailing charge recognized by the carrier and found acceptable by 
the Secretary for similar services in the same locality in administering 
this part on December 31, 1970, or (ii) the prevailing charge level 
that, on the basis of statistical data and methodology acceptable to the 
Secretary, would cover 75 percent of the customary charges made for 
similar services in the same locality during the 12-month period ending 
on the June 30 last preceding the start of the calendar year in which 
the service is rendered. In the case of physicians' services the 
prevailing charge level determined for purposes of clause (ii) of the 
preceding sentence for any twelve-month period (beginning after June 30, 
1973) specified in clause (ii) of such sentence may not exceed (in the 
aggregate) the level determined under such clause for the fiscal year 
ending June 30, 1973, or (with respect to physicians' services furnished 
in a year after 1987) the level determined under this sentence (or under 
any other provision of law affecting the prevailing charge level) for 
the previous year except to the extent that the Secretary finds, on the 
basis of appropriate economic index data, that such higher level is 
justified by year-to-year economic changes. With respect to power-
operated wheelchairs for which payment may be made in accordance with 
section 1395x(s)(6) of this title, charges determined to be reasonable 
may not exceed the lowest charge at which power-operated wheelchairs are 
available in the locality. In the case of medical services, supplies, 
and equipment (including equipment servicing) that, in the judgment of 
the Secretary, do not generally vary significantly in quality from one 
supplier to another, the charges incurred after December 31, 1972, 
determined to be reasonable may not exceed the lowest charge levels at 
which such services, supplies, and equipment are widely and consistently 
available in a locality except to the extent and under the circumstances 
specified by the Secretary. The requirement in subparagraph (B) that a 
bill be submitted or request for payment be made by the close of the 
following calendar year shall not apply if (I) failure to submit the 
bill or request the payment by the close of such year is due to the 
error or misrepresentation of an officer, employee, fiscal intermediary, 
carrier, or agent of the Department of Health and Human Services 
performing functions under this subchapter and acting within the scope 
of his or its authority, and (II) the bill is submitted or the payment 
is requested promptly after such error or misrepresentation is 
eliminated or corrected. Notwithstanding the provisions of the third and 
fourth sentences preceding this sentence, the prevailing charge level in 
the case of a physician service in a particular locality determined 
pursuant to such third and fourth sentences for any calendar year after 
1974 shall, if lower than the prevailing charge level for the fiscal 
year ending June 30, 1975, in the case of a similar physician service in 
the same locality by reason of the application of economic index data, 
be raised to such prevailing charge level for the fiscal year ending 
June 30, 1975, and shall remain at such prevailing charge level until 
the prevailing charge for a year (as adjusted by economic index data) 
equals or exceeds such prevailing charge level. The amount of any 
charges for outpatient services which shall be considered reasonable 
shall be subject to the limitations established by regulations issued by 
the Secretary pursuant to section 1395x(v)(1)(K) of this title, and in 
determining the reasonable charge for such services, the Secretary may 
limit such reasonable charge to a percentage of the amount of the 
prevailing charge for similar services furnished in a physician's 
office, taking into account the extent to which overhead costs 
associated with such outpatient services have been included in the 
reasonable cost or charge of the facility.
    (4)(A)(i) In determining the prevailing charge levels under the 
third and fourth sentences of paragraph (3) for physicians' services 
furnished during the 15-month period beginning July 1, 1984, the 
Secretary shall not set any level higher than the same level as was set 
for the 12-month period beginning July 1, 1983.
    (ii)(I) In determining the prevailing charge levels under the third 
and fourth sentences of paragraph (3) for physicians' services furnished 
during the 8-month period beginning May 1, 1986, by a physician who is 
not a participating physician (as defined in subsection (h)(1) of this 
section) at the time of furnishing the services, the Secretary shall not 
set any level higher than the same level as was set for the 12-month 
period beginning July 1, 1983.
    (II) In determining the prevailing charge levels under the fourth 
sentence of paragraph (3) for physicians' services furnished during the 
8-month period beginning May 1, 1986, by a physician who is a 
participating physician (as defined in subsection (h)(1) of this 
section) at the time of furnishing the services, the Secretary shall 
permit an additional one percentage point increase in the increase 
otherwise permitted under that sentence.
    (iii) In determining the maximum allowable prevailing charges which 
may be recognized consistent with the index described in the fourth 
sentence of paragraph (3) for physicians' services furnished on or after 
January 1, 1987, by participating physicians, the Secretary shall treat 
the maximum allowable prevailing charges recognized as of December 31, 
1986, under such sentence with respect to participating physicians as 
having been justified by economic changes.
    (iv) The reasonable charge for physicians' services furnished on or 
after January 1, 1987, and before January 1, 1992, by a nonparticipating 
physician shall be no greater than the applicable percent of the 
prevailing charge levels established under the third and fourth 
sentences of paragraph (3) (or under any other applicable provision of 
law affecting the prevailing charge level). In the previous sentence, 
the term ``applicable percent'' means for services furnished (I) on or 
after January 1, 1987, and before April 1, 1988, 96 percent, (II) on or 
after April 1, 1988, and before January 1, 1989, 95.5 percent, and (III) 
on or after January 1, 1989, 95 percent.
    (v) In determining the prevailing charge levels under the third and 
fourth sentences of paragraph (3) for physicians' services furnished 
during the 3-month period beginning January 1, 1988, the Secretary shall 
not set any level higher than the same level as was set for the 12-month 
period beginning January 1, 1987.
    (vi) Before each year (beginning with 1989), the Secretary shall 
establish a prevailing charge floor for primary care services (as 
defined in subsection (i)(4) of this section) equal to 60 percent of the 
estimated average prevailing charge levels based on the best available 
data (determined, under the third and fourth sentences of paragraph (3) 
and under paragraph (4), without regard to this clause and without 
regard to physician specialty) for such service for all localities in 
the United States (weighted by the relative frequency of the service in 
each locality) for the year.
    (vii) Beginning with 1987, the percentage increase in the MEI (as 
defined in subsection (i)(3) of this section) for each year shall be the 
same for nonparticipating physicians as for participating physicians.
    (B)(i) In determining the reasonable charge under paragraph (3) for 
physicians' services furnished during the 15-month period beginning July 
1, 1984, the customary charges shall be the same customary charges as 
were recognized under this section for the 12-month period beginning 
July 1, 1983.
    (ii) In determining the reasonable charge under paragraph (3) for 
physicians' services furnished during the 8-month period beginning May 
1, 1986, by a physician who is not a participating physician (as defined 
in subsection (h)(1) of this section) at the time of furnishing the 
services--
        (I) if the physician was not a participating physician at any 
    time during the 12-month period beginning on October 1, 1984, the 
    customary charges shall be the same customary charges as were 
    recognized under this section for the 12-month period beginning July 
    1, 1983, and
        (II) if the physician was a participating physician at any time 
    during the 12-month period beginning on October 1, 1984, the 
    physician's customary charges shall be determined based upon the 
    physician's actual charges billed during the 12-month period ending 
    on March 31, 1985.

    (iii) In determining the reasonable charge under paragraph (3) for 
physicians' services furnished during the 3-month period beginning 
January 1, 1988, the customary charges shall be the same customary 
charges as were recognized under this section for the 12-month period 
beginning January 1, 1987.
    (iv) In determining the reasonable charge under paragraph (3) for 
physicians' services (other than primary care services, as defined in 
subsection (i)(4) of this section) furnished during 1991, the customary 
charges shall be the same customary charges as were recognized under 
this section for the 9-month period beginning April 1, 1990. In a case 
in which subparagraph (F) applies (relating to new physicians) so as to 
limit the customary charges of a physician during 1990 to a percent of 
prevailing charges, the previous sentence shall not prevent such limit 
on customary charges under such subparagraph from increasing in 1991 to 
a higher percent of such prevailing charges.
    (C) In determining the prevailing charge levels under the third and 
fourth sentences of paragraph (3) for physicians' services furnished 
during periods beginning after September 30, 1985, the Secretary shall 
treat the level as set under subparagraph (A)(i) as having fully 
provided for the economic changes which would have been taken into 
account but for the limitations contained in subparagraph (A)(i).
    (D)(i) In determining the customary charges for physicians' services 
furnished during the 8-month period beginning May 1, 1986, or the 12-
month period beginning January 1, 1987, by a physician who was not a 
participating physician (as defined in subsection (h)(1) of this 
section) on September 30, 1985, the Secretary shall not recognize 
increases in actual charges for services furnished during the 15-month 
period beginning on July 1, 1984, above the level of the physician's 
actual charges billed in the 3-month period ending on June 30, 1984.
    (ii) In determining the customary charges for physicians' services 
furnished during the 12-month period beginning January 1, 1987, by a 
physician who is not a participating physician (as defined in subsection 
(h)(1) of this section) on April 30, 1986, the Secretary shall not 
recognize increases in actual charges for services furnished during the 
7-month period beginning on October 1, 1985, above the level of the 
physician's actual charges billed during the 3-month period ending on 
June 30, 1984.
    (iii) In determining the customary charges for physicians' services 
furnished during the 12-month period beginning January 1, 1987, or 
January 1, 1988, by a physician who is not a participating physician (as 
defined in subsection (h)(1) of this section) on December 31, 1986, the 
Secretary shall not recognize increases in actual charges for services 
furnished during the 8-month period beginning on May 1, 1986, above the 
level of the physician's actual charges billed during the 3-month period 
ending on June 30, 1984.
    (iv) In determining the customary charges for a physicians' service 
furnished on or after January 1, 1988, if a physician was a 
nonparticipating physician in a previous year (beginning with 1987), the 
Secretary shall not recognize any amount of such actual charges (for 
that service furnished during such previous year) that exceeds the 
maximum allowable actual charge for such service established under 
subsection (j)(1)(C) of this section.
    (E)(i) For purposes of this part for physicians' services furnished 
in 1987, the percentage increase in the MEI is 3.2 percent.
    (ii) For purposes of this part for physicians' services furnished in 
1988, on or after April 1, the percentage increase in the MEI is--
        (I) 3.6 percent for primary care services (as defined in 
    subsection (i)(4) of this section), and
        (II) 1 percent for other physicians' services.

    (iii) For purposes of this part for physicians' services furnished 
in 1989, the percentage increase in the MEI is--
        (I) 3.0 percent for primary care services, and
        (II) 1 percent for other physicians' services.

    (iv) For purposes of this part for items and services furnished in 
1990, after March 31, 1990, the percentage increase in the MEI is--
        (I) 0 percent for radiology services, for anesthesia services, 
    and for other services specified in the list referred to in 
    paragraph (14)(C)(i),
        (II) 2 percent for other services (other than primary care 
    services), and
        (III) such percentage increase in the MEI (as defined in 
    subsection (i)(3) of this section) as would be otherwise determined 
    for primary care services (as defined in subsection (i)(4) of this 
    section).

    (v) For purposes of this part for items and services furnished in 
1991, the percentage increase in the MEI is--
        (I) 0 percent for services (other than primary care services), 
    and
        (II) 2 percent for primary care services (as defined in 
    subsection (i)(4) of this section).

    (5) Each contract under this section shall be for a term of at least 
one year, and may be made automatically renewable from term to term in 
the absence of notice by either party of intention to terminate at the 
end of the current term; except that the Secretary may terminate any 
such contract at any time (after such reasonable notice and opportunity 
for hearing to the carrier involved as he may provide in regulations) if 
he finds that the carrier has failed substantially to carry out the 
contract or is carrying out the contract in a manner inconsistent with 
the efficient and effective administration of the insurance program 
established by this part.
    (6) No payment under this part for a service provided to any 
individual shall (except as provided in section 1395gg of this title) be 
made to anyone other than such individual or (pursuant to an assignment 
described in subparagraph (B)(ii) of paragraph (3)) the physician or 
other person who provided the service, except that (A) payment may be 
made (i) to the employer of such physician or other person if such 
physician or other person is required as a condition of his employment 
to turn over his fee for such service to his employer, or (ii) (where 
the service was provided in a hospital, critical access hospital, 
clinic, or other facility) to the facility in which the service was 
provided if there is a contractual arrangement between such physician or 
other person and such facility under which such facility submits the 
bill for such service, (B) payment may be made to an entity (i) which 
provides coverage of the services under a health benefits plan, but only 
to the extent that payment is not made under this part, (ii) which has 
paid the person who provided the service an amount (including the amount 
payable under this part) which that person has accepted as payment in 
full for the service, and (iii) to which the individual has agreed in 
writing that payment may be made under this part, (C) in the case of 
services described in clause (i) of section 1395x(s)(2)(K) of this 
title, payment shall be made to either (i) the employer of the physician 
assistant involved, or (ii) with respect to a physician assistant who 
was the owner of a rural health clinic (as described in section 
1395x(aa)(2) of this title) for a continuous period beginning prior to 
August 5, 1997, and ending on the date that the Secretary determines 
such rural health clinic no longer meets the requirements of section 
1395x(aa)(2) of this title, for such services provided before January 1, 
2003, payment may be made directly to the physician assistant; \2\ (D) 
payment may be made to a physician for physicians' services (and 
services furnished incident to such services) furnished by a second 
physician to patients of the first physician if (i) the first physician 
is unavailable to provide the services; (ii) the services are furnished 
pursuant to an arrangement between the two physicians that (I) is 
informal and reciprocal, or (II) involves per diem or other fee-for-time 
compensation for such services; (iii) the services are not provided by 
the second physician over a continuous period of more than 60 days; and 
(iv) the claim form submitted to the carrier for such services includes 
the second physician's unique identifier (provided under the system 
established under subsection (r) of this section) and indicates that the 
claim meets the requirements of this subparagraph for payment to the 
first physician, (E) in the case of an item or service (other than 
services described in section 1395yy(e)(2)(A)(ii) of this title) 
furnished to an individual who (at the time the item or service is 
furnished) is a resident of a skilled nursing facility or of a part of a 
facility that includes a skilled nursing facility (as determined under 
regulations), payment shall be made to the facility (without regard to 
whether or not the item or service was furnished by the facility, by 
others under arrangement with them made by the facility, under any other 
contracting or consulting arrangement, or otherwise), and (F) in the 
case of home health services (including medical supplies described in 
section 1395x(m)(5) of this title, but excluding durable medical 
equipment to the extent provided for in such section) furnished to an 
individual who (at the time the item or service is furnished) is under a 
plan of care of a home health agency, payment shall be made to the 
agency (without regard to whether or not the item or service was 
furnished by the agency, by others under arrangement with them made by 
the agency, or when any other contracting or consulting arrangement, or 
otherwise). No payment which under the preceding sentence may be made 
directly to the physician or other person providing the service involved 
(pursuant to an assignment described in subparagraph (B)(ii) of 
paragraph (3)) shall be made to anyone else under a reassignment or 
power of attorney (except to an employer or facility as described in 
clause (A) of such sentence); but nothing in this subsection shall be 
construed (i) to prevent the making of such a payment in accordance with 
an assignment from the individual to whom the service was provided or a 
reassignment from the physician or other person providing such service 
if such assignment or reassignment is made to a governmental agency or 
entity or is established by or pursuant to the order of a court of 
competent jurisdiction, or (ii) to preclude an agent of the physician or 
other person providing the service from receiving any such payment if 
(but only if) such agent does so pursuant to an agency agreement under 
which the compensation to be paid to the agent for his services for or 
in connection with the billing or collection of payments due such 
physician or other person under this subchapter is unrelated (directly 
or indirectly) to the amount of such payments or the billings therefor, 
and is not dependent upon the actual collection of any such payment. For 
purposes of subparagraph (C) of the first sentence of this paragraph, an 
employment relationship may include any independent contractor 
arrangement, and employer status shall be determined in accordance with 
the law of the State in which the services described in such clause are 
performed.
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    \2\ So in original. The semicolon probably should be a comma.
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    (7)(A) In the case of physicians' services furnished to a patient in 
a hospital with a teaching program approved as specified in section 
1395x(b)(6) of this title but which does not meet the conditions 
described in section 1395x(b)(7) of this title, the carrier shall not 
provide (except on the basis described in subparagraph (C)) for payment 
for such services under this part--
        (i) unless--
            (I) the physician renders sufficient personal and 
        identifiable physicians' services to the patient to exercise 
        full, personal control over the management of the portion of the 
        case for which the payment is sought,
            (II) the services are of the same character as the services 
        the physician furnishes to patients not entitled to benefits 
        under this subchapter, and
            (III) at least 25 percent of the hospital's patients (during 
        a representative past period, as determined by the Secretary) 
        who were not entitled to benefits under this subchapter and who 
        were furnished services described in subclauses (I) and (II) 
        paid all or a substantial part of charges (other than nominal 
        charges) imposed for such services; and

        (ii) to the extent that the payment is based upon a reasonable 
    charge for the services in excess of the customary charge as 
    determined in accordance with subparagraph (B).

    (B) The customary charge for such services in a hospital shall be 
determined in accordance with regulations issued by the Secretary and 
taking into account the following factors:
        (i) In the case of a physician who is not a teaching physician 
    (as defined by the Secretary), the carrier shall take into account 
    the amounts the physician charges for similar services in the 
    physician's practice outside the teaching setting.
        (ii) In the case of a teaching physician, if the hospital, its 
    physicians, or other appropriate billing entity has established one 
    or more schedules of charges which are collected for medical and 
    surgical services, the carrier shall base payment under this 
    subchapter on the greatest of--
            (I) the charges (other than nominal charges) which are most 
        frequently collected in full or substantial part with respect to 
        patients who were not entitled to benefits under this subchapter 
        and who were furnished services described in subclauses (I) and 
        (II) of subparagraph (A)(i),
            (II) the mean of the charges (other than nominal charges) 
        which were collected in full or substantial part with respect to 
        such patients, or
            (III) 85 percent of the prevailing charges paid for similar 
        services in the same locality.

        (iii) If all the teaching physicians in a hospital agree to have 
    payment made for all of their physicians' services under this part 
    furnished to patients in such hospital on an assignment-related 
    basis, the customary charge for such services shall be equal to 90 
    percent of the prevailing charges paid for similar services in the 
    same locality.

    (C) In the case of physicians' services furnished to a patient in a 
hospital with a teaching program approved as specified in section 
1395x(b)(6) of this title but which does not meet the conditions 
described in section 1395x(b)(7) of this title, if the conditions 
described in subclauses (I) and (II) of subparagraph (A)(i) are met and 
if the physician elects payment to be determined under this 
subparagraph, the carrier shall provide for payment for such services 
under this part on the basis of regulations of the Secretary governing 
reimbursement for the services of hospital-based physicians (and not on 
any other basis).
    (D)(i) In the case of physicians' services furnished to a patient in 
a hospital with a teaching program approved as specified in section 
1395x(b)(6) of this title but which does not meet the conditions 
described in section 1395x(b)(7) of this title, no payment shall be made 
under this part for services of assistants at surgery with respect to a 
surgical procedure if such hospital has a training program relating to 
the medical specialty required for such surgical procedure and a 
qualified individual on the staff of the hospital is available to 
provide such services; except that payment may be made under this part 
for such services, to the extent that such payment is otherwise allowed 
under this paragraph, if such services, as determined under regulations 
of the Secretary--
        (I) are required due to exceptional medical circumstances,
        (II) are performed by team physicians needed to perform complex 
    medical procedures, or
        (III) constitute concurrent medical care relating to a medical 
    condition which requires the presence of, and active care by, a 
    physician of another specialty during surgery,

and under such other circumstances as the Secretary determines by 
regulation to be appropriate.
    (ii) For purposes of this subparagraph, the term ``assistant at 
surgery'' means a physician who actively assists the physician in charge 
of a case in performing a surgical procedure.
    (iii) The Secretary shall determine appropriate methods of 
reimbursement of assistants at surgery where such services are 
reimbursable under this part.
    (8)(A)(i) The Secretary shall by regulation--
        (I) describe the factors to be used in determining the cases (of 
    particular items or services) in which the application of this 
    subchapter to payment under this part (other than to physicians' 
    services paid under section 1395w-4 of this title) results in the 
    determination of an amount that, because of its being grossly 
    excessive or grossly deficient, is not inherently reasonable, and
        (II) provide in those cases for the factors to be considered in 
    determining an amount that is realistic and equitable.

    (ii) Notwithstanding the determination made in clause (i), the 
Secretary may not apply factors that would increase or decrease the 
payment under this part during any year for any particular item or 
service by more than 15 percent from such payment during the preceding 
year except as provided in subparagraph (B).
    (B) The Secretary may make a determination under this subparagraph 
that would result in an increase or decrease under subparagraph (A) of 
more than 15 percent of the payment amount for a year, but only if--
        (i) the Secretary's determination takes into account the factors 
    described in subparagraph (C) and any additional factors the 
    Secretary determines appropriate,
        (ii) the Secretary's determination takes into account the 
    potential impacts described in subparagraph (D), and
        (iii) the Secretary complies with the procedural requirements of 
    paragraph (9).

    (C) The factors described in this subparagraph are as follows:
        (i) The programs established under this subchapter and 
    subchapter XIX of this chapter are the sole or primary sources of 
    payment for an item or service.
        (ii) The payment amount does not reflect changing technology, 
    increased facility with that technology, or reductions in 
    acquisition or production costs.
        (iii) The payment amount for an item or service under this part 
    is substantially higher or lower than the payment made for the item 
    or service by other purchasers.

    (D) The potential impacts of a determination under subparagraph (B) 
on quality, access, and beneficiary liability, including the likely 
effects on assignment rates and participation rates.
    (9)(A) The Secretary shall consult with representatives of suppliers 
or other individuals who furnish an item or service before making a 
determination under paragraph (8)(B) with regard to that item or 
service.
    (B) The Secretary shall publish notice of a proposed determination 
under paragraph (8)(B) in the Federal Register--
        (i) specifying the payment amount proposed to be established 
    with respect to an item or service,
        (ii) explaining the factors and data that the Secretary took 
    into account in determining the payment amount so specified, and
        (iii) explaining the potential impacts described in paragraph 
    (8)(D).

    (C) After publication of the notice required by subparagraph (B), 
the Secretary shall allow not less than 60 days for public comment on 
the proposed determination.
    (D)(i) Taking into consideration the comments made by the public, 
the Secretary shall publish in the Federal Register a final 
determination under paragraph (8)(B) with respect to the payment amount 
to be established with respect to the item or service.
    (ii) A final determination published pursuant to clause (i) shall 
explain the factors and data that the Secretary took into consideration 
in making the final determination.
    (10)(A)(i) In determining the reasonable charge for procedures 
described in subparagraph (B) and performed during the 9-month period 
beginning on April 1, 1988, the prevailing charge for such procedure 
shall be the prevailing charge otherwise recognized for such procedure 
for 1987--
        (I) subject to clause (iii), reduced by 2.0 percent, and
        (II) further reduced by the applicable percentage specified in 
    clause (ii).

    (ii) For purposes of clause (i), the applicable percentage specified 
in this clause is--
        (I) 15 percent, in the case of a prevailing charge otherwise 
    recognized (without regard to this paragraph and determined without 
    regard to physician specialty) that is at least 150 percent of the 
    weighted national average (as determined by the Secretary) of such 
    prevailing charges for such procedure for all localities in the 
    United States for 1987;
        (II) 0 percent, in the case of a prevailing charge that does not 
    exceed 85 percent of such weighted national average; and
        (III) in the case of any other prevailing charge, a percent 
    determined on the basis of a straight-line sliding scale, equal to 
    \3/13\ of a percentage point for each percent by which the 
    prevailing charge exceeds 85 percent of such weighted national 
    average.

    (iii) In no case shall the reduction under clause (i) for a 
procedure result in a prevailing charge in a locality for 1988 which is 
less than 85 percent of the Secretary's estimate of the weighted 
national average of such prevailing charges for such procedure for all 
localities in the United States for 1987 (based upon the best available 
data and determined without regard to physician specialty) after making 
the reduction described in clause (i)(I).
    (B) The procedures described in this subparagraph are as follows: 
bronchoscopy, carpal tunnel repair, cataract surgery (including 
subsequent insertion of an intraocular lens), coronary artery bypass 
surgery, diagnostic and/or therapeutic dilation and curettage, knee 
arthroscopy, knee arthroplasty, pacemaker implantation surgery, total 
hip replacement, suprapubic prostatectomy, transurethral resection of 
the prostate, and upper gastrointestinal endoscopy.
    (C) In the case of a reduction in the reasonable charge for a 
physicians' service under subparagraph (A), if a nonparticipating 
physician furnishes the service to an individual entitled to benefits 
under this part, after the effective date of such reduction, the 
physician's actual charge is subject to a limit under subsection 
(j)(1)(D) of this section.
    (D) There shall be no administrative or judicial review under 
section 1395ff of this title or otherwise of any determination under 
subparagraph (A) or under paragraph (11)(B)(ii).
    (11)(A) In providing payment for cataract eyeglasses and cataract 
contact lenses, and professional services relating to them, under this 
part, each carrier shall--
        (i) provide for separate determinations of the payment amount 
    for the eyeglasses and lenses and of the payment amount for the 
    professional services of a physician (as defined in section 1395x(r) 
    of this title), and
        (ii) not recognize as reasonable for such eyeglasses and lenses 
    more than such amount as the Secretary establishes in guidelines 
    relating to the inherent reasonableness of charges for such 
    eyeglasses and lenses.

    (B)(i) In determining the reasonable charge under paragraph (3) for 
a cataract surgical procedure, subject to clause (ii), the prevailing 
charge for such procedure otherwise recognized for participating and 
nonparticipating physicians shall be reduced by 10 percent with respect 
to procedures performed in 1987.
    (ii) In no case shall the reduction under clause (i) for a surgical 
procedure result in a prevailing charge in a locality for a year which 
is less than 75 percent of the weighted national average of such 
prevailing charges for such procedure for all the localities in the 
United States for 1986.
    (C)(i) The prevailing charge level determined with respect to A-mode 
ophthalmic ultrasound procedures may not exceed 5 percent of the 
prevailing charge level established with respect to extracapsular 
cataract removal with lens insertion.
    (ii) The reasonable charge for an intraocular lens inserted during 
or subsequent to cataract surgery in a physician's office may not exceed 
the actual acquisition cost for the lens (taking into account any 
discount) plus a handling fee (not to exceed 5 percent of such actual 
acquisition cost).
    (D) In the case of a reduction in the reasonable charge for a 
physicians' service or item under subparagraph (B) or (C), if a 
nonparticipating physician furnishes the service or item to an 
individual entitled to benefits under this part after the effective date 
of such reduction, the physician's actual charge is subject to a limit 
under subsection (j)(1)(D) of this section.
    (12) Repealed. Pub. L. 105-33, title IV, Sec. 4512(b)(2), Aug. 5, 
1997, 111 Stat. 444.
    (13)(A) In determining payments under section 1395l(l) of this title 
and section 1395w-4 of this title for anesthesia services furnished on 
or after January 1, 1994, the methodology for determining the base and 
time units used shall be the same for services furnished by physicians, 
for medical direction by physicians of two, three, or four certified 
registered nurse anesthetists, or for services furnished by a certified 
registered nurse anesthetist (whether or not medically directed) and 
shall be based on the methodology in effect, for anesthesia services 
furnished by physicians, as of August 10, 1993.
    (B) The Secretary shall require claims for physicians' services for 
medical direction of nurse anesthetists during the periods in which the 
provisions of subparagraph (A) apply to indicate the number of such 
anesthetists being medically directed concurrently at any time during 
the procedure, the name of each nurse anesthetist being directed, and 
the type of procedure for which the services are provided.
    (14)(A)(i) In determining the reasonable charge for a physicians' 
service specified in subparagraph (C)(i) and furnished during the 9-
month period beginning on April 1, 1990, the prevailing charge for such 
service shall be the prevailing charge otherwise recognized for such 
service for 1989 reduced by 15 percent or, if less, \1/3\ of the percent 
(if any) by which the prevailing charge otherwise applied in the 
locality in 1989 exceeds the locally-adjusted reduced prevailing amount 
(as determined under subparagraph (B)(i)) for the service.
    (ii) In determining the reasonable charge for a physicians' service 
specified in subparagraph (C)(i) and furnished during 1991, the 
prevailing charge for such service shall be the prevailing charge 
otherwise recognized for such service for the period during 1990 
beginning on April 1, reduced by the same amount as the amount of the 
reduction effected under this paragraph (as amended by the Omnibus 
Budget Reconciliation Act of 1990) for such service during such period.
    (B) For purposes of this paragraph:
        (i) The ``locally-adjusted reduced prevailing amount'' for a 
    locality for a physicians' service is equal to the product of--
            (I) the reduced national weighted average prevailing charge 
        for the service (specified under clause (ii)), and
            (II) the adjustment factor (specified under clause (iii)) 
        for the locality.

        (ii) The ``reduced national weighted average prevailing charge'' 
    for a physicians' service is equal to the national weighted average 
    prevailing charge for the service (specified in subparagraph 
    (C)(ii)) reduced by the percentage change (specified in subparagraph 
    (C)(iii)) for the service.
        (iii) The ``adjustment factor'', for a physicians' service for a 
    locality, is the sum of--
            (I) the practice expense component (percent), divided by 
        100, specified in appendix A (pages 187 through 194) of the 
        Report of the Medicare and Medicaid Health Budget Reconciliation 
        Amendments of 1989, prepared by the Subcommittee on Health and 
        the Environment of the Committee on Energy and Commerce, House 
        of Representatives, (Committee Print 101-M, 101st Congress, 1st 
        Session) for the service, multiplied by the geographic practice 
        cost index value (specified in subparagraph (C)(iv)) for the 
        locality, and
            (II) 1 minus the practice expense component (percent), 
        divided by 100.

    (C) For purposes of this paragraph:
        (i) The physicians' services specified in this clause are the 
    procedures specified (by code and description) in the Overvalued 
    Procedures List for Finance Committee, Revised September 20, 1989, 
    prepared by the Physician Payment Review Commission which 
    specification is of physicians' services that have been identified 
    as overvalued by at least 10 percent based on a comparison of 
    payments for such services under a resource-based relative value 
    scale and of the national average prevailing charges under this 
    part.
        (ii) The ``national weighted average prevailing charge'' 
    specified in this clause, for a physicians' service specified in 
    clause (i), is the national weighted average prevailing charge for 
    the service in 1989 as determined by the Secretary using the best 
    data available.
        (iii) The ``percentage change'' specified in this clause, for a 
    physicians' service specified in clause (i), is the percent 
    difference (but expressed as a positive number) specified for the 
    service in the list referred to in clause (i).
        (iv) The geographic practice cost index value specified in this 
    clause for a locality is the Geographic Overhead Costs Index 
    specified for the locality in table 1 of the September 1989 
    Supplement to the Geographic Medicare Economic Index: Alternative 
    Approaches (prepared by the Urban Institute and the Center for 
    Health Economics Research).

    (D) In the case of a reduction in the prevailing charge for a 
physicians' service under subparagraph (A), if a nonparticipating 
physician furnishes the service to an individual entitled to benefits 
under this part, after the effective date of such reduction, the 
physician's actual charge is subject to a limit under subsection 
(j)(1)(D) of this section.
    (15)(A) In determining the reasonable charge for surgery, radiology, 
and diagnostic physicians' services which the Secretary shall designate 
(based on their high volume of expenditures under this part) and for 
which the prevailing charge (but for this paragraph) differs by 
physician specialty, the prevailing charge for such a service may not 
exceed the prevailing charge or fee schedule amount for that specialty 
of physicians that furnish the service most frequently nationally.
    (B) In the case of a reduction in the prevailing charge for a 
physician's service under subparagraph (A), if a nonparticipating 
physician furnishes the service to an individual entitled to benefits 
under this part, after the effective date of the reduction, the 
physician's actual charge is subject to a limit under subsection 
(j)(1)(D) of this section.
    (16)(A) In determining the reasonable charge for all physicians' 
services other than physicians' services specified in subparagraph (B) 
furnished during 1991, the prevailing charge for a locality shall be 6.5 
percent below the prevailing charges used in the locality under this 
part in 1990 after March 31.
    (B) For purposes of subparagraph (A), the physicians' services 
specified in this subparagraph are as follows:
        (i) Radiology, anesthesia and physician pathology services, the 
    technical components of diagnostic tests specified in paragraph (17) 
    and physicians' services specified in paragraph (14)(C)(i).
        (ii) Primary care services specified in subsection (i)(4) of 
    this section, hospital inpatient medical services, consultations, 
    other visits, preventive medicine visits, psychiatric services, 
    emergency care facility services, and critical care services.
        (iii) Partial mastectomy; tendon sheath injections and small 
    joint arthrocentesis; femoral fracture and trochanteric fracture 
    treatments; endotracheal intubation; thoracentesis; thoracostomy; 
    aneurysm repair; cystourethroscopy; transurethral fulguration and 
    resection; tympanoplasty with mastoidectomy; and ophthalmoscopy.

    (17) With respect to payment under this part for the technical (as 
distinct from professional) component of diagnostic tests (other than 
clinical diagnostic laboratory tests, tests specified in paragraph 
(14)(C)(i), and radiology services, including portable x-ray services) 
which the Secretary shall designate (based on their high volume of 
expenditures under this part), the reasonable charge for such technical 
component (including the applicable portion of a global service) may not 
exceed the national median of such charges for all localities, as 
estimated by the Secretary using the best available data.
    (18)(A) Payment for any service furnished by a practitioner 
described in subparagraph (C) and for which payment may be made under 
this part on a reasonable charge or fee schedule basis may only be made 
under this part on an assignment-related basis.
    (B) A practitioner described in subparagraph (C) or other person may 
not bill (or collect any amount from) the individual or another person 
for any service described in subparagraph (A), except for deductible and 
coinsurance amounts applicable under this part. No person is liable for 
payment of any amounts billed for such a service in violation of the 
previous sentence. If a practitioner or other person knowingly and 
willfully bills (or collects an amount) for such a service in violation 
of such sentence, the Secretary may apply sanctions against the 
practitioner or other person in the same manner as the Secretary may 
apply sanctions against a physician in accordance with subsection (j)(2) 
of this section in the same manner as such section applies with respect 
to a physician. Paragraph (4) of subsection (j) of this section shall 
apply in this subparagraph in the same manner as such paragraph applies 
to such section.
    (C) A practitioner described in this subparagraph is any of the 
following:
        (i) A physician assistant, nurse practitioner, or clinical nurse 
    specialist (as defined in section 1395x(aa)(5) of this title).
        (ii) A certified registered nurse anesthetist (as defined in 
    section 1395x(bb)(2) of this title).
        (iii) A certified nurse-midwife (as defined in section 
    1395x(gg)(2) of this title).
        (iv) A clinical social worker (as defined in section 
    1395x(hh)(1) of this title).
        (v) A clinical psychologist (as defined by the Secretary for 
    purposes of section 1395x(ii) of this title).

    (D) For purposes of this paragraph, a service furnished by a 
practitioner described in subparagraph (C) includes any services and 
supplies furnished as incident to the service as would otherwise be 
covered under this part if furnished by a physician or as incident to a 
physician's service.
    (19) For purposes of section 1395l(a)(1) of this title, the 
reasonable charge for ambulance services (as described in section 
1395x(s)(7) of this title) provided during calendar year 1998 and 
calendar year 1999 may not exceed the reasonable charge for such 
services provided during the previous calendar year (after application 
of this paragraph), increased by the percentage increase in the consumer 
price index for all urban consumers (U.S. city average) as estimated by 
the Secretary for the 12-month period ending with the midpoint of the 
year involved reduced by 1.0 percentage point.

(c) Advances of funds to carrier; prompt payment of claims

    (1) Any contract entered into with a carrier under this section 
shall provide for advances of funds to the carrier for the making of 
payments by it under this part, and shall provide for payment of the 
cost of administration of the carrier, as determined by the Secretary to 
be necessary and proper for carrying out the functions covered by the 
contract. The Secretary shall provide that in determining a carrier's 
necessary and proper cost of administration, the Secretary shall, with 
respect to each contract, take into account the amount that is 
reasonable and adequate to meet the costs which must be incurred by an 
efficiently and economically operated carrier in carrying out the terms 
of its contract. The Secretary shall cause to have published in the 
Federal Register, by not later than September 1 before each fiscal year, 
data, standards, and methodology to be used to establish budgets for 
carriers under this section for that fiscal year, and shall cause to be 
published in the Federal Register for public comment, at least 90 days 
before such data, standards, and methodology are published, the data, 
standards, and methodology proposed to be used.
    (2)(A) Each contract under this section which provides for the 
disbursement of funds, as described in subsection (a)(1)(B) of this 
section, shall provide that payment shall be issued, mailed, or 
otherwise transmitted with respect to not less than 95 percent of all 
claims submitted under this part--
        (i) which are clean claims, and
        (ii) for which payment is not made on a periodic interim payment 
    basis,

within the applicable number of calendar days after the date on which 
the claim is received.
    (B) In this paragraph:
        (i) The term ``clean claim'' means a claim that has no defect or 
    impropriety (including any lack of any required substantiating 
    documentation) or particular circumstance requiring special 
    treatment that prevents timely payment from being made on the claim 
    under this part.
        (ii) The term ``applicable number of calendar days'' means--
            (I) with respect to claims received in the 12-month period 
        beginning October 1, 1986, 30 calendar days,
            (II) with respect to claims received in the 12-month period 
        beginning October 1, 1987, 26 calendar days (or 19 calendar days 
        with respect to claims submitted by participating physicians),
            (III) with respect to claims received in the 12-month period 
        beginning October 1, 1988, 25 calendar days (or 18 calendar days 
        with respect to claims submitted by participating physicians), 
        and \3\
---------------------------------------------------------------------------
    \3\ So in original. The word ``and'' probably should not appear.
---------------------------------------------------------------------------
            (IV) with respect to claims received in the 12-month period 
        beginning October 1, 1989, and claims received in any succeeding 
        12-month period ending on or before September 30, 1993, 24 
        calendar days (or 17 calendar days with respect to claims 
        submitted by participating physicians).\4\
---------------------------------------------------------------------------
    \4\ So in original. The period probably should be ``, and''.
---------------------------------------------------------------------------
            (V) with respect to claims received in the 12-month period 
        beginning October 1, 1993, and claims received in any succeeding 
        12-month period, 30 calendar days.

    (C) If payment is not issued, mailed, or otherwise transmitted 
within the applicable number of calendar days (as defined in clause (ii) 
of subparagraph (B)) after a clean claim (as defined in clause (i) of 
such subparagraph) is received, interest shall be paid at the rate used 
for purposes of section 3902(a) of title 31 (relating to interest 
penalties for failure to make prompt payments) for the period beginning 
on the day after the required payment date and ending on the date on 
which payment is made.
    (3)(A) Each contract under this section which provides for the 
disbursement of funds, as described in subsection (a)(1)(B) of this 
section, shall provide that no payment shall be issued, mailed, or 
otherwise transmitted with respect to any claim submitted under this 
subchapter within the applicable number of calendar days after the date 
on which the claim is received.
    (B) In this paragraph, the term ``applicable number of calendar 
days'' means--
        (i) with respect to claims submitted electronically as 
    prescribed by the Secretary, 13 days, and
        (ii) with respect to claims submitted otherwise, 26 days.

    (4) Neither a carrier nor the Secretary may impose a fee under this 
subchapter--
        (A) for the filing of claims related to physicians' services,
        (B) for an error in filing a claim relating to physicians' 
    services or for such a claim which is denied,
        (C) for any appeal under this subchapter with respect to 
    physicians' services,
        (D) for applying for (or obtaining) a unique identifier under 
    subsection (r) of this section, or
        (E) for responding to inquiries respecting physicians' services 
    or for providing information with respect to medical review of such 
    services.

    (5) Each contract under this section which provides for the 
disbursement of funds, as described in subsection (a)(1)(B) of this 
section, shall require the carrier to meet criteria developed by the 
Secretary to measure the timeliness of carrier responses to requests for 
payment of items described in section 1395m(a)(15)(C) of this title.
    (6) No carrier may carry out (or receive payment for carrying out) 
any activity pursuant to a contract under this subsection to the extent 
that the activity is carried out pursuant to a contract under the 
Medicare Integrity Program under section 1395ddd of this title. The 
previous sentence shall not apply with respect to the activity described 
in section 1395ddd(b)(5) of this title (relating to prior authorization 
of certain items of durable medical equipment under section 1395m(a)(15) 
of this title).

(d) Surety bonds

    Any contract with a carrier under this section may require such 
carrier or any of its officers or employees certifying payments or 
disbursing funds pursuant to the contract, or otherwise participating in 
carrying out the contract, to give surety bond to the United States in 
such amount as the Secretary may deem appropriate.

(e) Liability of certifying or disbursing officers or carriers

    (1) No individual designated pursuant to a contract under this 
section as a certifying officer shall, in the absence of gross 
negligence or intent to defraud the United States, be liable with 
respect to any payments certified by him under this section.
    (2) No disbursing officer shall, in the absence of gross negligence 
or intent to defraud the United States, be liable with respect to any 
payment by him under this section if it was based upon a voucher signed 
by a certifying officer designated as provided in paragraph (1) of this 
subsection.
    (3) No such carrier shall be liable to the United States for any 
payments referred to in paragraph (1) or (2).

(f) ``Carrier'' defined

    For purposes of this part, the term ``carrier'' means--
        (1) with respect to providers of services and other persons, a 
    voluntary association, corporation, partnership, or other 
    nongovernmental organization which is lawfully engaged in providing, 
    paying for, or reimbursing the cost of, health services under group 
    insurance policies or contracts, medical or hospital service 
    agreements, membership or subscription contracts, or similar group 
    arrangements, in consideration of premiums or other periodic charges 
    payable to the carrier, including a health benefits plan duly 
    sponsored or underwritten by an employee organization; and
        (2) with respect to providers of services only, any agency or 
    organization (not described in paragraph (1)) with which an 
    agreement is in effect under section 1395h of this title.

(g) Authority of Railroad Retirement Board to enter into contracts with 
        carriers

    The Railroad Retirement Board shall, in accordance with such 
regulations as the Secretary may prescribe, contract with a carrier or 
carriers to perform the functions set out in this section with respect 
to individuals entitled to benefits as qualified railroad retirement 
beneficiaries pursuant to section 426(a) of this title and section 
231f(d) of title 45.

(h) Participating physician or supplier; agreement with Secretary; 
        publication of directories; availability; inclusion of program 
        in explanation of benefits; payment of claims on assignment-
        related basis

    (1) Any physician or supplier may voluntarily enter into an 
agreement with the Secretary to become a participating physician or 
supplier. For purposes of this section, the term ``participating 
physician or supplier'' means a physician or supplier (excluding any 
provider of services) who, before the beginning of any year beginning 
with 1984, enters into an agreement with the Secretary which provides 
that such physician or supplier will accept payment under this part on 
an assignment-related basis for all items and services furnished to 
individuals enrolled under this part during such year. In the case of a 
newly licensed physician or a physician who begins a practice in a new 
area, or in the case of a new supplier who begins a new business, or in 
such similar cases as the Secretary may specify, such physician or 
supplier may enter into such an agreement after the beginning of a year, 
for items and services furnished during the remainder of the year.
    (2) Each carrier having an agreement with the Secretary under 
subsection (a) of this section shall maintain a toll-free telephone 
number or numbers at which individuals enrolled under this part may 
obtain the names, addresses, specialty, and telephone numbers of 
participating physicians and suppliers and may request a copy of an 
appropriate directory published under paragraph (4). Each such carrier 
shall, without charge, mail a copy of such directory upon such a 
request.
    (3)(A) In any case in which a carrier having an agreement with the 
Secretary under subsection (a) of this section is able to develop a 
system for the electronic transmission to such carrier of bills for 
services, such carrier shall establish direct lines for the electronic 
receipt of claims from participating physicians and suppliers.
    (B) The Secretary shall establish a procedure whereby an individual 
enrolled under this part may assign, in an appropriate manner on the 
form claiming a benefit under this part for an item or service furnished 
by a participating physician or supplier, the individual's rights of 
payment under a medicare supplemental policy (described in section 
1395ss(g)(1) of this title) in which the individual is enrolled. In the 
case such an assignment is properly executed and a payment determination 
is made by a carrier with a contract under this section, the carrier 
shall transmit to the private entity issuing the medicare supplemental 
policy notice of such fact and shall include an explanation of benefits 
and any additional information that the Secretary may determine to be 
appropriate in order to enable the entity to decide whether (and the 
amount of) any payment is due under the policy. The Secretary may enter 
into agreements for the transmittal of such information to entities 
electronically. The Secretary shall impose user fees for the transmittal 
of information under this subparagraph by a carrier, whether 
electronically or otherwise, and such user fees shall be collected and 
retained by the carrier.
    (4) At the beginning of each year the Secretary shall publish 
directories (for appropriate local geographic areas) containing the 
name, address, and specialty of all participating physicians and 
suppliers (as defined in paragraph (1)) for that area for that year. 
Each directory shall be organized to make the most useful presentation 
of the information (as determined by the Secretary) for individuals 
enrolled under this part. Each participating physician directory for an 
area shall provide an alphabetical listing of all participating 
physicians practicing in the area and an alphabetical listing by 
locality and specialty of such physicians.
    (5)(A) The Secretary shall promptly notify individuals enrolled 
under this part through an annual mailing of the participation program 
under this subsection and the publication and availability of the 
directories and shall make the appropriate area directory or directories 
available in each district and branch office of the Social Security 
Administration, in the offices of carriers, and to senior citizen 
organizations.
    (B) The annual notice provided under subparagraph (A) shall 
include--
        (i) a description of the participation program,
        (ii) an explanation of the advantages to beneficiaries of 
    obtaining covered services through a participating physician or 
    supplier,
        (iii) an explanation of the assistance offered by carriers in 
    obtaining the names of participating physicians and suppliers, and
        (iv) the toll-free telephone number under paragraph (2)(A) for 
    inquiries concerning the program and for requests for free copies of 
    appropriate directories.

    (6) The Secretary shall provide that the directories shall be 
available for purchase by the public. The Secretary shall provide that 
each appropriate area directory is sent to each participating physician 
located in that area and that an appropriate number of copies of each 
such directory is sent to hospitals located in the area. Such copies 
shall be sent free of charge.
    (7) The Secretary shall provide that each explanation of benefits 
provided under this part for services furnished in the United States, in 
conjunction with the payment of claims under section 1395l(a)(1) of this 
title (made other than on an assignment-related basis), shall include--
        (A) a prominent reminder of the participating physician and 
    supplier program established under this subsection (including the 
    limitation on charges that may be imposed by such physicians and 
    suppliers and a clear statement of any amounts charged for the 
    particular items or services on the claim involved above the amount 
    recognized under this part),
        (B) the toll-free telephone number or numbers, maintained under 
    paragraph (2), at which an individual enrolled under this part may 
    obtain information on participating physicians and suppliers,
        (C)(i) an offer of assistance to such an individual in obtaining 
    the names of participating physicians of appropriate specialty and 
    (ii) an offer to provide a free copy of the appropriate 
    participating physician directory; and
        (D) in the case of services for which the billed amount exceeds 
    the limiting charge imposed under section 1395w-4(g) of this title, 
    information regarding such applicable limiting charge (including 
    information concerning the right to a refund under section 1395w-
    4(g)(1)(A)(iv) of this title).

    (8) The Secretary may refuse to enter into an agreement with a 
physician or supplier under this subsection, or may terminate or refuse 
to renew such agreement, in the event that such physician or supplier 
has been convicted of a felony under Federal or State law for an offense 
which the Secretary determines is detrimental to the best interests of 
the program or program beneficiaries.

(i) Definitions

    For purposes of this subchapter:
        (1) A claim is considered to be paid on an ``assignment-related 
    basis'' if the claim is paid on the basis of an assignment described 
    in subsection (b)(3)(B)(ii) of this section, in accordance with 
    subsection (b)(6)(B) of this section, or under the procedure 
    described in section 1395gg(f)(1) of this title.
        (2) The term ``participating physician'' refers, with respect to 
    the furnishing of services, to a physician who at the time of 
    furnishing the services is a participating physician (under 
    subsection (h)(1) of this section); the term ``nonparticipating 
    physician'' refers, with respect to the furnishing of services, a 
    \5\ physician who at the time of furnishing the services is not a 
    participating physician; and the term ``nonparticipating supplier or 
    other person'' means a supplier or other person (excluding a 
    provider of services) that is not a participating physician or 
    supplier (as defined in subsection (h)(1) of this section).
---------------------------------------------------------------------------
    \5\ So in original. Probably should be ``to a''.
---------------------------------------------------------------------------
        (3) The term ``percentage increase in the MEI'' means, with 
    respect to physicians' services furnished in a year, the percentage 
    increase in the medicare economic index (referred to in the fourth 
    sentence of subsection (b)(3) of this section) applicable to such 
    services furnished as of the first day of that year.
        (4) The term ``primary care services'' means physicians' 
    services which constitute office medical services, emergency 
    department services, home medical services, skilled nursing, 
    intermediate care, and long-term care medical services, or nursing 
    home, boarding home, domiciliary, or custodial care medical 
    services.

(j) Monitoring of charges of nonparticipating physicians; sanctions; 
        restitution

    (1)(A) In the case of a physician who is not a participating 
physician for items and services furnished during a portion of the 30-
month period beginning July 1, 1984, the Secretary shall monitor the 
physician's actual charges to individuals enrolled under this part for 
physicians' services during that portion of that period. If such 
physician knowingly and willfully bills individuals enrolled under this 
part for actual charges in excess of such physician's actual charges for 
the calendar quarter beginning on April 1, 1984, the Secretary may apply 
sanctions against such physician in accordance with paragraph (2).
    (B)(i) During any period (on or after January 1, 1987, and before 
the date specified in clause (ii)), during which a physician is a 
nonparticipating physician, the Secretary shall monitor the actual 
charges of each such physician for physicians' services furnished to 
individuals enrolled under this part. If such physician knowingly and 
willfully bills on a repeated basis for such a service an actual charge 
in excess of the maximum allowable actual charge determined under 
subparagraph (C) for that service, the Secretary may apply sanctions 
against such physician in accordance with paragraph (2).
    (ii) Clause (i) shall not apply to services furnished after December 
31, 1990.
    (C)(i) For a particular physicians' service furnished by a 
nonparticipating physician to individuals enrolled under this part 
during a year, for purposes of subparagraph (B), the maximum allowable 
actual charge is determined as follows: If the physician's maximum 
allowable actual charge for that service in the previous year was--
        (I) less than 115 percent of the applicable percent (as defined 
    in subsection (b)(4)(A)(iv) of this section) of the prevailing 
    charge for the year and service involved, the maximum allowable 
    actual charge for the year involved is the greater of the maximum 
    allowable actual charge described in subclause (II) or the charge 
    described in clause (ii), or
        (II) equal to, or greater than, 115 percent of the applicable 
    percent (as defined in subsection (b)(4)(A)(iv) of this section) of 
    the prevailing charge for the year and service involved, the maximum 
    allowable actual charge is 101 percent of the physician's maximum 
    allowable actual charge for the service for the previous year.

    (ii) For purposes of clause (i)(I), the charge described in this 
clause for a particular physicians' service furnished in a year is the 
maximum allowable actual charge for the service of the physician for the 
previous year plus the product of (I) the applicable fraction (as 
defined in clause (iii)) and (II) the amount by which 115 percent of the 
prevailing charge for the year involved for such service furnished by 
nonparticipating physicians, exceeds the physician's maximum allowable 
actual charge for the service for the previous year.
    (iii) In clause (ii), the ``applicable fraction'' is--
        (I) for 1987, \1/4\,
        (II) for 1988, \1/3\,
        (III) for 1989, \1/2\, and
        (IV) for any subsequent year, 1.

    (iv) For purposes of determining the maximum allowable actual charge 
under clauses (i) and (ii) for 1987, in the case of a physicians' 
service for which the physician has actual charges for the calendar 
quarter beginning on April 1, 1984, the ``maximum allowable actual 
charge'' for 1986 is the physician's actual charge for such service 
furnished during such quarter.
    (v) For purposes of determining the maximum allowable actual charge 
under clauses (i) and (ii) for a year after 1986, in the case of a 
physicians' service for which the physician has no actual charges for 
the calendar quarter beginning on April 1, 1984, and for which a maximum 
allowable actual charge has not been previously established under this 
clause, the ``maximum allowable actual charge'' for the previous year 
shall be the 50th percentile of the customary charges for the service 
(weighted by frequency of the service) performed by nonparticipating 
physicians in the locality during the 12-month period ending June 30 of 
that previous year.
    (vi) For purposes of this subparagraph, a ``physician's actual 
charge'' for a physicians' service furnished in a year or other period 
is the weighted average (or, at the option of the Secretary for a 
service furnished in the calendar quarter beginning April 1, 1984, the 
median) of the physician's charges for such service furnished in the 
year or other period.
    (vii) In the case of a nonparticipating physician who was a 
participating physician during a previous period, for the purpose of 
computing the physician's maximum allowable actual charge during the 
physician's period of nonparticipation, the physician shall be deemed to 
have had a maximum allowable actual charge during the period of 
participation, and such deemed maximum allowable actual charge shall be 
determined according to clauses (i) through (vi).
    (viii) Notwithstanding any other provision of this subparagraph, the 
maximum allowable actual charge for a particular physician's service 
furnished by a nonparticipating physician to individuals enrolled under 
this part during the 3-month period beginning on January 1, 1988, shall 
be the amount determined under this subparagraph for 1987. The maximum 
allowable actual charge for any such service otherwise determined under 
this subparagraph for 1988 shall take effect on April 1, 1988.
    (ix) If there is a reduction under subsection (b)(13) of this 
section in the reasonable charge for medical direction furnished by a 
nonparticipating physician, the maximum allowable actual charge 
otherwise permitted under this subsection for such services shall be 
reduced in the same manner and in the same percentage as the reduction 
in such reasonable charge.
    (D)(i) If an action described in clause (ii) results in a reduction 
in a reasonable charge for a physicians' service or item and a 
nonparticipating physician furnishes the service or item to an 
individual entitled to benefits under this part after the effective date 
of such action, the physician may not charge the individual more than 
125 percent of the reduced payment allowance (as defined in clause 
(iii)) plus (for services or items furnished during the 12-month period 
(or 9-month period in the case of an action described in clause 
(ii)(II)) beginning on the effective date of the action) \1/2\ of the 
amount by which the physician's maximum allowable actual charge for the 
service or item for the previous 12-month period exceeds such 125 
percent level.
    (ii) The first sentence of clause (i) shall apply to--
        (I) an adjustment under subsection (b)(8)(B) of this section 
    (relating to inherent reasonableness),
        (II) a reduction under subsection (b)(10)(A) or (b)(14)(A) of 
    this section (relating to certain overpriced procedures),
        (III) a reduction under subsection (b)(11)(B) of this section 
    (relating to certain cataract procedures),
        (IV) a prevailing charge limit established under subsection 
    (b)(11)(C)(i) or (b)(15)(A) of this section,
        (V) a reasonable charge limit established under subsection 
    (b)(11)(C)(ii) of this section, and
        (VI) an adjustment under section 1395l(l)(3)(B) of this title 
    (relating to physician supervision of certified registered nurse 
    anesthetists).

    (iii) In clause (i), the term ``reduced payment allowance'' means, 
with respect to an action--
        (I) under subsection (b)(8)(B) of this section, the inherently 
    reasonable charge established under subsection (b)(8) of this 
    section;
        (II) under subsection (b)(10)(A), (b)(11)(B), (b)(11)(C)(i), 
    (b)(14)(A), or (b)(15)(A) of this section or under section 
    1395l(l)(3)(B) of this title, the prevailing charge for the service 
    after the action; or
        (III) under subsection (b)(11)(C)(ii) of this section, the 
    payment allowance established under such subsection.

    (iv) If a physician knowingly and willfully bills in violation of 
clause (i) (whether or not such charge violates subparagraph (B)), the 
Secretary may apply sanctions against such physician in accordance with 
paragraph (2).
    (v) Clause (i) shall not apply to items and services furnished after 
December 31, 1990.
    (2) Subject to paragraph (3), the sanctions which the Secretary may 
apply under this paragraph are--
        (A) excluding a physician from participation in the programs 
    under this chapter for a period not to exceed 5 years, in accordance 
    with the procedures of subsections (c), (f), and (g) of section 
    1320a-7 of this title, or
        (B) civil monetary penalties and assessments, in the same manner 
    as such penalties and assessments are authorized under section 
    1320a-7a(a) of this title,

or both. The provisions of section 1320a-7a of this title (other than 
the first 2 sentences of subsection (a) and other than subsection (b)) 
shall apply to a civil money penalty and assessment under subparagraph 
(B) in the same manner as such provisions apply to a penalty, 
assessment, or proceeding under section 1320a-7a(a) of this title, 
except to the extent such provisions are inconsistent with subparagraph 
(A) or paragraph (3).
    (3)(A) The Secretary may not exclude a physician pursuant to 
paragraph (2)(A) if such physician is a sole community physician or sole 
source of essential specialized services in a community.
    (B) The Secretary shall take into account access of beneficiaries to 
physicians' services for which payment may be made under this part in 
determining whether to bar a physician from participation under 
paragraph (2)(A).
    (4) The Secretary may, out of any civil monetary penalty or 
assessment collected from a physician pursuant to this subsection, make 
a payment to a beneficiary enrolled under this part in the nature of 
restitution for amounts paid by such beneficiary to such physician which 
was determined to be an excess charge under paragraph (1).

(k) Sanctions for billing for services of assistant at cataract 
        operations

    (1) If a physician knowingly and willfully presents or causes to be 
presented a claim or bills an individual enrolled under this part for 
charges for services as an assistant at surgery for which payment may 
not be made by reason of section 1395y(a)(15) of this title, the 
Secretary may apply sanctions against such physician in accordance with 
subsection (j)(2) of this section in the case of surgery performed on or 
after March 1, 1987.
    (2) If a physician knowingly and willfully presents or causes to be 
presented a claim or bills an individual enrolled under this part for 
charges that includes a charge for an assistant at surgery for which 
payment may not be made by reason of section 1395y(a)(15) of this title, 
the Secretary may apply sanctions against such physician in accordance 
with subsection (j)(2) of this section in the case of surgery performed 
on or after March 1, 1987.

(l) Prohibition of unassigned billing of services determined to be 
        medically unnecessary by carrier

    (1)(A) Subject to subparagraph (C), if--
        (i) a nonparticipating physician furnishes services to an 
    individual enrolled for benefits under this part,
        (ii) payment for such services is not accepted on an assignment-
    related basis,
        (iii)(I) a carrier determines under this part or a peer review 
    organization determines under part B of subchapter XI of this 
    chapter that payment may not be made by reason of section 
    1395y(a)(1) of this title because a service otherwise covered under 
    this subchapter is not reasonable and necessary under the standards 
    described in that section or (II) payment under this subchapter for 
    such services is denied under section 1320c-3(a)(2) of this title by 
    reason of a determination under section 1320c-3(a)(1)(B) of this 
    title, and
        (iv) the physician has collected any amounts for such services,

the physician shall refund on a timely basis to the individual (and 
shall be liable to the individual for) any amounts so collected.
    (B) A refund under subparagraph (A) is considered to be on a timely 
basis only if--
        (i) in the case of a physician who does not request 
    reconsideration or seek appeal on a timely basis, the refund is made 
    within 30 days after the date the physician receives a denial notice 
    under paragraph (2), 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 
    physician receives notice of an adverse determination on 
    reconsideration or appeal.

    (C) Subparagraph (A) shall not apply to the furnishing of a service 
by a physician to an individual in the case described in subparagraph 
(A)(iii)(I) if--
        (i) the physician establishes that the physician did not know 
    and could not reasonably have been expected to know that payment may 
    not be made for the service by reason of section 1395y(a)(1) of this 
    title, or
        (ii) before the service was provided, the individual was 
    informed that payment under this part may not be made for the 
    specific service and the individual has agreed to pay for that 
    service.

    (2) Each carrier with a contract in effect under this section with 
respect to physicians and each peer review organization with a contract 
under part B of subchapter XI of this chapter shall send any notice of 
denial of payment for physicians' services based on section 1395y(a)(1) 
of this title and for which payment is not requested on an assignment-
related basis to the physician and the individual involved.
    (3) If a physician knowingly and willfully fails to make refunds in 
violation of paragraph (1)(A), the Secretary may apply sanctions against 
such physician in accordance with subsection (j)(2) of this section.

(m) Disclosure of information of unassigned claims for certain 
        physicians' services

    (1) In the case of a nonparticipating physician who--
        (A) performs an elective surgical procedure for an individual 
    enrolled for benefits under this part and for which the physician's 
    actual charge is at least $500, and
        (B) does not accept payment for such procedure on an assignment-
    related basis,

the physician must disclose to the individual, in writing and in a form 
approved by the Secretary, the physician's estimated actual charge for 
the procedure, the estimated approved charge under this part for the 
procedure, the excess of the physician's actual charge over the approved 
charge, and the coinsurance amount applicable to the procedure. The 
written estimate may not be used as the basis for, or evidence in, a 
civil suit.
    (2) A physician who fails to make a disclosure required under 
paragraph (1) with respect to a procedure shall refund on a timely basis 
to the individual (and shall be liable to the individual for) any 
amounts collected for the procedure in excess of the charges recognized 
and approved under this part.
    (3) If a physician knowingly and willfully fails to comply with 
paragraph (2), the Secretary may apply sanctions against such physician 
in accordance with subsection (j)(2) of this section.
    (4) The Secretary shall provide for such monitoring of requests for 
payment for physicians' services to which paragraph (1) applies as is 
necessary to assure compliance with paragraph (2).

(n) Elimination of markup for certain purchased services

    (1) If a physician's bill or a request for payment for services 
billed by a physician includes a charge for a diagnostic test described 
in section 1395x(s)(3) of this title (other than a clinical diagnostic 
laboratory test) for which the bill or request for payment does not 
indicate that the billing physician personally performed or supervised 
the performance of the test or that another physician with whom the 
physician who shares a practice personally performed or supervised the 
performance of the test, the amount payable with respect to the test 
shall be determined as follows:
        (A) If the bill or request for payment indicates that the test 
    was performed by a supplier, identifies the supplier, and indicates 
    the amount the supplier charged the billing physician, payment for 
    the test (less the applicable deductible and coinsurance amounts) 
    shall be the actual acquisition costs (net of any discounts) or, if 
    lower, the supplier's reasonable charge (or other applicable limit) 
    for the test.
        (B) If the bill or request for payment (i) does not indicate who 
    performed the test, or (ii) indicates that the test was performed by 
    a supplier but does not identify the supplier or include the amount 
    charged by the supplier, no payment shall be made under this part.

    (2) A physician may not bill an individual enrolled under this 
part--
        (A) any amount other than the payment amount specified in 
    paragraph (1)(A) and any applicable deductible and coinsurance for a 
    diagnostic test for which payment is made pursuant to paragraph 
    (1)(A), or
        (B) any amount for a diagnostic test for which payment may not 
    be made pursuant to paragraph (1)(B).

    (3) If a physician knowingly and willfully in repeated cases bills 
one or more individuals in violation of paragraph (2), the Secretary may 
apply sanctions against such physician in accordance with subsection 
(j)(2) of this section.

(o) Reimbursement for drugs and biologicals

    (1) If a physician's, supplier's, or any other person's bill or 
request for payment for services includes a charge for a drug or 
biological for which payment may be made under this part and the drug or 
biological is not paid on a cost or prospective payment basis as 
otherwise provided in this part, the amount payable for the drug or 
biological is equal to 95 percent of the average wholesale price.
    (2) If payment for a drug or biological is made to a licensed 
pharmacy approved to dispense drugs or biologicals under this part, the 
Secretary may pay a dispensing fee (less the applicable deductible and 
coinsurance amounts) to the pharmacy.

(p) Requiring submission of diagnostic information

    (1) Each request for payment, or bill submitted, for an item or 
service furnished by a physician or practitioner specified in subsection 
(b)(18)(C) of this section for which payment may be made under this part 
shall include the appropriate diagnosis code (or codes) as established 
by the Secretary for such item or service.
    (2) In the case of a request for payment for an item or service 
furnished by a physician or practitioner specified in subsection 
(b)(18)(C) of this section on an assignment-related basis which does not 
include the code (or codes) required under paragraph (1), payment may be 
denied under this part.
    (3) In the case of a request for payment for an item or service 
furnished by a physician not submitted on an assignment-related basis 
and which does not include the code (or codes) required under paragraph 
(1)--
        (A) if the physician knowingly and willfully fails to provide 
    the code (or codes) promptly upon request of the Secretary or a 
    carrier, the physician may be subject to a civil money penalty in an 
    amount not to exceed $2,000, and
        (B) if the physician knowingly, willfully, and in repeated cases 
    fails, after being notified by the Secretary of the obligations and 
    requirements of this subsection, to include the code (or codes) 
    required under paragraph (1), the physician may be subject to the 
    sanction described in subsection (j)(2)(A) of this section.

The provisions of section 1320a-7a of this title (other than subsections 
(a) and (b)) shall apply to civil money penalties under subparagraph (A) 
in the same manner as they apply to a penalty or proceeding under 
section 1320a-7a(a) of this title.
    (4) In the case of an item or service defined in paragraph (3), (6), 
(8), or (9) of subsection 1395x(s) of this title ordered by a physician 
or a practitioner specified in subsection (b)(18)(C) of this section, 
but furnished by another entity, if the Secretary (or fiscal agent of 
the Secretary) requires the entity furnishing the item or service to 
provide diagnostic or other medical information in order for payment to 
be made to the entity, the physician or practitioner shall provide that 
information to the entity at the time that the item or service is 
ordered by the physician or practitioner.

(q) Anesthesia services; counting actual time units

    (1)(A) The Secretary, in consultation with groups representing 
physicians who furnish anesthesia services, shall establish by 
regulation a relative value guide for use in all carrier localities in 
making payment for physician anesthesia services furnished under this 
part. Such guide shall be designed so as to result in expenditures under 
this subchapter for such services in an amount that would not exceed the 
amount of such expenditures which would otherwise occur.
    (B) For physician anesthesia services furnished under this part 
during 1991, the prevailing charge conversion factor used in a locality 
under this subsection shall, subject to clause (iv), be reduced to the 
adjusted prevailing charge conversion factor for the locality determined 
as follows:
        (i) The Secretary shall estimate the national weighted average 
    of the prevailing charge conversion factors used under this 
    subsection for services furnished during 1990 after March 31, using 
    the best available data.
        (ii) The national weighted average estimated under clause (i) 
    shall be reduced by 7 percent.
        (iii) The adjusted prevailing charge conversion factor for a 
    locality is the sum of--
            (I) the product of (a) the portion of the reduced national 
        weighted average prevailing charge 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 prevailing charge conversion factor 
        computed under clause (ii) and (b) the geographic practice cost 
        index value specified in subsection (b)(14)(C)(iv) of this 
        section for the locality.

    In applying this clause, 70 percent of the prevailing charge 
    conversion factor shall be considered to be attributable to 
    physician work.
        (iv) The prevailing charge conversion factor to be applied to a 
    locality under this subparagraph shall not be reduced by more than 
    15 percent below the prevailing charge conversion factor applied in 
    the locality for the period during 1990 after March 31, but in no 
    case shall the prevailing charge conversion factor be less than 60 
    percent of the national weighted average of the prevailing charge 
    conversion factors (computed under clause (i)).

    (2) For purposes of payment for anesthesia services (whether 
furnished by physicians or by certified registered nurse anesthetists) 
under this part, the time units shall be counted based on actual time 
rather than rounded to full time units.

(r) Establishment of physician identification system

    The Secretary shall establish a system which provides for a unique 
identifier for each physician who furnishes services for which payment 
may be made under this subchapter. Under such system, the Secretary may 
impose appropriate fees on such physicians to cover the costs of 
investigation and recertification activities with respect to the 
issuance of the identifiers.

(s) Application of fee schedule

    (1) The Secretary may implement a statewide or other areawide fee 
schedule to be used for payment of any item or service described in 
paragraph (2) which is paid on a reasonable charge basis. Any fee 
schedule established under this paragraph for such item or service shall 
be updated each year by the percentage increase in the consumer price 
index for all urban consumers (United States city average) for the 12-
month period ending with June of the preceding year, except that in no 
event shall a fee schedule for an item described in paragraph (2)(D) be 
updated before 2003.
    (2) The items and services described in this paragraph are as 
follows:
        (A) Medical supplies.
        (B) Home dialysis supplies and equipment (as defined in section 
    1395rr(b)(8) of this title).
        (C) Therapeutic shoes.
        (D) Parenteral and enteral nutrients, equipment, and supplies.
        (E) Electromyogram devices.
        (F) Salivation devices.
        (G) Blood products.
        (H) Transfusion medicine.

(t) Facility provider number required on claims submitted by physicians

    Each request for payment, or bill submitted, for an item or service 
furnished by a physician to an individual who is a resident of a skilled 
nursing facility or of a part of a facility that includes a skilled 
nursing facility (as determined under regulations), for which payment 
may be made under this part shall include the facility's medicare 
provider number.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1842, as added Pub. L. 89-97, 
title I, Sec. 102(a), July 30, 1965, 79 Stat. 309; amended Pub. L. 90-
248, title I, Secs. 125(a), 154(d), Jan. 2, 1968, 81 Stat. 845, 863; 
Pub. L. 92-603, title II, Secs. 211(c)(3), 224(a), 227(e)(3), 236(a), 
258(a), 262(a), 263(d)(5), 281(d), Oct. 30, 1972, 86 Stat. 1384, 1395, 
1407, 1414, 1447-1449, 1455; Pub. L. 93-445, title III, Sec. 307, Oct. 
16, 1974, 88 Stat. 1358; Pub. L. 94-182, title I, Sec. 101(a), Dec. 31, 
1975, 89 Stat. 1051; Pub. L. 94-368, Secs. 2, 3(a), (b), July 16, 1976, 
90 Stat. 997; Pub. L. 95-142, Sec. 2(a)(1), Oct. 25, 1977, 91 Stat. 
1175; Pub. L. 95-216, title V, Sec. 501(b), Dec. 20, 1977, 91 Stat. 
1565; Pub. L. 96-499, title IX, Secs. 918(a)(1), 946(a), (b), 948(b), 
Dec. 5, 1980, 94 Stat. 2625, 2642, 2643; Pub. L. 97-35, title XXI, 
Sec. 2142(b), Aug. 13, 1981, 95 Stat. 798; Pub. L. 97-248, title I, 
Secs. 104(a), 113(a), 128(d)(1), Sept. 3, 1982, 96 Stat. 336, 340, 367; 
Pub. L. 98-369, div. B, title III, Secs. 2303(e), 2306(a), (b)(1), (c), 
2307(a)(1), (2), 2326(c)(2), (d)(2), 2339, 2354(b)(13), (14), title VI, 
2663(j)(2)(F)(iv), July 18, 1984, 98 Stat. 1066, 1070, 1071, 1073, 1087, 
1088, 1093, 1101, 1170; Pub. L. 98-617, Sec. 3(a)(1), (b)(5), (6), Nov. 
8, 1984, 98 Stat. 3295, 3296; Pub. L. 99-272, title IX, 
Secs. 9219(b)(1)(A), (2)(A), 9301(b)(1), (2), (c)(2)-(4), (d)(1)-(3), 
9304(a), 9306(a), 9307(c), Apr. 7, 1986, 100 Stat. 182-188, 190, 193, 
194; Pub. L. 99-509, title IX, Secs. 9307(c)(2)(A), 9311(c), 9320(e)(3), 
9331(a)(1)-(3), (b)(1)-(3), (c)(3)(A), 9332(a)(1), (b)(1), (2), (c)(1), 
(d)(1), 9333(a), (b), 9334(a), 9338(b), (c), 9341(a)(2), Oct. 21, 1986, 
100 Stat. 1995, 1998, 2015, 2018-2026, 2028, 2035, 2038; Pub. L. 99-514, 
title XVIII, Sec. 1895(b)(14)(A), (15), (16)(A), Oct. 22, 1986, 100 
Stat. 2934; Pub. L. 100-93, Sec. 8(c)(2), Aug. 18, 1987, 101 Stat. 692; 
Pub. L. 100-203, title IV, Secs. 4031(a)(2), 4035(a)(2), 4041(a)(1), 
(3)(A), 4042(a), (b)(1), (2)(A), (c), 4044(a), 4045(a), (c)(1), (2)(B), 
(D), 4046(a), 4047(a), 4048(a), (e), 4051(a), 4053(a), formerly 4052(a), 
4054(a), formerly 4053(a), 4063(a), 4081(a), 4082(c), 4085(g)(1), 
(i)(5)-(7), (22)(C), (24)-(27), 4096(a)(1), Dec. 22, 1987, 101 Stat. 
1330-76, 1330-78, 1330-83 to 1330-89, 1330-93, 1330-97, 1330-109, 1330-
126, 1330-128, 1330-131, 1330-132, 1330-139, as amended Pub. L. 100-360, 
title IV, Sec. 411(f)(1)(A), (2)(C), (D), (F), (3)(A), (4)(B), (7)(B), 
(11)(A), (14), (g)(2)(C), (i)(2), (4)(C)(vi), (j)(4)(A), July 1, 1988, 
102 Stat. 776-779, 781, 783, 788, 789, 791; Pub. L. 100-360, title II, 
Secs. 201(c), 202(c)(1), (e)(1)-(3)(A), (C), (4)(A), (5), (g), 223(b), 
(c), title IV, Sec. 411(a)(3)(A), (C)(i), (f)(1)(B), (2)(A), (B), (E), 
(3)(B), (4)(A), (C), (5), (6)(B), (7)(A), (9), (g)(2)(A), (B), 
(i)(1)(A), July 1, 1988, 102 Stat. 702, 713, 716-718, 747, 768, 776-780, 
783, 787; Pub. L. 100-485, title VI, Sec. 608(d)(5)(A)-(D), (F)-(H), 
(17), (21)(A), (B), (D), (24)(B), Oct. 13, 1988, 102 Stat. 2414, 2418, 
2420, 2421; Pub. L. 101-234, title II, Sec. 201(a), title III, 
Sec. 301(b)(2), (6), (c)(2), (d)(3), Dec. 13, 1989, 103 Stat. 1981, 
1985, 1986; Pub. L. 101-239, title VI, Secs. 6003(g)(3)(D)(ix), 6102(b), 
(e)(2)-(4), (9), 6104, 6106(a), 6107(b), 6108(a)(1), (b)(1), (2), 
6114(b), (c), 6202(d)(2), Dec. 19, 1989, 103 Stat. 2153, 2184, 2187, 
2188, 2208, 2210, 2212, 2213, 2218, 2234; Pub. L. 101-508, title IV, 
Secs. 4101(a), (b)(1), 4103, 4105(a)(1), (2), (b)(1), 4106(a)(1), 
(b)(2), 4108(a), 4110(a), 4118(a)(1), (2), (f)(2)(A)-(C), (i)(1), 
(j)(2), 4155(c), Nov. 5, 1990, 104 Stat. 1388-54, 1388-58 to 1388-63, 
1388-66, 1388-67, 1388-69 to 1388-71, 1388-87; Pub. L. 101-597, title 
IV, Sec. 401(c)(2), Nov. 16, 1990, 104 Stat. 3035; Pub. L. 103-66, title 
XIII, Secs. 13515(a)(2), 13516(a)(2), 13517(b), 13568(a), (b), Aug. 10, 
1993, 107 Stat. 583-585, 608; Pub. L. 103-432, title I, Secs. 123(b)(1), 
(2)(B), (c), 125(a), (b)(1), 126(a)(1), (c), (e), (g)(9), (h)(2), 
135(b)(2), 151(b)(1)(B), (2)(B), Oct. 31, 1994, 108 Stat. 4411-4416, 
4423, 4434; Pub. L. 104-191, title II, Secs. 202(b)(2), 221(b), Aug. 21, 
1996, 110 Stat. 1998, 2011; Pub. L. 105-33, title IV, Secs. 4201(c)(1), 
4205(d)(3)(B), 4302(b), 4315(a), 4316(a), 4317(a), (b), 4432(b)(2), (4), 
4512(b)(2), (c), 4531(a)(2), 4556(a), 4603(c)(2)(B)(i), 4611(d), Aug. 5, 
1997, 111 Stat. 373, 377, 382, 390, 392, 421, 444, 450, 462, 471, 473; 
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 223(c), title 
III, Secs. 305(a), 321(k)(4)], Nov. 29, 1999, 113 Stat. 1536, 1501A-353, 
1501A-361, 1501A-366.)

                       References in Text

    Part A of this subchapter, referred to in subsecs. (a) and 
(b)(2)(E), is classified to section 1395c et seq. of this title.
    Section 1395w-1 of this title, referred to in subsec. (b)(2)(A), was 
repealed by Pub. L. 105-33, title IV, Sec. 4022(b)(2)(A), Aug. 5, 1997, 
111 Stat. 354.
    Section 4611 of the Balanced Budget Act of 1997, referred to in 
subsec. (b)(2)(E), is section 4611 of Pub. L. 105-33, which amended this 
section and sections 1395d, 1395x and 1395ff of this title.
    The Omnibus Budget Reconciliation Act of 1990, referred to in 
subsec. (b)(14)(A)(ii), is Pub. L. 101-508, Nov. 5, 1990, 104 Stat. 
1388. For complete classification of this Act to the Code, see Tables.
    Part B of subchapter XI of this chapter, referred to in subsec. 
(l)(1)(A)(iii), (2), is classified to section 1320c et seq. of this 
title.


                               Amendments

    1999--Subsec. (b)(6)(F). Pub. L. 106-113, Sec. 1000(a)(6) [title 
III, Sec. 305(a)], inserted ``(including medical supplies described in 
section 1395x(m)(5) of this title, but excluding durable medical 
equipment to the extent provided for in such section)'' after ``home 
health services''.
    Subsec. (b)(8)(A)(i)(I). Pub. L. 106-113, Sec. 1000(a)(6) [title II, 
Sec. 223(c)], substituted ``the application of this subchapter to 
payment under this part'' for ``the application of this part''.
    Subsec. (s)(2)(E). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(4)], inserted period at end.
    1997--Subsec. (b)(2)(E). Pub. L. 105-33, Sec. 4611(d), added subpar. 
(E).
    Subsec. (b)(6). Pub. L. 105-33, Sec. 4512(c), inserted at end ``For 
purposes of subparagraph (C) of the first sentence of this paragraph, an 
employment relationship may include any independent contractor 
arrangement, and employer status shall be determined in accordance with 
the law of the State in which the services described in such clause are 
performed.''
    Subsec. (b)(6)(A)(ii). Pub. L. 105-33, Sec. 4201(c)(1), substituted 
``critical access'' for ``rural primary care''.
    Subsec. (b)(6)(C). Pub. L. 105-33, Sec. 4205(d)(3)(B), amended 
subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: 
``in the case of services described in clauses (i), (ii), or (iv) of 
section 1395x(s)(2)(K) of this title payment shall be made to the 
employer of the physician assistant or nurse practitioner involved, 
and''.
    Subsec. (b)(6)(E). Pub. L. 105-33, Sec. 4432(b)(2), added subpar. 
(E).
    Subsec. (b)(6)(F). Pub. L. 105-33, Sec. 4603(c)(2)(B)(i), added 
subpar. (F).
    Subsec. (b)(8), (9). Pub. L. 105-33, Sec. 4316(a), amended pars. (8) 
and (9) generally. Prior to amendment, par. (8) related to determination 
of reasonable charges for physician services, including factors to be 
considered, provision for increase or decrease of charge, consideration 
of resource costs, accounting for regional differences in prevailing 
charges, and impact of changes in reasonable charges, and par. (9) 
related to notice of proposed reasonable charges to be published in 
Federal Register, provision for comments on proposed changes, and 
publication of final determinations with respect to change in reasonable 
charges.
    Subsec. (b)(12). Pub. L. 105-33, Sec. 4512(b)(2), struck out par. 
(12) which read as follows:
    ``(12)(A) With respect to services described in clauses (i), (ii), 
or (iv) of section 1395x(s)(2)(K) of this title (relating to a physician 
assistants and nurse practitioners)--
        ``(i) payment under this part may only be made on an assignment-
    related basis; and
        ``(ii) the prevailing charges determined under paragraph (3) 
    shall not exceed--
            ``(I) in the case of services performed as an assistant at 
        surgery, 65 percent of the amount that would otherwise be 
        recognized if performed by a physician who is serving as an 
        assistant at surgery, or
            ``(II) in other cases, the applicable percentage (as defined 
        in subparagraph (B)) of the prevailing charge rate determined 
        for such services (or, for services furnished on or after 
        January 1, 1992, the fee schedule amount specified in section 
        1395w-4 of this title) performed by physicians who are not 
        specialists.
    ``(B) In subparagraph (A)(ii)(II), the term `applicable percentage' 
means--
        ``(i) 75 percent in the case of services performed (other than 
    as an assistant at surgery) in a hospital, and
        ``(ii) 85 percent in the case of other services.''
    Subsec. (b)(19). Pub. L. 105-33, Sec. 4531(a)(2), added par. (19).
    Subsec. (h)(8). Pub. L. 105-33, Sec. 4302(b), added par. (8).
    Subsec. (o). Pub. L. 105-33, Sec. 4556(a), added subsec. (o).
    Subsec. (p)(1), (2). Pub. L. 105-33, Sec. 4317(a), inserted ``or 
practitioner specified in subsection (b)(18)(C) of this section'' after 
``by a physician''.
    Subsec. (p)(4). Pub. L. 105-33, Sec. 4317(b), added par. (4).
    Subsec. (s). Pub. L. 105-33, Sec. 4315(a), added subsec. (s).
    Subsec. (t). Pub. L. 105-33, Sec. 4432(b)(4), added subsec. (t).
    1996--Subsec. (c)(6). Pub. L. 104-191, Sec. 202(b)(2), added par. 
(6).
    Subsec. (r). Pub. L. 104-191, Sec. 221(b), inserted at end ``Under 
such system, the Secretary may impose appropriate fees on such 
physicians to cover the costs of investigation and recertification 
activities with respect to the issuance of the identifiers.''
    1994--Subsec. (b)(2)(A). Pub. L. 103-432, Sec. 126(g)(9), made 
technical amendment to directory language of Pub. L. 101-508, 
Sec. 4118(j)(2). See 1990 Amendment note below.
    Subsec. (b)(2)(D). Pub. L. 103-432, Sec. 151(b)(2)(B), added subpar. 
(D).
    Subsec. (b)(3)(G). Pub. L. 103-432, Sec. 151(b)(1)(B)(i), which 
directed striking out ``and'' at end of subpar. (G), could not be 
executed because ``and'' did not appear at end of subpar. (G) subsequent 
to amendment by Pub. L. 103-432, Sec. 123(c)(2). See below.
    Pub. L. 103-432, Sec. 123(c)(2), amended subpar. (G) generally. 
Prior to amendment, subpar. (G) read as follows: ``will provide to each 
nonparticipating physician, at the beginning of each year, a list of the 
physician's limiting charges established under section 1395w-4(g)(2) of 
this title for the year for the physicians' services mostly commonly 
furnished by that physician; and''.
    Subsec. (b)(3)(H). Pub. L. 103-432, Sec. 151(b)(1)(B)(ii), which 
directed striking out ``and'' at end of subpar. (H), could not be 
executed because ``and'' does not appear at end.
    Subsec. (b)(3)(I). Pub. L. 103-432, Sec. 151(b)(1)(B)(iii), added 
subpar. (I).
    Subsec. (b)(6)(D). Pub. L. 103-432, Sec. 125(b)(1), amended subpar. 
(D) generally. Prior to amendment, subpar. (D) read as follows: 
``payment may be made to a physician who arranges for visit services 
(including emergency visits and related services) to be provided to an 
individual by a second physician on an occasional, reciprocal basis if 
(i) the first physician is unavailable to provide the visit services, 
(ii) the individual has arranged or seeks to receive the visit services 
from the first physician, (iii) the claim form submitted to the carrier 
includes the second physician's unique identifier (provided under the 
system established under subsection (r) of this section) and indicates 
that the claim is for such a `covered visit service (and related 
services)', and (iv) the visit services are not provided by the second 
physician over a continuous period of longer than 60 days.''
    Subsec. (b)(12)(C). Pub. L. 103-432, Sec. 123(b)(2)(B), struck out 
subpar. (C). Prior to amendment, subpar. (C) read as follows: ``Except 
for deductible and coinsurance amounts applicable under section 1395l of 
this title, any person who knowingly and willfully presents, or causes 
to be presented, to an individual enrolled under this part a bill or 
request for payment for services described in clauses (i), (ii), or (iv) 
of section 1395x(s)(2)(K) of this title in violation of subparagraph 
(A)(i) is subject to a civil money penalty of not to exceed $2,000 for 
each such bill or request. The provisions of section 1320a-7a of this 
title (other than subsections (a) and (b)) shall apply to a civil money 
penalty under the previous sentence in the same manner as such 
provisions apply to a penalty or proceeding under section 1320a-7a(a) of 
this title.''
    Subsec. (b)(16)(B)(iii). Pub. L. 103-432, Sec. 126(a)(1), struck out 
``, simple and subcutaneous'' after ``Partial'', substituted 
``injections and small joint'' for ``injections; small joint'' and 
``femoral fracture and'' for ``femoral fracture treatments;'', struck 
out ``lobectomy;'' after ``thoracostomy;'' and ``enterectomy; colectomy; 
cholecystectomy;'' after ``aneurysm repair;'', substituted ``fulguration 
and resection'' for ``fulguration; transurerethral resection'', and 
struck out ``sacral laminectomy;'' before ``tympanoplasty''.
    Subsec. (b)(17). Pub. L. 103-432, Sec. 126(e), redesignated par. 
(18), relating to payment for technical component of diagnostic tests, 
as (17) and inserted ``, tests specified in paragraph (14)(C)(i),'' 
after ``diagnostic laboratory tests''.
    Subsec. (b)(18). Pub. L. 103-432, Sec. 126(e), redesignated par. 
(18), relating to payment for technical component of diagnostic tests, 
as (17).
    Pub. L. 103-432, Sec. 123(b)(1), added par. (18), relating to 
payment for service furnished by a practitioner described in subpar. 
(C).
    Subsec. (c)(1). Pub. L. 103-432, Sec. 126(h)(2), struck out subpar. 
(A) designation before ``Any contract entered'' and struck out subpar. 
(B) which read as follows: ``Of the amounts appropriated for 
administrative activities to carry out this part, the Secretary shall 
provide payments, totaling 1 percent of the total payments to carriers 
for claims processing in any fiscal year, to carriers under this 
section, to reward carriers for their success in increasing the 
proportion of physicians in the carrier's service area who are 
participating physicians or in increasing the proportion of total 
payments for physicians' services which are payments for such services 
rendered by participating physicians.''
    Subsec. (c)(4). Pub. L. 103-432, Sec. 125(a), added par. (4).
    Subsec. (c)(5). Pub. L. 103-432, Sec. 135(b)(2), added par. (5).
    Subsec. (h)(7)(C). Pub. L. 103-432, Sec. 123(c)(1)(B), struck out 
``shall include'' before cl. (i).
    Subsec. (h)(7)(D). Pub. L. 103-432, Sec. 123(c)(1)(A), (C), (D), 
added subpar. (D).
    Subsec. (q)(1). Pub. L. 103-432, Sec. 126(c)(1), made technical 
amendment to Pub. L. 101-508, Sec. 4103(a). See 1990 Amendment note 
below.
    Subsec. (q)(1)(B). Pub. L. 103-432, Sec. 126(c)(2)(A), substituted 
``shall, subject to clause (iv), be reduced to the adjusted prevailing 
charge conversion factor for the locality determined as follows:'' for 
``shall be determined as follows:'' in introductory provisions.
    Subsec. (q)(1)(B)(iii). Pub. L. 103-432, Sec. 126(c)(2)(B), 
substituted ``The adjusted prevailing charge conversion factor for'' for 
``Subject to clause (iv), the prevailing charge conversion factor to be 
applied in''.
    1993--Subsec. (b)(4)(F). Pub. L. 103-66, Sec. 13515(a)(2), struck 
out subpar. (F) which related to prevailing charge or fee schedule 
amount in case of professional services of health care practitioner 
(other than primary care services and other than services furnished in 
rural area designated as health professional shortage area) furnished 
during practitioner's first through fourth years of practice.
    Subsec. (b)(13)(A). Pub. L. 103-66, Sec. 13516(a)(2)(A), added 
subpar. (A) and struck out former subpar. (A) which read as follows: 
``In determining the reasonable charge under paragraph (3) of a 
physician for medical direction of two or more nurse anesthetists 
performing, on or after April 1, 1988, and before January 1, 1996, 
anesthesia services in whole or in part concurrently, the number of base 
units which may be recognized with respect to such medical direction for 
each concurrent procedure (other than cataract surgery or an iridectomy) 
shall be reduced by--
        ``(i) 10 percent, in the case of medical direction of 2 nurse 
    anesthetists concurrently,
        ``(ii) 25 percent, in the case of medical direction of 3 nurse 
    anesthetists concurrently, and
        ``(iii) 40 percent, in the case of medical direction of 4 nurse 
    anesthetists concurrently.''
    Subsec. (b)(13)(B), (C). Pub. L. 103-66, Sec. 13516(a)(2), 
redesignated subpar. (C) as (B), substituted ``subparagraph (A)'' for 
``subparagraph (A) or (B)'', and struck out former subpar. (B) which 
read as follows: ``In determining the reasonable charge under paragraph 
(3) of a physician for medical direction of two or more nurse 
anesthetists performing, on or after January 1, 1989, and before January 
1, 1996, anesthesia services in whole or in part concurrently, the 
number of base units which may be recognized with respect to such 
medical direction for each concurrent cataract surgery or iridectomy 
procedure shall be reduced by 10 percent.''
    Subsec. (c)(2)(B)(ii). Pub. L. 103-66, Sec. 13568(b), substituted 
``period ending on or before September 30, 1993'' for ``period'' in 
subcl. (IV) and added subcl. (V).
    Subsec. (c)(3)(B). Pub. L. 103-66, Sec. 13568(a), added cls. (i) and 
(ii) and struck out former cls. (i) and (ii) which read as follows:
    ``(i) with respect to claims received in the 3-month period 
beginning July 1, 1988, 10 days, and
    ``(ii) with respect to claims received in the 12-month period 
beginning October 1, 1988, 14 days.''
    Subsec. (i)(2). Pub. L. 103-66, Sec. 13517(b), substituted ``; the 
term'' for ``, and the term'' and inserted before period at end ``; and 
the term `nonparticipating supplier or other person' means a supplier or 
other person (excluding a provider of services) that is not a 
participating physician or supplier (as defined in subsection (h)(1) of 
this section)''.
    1990--Subsec. (b)(2)(A). Pub. L. 101-508, Sec. 4118(j)(2), as 
amended by Pub. L. 103-432, Sec. 126(g)(9), substituted ``section 1395w-
1(e)(2)'' for ``section 1395w-1(f)(2)''.
    Subsec. (b)(3)(G). Pub. L. 101-508, Sec. 4118(f)(2)(B), substituted 
``section 1395w-4(g)(2) of this title'' for ``subsection (j)(1)(C) of 
this section''.
    Subsec. (b)(4)(A)(vi). Pub. L. 101-508, Sec. 4105(b)(1), substituted 
``60 percent'' for ``50 percent''.
    Subsec. (b)(4)(B)(iv). Pub. L. 101-508, Sec. 4105(a)(2), added cl. 
(iv).
    Subsec. (b)(4)(E)(iv)(I). Pub. L. 101-508, Sec. 4118(a)(2), 
substituted ``the list referred to in paragraph (14)(C)(i)'' for ``Table 
<greek-i>2 in the Joint Explanatory Statement of the Committee of 
Conference submitted with the Conference Report to accompany H.R. 3299 
(the `Omnibus Budget Reconciliation Act of 1989'), 101st Congress''.
    Subsec. (b)(4)(E)(v). Pub. L. 101-508, Sec. 4105(a)(1), added cl. 
(v).
    Subsec. (b)(4)(F). Pub. L. 101-508, Sec. 4106(a)(1), amended subpar. 
(F) generally. Prior to amendment, subpar. (F) read as follows: ``In 
determining the customary charges for physicians' services furnished 
during a calendar year (other than primary care services and other than 
services furnished in a rural area (as defined in section 
1395ww(d)(2)(D) of this title) that is designated, under section 
254e(a)(1)(A) of this title, as a health manpower shortage area) for 
which adequate actual charge data are not available because a physician 
has not yet been in practice for a sufficient period of time, the 
Secretary shall set a customary charge at a level no higher than 80 
percent of the prevailing charge for a service. For the first calendar 
year during which the preceding sentence no longer applies, the 
Secretary shall set the customary charge at a level no higher than 85 
percent of the prevailing charge for the service.''
    Subsec. (b)(4)(F)(i). Pub. L. 101-597 substituted ``health 
professional shortage area'' for ``health manpower shortage area''.
    Pub. L. 101-508, Sec. 4106(b)(2)(A), (B), substituted ``professional 
services'' for ``physicians' services and professional services'' and 
``practitioner's first'' for ``physician's or practitioner's first''.
    Subsec. (b)(4)(F)(ii)(II). Pub. L. 101-508, Sec. 4106(b)(2)(C), 
substituted ``practitioner'' for ``physician or practitioner'' in two 
places.
    Subsec. (b)(6)(C). Pub. L. 101-508, Sec. 4155(c), substituted 
``clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)'' for ``section 
1395x(s)(2)(K)''.
    Subsec. (b)(6)(D). Pub. L. 101-508, Sec. 4110(a), added subpar. (D).
    Subsec. (b)(12)(A). Pub. L. 101-508, Sec. 4155(c), substituted 
``clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)'' for ``section 
1395x(s)(2)(K)'' in introductory provisions.
    Subsec. (b)(12)(A)(ii)(II). Pub. L. 101-508, Sec. 4118(f)(2)(C), 
struck out ``, as the case may be'' after ``section 1395w-4 of this 
title''.
    Pub. L. 101-508, Sec. 4118(f)(2)(A), made technical correction to 
Pub. L. 101-239, Sec. 6102(e)(4). See 1989 Amendment note below.
    Subsec. (b)(12)(C). Pub. L. 101-508, Sec. 4155(c), substituted 
``clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)'' for ``section 
1395x(s)(2)(K)''.
    Subsec. (b)(13)(A), (B). Pub. L. 101-508, Sec. 4103(b), substituted 
``1996'' for ``1991''.
    Subsec. (b)(14)(A). Pub. L. 101-508, Sec. 4101(a), designated 
existing provisions as cl. (i) and added cl. (ii).
    Subsec. (b)(14)(B)(iii)(I). Pub. L. 101-508, Sec. 4118(a)(1)(A), 
which directed amendment of subcl. (I) by substituting ``practice 
expense component (percent), divided by 100, specified in appendix A 
(pages 187 through 194) of the Report of the Medicare and Medicaid 
Health Budget Reconciliation Amendments of 1989, prepared by the 
Subcommittee on Health and the Environment of the Committee on Energy 
and Commerce, House of Representatives, (Committee Print 101-M, 101st 
Congress, 1st Session) for the service'' for ``practice expense ratio 
for the service (specified in table <greek-i>1 in the Joint Explanatory 
Statement referred to in subparagraph (C)(i))'', was executed by making 
the substitution for ``practice expense ratio for the service (specified 
in Table <greek-i>1 in the Joint Explanatory Statement referred to in 
subparagraph (C)(i))'' to reflect the probable intent of Congress.
    Subsec. (b)(14)(B)(iii)(II). Pub. L. 101-508, Sec. 4118(a)(1)(B), 
substituted ``practice expense component (percent), divided by 100'' for 
``practice expense ratio''.
    Subsec. (b)(14)(C)(i). Pub. L. 101-508, Sec. 4118(a)(1)(C), 
substituted ``procedures specified (by code and description) in the 
Overvalued Procedures List for Finance Committee, Revised September 20, 
1989, prepared by the Physician Payment Review Commission'' for 
``physicians' services specified in Table <greek-i>2 in the Joint 
Explanatory Statement of the Committee of Conference submitted with the 
Conference Report to accompany H.R. 3299 (the `Omnibus Budget 
Reconciliation Act of 1989'), 101st Congress,''.
    Subsec. (b)(14)(C)(iii). Pub. L. 101-508, Sec. 4118(a)(1)(D), which 
directed amendment of cl. (iii) by substituting ``The `percentage 
change' specified in this clause, for a physicians' service specified in 
clause (i), is the percent difference (but expressed as a positive 
number) specified for the service in the list'' for ``The `percent 
change' specified in this clause, for a physicians' service specified in 
clause (i), is the percent change specified for the service in table 
<greek-i>2 in the Joint Explanatory Statement'', was executed by making 
the substitution for ``The `percent change' specified in this clause, 
for a physicians' service specified in clause (i), is the percent change 
specified for the service in Table <greek-i>2 in the Joint Explanatory 
Statement'' to reflect the probable intent of Congress.
    Subsec. (b)(14)(C)(iv). Pub. L. 101-508, Sec. 4118(a)(1)(E), which 
directed amendment of cl. (iv) by substituting ``the Geographic Overhead 
Costs Index specified for the locality in table 1 of the September 1989 
Supplement to the Geographic Medicare Economic Index: Alternative 
Approaches (prepared by the Urban Institute and the Center for Health 
Economics Research)'' for ``such value specified for the locality in 
table <greek-i>3 in the Joint Explanatory Statement referred to in 
clause (i)'', was executed by making the substitution for ``such value 
specified for the locality in Table <greek-i>3 in the Joint Explanatory 
Statement referred to in clause (i)'' to reflect the probable intent of 
Congress.
    Subsec. (b)(16). Pub. L. 101-508, Sec. 4101(b), added par. (16).
    Subsec. (b)(18). Pub. L. 101-508, Sec. 4108(a), added par. (18).
    Subsec. (q)(1). Pub. L. 101-508, Sec. 4103(a), as amended by Pub. L. 
103-432, Sec. 126(c)(1), designated existing provisions as subpar. (A) 
and added subpar. (B).
    Subsec. (r). Pub. L. 101-508, Sec. 4118(i)(1), added subsec. (r).
    1989--Subsec. (b)(2)(A). Pub. L. 101-239, Sec. 6202(d)(2), inserted 
at end ``The Secretary may not require, as a condition of entering into 
or renewing a contract under this section or under section 1395hh of 
this title, that a carrier match data obtained other than in its 
activities under this part with data used in the administration of this 
part for purposes of identifying situations in which section 1395y(b) of 
this title may apply.''
    Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 202(e)(3)(C), and provided that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, see 1988 Amendment note below.
    Subsec. (b)(2)(C). Pub. L. 101-239, Sec. 6114(c)(2), added subpar. 
(C).
    Subsec. (b)(3)(G). Pub. L. 101-239, Sec. 6102(e)(2), substituted 
``limiting charges established under subsection (j)(1)(C) of this 
section'' for ``maximum allowable actual charges (established under 
subsection (j)(1)(C) of this section)''.
    Subsec. (b)(3)(I) to (K). Pub. L. 101-234, Sec. 201(a), repealed 
Pub. L. 100-360, Secs. 201(c), 202(e)(2), and provided that the 
provisions of law amended or repealed by such sections are restored or 
revived as if such sections had not been enacted, see 1988 Amendment 
notes below.
    Subsec. (b)(3)(L). Pub. L. 101-239, Sec. 6102(b), added subpar. (L).
    Subsec. (b)(4)(A)(iv). Pub. L. 101-239, Sec. 6102(e)(3), inserted 
``and before January 1, 1992,'' after ``January 1, 1987,''.
    Subsec. (b)(4)(E)(iv). Pub. L. 101-239, Sec. 6107(b), added cl. 
(iv).
    Subsec. (b)(4)(F). Pub. L. 101-239, Sec. 6108(a)(1), inserted 
``furnished during a calendar year'' after ``physicians' services'' and 
inserted at end ``For the first calendar year during which the preceding 
sentence no longer applies, the Secretary shall set the customary charge 
at a level no higher than 85 percent of the prevailing charge for the 
service.''
    Subsec. (b)(6)(A)(ii). Pub. L. 101-239, Sec. 6003(g)(3)(D)(ix), 
inserted ``rural primary care hospital,'' after ``hospital,''.
    Subsec. (b)(6)(C). Pub. L. 101-239, Sec. 6114(c)(1), inserted ``or 
nurse practitioner'' after ``physician assistant''.
    Subsec. (b)(12)(A). Pub. L. 101-239, Sec. 6114(b), substituted 
``physician assistants and nurse practitioners'' for ``physician 
assistant acting under the supervision of a physician'' in introductory 
provisions.
    Subsec. (b)(12)(A)(ii)(II). Pub. L. 101-239, Sec. 6102(e)(4), as 
amended by Pub. L. 101-508, Sec. 4118(f)(2)(A), inserted ``(or, for 
services furnished on or after January 1, 1992, the fee schedule amount 
specified in section 1395w-4 of this title, as the case may be)'' after 
``prevailing charge rate determined for such services''.
    Subsec. (b)(14). Pub. L. 101-239, Sec. 6104(a), added par. (14).
    Subsec. (b)(15). Pub. L. 101-239, Sec. 6108(b)(1), added par. (15).
    Subsecs. (c)(1)(A), (2)(A), (3)(A), (4), (f)(3), (h)(1), (2), (4). 
Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 202(c)(1)(A), (B), (e)(1), (3)(A), (4)(A), (5), and provided that 
the provisions of law amended or repealed by such section are restored 
or revived as if such section had not been enacted, see 1988 Amendment 
notes below.
    Subsec. (j)(1)(B)(ii). Pub. L. 101-239, Sec. 6102(e)(9), substituted 
``December 31, 1990.'' for ``the earlier of (I) December 31, 1990, or 
(II) one-year after the date the Secretary reports to Congress, under 
section 1395w-1(e)(3) of this title, on the development of the relative 
value scale under section 1395w-1 of this title.''
    Subsec. (j)(1)(C)(vii). Pub. L. 101-234, Sec. 301(b)(2), (c)(2), 
amended cl. (vii) identically, substituting ``according'' for 
``accordingly''.
    Subsec. (j)(1)(D)(ii)(II). Pub. L. 101-239, Sec. 6104(b)(1), 
inserted ``or (b)(14)(A)'' after ``(b)(10)(A)''.
    Subsec. (j)(1)(D)(ii)(IV). Pub. L. 101-239, Sec. 6108(b)(2)(A), 
inserted ``or (b)(15)(A)'' after ``subsection (b)(11)(C)(i)''.
    Subsec. (j)(1)(D)(iii)(II). Pub. L. 101-239, Sec. 6108(b)(2)(B), 
substituted ``(b)(14)(A), or (b)(15)(A)'' for ``or (b)(14)(A)''.
    Pub. L. 101-239, Sec. 6104(b)(2), substituted ``(b)(11)(C)(i), or 
(b)(14)(A)'' for ``or (b)(11)(C)(i)''.
    Subsec. (j)(1)(D)(v). Pub. L. 101-239, Sec. 6102(e)(9), substituted 
``December 31, 1990.'' for ``the earlier of (I) December 31, 1990, or 
(II) one-year after the date the Secretary reports to Congress, under 
section 1395w-1(e)(3) of this title, on the development of the relative 
value scale under section 1395w-1 of this title.''
    Subsec. (j)(2). Pub. L. 101-234, Sec. 301(b)(6), (d)(3), which 
directed identical amendments to subsec. (j)(2) by substituting 
``subsections'' for ``paragraphs'' in subpar. (B) as amended by section 
8(c)(2)(A) of the Medicare and Medicaid Fraud and Abuse Patient 
Protection Act of 1987 [probably meaning section 8(c)(2)(A) of Pub. L. 
100-93, the Medicare and Medicaid Patient and Program Protection Act of 
1987, which amended subpar. (A) of subsec. (j)(2), generally] could not 
be executed because the word ``paragraphs'' did not appear.
    Subsec. (o). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 202(c)(1)(C), and provided that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, see 1988 Amendment note below.
    Subsec. (q). Pub. L. 101-239, Sec. 6106(a), added subsec. (q).
    1988--Subsec. (b)(2). Pub. L. 100-360, Sec. 411(i)(2), amended Pub. 
L. 100-203, Sec. 4082(c), see 1987 Amendment note below.
    Subsec. (b)(2)(A). Pub. L. 100-485, Sec. 608(d)(5)(G), inserted ``, 
including claims processing functions'' after ``and related functions'' 
in last sentence.
    Pub. L. 100-360, Sec. 411(f)(1)(B), inserted reference to section 
1395w-1(f)(2) of this title in third sentence.
    Pub. L. 100-360, Sec. 202(e)(3)(C), as amended by Pub. L. 100-485, 
Sec. 608(d)(5)(F), inserted at end ``With respect to activities relating 
to implementation and operation (and related functions) of the 
electronic system established under subsection (o)(4) of this section, 
the Secretary may enter into contracts with carriers under this section 
to perform such activities on a regional basis.''
    Subsec. (b)(3). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added Pub. 
L. 100-203, Sec. 4085(i)(24), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(f)(4)(B)(ii), added Pub. L. 100-203, 
Sec. 4045(c)(2)(D), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(f)(11)(A), (14), renumbered and amended 
Pub. L. 100-203, Sec. 4053(a), see 1987 Amendment note below.
    Subsec. (b)(3)(B)(ii). Pub. L. 100-360, Sec. 411(j)(4)(A), made 
technical correction to directory language of Pub. L. 100-203, 
Sec. 4096(a)(1)(A), see 1987 Amendment note below.
    Subsec. (b)(3)(I). Pub. L. 100-360, Sec. 201(c), added subpar. (I) 
requiring notice that an individual has reached the part B catastrophic 
limit on out-of-pocket cost sharing for the year.
    Subsec. (b)(3)(J). Pub. L. 100-360, Sec. 202(e)(2), added subpar. 
(J) relating to requirements for determinations or payments with respect 
to covered outpatient drugs, to receive information and respond to 
requests by participating pharmacies.
    Subsec. (b)(3)(K). Pub. L. 100-485, Sec. 608(d)(5)(C), inserted ``, 
including claims processing functions,'' after ``and for related 
functions''.
    Pub. L. 100-360, Sec. 202(e)(2), added subpar. (K) requiring 
contracts with organizations described in subsection (f)(3) of this 
section to implement and operate the electronic system established under 
subsection (o)(4) of this section for covered outpatient drugs.
    Subsec. (b)(4)(A)(iv). Pub. L. 100-360, Sec. 411(f)(2)(F)(i), as 
amended by Pub. L. 100-485, Sec. 608(d)(21)(B), redesignated and amended 
Pub. L. 100-203, Sec. 4042(c)(1), see 1987 Amendment note below.
    Subsec. (b)(4)(A)(iv)(II). Pub. L. 100-360, Sec. 411(f)(2)(E), 
substituted ``before January 1, 1989'' for ``before January 1, 1988''.
    Subsec. (b)(4)(A)(vi). Pub. L. 100-360, Sec. 411(f)(3)(A), made 
technical amendment to directory language of Pub. L. 100-203, 
Sec. 4044(a), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(f)(3)(B), substituted ``subsection (i)(4) 
of this section'' for ``subparagraph (E)(iii)'' and ``the estimated 
average prevailing charge levels based on the best available data'' for 
``the average of the prevailing charge levels'' and struck out ``for 
participating physicians'' before ``under the third''.
    Subsec. (b)(4)(A)(vii). Pub. L. 100-360, Sec. 411(f)(2)(D), added 
Pub. L. 100-203, Sec. 4042(b)(2)(A), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(f)(3)(A), made technical amendment to 
directory language of Pub. L. 100-203, Sec. 4044(a), see 1987 Amendment 
note below.
    Subsec. (b)(4)(E). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 
100-203, Sec. 4042(b)(1)(C), (D), see 1987 Amendment notes below.
    Subsec. (b)(4)(F). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 
100-203, Sec. 4042(b)(1)(D), see 1987 Amendment note below.
    Subsec. (b)(4)(F)(ii)(I). Pub. L. 100-360, Sec. 411(f)(2)(B), 
substituted ``subsection (i)(4) of this section'' for ``subparagraph 
(E)(iii)''.
    Subsec. (b)(4)(F)(iii). Pub. L. 100-360, Sec. 411(f)(2)(A), 
substituted ``services,'' for ``services;'' in subcl. (I) and 
``physicians' '' for ``physician's'' in subcl. (II).
    Subsec. (b)(4)(G). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 
100-203, Sec. 4042(b)(1)(D), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(f)(6)(B), substituted ``other than primary 
care services'' for ``other primary care services'' and struck out ``(as 
determined under the third and fourth sentences of paragraph (3) and 
under paragraph (4))'' after ``the prevailing charge''.
    Subsec. (b)(7)(B)(iii). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), 
added Pub. L. 100-203, Sec. 4085(i)(22)(C), see 1987 Amendment note 
below.
    Subsec. (b)(10)(A)(i). Pub. L. 100-360, Sec. 411(f)(4)(A)(i), struck 
out ``under paragraph (3)'' after ``reasonable charge'', substituted 
``subparagraph (B)'' for ``subparagraph (C)'', and struck out ``for 
participating and nonparticipating physicians'' after ``charge for such 
procedure''.
    Subsec. (b)(10)(A)(iii). Pub. L. 100-360, Sec. 411(f)(4)(A)(ii), 
substituted ``clause (i)(I)'' for ``clause (i)(II)''.
    Subsec. (b)(10)(B). Pub. L. 100-360, Sec. 411(f)(4)(A)(iii), 
inserted ``(including subsequent insertion of an intraocular lens)'' 
after ``cataract surgery''.
    Subsec. (b)(10)(D). Pub. L. 100-360, Sec. 411(f)(4)(A)(iv), 
substituted ``under section 1395ff'' for ``section 1395ff''.
    Subsec. (b)(11)(B)(i). Pub. L. 100-360, Sec. 411(f)(4)(B)(i), 
amended Pub. L. 100-203, Sec. 4045(c)(2)(B), see 1987 Amendment note 
below.
    Subsec. (b)(11)(C)(i). Pub. L. 100-360, Sec. 411(f)(5)(A), 
substituted ``insertion'' for ``implantation''.
    Subsec. (b)(11)(C)(ii). Pub. L. 100-360, Sec. 411(g)(2)(A), 
substituted ``inserted during or subsequent to'' for ``implanted 
during''.
    Subsec. (b)(12)(C). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added 
Pub. L. 100-203, Sec. 4085(i)(25), see 1987 Amendment note below.
    Subsec. (b)(13), (14). Pub. L. 100-360, Sec. 411(f)(7)(A), 
redesignated par. (14) as (13).
    Subsec. (c)(1)(A). Pub. L. 100-360, Sec. 202(e)(3)(A), designated 
existing provisions as cl. (i), inserted ``, except as provided in 
clause (ii),'' after ``under this part, and'' and added cl. (ii) 
relating to payment for implementation and operation of the electronic 
system for covered outpatient drugs.
    Subsec. (c)(1)(A)(ii). Pub. L. 100-485, Sec. 608(d)(5)(D), inserted 
``, including claims processing functions'' after ``and related 
functions''.
    Subsec. (c)(2)(A), (3)(A). Pub. L. 100-360, Sec. 202(e)(5)(A), as 
amended by Pub. L. 100-485, Sec. 608(d)(5)(H), substituted ``Except as 
provided in paragraph (4), each'' for ``Each''.
    Subsec. (c)(4). Pub. L. 100-360, Sec. 202(e)(5)(B), added par. (4) 
requiring contracts for the disbursement of funds with respect to claims 
for payment for covered outpatient drugs to provide for a payment cycle, 
and requiring interest if such requirements are not met.
    Subsec. (f)(3). Pub. L. 100-485, Sec. 608(d)(5)(B), inserted ``, 
including claims processing functions'' after ``and related functions''.
    Pub. L. 100-360, Sec. 202(e)(1), added par. (3) which read as 
follows: ``with respect to implementation and operation (and related 
functions) of the electronic system established under subsection (o)(4) 
of this section, a voluntary association, corporation, partnership, or 
other nongovernmental organization, which the Secretary determines to be 
qualified to conduct such activities.''
    Subsec. (h)(1). Pub. L. 100-360, Sec. 202(c)(1)(A), inserted ``, 
except that, with respect to a supplier of covered outpatient drugs, the 
term `participating supplier' means a participating pharmacy (as defined 
in subsection (o)(1) of this section)'' after ``part during such year''.
    Subsec. (h)(2). Pub. L. 100-360, Sec. 202(e)(4)(A), inserted 
``(other than a carrier described in subsection (f)(3) of this 
section)'' after ``Each carrier''.
    Subsec. (h)(3)(B). Pub. L. 100-360, Sec. 411(i)(1)(A), substituted 
``payment determination'' for ``claims determination'', ``shall include 
an explanation of benefits and any additional information that the 
Secretary may determine to be appropriate in order'' for ``including 
such information as the Secretary determines is generally provided'', 
``enter into agreements'' for ``enter into arrangements'', and ``under 
this subparagraph by a carrier'' for ``under this subparagraph'' and 
inserted ``, and such user fees shall be collected and retained by the 
carrier''.
    Subsec. (h)(4). Pub. L. 100-360, Sec. 202(c)(1)(B), inserted at end 
``In publishing directories under this paragraph, the Secretary shall 
provide for separate directories (wherever appropriate) for 
participating pharmacies.''
    Subsec. (h)(5). Pub. L. 100-360, Sec. 223(b), designated existing 
provisions as subpar. (A), inserted ``through an annual mailing'', 
struck out at end ``The Secretary shall include such notice in the 
mailing of appropriate benefit checks provided under subchapter II of 
this chapter.'', and added subpar. (B).
    Subsec. (h)(7). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 
100-203, Sec. 4042(b)(1)(A), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 223(c), in subpar. (A) inserted ``prominent'' 
before ``reminder'' and substituted ``and a clear statement of any 
amounts charged for the particular items or services on the claim 
involved above the amount recognized under this part),'' for ``7E), 
and'' and added subpar. (C).
    Subsec. (h)(8). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 
100-203, Sec. 4042(b)(1)(B), see 1987 Amendment note below.
    Subsec. (i). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 100-
203, Sec. 4042(b)(1)(B), see 1987 Amendment note below.
    Subsec. (i)(2), (3). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. 
L. 100-203, Sec. 4042(b)(1)(C), see 1987 Amendment note below.
    Subsec. (i)(3). Pub. L. 100-485, Sec. 608(d)(21)(A), substituted 
``subsection (b)(3) of this section'' for ``paragraph (3)''.
    Subsec. (i)(4). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L. 
100-203, Sec. 4042(b)(1)(E), see 1987 Amendment note below.
    Subsec. (j)(1)(C)(i). Pub. L. 100-360, Sec. 411(f)(2)(F)(ii), added 
Pub. L. 100-203, Sec. 4042(c)(2), see 1987 Amendment note below.
    Subsec. (j)(1)(C)(viii). Pub. L. 100-360, Sec. 411(f)(1)(A), amended 
Pub. L. 100-203, Sec. 4041(a)(1)(B), see 1987 Amendment note below.
    Subsec. (j)(1)(C)(ix). Pub. L. 100-360, Sec. 411(f)(7)(B), added 
Pub. L. 100-203, Sec. 4048(e), see 1987 Amendment note below.
    Subsec. (j)(1)(D)(ii)(IV). Pub. L. 100-360, Sec. 411(f)(5)(B), 
struck out ``is'' after ``limit''.
    Subsec. (j)(1)(D)(ii)(V). Pub. L. 100-360, Sec. 411(g)(2)(B), 
redesignated subcl. (IV) as (V) and struck out ``is'' after ``limit''.
    Subsec. (j)(1)(D)(iii). Pub. L. 100-360, Sec. 411(g)(2)(C), amended 
Pub. L. 100-203, Sec. 4063(a)(2)(B), see 1987 Amendment note below.
    Subsec. (j)(1)(D)(iv). Pub. L. 100-360, Sec. 411(f)(4)(C), 
substituted ``bills'' for ``imposes a charge''.
    Subsec. (j)(2). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), as amended 
by Pub. L. 100-485, Sec. 608(d)(24)(B), added Pub. L. 100-203, 
Sec. 4085(i)(26), see 1987 Amendment note below.
    Subsec. (l)(1)(C)(i). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added 
Pub. L. 100-203, Sec. 4085(i)(27), see 1987 Amendment note below.
    Subsec. (n)(1). Pub. L. 100-360, Sec. 411(f)(9)(A), in introductory 
provisions, struck out ``to a patient'' after ``includes a charge'', 
inserted ``the bill or request for'' after ``for which'', and 
substituted ``shares a practice'' for ``shares his practice'' and 
``supervised the performance of the test, the'' for ``supervised the 
test, the''.
    Subsec. (n)(1)(A). Pub. L. 100-485, Sec. 608(d)(17), substituted 
``the supplier's'' for ``the the supplier's''.
    Pub. L. 100-360, Sec. 411(f)(9)(B), as amended by Pub. L. 100-485, 
Sec. 608(d)(21)(D), substituted ``(or other applicable limit)'' for ``to 
individuals enrolled under this part''.
    Pub. L. 100-360, Sec. 411(a)(3)(A), (C)(i), clarified that illegible 
matter after ``or, if lower, the'' was ``the supplier's reasonable 
charge to individuals enrolled under this part for the test''.
    Subsec. (n)(2)(A). Pub. L. 100-360, Sec. 411(f)(9)(C), inserted 
``the payment amount specified in paragraph (1)(A) and'' after ``other 
than''.
    Subsec. (n)(3). Pub. L. 100-360, Sec. 411(f)(9)(D), struck out ``or 
supplier'' after ``such physician''.
    Subsec. (o). Pub. L. 100-360, Sec. 202(c)(1)(C), added subsec. (o) 
relating to ``participating pharmacies'' as entities authorized under 
State law to dispense covered outpatient drugs which had entered into 
agreements with Secretary to participate in catastrophic coverage 
program.
    Subsec. (o)(1)(A)(i). Pub. L. 100-485, Sec. 608(d)(5)(A)(i), 
substituted ``paragraph (4)'' for ``subparagraph (D)(i)''.
    Subsec. (o)(1)(B)(ii). Pub. L. 100-485, Sec. 608(d)(5)(A)(ii), 
substituted ``an eligible organization'' for ``eligible organization''.
    Subsec. (p). Pub. L. 100-360, Sec. 202(g), added subsec. (p).
    1987--Subsec. (b)(2). Pub. L. 100-203, Sec. 4082(c), as amended by 
Pub. L. 100-360, Sec. 411(i)(2), designated existing provisions as 
subpar. (A) and added subpar. (B).
    Pub. L. 100-203, Sec. 4041(a)(3)(A)(i), inserted at end ``In 
establishing such standards and criteria, the Secretary shall provide a 
system to measure a carrier's performance of responsibilities described 
in paragraph (3)(H) and subsection (h) of this section.''
    Subsec. (b)(3). Pub. L. 100-203, Sec. 4085(i)(24), as added by Pub. 
L. 100-360, Sec. 411(i)(4)(C)(vi), substituted ``In the case of 
physicians' services'' for ``In the case of physician services'' and 
``(with respect to physicians' services'' for ``(with respect to 
physicians services'' in fourth sentence.
    Pub. L. 100-203, Sec. 4045(c)(2)(D), as added by Pub. L. 100-360, 
Sec. 411(f)(4)(B)(ii), inserted ``(or under any other provision of law 
affecting the prevailing charge level)'' in fourth sentence.
    Pub. L. 100-203, Sec. 4053(a), formerly Sec. 4052(a), as renumbered 
and amended by Pub. L. 100-360, Sec. 411(f)(11)(A), (14), inserted ``, 
and shall remain at such prevailing charge level until the prevailing 
charge for a year (as adjusted by economic index data) equals or exceeds 
such prevailing charge level'' before period at end of penultimate 
sentence.
    Subsec. (b)(3)(B)(ii). Pub. L. 100-203, Sec. 4096(a)(1)(A), as 
amended by Pub. L. 100-360, Sec. 411(j)(4)(A), added subcl. (II), 
redesignated former subcl. (II) as (III), and inserted ``(and to refund 
amounts already collected)''.
    Subsec. (b)(3)(C). Pub. L. 100-203, Sec. 4085(i)(5), substituted 
``less than $500'' for ``not more than $500''.
    Subsec. (b)(4)(A)(iv). Pub. L. 100-203, Sec. 4042(c)(1), formerly 
Sec. 4042(c), as redesignated and amended by Pub. L. 100-360, 
Sec. 411(f)(2)(F)(i), and by Pub. L. 100-485, Sec. 608(d)(21)(B), 
amended cl. (iv) generally. Prior to amendment, cl. (iv) read as 
follows: ``In determining the prevailing charge level under the third 
and fourth sentences of paragraph (3) for a physicians' service 
furnished on or after January 1, 1987, by a nonparticipating physician, 
the Secretary shall set the level at 96 percent of the prevailing charge 
levels established under such sentences with respect to such service 
furnished by participating physicians.''
    Subsec. (b)(4)(A)(v). Pub. L. 100-203, Sec. 4041(a)(1)(A)(i), added 
cl. (v). Former cl. (v) redesignated (vi).
    Subsec. (b)(4)(A)(vi). Pub. L. 100-203, Sec. 4044(a), as amended by 
Pub. L. 100-360, Sec. 411(f)(3)(A), added cl. (vi). Former cl. (vi) 
redesignated (vii).
    Pub. L. 100-203, Sec. 4041(a)(1)(A)(i), redesignated former cl. (v) 
as (vi).
    Subsec. (b)(4)(A)(vii). Pub. L. 100-203, Sec. 4042(b)(2)(A), as 
added by Pub. L. 100-360, Sec. 411(f)(2)(D), substituted ``subsection 
(i)(3) of this section'' for ``subparagraph (E)(ii)''.
    Pub. L. 100-203, Sec. 4044(a), as amended by Pub. L. 100-360, 
Sec. 411(f)(3)(A), redesignated former cl. (vi) as (vii).
    Subsec. (b)(4)(B)(iii). Pub. L. 100-203, Sec. 4041(a)(1)(A)(ii), 
added cl. (iii).
    Subsec. (b)(4)(E). Pub. L. 100-203, Sec. 4042(b)(1)(D), as added by 
Pub. L. 100-360, Sec. 411(f)(2)(C), redesignated subpar. (F) as (E). 
Former subpar. (E) transferred to subsec. (i).
    Pub. L. 100-203, Sec. 4042(b)(1)(C), as added by Pub. L. 100-360, 
Sec. 411(f)(2)(C), struck out ``(E) In this section:'' before cl. (i), 
redesignated cls. (i) and (ii) as pars. (2) and (3), respectively, and 
transferred those pars. to subsec. (i).
    Subsec. (b)(4)(F). Pub. L. 100-203, Sec. 4042(b)(1)(D), as added by 
Pub. L. 100-360, Sec. 411(f)(2)(C), redesignated subpar. (G) as (F). 
Former subpar. (F) redesignated (E).
    Pub. L. 100-203, Sec. 4042(a), added subpar. (F).
    Subsec. (b)(4)(G). Pub. L. 100-203, Sec. 4042(b)(1)(D), as added by 
Pub. L. 100-360, Sec. 411(f)(2)(C), redesignated subpar. (G) as (F).
    Pub. L. 100-203, Sec. 4047(a), added subpar. (G).
    Subsec. (b)(7)(B)(iii). Pub. L. 100-203, Sec. 4085(i)(22)(C), as 
added by Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted ``an 
assignment-related basis'' for ``the basis of an assignment described in 
paragraph (3)(B)(ii) or under the procedure described in section 
1395gg(f)(1) of this title''.
    Subsec. (b)(10). Pub. L. 100-203, Sec. 4045(a), amended par. (10) 
generally, revising and restating as subpars. (A) to (D) provisions of 
former subpars. (A) to (C).
    Subsec. (b)(11)(B)(i). Pub. L. 100-203, Sec. 4045(c)(2)(B), as 
amended by Pub. L. 100-360, Sec. 411(f)(4)(B)(i), struck out ``and shall 
be further reduced by 2 percent with respect to procedures performed in 
1988'' after ``in 1987'' and struck out second sentence which read as 
follows: ``A reduced prevailing charge under this subparagraph shall 
become the prevailing charge level for subsequent years for purposes of 
applying the economic index under the fourth sentence of paragraph 
(3).''
    Subsec. (b)(11)(C). Pub. L. 100-203, Sec. 4063(a)(1)(A), designated 
existing provisions as cl. (i) and added cl. (ii).
    Pub. L. 100-203, Sec. 4046(a)(1)(B), (C), added subpar. (C) and 
redesignated former subpar. (C) as (D).
    Pub. L. 100-203, Sec. 4045(c)(1)(A), struck out former cl. (i) 
designation before ``In the case of'' and substituted ``, the 
physician's actual charge is subject to a limit under subsection 
(j)(1)(D) of this section.'' for ``(subject to clause (iv)), the 
physician may not charge the individual more than the limiting charge 
(as defined in clause (ii)) plus (for services furnished during the 12-
month period beginning on the effective date of the reduction) \1/2\ of 
the amount by which the physician's actual charges for the service for 
the previous 12-month period exceeds the limiting charge.'', and struck 
out former cls. (ii) to (iv) which read as follows:
    ``(ii) In clause (i), the term `limiting charge' means, with respect 
to a service, 125 percent of the prevailing charge for the service after 
the reduction referred to in clause (i).
    ``(iii) If a physician knowingly and willfully imposes charges in 
violation of clause (i), the Secretary may apply sanctions against such 
physician in accordance with subsection (j)(2) of this section.
    ``(iv) This subparagraph shall not apply to services furnished after 
the earlier of (I) December 31, 1990, or (II) one-year after the date 
the Secretary reports to Congress, under section 1395w-1(e)(3) of this 
title, on the development of the relative value scale under section 
1395w-1 of this title.''
    Subsec. (b)(11)(D). Pub. L. 100-203, Sec. 4063(a)(1)(B), which 
directed that subpar. (D) be amended by inserting ``or item'' after 
``service'' or ``services'' each place either appears, was executed by 
inserting ``or item'' after ``service'' wherever appearing. The word 
``services'' does not appear because of a prior amendment by section 
4045(c)(1)(A) of Pub. L. 100-203 to subpar. (D), formerly (C), see 
above.
    Pub. L. 100-203, Sec. 4046(a)(1)(A), (B), redesignated former 
subpar. (C) as (D) and substituted ``subparagraph (B) or (C)'' for 
``subparagraph (B)''.
    Subsec. (b)(12)(C). Pub. L. 100-203, Sec. 4085(i)(25), as added by 
Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted ``money penalty'' 
for ``monetary penalty'' and amended second sentence generally. Prior to 
amendment, second sentence read as follows: ``Such a penalty shall be 
imposed in the same manner as civil monetary penalties are imposed under 
section 1320a-7a of this title with respect to actions described in 
subsection (a) of that section.''
    Subsec. (b)(14). Pub. L. 100-203, Sec. 4048(a), added par. (14).
    Subsec. (c)(1). Pub. L. 100-203, Sec. 4041(a)(3)(A)(ii), designated 
existing provisions as subpar. (A) and added subpar. (B).
    Pub. L. 100-203, Sec. 4035(a)(2), inserted at end ``The Secretary 
shall cause to have published in the Federal Register, by not later than 
September 1 before each fiscal year, data, standards, and methodology to 
be used to establish budgets for carriers under this section for that 
fiscal year, and shall cause to be published in the Federal Register for 
public comment, at least 90 days before such data, standards, and 
methodology are published, the data, standards, and methodology proposed 
to be used.''
    Subsec. (c)(3). Pub. L. 100-203, Sec. 4031(a)(2), added par. (3).
    Subsec. (h)(3). Pub. L. 100-203, Sec. 4081(a), designated existing 
provisions as subpar. (A) and added subpar. (B).
    Subsec. (h)(5). Pub. L. 100-203, Sec. 4085(i)(6), substituted ``the 
participation program'' for ``the the participation program''.
    Subsec. (h)(7). Pub. L. 100-203, Sec. 4042(b)(1)(A), as added by 
Pub. L. 100-360, Sec. 411(f)(2)(C), struck out ``, described in 
paragraph (8)'' after ``assignment-related basis'' in introductory 
provisions.
    Subsec. (h)(8). Pub. L. 100-203, Sec. 4042(b)(1)(B), as added by 
Pub. L. 100-360, Sec. 411(f)(2)(C), substituted ``(1) A'' for ``(8) For 
purposes of this subchapter, a'', indented such par. 2 ems, and inserted 
subsec. (i) designation and ``For purposes of this subchapter:'', 
effectively transferring former subsec. (h)(8) to subsec. (i).
    Subsec. (i). Pub. L. 100-203, Sec. 4042(b)(1)(B), as added by Pub. 
L. 100-360, Sec. 411(f)(2)(C), transferred introductory provisions and 
par. (1) from former subsec. (h)(8).
    Subsec. (i)(2), (3). Pub. L. 100-203, Sec. 4042(b)(1)(C), as added 
by Pub. L. 100-360, Sec. 411(f)(2)(C), transferred pars. (2) and (3) 
from subsec. (b)(4)(E).
    Subsec. (i)(4). Pub. L. 100-203, Sec. 4042(b)(1)(E), as added by 
Pub. L. 100-360, Sec. 411(f)(2)(C), added par. (4).
    Subsec. (j)(1)(B)(i). Pub. L. 100-203, Sec. 4054(a)(1), (2), 
formerly Sec. 4053(a)(1), (2), as renumbered by Pub. L. 100-360, 
Sec. 411(f)(14), substituted ``the actual charges of each such 
physician'' for ``each such physician's actual charges'' and ``on a 
repeated basis for such a service an actual charge'' for ``for such a 
service a physician's actual charge (as defined in subparagraph 
(C)(vi)''.
    Subsec. (j)(1)(C)(i). Pub. L. 100-203, Sec. 4085(i)(7)(A), inserted 
``maximum allowable'' after ``If the physician's''.
    Pub. L. 100-203, Sec. 4042(c)(2), as added by Pub. L. 100-360, 
Sec. 411(f)(2)(F)(ii), substituted ``applicable percent (as defined in 
subsection (b)(4)(A)(iv) of this section) of the prevailing charge for 
the year and service involved'' for ``prevailing charge for the year 
involved for such service furnished by nonparticipating physicians'' in 
subcls. (I) and (II).
    Subsec. (j)(1)(C)(v). Pub. L. 100-203, Sec. 4085(i)(7)(B), 
substituted ``1986'' for ``1987''.
    Subsec. (j)(1)(C)(vi). Pub. L. 100-203, Sec. 4054(a)(3), formerly 
Sec. 4053(a)(3), as renumbered by Pub. L. 100-360, Sec. 411(f)(14), 
struck out ``and subparagraph (B)'' after ``purposes of this 
subparagraph''.
    Subsec. (j)(1)(C)(vii). Pub. L. 100-203, Sec. 4085(i)(7)(C), added 
cl. (vii).
    Subsec. (j)(1)(C)(viii). Pub. L. 100-203, Sec. 4041(a)(1)(B), as 
amended by Pub. L. 100-360, Sec. 411(f)(1)(A), added cl. (viii).
    Subsec. (j)(1)(C)(ix). Pub. L. 100-203, Sec. 4048(e), as added by 
Pub. L. 100-360, Sec. 411(f)(7)(B), added cl. (ix).
    Subsec. (j)(1)(D). Pub. L. 100-203, Sec. 4045(c)(1)(B), added 
subpar. (D).
    Subsec. (j)(1)(D)(ii)(IV). Pub. L. 100-203, Sec. 4063(a)(2)(A), 
added subcl. (IV) relating to establishment of reasonable charge limit 
under subsec. (b)(11)(C)(ii) of this section.
    Pub. L. 100-203, Sec. 4046(a)(2)(A), added subcl. (IV) relating to 
establishment of prevailing charge limit under subsec. (b)(11)(C)(i) of 
this section. Former subcl. (IV) redesignated (V).
    Subsec. (j)(1)(D)(ii)(V), (VI). Pub. L. 100-203, Sec. 4063(a)(2)(A), 
redesignated former subcl. (V) as (VI).
    Pub. L. 100-203, Sec. 4046(a)(2)(A), redesignated former subcl. (IV) 
as (V).
    Subsec. (j)(1)(D)(iii). Pub. L. 100-203, Sec. 4063(a)(2)(B), as 
amended by Pub. L. 100-360, Sec. 411(g)(2)(C), struck out ``or'' at end 
of subcl. (I), substituted ``; or'' for period at end of subcl. (II), 
and added subcl. (III).
    Pub. L. 100-203, Sec. 4046(a)(2)(B), substituted ``, (b)(11)(B), or 
(b)(11)(C)(i)'' for ``or (b)(11)(B)'' in subcl. (II).
    Subsec. (j)(2). Pub. L. 100-203, Sec. 4085(i)(26), as added by Pub. 
L. 100-360, Sec. 411(i)(4)(C)(vi), and amended by Pub. L. 100-485, 
Sec. 608(d)(24)(B), substituted ``chapter'' for ``subchapter'' in 
subpar. (A), struck out ``the imposition of'' before ``civil monetary 
penalties'' and inserted ``and assessments'' in subpar. (B), substituted 
``chapter'' for ``subchapter'' in two places in last sentence, and 
amended last sentence generally. Prior to amendment, last sentence read 
as follows: ``No payment may be made under this chapter with respect to 
any item or service furnished by a physician during the period when he 
is excluded from participation in the programs under this chapter 
pursuant to this subsection.''
    Pub. L. 100-93, Sec. 8(c)(2)(A), amended subpar. (A) generally and 
substituted ``excluded from participation in the programs'' for ``barred 
from participation in the program'' in last sentence. Prior to 
amendment, subpar. (A) read as follows: ``barring a physician from 
participation under the program under this subchapter for a period not 
to exceed 5 years, in accordance with the procedures of paragraphs (2) 
and (3) of section 1395y(d) of this title, or''.
    Subsec. (j)(3)(A). Pub. L. 100-93, Sec. 8(c)(2)(B), substituted 
``exclude'' for ``bar''.
    Subsec. (k)(1), (2). Pub. L. 100-203, Sec. 4085(g)(1), substituted 
``subsection (j)(2) of this section in the case of surgery performed on 
or after March 1, 1987'' for ``subsection (j)(2) of this section''.
    Subsec. (l)(1)(A)(iii). Pub. L. 100-203, Sec. 4096(a)(1)(B), 
designated existing provisions as subcl. (I) and added subcl. (II).
    Subsec. (l)(1)(C). Pub. L. 100-203, Sec. 4096(a)(1)(C), inserted 
``in the case described in subparagraph (A)(iii)(I)'' after ``to an 
individual'' in introductory provisions.
    Subsec. (l)(1)(C)(i). Pub. L. 100-203, Sec. 4085(i)(27), as added by 
Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), inserted ``the physician 
establishes that'' after ``(i)''.
    Subsec. (n). Pub. L. 100-203, Sec. 4051(a), added subsec. (n).
    1986--Subsec. (b)(3). Pub. L. 99-509, Sec. 9331(c)(3)(A), inserted 
``or (with respect to physicians services furnished in a year after 
1987) the level determined under this sentence for the previous year'' 
after ``ending June 30, 1973,'' and ``year-to-year'' before ``economic 
changes'' in fourth sentence.
    Pub. L. 99-272, Sec. 9301(d)(1)(B), (C), substituted ``June 30 last 
preceding the start of the calendar year'' for ``March 31 last preceding 
the start of the twelve-month period (beginning October 1 of each 
year)'' in third sentence, and struck out ``the twelve-month period 
beginning on October 1 in'' before ``any calendar year after 1974'' in 
eighth sentence.
    Subsec. (b)(3)(C). Pub. L. 99-509, Sec. 9341(a)(2), substituted ``at 
least $100, but not more than $500'' for ``$100 or more''.
    Subsec. (b)(3)(F). Pub. L. 99-272, Sec. 9301(d)(1)(A), struck out 
``(ending on September 30)'' after ``before the year''.
    Subsec. (b)(3)(G). Pub. L. 99-509, Sec. 9331(b)(2), added subpar. 
(G).
    Subsec. (b)(3)(H). Pub. L. 99-509, Sec. 9332(a)(1), added subpar. 
(H).
    Subsec. (b)(4)(A)(i), (ii). Pub. L. 99-272, Sec. 9301(b)(1)(A), 
designated existing provisions as cl. (i) and added cl. (ii).
    Subsec. (b)(4)(A)(iii). Pub. L. 99-509, Sec. 9331(a)(1), added cl. 
(iii) and struck out former cl. (iii) which read as follows: ``In 
determining the prevailing charge levels under the third and fourth 
sentences of paragraph (3) for physicians' services furnished during a 
12-month period beginning on or after January 1, 1987, by a physician 
who is not a participating physician (as defined in subsection (h)(1) of 
this section) at the time of furnishing the services, the Secretary 
shall not set any level higher than the same level as was set for 
services furnished during the previous calendar year (without regard to 
clause (ii)(II)) for physicians who were participating physicians during 
that year.''
    Pub. L. 99-272, Sec. 9301(b)(1)(A)(ii), added cl. (iii).
    Subsec. (b)(4)(A)(iv), (v). Pub. L. 99-509, Sec. 9331(a)(1), added 
cls. (iv) and (v).
    Subsec. (b)(4)(B). Pub. L. 99-272, Sec. 9301(b)(1)(B), designated 
existing provisions as cl. (i) and added cl. (ii).
    Subsec. (b)(4)(C). Pub. L. 99-509, Sec. 9331(a)(2), directed 
amendment of subpar. (C) by striking out ``(i)'' after ``(C)'' and 
striking out cl. (ii), applicable to services furnished on or after Jan. 
1, 1987, which is identical to amendment by Pub. L. 99-514, 
Sec. 1895(b)(14)(A), as amended, effective as if included in enactment 
of Pub. L. 99-272.
    Pub. L. 99-514, Sec. 1895(b)(14)(A), as amended by Pub. L. 99-509, 
Sec. 9307(c)(2)(A), struck out cl. (i) designation, and struck out cl. 
(ii) which read as follows: ``In determining the prevailing charge 
levels under the third and fourth sentences of paragraph (3) for 
physicians' services furnished during the periods beginning after 
December 31, 1986, by a physician who was not a participating physician 
on that date, the Secretary shall treat the level as set under 
subparagraph (A)(ii) as having fully provided for the economic changes 
which would have been taken into account but for the limitations 
contained in subparagraph (A)(ii).''
    Pub. L. 99-272, Sec. 9301(b)(1)(C), designated existing provisions 
as cl. (i), substituted ``subparagraph (A)(i)'' for ``subparagraph (A)'' 
wherever appearing, and added cl. (ii).
    Subsec. (b)(4)(D)(i) to (iii). Pub. L. 99-272, Sec. 9301(b)(1)(D), 
designated existing provisions as cl. (i), substituted ``In determining 
the customary charges for physicians' services furnished during the 8-
month period beginning May 1, 1986, or the 12-month period beginning 
January 1, 1987, by a physician who was not a participating physician 
(as defined in subsection (h)(1) of this section) on September 30, 
1985'' for ``In determining the customary charges for physicians' 
services furnished during the 12-month period beginning October 1, 1985, 
or October 1, 1986, by a physician who at no time for any services 
furnished during the 12-month period beginning October 1, 1984, was a 
participating physician (as defined in subsection (h)(1) of this 
section)'', and added cls. (ii) and (iii).
    Subsec. (b)(4)(D)(iv). Pub. L. 99-509, Sec. 9331(b)(3), added cl. 
(iv).
    Subsec. (b)(4)(E). Pub. L. 99-509, Sec. 9331(a)(3), added subpar. 
(E).
    Subsec. (b)(6). Pub. L. 99-509, Sec. 9338(c), substituted ``except 
that (A) payment may be made (i)'' for ``except that payment may be made 
(A)(i)'', substituted ``(B) payment may be made'' for ``or (B)'', and 
inserted before the period at end ``, and (C) in the case of services 
described in section 1395x(s)(2)(K) of this title payment shall be made 
to the employer of the physician assistant involved''.
    Subsec. (b)(7)(B)(ii)(III). Pub. L. 99-272, Sec. 9219(b)(1)(A), 
realigned margin of subcl. (III).
    Subsec. (b)(7)(B)(iii). Pub. L. 99-272, Sec. 9219(b)(2)(A), 
realigned margin of cl. (iii).
    Subsec. (b)(8). Pub. L. 99-509, Sec. 9333(a), designated existing 
provisions as subpar. (A), redesignated former subpars. (A) and (B) as 
cls. (i) and (ii), respectively, and added subpars. (B) and (C).
    Pub. L. 99-272, Sec. 9304(a), added par. (8).
    Subsec. (b)(9). Pub. L. 99-509, Sec. 9333(b), added par. (9). Former 
par. (9) redesignated (11).
    Pub. L. 99-272, Sec. 9306(a), added par. (9).
    Subsec. (b)(10). Pub. L. 99-509, Sec. 9333(b), added par. (10).
    Subsec. (b)(11). Pub. L. 99-509, Sec. 9334(a), designated existing 
provisions as subpar. (A), redesignated former subpars. (A) and (B) as 
cls. (i) and (ii), respectively, and added subpars. (B) and (C).
    Pub. L. 99-509, Sec. 9333(b), redesignated former par. (9) as (11).
    Subsec. (b)(12). Pub. L. 99-509, Sec. 9338(b), added par. (12).
    Subsec. (c). Pub. L. 99-509, Sec. 9311(c), designated existing 
provisions as par. (1) and added par. (2).
    Subsec. (h)(1). Pub. L. 99-272, Sec. 9301(d)(2), substituted 
``before the beginning of any year beginning with 1984'' for ``before 
October 1 of any year beginning with 1984'', ``on an assignment-related 
basis'' for ``on the basis of an assignment described in subsection 
(b)(3)(B)(ii) of this section, in accordance with subsection (b)(6)(B) 
of this section, or under the procedure described in section 
1395gg(f)(1) of this title'', ``during such year'' for ``during the 12-
month period beginning on October 1 of such year'', ``after the 
beginning of a year'' for ``after October 1 of a year'', and ``during 
the remainder of the year'' for ``during the remainder of the 12-month 
period beginning on such October 1''.
    Subsec. (h)(2). Pub. L. 99-509, Sec. 9332(b)(1)(A), struck out 
period at end and substituted ``and may request a copy of an appropriate 
directory published under paragraph (4). Each such carrier shall, 
without charge, mail a copy of such directory upon such a request.''
    Subsec. (h)(4). Pub. L. 99-509, Sec. 9332(b)(2), inserted at end 
``Each participating physician directory for an area shall provide an 
alphabetical listing of all participating physicians practicing in the 
area and an alphabetical listing by locality and specialty of such 
physicians.''
    Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated par. (2) of subsec. 
(i) as par. (4) of this subsection.
    Subsec. (h)(5). Pub. L. 99-509, Sec. 9332(b)(1)(B), substituted 
``the participation program under this subsection and the publication 
and availability of the directories'' for ``publication of the 
directories'' and inserted at end ``The Secretary shall include such 
notice in the mailing of appropriate benefit checks provided under 
subchapter II of this chapter.''
    Pub. L. 99-514, Sec. 1895(b)(15)(A), struck out ``such'' before 
``the directories'' and before ``the appropriate area directory''.
    Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated par. (3) of subsec. 
(i) as par. (5) of this subsection.
    Subsec. (h)(6). Pub. L. 99-509, Sec. 9332(b)(1)(C), inserted before 
period at end of second sentence ``and that an appropriate number of 
copies of each such directory is sent to hospitals located in the area'' 
and inserted at end ``Such copies shall be sent free of charge.''
    Pub. L. 99-514, Sec. 1895(b)(15)(B), substituted ``the'' for ``the 
the'' before ``directories''.
    Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated par. (4) of subsec. 
(i) as par. (6) of this subsection.
    Subsec. (h)(7), (8). Pub. L. 99-272, Sec. 9301(c)(4), added pars. 
(7) and (8).
    Subsec. (i)(1). Pub. L. 99-272, Sec. 9301(c)(3)(A), struck out par. 
(1) which required the Secretary to publish a list containing the name, 
address, specialty, and percent of claims submitted with respect to each 
physician and supplier during preceding year that were paid on the basis 
of an assignment described in subsec. (b)(3)(B)(ii) of this section, in 
accordance with subsec. (b)(6)(B) of this section, or under procedure 
described in section 1395gg(f)(1) of this title.
    Subsec. (i)(2). Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated 
par. (2) of this subsection as par. (4) of subsec. (h).
    Pub. L. 99-272, Sec. 9301(d)(3), substituted ``year'' for ``fiscal 
year'', wherever appearing.
    Pub. L. 99-272, Sec. 9301(c)(2)(A), (B), (3)(B), substituted ``shall 
publish directories (for appropriate local geographic areas)'' for 
``shall publish a directory'', inserted ``for that area'' before ``for 
that fiscal year'', substituted ``Each directory shall'' for ``The 
directory shall'', and substituted ``paragraph (1)'' for ``subsection 
(h)(1) of this section''.
    Subsec. (i)(3). Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated 
par. (3) of this subsection as par. (5) of subsec. (h).
    Pub. L. 99-272, Sec. 9301(c)(2)(C), (3)(C), struck out ``directory'' 
first place it appeared and inserted in lieu ``the directories'', struck 
out ``directory'' second place it appeared and inserted in lieu ``the 
appropriate area directory or directories'', and struck out ``list and'' 
wherever appearing.
    Subsec. (i)(4). Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated 
par. (4) of this subsection as par. (6) of subsec. (h).
    Pub. L. 99-272, Sec. 9301(c)(2)(D), (3)(C), struck out ``list and'' 
after ``The Secretary shall provide that the'' in first sentence, 
substituted ``the directories shall'' for ``directory shall'', and 
inserted provision requiring the Secretary to provide that each 
appropriate area directory be sent to each participating physician 
located in that area.
    Subsec. (j)(1). Pub. L. 99-509, Sec. 9331(b)(1), designated existing 
provisions as subpar. (A) and added subpars. (B) and (C).
    Pub. L. 99-272, Sec. 9301(b)(2), amended first sentence generally. 
Prior to amendment, first sentence read as follows: ``In the case of a 
physician who is not a participating physician, the Secretary shall 
monitor each such physician's actual charges to individuals enrolled 
under this part for physicians' services furnished during the 15-month 
period beginning July 1, 1984.''
    Subsec. (j)(2). Pub. L. 99-509, Sec. 9320(e)(3), substituted ``this 
paragraph'' for ``paragraph (1) or subsection (k) of this section'' in 
introductory text.
    Pub. L. 99-272, Sec. 9307(c)(1), inserted reference to subsec. (k) 
of this section in introductory text.
    Subsec. (k). Pub. L. 99-514, Sec. 1895(b)(16)(A), inserted 
``presents or causes to be presented a claim or'' in pars. (1) and (2).
    Pub. L. 99-272, Sec. 9307(c)(2), added subsec. (k).
    Subsec. (l). Pub. L. 99-509, Sec. 9332(c)(1), added subsec. (l).
    Subsec. (m). Pub. L. 99-509, Sec. 9332(d)(1), added subsec. (m).
    1984--Subsec. (b)(2). Pub. L. 98-369, Sec. 2326(c)(2), inserted at 
end provision that the Secretary publish in the Federal Register 
standards and criteria for efficient and effective performance of 
contract obligations under this section and provide an opportunity for 
public comment prior to implementation.
    Subsec. (b)(3). Pub. L. 98-369, Sec. 2306(b)(1)(B), (C), substituted 
``during the 12-month period ending on the March 31 last preceding'' for 
``during the last preceding calendar year elapsing prior to'' in third 
sentence and substituted ``October 1'' for ``July 1'' wherever appearing 
in third and eighth sentences.
    Pub. L. 98-369, Sec. 2354(b)(14), substituted ``(I)'' and ``(II)'' 
for ``(i)'' and ``(ii)'', respectively in concluding provisions.
    Pub. L. 98-369, Sec. 2663(j)(2)(F)(iv), substituted ``Health and 
Human Services'' for ``Health, Education, and Welfare'' in concluding 
provisions.
    Subsec. (b)(3)(B)(ii)(II). Pub. L. 98-369, Sec. 2354(b)(13), struck 
out the period after ``subchapter''.
    Subsec. (b)(3)(F). Pub. L. 98-369, Sec. 2306(b)(1)(A), substituted 
``September 30'' for ``June 30''.
    Subsec. (b)(4), (5). Pub. L. 98-369, Sec. 2306(a), added par. (4) 
and redesignated former pars. (4) and (5) as (5) and (6), respectively.
    Subsec. (b)(6). Pub. L. 98-369, Sec. 2339, redesignated cl. (A) as 
cl. (A)(i) and former cl. (B) as cl. (A)(ii), added a new cl. (B), and 
in the provisions after cl. (B), substituted ``clause (A) of such 
sentence'' for ``clause (A) or (B) of such sentence''.
    Pub. L. 98-369, Sec. 2306(a), redesignated par. (5) as (6). Former 
par. (6) redesignated (7).
    Subsec. (b)(7). Pub. L. 98-369, Sec. 2306(a), redesignated par. (6) 
as (7).
    Subsec. (b)(7)(A). Pub. L. 98-617, Sec. 3(b)(5)(B), struck out at 
end ``If all the teaching physicians in a hospital agree to have payment 
made for all of their physicians' services under this part furnished 
patients in the hospital on the basis of an assignment described in 
paragraph (3)(B)(ii) or under the procedure described in section 
1395gg(f)(1) of this title, notwithstanding clause (ii) of this 
subparagraph, the carrier shall provide for payment in an amount equal 
to 90 percent of the prevailing charges paid for similar services in the 
same locality.''
    Pub. L. 98-369, Sec. 2307(a)(1), as amended by Pub. L. 98-617, 
Sec. 3(a)(1), inserted ``If all the teaching physicians in a hospital 
agree to have payment made for all of their physicians' services under 
this part furnished patients in the hospital on the basis of an 
assignment described in paragraph (3)(B)(ii) or under the procedure 
described in section 1395gg(f)(1) of this title, notwithstanding clause 
(ii) of this subparagraph, the carrier shall provide for payment in an 
amount equal to 90 percent of the prevailing charges paid for similar 
services in the same locality.'' at the end.
    Subsec. (b)(7)(A)(ii). Pub. L. 98-617, Sec. 3(b)(5)(A), substituted 
``the payment is based upon a reasonable charge for the services in 
excess of the customary charge as determined in accordance with 
subparagraph (B)'' for ``the amount of the payment exceeds the 
reasonable charge for the services (with the customary charge determined 
consistent with subparagraph (B))''.
    Subsec. (b)(7)(B)(i). Pub. L. 98-369, Sec. 2307(a)(2)(A), (B), 
substituted ``physician who is not a teaching physician (as defined by 
the Secretary)'' for ``physician who has a substantial practice outside 
the teaching setting'' and ``practice outside the teaching setting'' for 
``outside practice''.
    Subsec. (b)(7)(B)(ii). Pub. L. 98-369, Sec. 2307(a)(2)(C), (D), 
substituted ``In the case of a teaching physician'' for ``In the case of 
a physician who does not have a practice described in clause (i)'' and 
``greatest'' for ``greater''.
    Subsec. (b)(7)(B)(ii)(III). Pub. L. 98-369, Sec. 2307(a)(2)(E)-(G), 
added subcl. (III).
    Subsec. (b)(7)(B)(iii). Pub. L. 98-617, Sec. 3(b)(6), added cl. 
(iii).
    Subsec. (c). Pub. L. 98-369, Sec. 2326(d)(2), inserted provision 
that the Secretary, in determining a carrier's necessary and proper cost 
of administration with respect to each contract, take into account the 
amount that is reasonable and adequate to meet the costs which must be 
incurred by an efficiently and economically operated carrier in carrying 
out the terms of its contract.
    Subsec. (h). Pub. L. 98-369, Sec. 2306(c), added subsec. (h).
    Pub. L. 98-369, Sec. 2303(e), struck out subsec. (h) providing for 
payment for laboratory tests.
    Subsecs. (i), (j). Pub. L. 98-369, Sec. 2306(c), added subsecs. (i) 
and (j).
    1982--Subsec. (b)(3)(B)(ii)(II). Pub. L. 97-248, Sec. 128(d)(1), 
substituted ``section 1395y(a)'' for ``section 1395y''.
    Subsec. (b)(3). Pub. L. 97-248, Sec. 104(a), in provisions following 
subpar. (F), inserted provisions that in determining the reasonable 
charge for outpatient services, the Secretary may limit such reasonable 
charge to a percentage of the amount of the prevailing charge for 
similar services furnished in a physician's office, taking into account 
the extent to which overhead costs associated with such outpatient 
services have been included in the reasonable cost or charge of the 
facility.
    Subsec. (b)(6)(D). Pub. L. 97-248, Sec. 113(a), added subpar. (D).
    1981--Subsec. (b)(3). Pub. L. 97-35 inserted provision that the 
amount of any charges for outpatient services which shall be considered 
reasonable shall be subject to the limitations established by 
regulations issued by the Secretary pursuant to section 1395x(v)(1)(K) 
of this title.
    1980--Subsec. (b)(3). Pub. L. 96-499, Sec. 946(a), in provisions 
following subpar. (F), substituted ``service is rendered'' for ``bill is 
submitted or the request for payment is made''.
    Subsec. (b)(3)(F). Pub. L. 96-499, Sec. 946(b), added subpar. (F).
    Subsec. (b)(6). Pub. L. 96-499, Sec. 948(b), added par. (6).
    Subsec. (h). Pub. L. 96-499, Sec. 918(a)(1), added subsec. (h).
    1977--Subsec. (b)(3). Pub. L. 95-216 provided that, with respect to 
power-operated wheelchairs for which payment may be made in accordance 
with section 1395x(s)(6) of this title, charges determined to be 
reasonable may not exceed the lowest charge at which power-operated 
wheelchairs are available in the locality.
    Subsec. (b)(5). Pub. L. 95-142 inserted provisions relating to 
payments under a reassignment or power of attorney in cases other than 
direct payments to physicians or service providers.
    1976--Subsec. (b)(3). Pub. L. 94-368 substituted ``for the twelve-
month period beginning on July 1 in any calendar year after 1974'' for 
``for the fiscal year beginning July 1, 1975,'', ``prior to the start of 
the twelve-month period (beginning July 1, of each year) in which the 
bill is submitted or the request for payment is made'' for ``prior to 
the start of the fiscal year in which the bill is submitted or the 
request for payment is made'', and ``for any twelve-month period 
(beginning after June 30, 1973) specified in clause (ii) of such 
sentence'' for ``for any fiscal year beginning after June 30, 1973,''.
    1975--Subsec. (b)(3). Pub. L. 94-182 inserted provisions relating to 
raising for fiscal year beginning July 1, 1975 inadequate prevailing 
charge levels for services of physicians in certain localities.
    1974--Subsec. (g). Pub. L. 93-445 substituted ``section 231f(d) of 
title 45'' for ``section 228s-2(b) of title 45''.
    1972--Subsec. (a). Pub. L. 92-603, Sec. 227(e)(3), substituted 
``which involve payments for physicians' services on a reasonable charge 
basis'' for ``which involve payments for physicians' services''.
    Subsec. (b)(3). Pub. L. 92-603, Secs. 244(a), 258(a), inserted 
provisions relating to determination of reasonableness of physician 
charges, medical services, supplies, and equipment and for the extension 
of time for filing claims for supplementary medical insurance benefits 
where the delay is due to administrative error, at end thereof.
    Subsec. (b)(3)(B)(ii). Pub. L. 92-603, Secs. 211(c)(3), 281(d), 
designated existing provisions as subcl. (I), added subcl. II, inserted 
exception in the case of services furnished as described in section 
1395y(a)(4) of this title, other than for purposes of section 1395gg(f) 
of this title.
    Subsec. (b)(3)(C). Pub. L. 92-603, Sec. 262(a), inserted provisions 
setting a $100 minimum amount on claims to establish entitlement to a 
hearing.
    Subsec. (b)(5). Pub. L. 92-603, Sec. 236(a), added par. (5).
    Subsec. (g). Pub. L. 92-603, Sec. 263(d)(5), added subsec. (g).
    1968--Subsec. (b)(3)(B). Pub. L. 90-248 provided that payment be 
made on the basis of an itemized bill instead of a receipted bill as 
formerly required, and established a time limit within which payment may 
be requested, and inserted ``(except as otherwise provided in section 
1395gg(f) of this title)'' after ``payment will''.

                         Change of Name

    Committee on Energy and Commerce of House of Representatives treated 
as referring to Committee on Commerce of House of Representatives by 
section 1(a) of Pub. L. 104-14, set out as a note preceding section 21 
of Title 2, The Congress.


                    Effective Date of 1999 Amendment

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 305(c)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-362, provided that: ``The 
amendments made by this section [amending this section and section 1395y 
of this title] shall apply to payments for services provided on or after 
the date of enactment of this Act [Nov. 29, 1999].''
    Amendment by section 1000(a)(6) [title III, Sec. 321(k)(4)] 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.


                    Effective Date of 1997 Amendment

    Amendment by section 4201(c)(1) 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.
    Amendment by section 4205(d)(3)(B) of Pub. L. 105-33 effective Aug. 
5, 1997, see section 4205(d)(4) of Pub. L. 105-33, set out as a note 
under section 1395x of this title.
    Section 4302(c) of Pub. L. 105-33 provided that: ``The amendments 
made by this section [amending this section and section 1395cc of this 
title] shall take effect on the date of the enactment of this Act [Aug. 
5, 1997] and apply to the entry and renewal of contracts on or after 
such date.''
    Amendment by section 4315(a) of Pub. L. 105-33, to the extent such 
amendment substitutes fee schedules for reasonable charges, applicable 
to particular services as of date specified by the Secretary of Health 
and Human Services, see section 4315(c) of Pub. L. 105-33, set out as a 
note under section 1395l of this title.
    Amendment by section 4316(a) of Pub. L. 105-33 effective Aug. 5, 
1997, see section 4316(c) of Pub. L. 105-33, set out as a note under 
section 1395m of this title.
    Section 4317(c) of Pub. L. 105-33 provided that: ``The amendments 
made by this section [amending this section] shall apply to items and 
services furnished on or after January 1, 1998.''
    Amendment by section 4432(b)(2), (4) of Pub. L. 105-33 applicable to 
items and services furnished on or after July 1, 1998, see section 
4432(d) of Pub. L. 105-33, set out as a note under section 1395i-3 of 
this title.
    Amendment by section 4512(b)(2), (c) of Pub. L. 105-33 applicable 
with respect to services furnished and supplies provided on and after 
Jan. 1, 1998, see section 4512(d) of Pub. L. 105-33, set out as a note 
under section 1395l of this title.
    Amendment by section 4556(a) of Pub. L. 105-33 applicable to drugs 
and biologicals furnished on or after Jan. 1, 1998, see section 4556(d) 
of Pub. L. 105-33, set out as a note under section 1395l of this title.
    Amendment by section 4603(c)(2)(B)(i) of Pub. L. 105-33 applicable 
to cost reporting periods beginning on or after Oct. 1, 1999, except as 
otherwise provided, see section 4603(d) of Pub. L. 105-33, set out as an 
Effective Date note under section 1395fff of this title.
    Amendment by section 4611(d) of Pub. L. 105-33 applicable to 
services furnished on or after Jan. 1, 1998, and for purposes of 
applying such amendment, any home health spell of illness that began, 
but did not end, before such date, to be considered to have begun as of 
such date, see section 4611(f) of Pub. L. 105-33, set out as a note 
under section 1395d of this title.


                    Effective Date of 1994 Amendment

    Amendment by section 123(b)(1), (2)(B) of Pub. L. 103-432 applicable 
to services furnished on or after Jan. 1, 1995, see section 123(f)(2) of 
Pub. L. 103-432, set out as a note under section 1395l of this title.
    Section 123(f)(3), (4) of Pub. L. 103-432 provided that:
    ``(3) EOMBs.--The amendments made by subsection (c)(1) [amending 
this section] shall apply to explanations of benefits provided on or 
after July 1, 1995.
    ``(4) Carrier determinations.--The amendments made by subsection 
(c)(2) [amending this section] shall apply to contracts as of January 1, 
1995.''
    Section 125(b)(2) of Pub. L. 103-432 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to services 
furnished on or after the first day of the first month beginning more 
than 60 days after the date of the enactment of this Act [Oct. 31, 
1994].''
    Amendment by section 126(a)(1), (c), (e), (g)(9) of Pub. L. 103-432 
effective as if included in the enactment of Pub. L. 101-508, see 
section 126(i) of Pub. L. 103-432, set out as a note under section 1395m 
of this title.
    Section 126(h)(2) of Pub. L. 103-432 provided that the amendment 
made by that section is effective for payments for fiscal years 
beginning with fiscal year 1994.
    Section 135(b)(2) of Pub. L. 103-432 provided that the amendment 
made by that section is effective for standards applied for contract 
years beginning after Oct. 31, 1994.
    Amendment by section 151(b)(1)(B), (2)(B) of Pub. L. 103-432 
applicable to contracts with fiscal intermediaries and carriers under 
this subchapter for contract years beginning with 1995, see section 
151(b)(4) of Pub. L. 103-432, set out as a note under section 1395h of 
this title.


                    Effective Date of 1993 Amendment

    Section 13515(d) of Pub. L. 103-66 provided that: ``The amendments 
made by subsection (a) [amending this section and section 1395w-4 of 
this title] shall apply to services furnished on or after January 1, 
1994.''
    Amendment by section 13568(a), (b) of Pub. L. 103-66 applicable to 
claims received on or after Oct. 1, 1993, see section 13568(c) of Pub. 
L. 103-66, set out as a note under section 1395h of this title.


                    Effective Date of 1990 Amendment

    Section 4105(b)(3) of Pub. L. 101-508, as amended by Pub. L. 103-
432, title I, Sec. 126(g)(2)(A)(ii), Oct. 31, 1994, 108 Stat. 4415, 
provided that: ``The amendment made by paragraph (1) [amending this 
section] shall apply to services furnished on or after January 1, 
1991.''
    Section 4106(d) of Pub. L. 101-508 provided that:
    ``(1) The amendments made by subsection (a) [amending this section 
and provisions set out below] apply to services furnished after 1990, 
except that--
        ``(A) the provisions concerning the third and fourth years of 
    practice apply only to physicians' services furnished after 1990 and 
    1991, respectively, and
        ``(B) the provisions concerning the second, third, and fourth 
    years of practice apply only to services of a health care 
    practitioner furnished after 1991, 1992, and 1993, respectively.
    ``(2) The amendments made by subsection (b) [amending this section 
and section 1395w-4 of this title] shall apply to services furnished 
after 1991.''
    Section 4108(b) of Pub. L. 101-508 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to tests and 
services furnished on or after January 1, 1991.''
    Section 4110(b) of Pub. L. 101-508 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after the first day of the first month beginning more 
than 60 days after the date of the enactment of this Act [Nov. 5, 
1990].''
    Section 4118(a)(3) of Pub. L. 101-508 provided that: ``The 
amendments made by paragraphs (1) and (2) [amending this section] apply 
to services furnished after March 1990.''
    Section 4118(f)(2)(A) of Pub. L. 101-508 provided that the amendment 
by that section is effective as if included in the Omnibus Budget 
Reconciliation Act of 1989, Pub. L. 101-239.
    Section 4118(f)(2)(B) of Pub. L. 101-508 provided that the amendment 
by that section is effective Jan. 1, 1991.
    Amendment by section 4155(c) of Pub. L. 101-508 applicable to 
services furnished on or after Jan. 1, 1991, see section 4155(e) of Pub. 
L. 101-508, set out as a note under section 1395k of this title.


                    Effective Date of 1989 Amendments

    Section 6102(e)(3) of Pub. L. 101-239 provided that the amendment 
made by that section is effective for physicians' services furnished on 
or after Jan. 1, 1992.
    Section 6106(b) of Pub. L. 101-239 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after April 1, 1990.''
    Section 6108(a)(2) of Pub. L. 101-239, as amended by Pub. L. 101-
508, title IV, Sec. 4106(a)(2), Nov. 5, 1990, 104 Stat. 1388-61, 
provided that:
    ``(A) Subject to subparagraph (B), the amendments made by paragraph 
(1) [amending this section] apply to services furnished in 1990 or 1991 
which were subject to the first sentence of section 1842(b)(4)(F) of the 
Social Security Act [subsec. (b)(4)(F) of this section] in 1989 or 1990.
    ``(B) The amendments made by paragraph (1) shall not apply to 
services furnished in 1990 before April 1, 1990. With respect to 
physicians' services furnished during 1990 on and after April 1, such 
amendments shall be applied as though any reference, in the matter 
inserted by such amendments, to the `first calendar year during which 
the preceding sentence no longer applies' were deemed a reference to the 
remainder of 1990.''
    Section 6108(b)(3) of Pub. L. 101-239 provided that: ``The 
amendments made by this subsection [amending this section] apply to 
procedures performed after March 31, 1990.''
    Section 6114(f) of Pub. L. 101-239 provided that: ``The amendments 
made by this section [amending this section and section 1395x of this 
title] shall apply to services furnished on or after April 1, 1990.''
    Amendment by section 6202(d)(2) of Pub. L. 101-239 applicable to 
agreements and contracts entered into or renewed on or after Dec. 19, 
1989, see section 6202(d)(3) of Pub. L. 101-239, set out as a note under 
section 1395h of this title.
    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(e) of Pub. L. 101-234 provided that: ``The provisions of 
this section [amending this section and sections 1395m, 1395cc, 1395ll, 
and 1395ww of this title, enacting provisions set out as notes under 
section 1395m of this title, and repealing provisions set out as notes 
under sections 1395b, 1395b-1, 1395b-2, and 1395h of this title and 
section 8902 of Title 5, Government Organization and Employees] (other 
than subsections (c) and (d) [amending this section and sections 1395m, 
1395cc, 1395ll, and 1395ww of this title and enacting provisions set out 
as a note under section 1395m of this title]) shall take effect January 
1, 1990, except that--
        ``(1) the repeal of section 421 of MCCA [Pub. L. 100-360, set 
    out as a note under section 1395b of this title] shall not apply to 
    duplicative part A benefits for periods before January 1, 1990, and
        ``(2) the amendments made by subsection (b) [amending this 
    section and sections 1395m, 1395cc, 1395ll, and 1395ww of this 
    title] shall take effect on the date of the enactment of this Act 
    [Dec. 13, 1989].''


                    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.
    Section 202(m) of Pub. L. 100-360, as amended by Pub. L. 101-234, 
title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981, provided that:
    ``(1) [Repealed. Prior to repeal by Pub. L. 101-234, par. (1) read 
as follows: `In general.--Except as otherwise provided in this 
subsection, the amendments made by this section [enacting section 1395w-
3 of this title and amending this section and sections 1320a-7a, 1395l, 
1395m, 1395x, 1395y, 1395cc, 1395mm, and 1396b of this title] shall 
apply to items dispensed on or after January 1, 1990.']
    ``(2) [Repealed. Prior to repeal by Pub. L. 101-234, par. (2) read 
as follows: `Carriers.--The amendments made by subsection (e) [amending 
this section] shall take effect on the date of the enactment of this Act 
[July 1, 1988]; except that the amendments made by subsection (e)(5) 
[amending this section] shall take effect on January 1, 1991, but shall 
not be construed as requiring payment before February 1, 1991.']
    ``(3) [Repealed. Prior to repeal by Pub. L. 101-234, par. (3) read 
as follows: `HMO/CMP enrollments.--The amendment made by subsection (f) 
[amending section 1395mm of this title] shall apply to enrollments 
effected on or after January 1, 1990.']
    ``(4) Diagnostic coding.--The amendment made by subsection (g) 
[amending this section] shall apply to services furnished after March 
31, 1989.
    ``(5) [Repealed. Prior to repeal by Pub. L. 101-234, par. (5) read 
as follows: `Transition.--With respect to administrative expenses (and 
costs of the Prescription Drug Payment Review Commission) for periods 
before January 1, 1990, amounts otherwise payable from the Federal 
Catastrophic Drug Insurance Trust Fund shall be payable from the Federal 
Supplementary Medical Insurance Trust Fund and shall also be treated as 
a debit to the Medicare Catastrophic Coverage Account.'].''
    [Amendment of section 202(m) of Pub. L. 100-360, set out above, 
effective Jan. 1, 1990, see section 201(c) of Pub. L. 101-234, set out 
as an Effective Date of 1989 Amendment note under section 1320a-7a of 
this title.]
    Section 223(d)(2), (3) of Pub. L. 100-360 provided that:
    ``(2) The amendments made by subsection (b) [amending this section] 
shall apply to annual notices beginning with 1989.
    ``(3) The amendments made by subsection (c) [amending this section] 
shall first apply to explanations of benefits provided for items and 
services furnished on or after January 1, 1989.''
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(a)(3)(A), (C)(i), (f)(1)(A), (B), (2)-(4)(C), 
(5), (6)(B), (7), (9), (11)(A), (14), (g)(2)(A)-(C), (i)(1)(A), (2), 
(4)(C)(vi), and (j)(4)(A) of 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 Amendments

    Amendment by section 4031(a)(2) of Pub. L. 100-203 applicable to 
claims received on or after July 1, 1988, see section 4031(a)(3)(A) of 
Pub. L. 100-203, set out as a note under section 1395h of this title.
    Amendment by section 4035(a)(2) of Pub. L. 100-203 effective Dec. 
22, 1987, and applicable to budgets for fiscal years beginning with 
fiscal year 1989, see section 4035(a)(3) of Pub. L. 100-203, set out as 
a note under section 1395h of this title.
    Section 4044(b) of Pub. L. 100-203 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to payment 
for physicians' services furnished on or after January 1, 1989.''
    Section 4045(d) of Pub. L. 100-203 provided that: ``The amendments 
made by this section [amending this section and sections 1395l and 
1395w-1 of this title and amending provisions set out below] shall apply 
to items and services furnished on or after April 1, 1988, except the 
amendment made by subsection (c)(2)(B) [amending this section] shall 
apply to services furnished on or after January 1, 1988.''
    Section 4046(b) of Pub. L. 100-203 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after April 1, 1988.''
    Section 4047(b) of Pub. L. 100-203, as amended by Pub. L. 100-360, 
title IV, Sec. 411(f)(6)(C), July 1, 1988, 102 Stat. 779, provided that: 
``The amendment made by subsection (a) [amending this section] shall 
apply to physicians who first furnish services to medicare beneficiaries 
on or after April 1, 1988.''
    Section 4051(c) of Pub. L. 100-203 provided that:
    ``(1) The amendment made by subsection (a) [amending this section] 
shall apply to diagnostic tests performed on or after April 1, 1988.
    ``(2) The Secretary of Health and Human Services shall complete the 
review and make an appropriate adjustment of prevailing charge levels 
under subsection (b) [set out below] for items and services furnished no 
later than January 1, 1989.''
    Section 4053(b), formerly Sec. 4052(b), of Pub. L. 100-203, as 
renumbered and amended by Pub. L. 100-360, title IV, Sec. 411(f)(11)(B), 
(14), July 1, 1988, 102 Stat. 781, provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply to payment for 
services furnished on or after April 1, 1988.''
    Section 4054(c), formerly Sec. 4053(c), of Pub. L. 100-203, as 
renumbered by Pub. L. 100-360, title IV, Sec. 411(f)(14), July 1, 1988, 
102 Stat. 781, provided that: ``The amendment made by subsection (a) 
[amending this section] shall apply to charges imposed for services 
furnished on or after April 1, 1988.''
    Amendment by section 4063(a) of Pub. L. 100-203 applicable to items 
furnished on or after July 1, 1988, see section 4063(c) of Pub. L. 100-
203, set out as a note under section 1395(l) of this title.
    Section 4081(c)(1) of Pub. L. 100-203 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to contracts 
with carriers for claims for items and services furnished by 
participating physicians and suppliers on or after January 1, 1989.''
    Section 4082(e)(3) of Pub. L. 100-203 provided that: ``The 
amendments made by subsection (c) [amending this section] shall apply to 
evaluation of performance of carriers under contracts entered into or 
renewed on or after October 1, 1988.''
    Section 4085(g)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective as if 
included in section 9307(c) of the Consolidated Omnibus Budget 
Reconciliation Act of 1985 [Pub. L. 99-272].''
    Section 4085(i)(7) of Pub. L. 100-203 provided that the amendment 
made by that section is effective as if included in the enactment of 
Pub. L. 99-509.
    Amendment by section 4096(a)(1) of Pub. L. 100-203 applicable to 
services furnished on or after Jan. 1, 1988, see section 4096(d) of Pub. 
L. 100-203, set out as a note under section 1320c-3 of this title.
    Amendment by Pub. L. 100-93 effective at end of fourteen-day period 
beginning Aug. 18, 1987, and inapplicable to administrative proceedings 
commenced before end of such period, see section 15(a) of Pub. L. 100-
93, set out as a note under section 1320a-7 of this title.


                    Effective Date of 1986 Amendments

    Section 1895(b)(16)(B) of Pub. L. 99-514 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall apply 
to claims presented after the date of the enactment of this Act [Oct. 
22, 1986].''
    Amendment by section 1895(b)(14)(A), (15) of Pub. L. 99-514 
effective, except as otherwise provided, as if included in enactment of 
the Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L. 99-
272, see section 1895(e) of Pub. L. 99-514, set out as a note under 
section 162 of Title 26, Internal Revenue Code.
    Section 9307(c)(2) of Pub. L. 99-509 provided that the amendment 
made by section 9307(c)(2)(A) of Pub. L. 99-509 [amending directory 
language of section 1895(b)(14)(A)(ii) of Pub. L. 99-514 which amended 
this section] is effective as if included in the enactment of the Tax 
Reform Act of 1986, Pub. L. 99-514.
    Amendment by section 9311(c) of Pub. L. 99-509 applicable to claims 
received on or after Nov. 1, 1986, with subsec. (c)(2)(C) of this 
section applicable to claims received on or after Apr. 1, 1987, see 
section 9311(d) of Pub. L. 99-509, set out as a note under section 1395h 
of this title.
    Amendment by section 9320(e)(3) of Pub. L. 99-509 applicable to 
services furnished on or after Jan. 1, 1989, with exceptions for 
hospitals located in rural areas which meet certain requirements related 
to certified registered nurse anesthetists, see section 9320(i), (k) of 
Pub. L. 99-509, as amended, set out as notes under section 1395k of this 
title.
    Section 9331(a)(4) of Pub. L. 99-509 provided that: ``The amendments 
made by this subsection [amending this section] shall apply to services 
furnished on or after January 1, 1987.''
    Section 9331(b)(4) of Pub. L. 99-509 provided that: ``The amendments 
made by this subsection [amending this section] shall apply to services 
furnished on or after January 1, 1987.''
    Section 9331(c)(3)(B) of Pub. L. 99-509 provided that: ``The 
amendments made by subparagraph (A) [amending this section] shall apply 
to physicians' services furnished on or after January 1, 1988.''
    Section 9332(a)(4)(A) of Pub. L. 99-509 provided that: ``The 
amendment made by paragraph (1) [amending this section] shall be 
effective for contracts under section 1842 of the Social Security Act 
[this section] as of October 1, 1987.''
    Section 9332(b)(3) of Pub. L. 99-509 provided that: ``The amendments 
made by this paragraph [probably means `this subsection' which amended 
this section] shall first apply to directories for 1987.''
    Section 9332(c)(2) of Pub. L. 99-509 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to services 
furnished on or after October 1, 1987.''
    Section 9332(d)(2) of Pub. L. 99-509 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to surgical 
procedures performed on or after October 1, 1987.''
    Section 9333(d) of Pub. L. 99-509 provided that: ``The amendments 
made by this section [amending this section] shall take effect on the 
date of the enactment of this Act [Oct. 21, 1986].''
    Section 9334(c) of Pub. L. 99-509 provided that: ``The amendments 
made by this section [amending this section] shall apply to services 
furnished on or after January 1, 1987.''
    Amendment by section 9338(b), (c) of Pub. L. 99-509 applicable to 
services furnished on or after Jan. 1, 1987, see section 9338(f) of Pub. 
L. 99-509 set out as a note under section 1395x of this title.
    Amendment by section 9341(a)(2) of Pub. L. 99-509 applicable to 
items and services furnished on or after Jan. 1, 1987, see section 
9341(b) of Pub. L. 99-509, set out as a note under section 1395ff of 
this title.
    Section 9219(b)(1)(D) of Pub. L. 99-272 provided that: ``The 
amendments made by this paragraph [amending this section and sections 
1395x and 1395yy of this title] shall be effective as if they had been 
originally included in the Deficit Reduction Act of 1984 [Pub. L. 98-
369].''
    Section 9219(b)(2)(B) of Pub. L. 99-272 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall be 
effective as if it had been originally included in Public Law 98-617.''
    Section 9301(b)(4) of Pub. L. 99-272 provided that: ``The amendments 
made by this subsection [amending this section and enacting provisions 
set out as a note under this section] shall apply to services furnished 
on or after May 1, 1986.''
    Section 9301(c)(5) of Pub. L. 99-272, as amended by Pub. L. 99-514, 
title XVIII, Sec. 1895(b)(14)(B), Oct. 22, 1986, 100 Stat. 2934, 
provided that: ``Section 1842(h)(7) of the Social Security Act [subsec. 
(h)(7) of this section], as added by paragraph (4) of this subsection, 
shall apply to explanations of benefits provided on or after such date 
(not later than October 1, 1986) as the Secretary of Health and Human 
Services shall specify.''
    Section 9301(d)(4) of Pub. L. 99-272 provided that: ``The amendments 
made by this subsection [amending this section and enacting provisions 
set out as a note under this section] shall apply to items and services 
furnished on or after October 1, 1986.''
    Section 9306(b) of Pub. L. 99-272 provided that: ``The amendments 
made by this section [amending this section] shall apply to items and 
services furnished on or after April 1, 1986.''
    Amendment by section 9307(c) of Pub. L. 99-272 applicable to 
services performed on or after April 1, 1986, see section 9307(e) of 
Pub. L. 99-272, set out as a note under section 1320c-3 of this title.


                    Effective Date of 1984 Amendments

    Amendment by Pub. L. 98-617 effective as if originally included in 
the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of 
Pub. L. 98-617, set out as a note under section 1395f of this title.
    Amendment by section 2303(e) of Pub. L. 98-369 applicable to 
clinical diagnostic laboratory tests furnished on or after July 1, 1984, 
but not applicable to clinical diagnostic laboratory tests furnished to 
inpatients of a provider operating under a waiver granted pursuant to 
section 602(k) of Pub. L. 98-21, set out as a note under section 1395y 
of this title, see section 2303(j)(1), (3) of Pub. L. 98-369, set out as 
a note under section 1395l of this title.
    Section 2306(b)(2) of Pub. L. 98-369 provided that: ``The amendments 
made by paragraph (1) [amending this section] shall apply to items and 
services furnished on or after October 1, 1985.''
    Section 2307(a)(3) of Pub. L. 98-369 provided that: ``The amendments 
made by this subsection [amending this section] shall apply to services 
furnished on or after July 1, 1984.''
    Amendment by section 2326(d)(2) of Pub. L. 98-369 applicable to 
agreements and contracts entered into or renewed after Sept. 30, 1984, 
see section 2326(d)(3) of Pub. L. 98-369, set out as a note under 
section 1395h of this title.
    Amendment by section 2354(b)(13), (14) of Pub. L. 98-369 effective 
July 18, 1984, but not to be construed as changing or affecting any 
right, liability, status, or interpretation which existed (under the 
provisions of law involved) before that date, see section 2354(e)(1) of 
Pub. L. 98-369, set out as a note under section 1320a-1 of this title.
    Amendment by section 2663(j)(2)(F)(iv) of Pub. L. 98-369 effective 
July 18, 1984, but not to be construed as changing or affecting any 
right, liability, status, or interpretation which existed (under the 
provisions of law involved) before that date, see section 2664(b) of 
Pub. L. 98-369, set out as a note under section 401 of this title.


                    Effective Date of 1982 Amendment

    Section 104(b) of Pub. L. 97-248, as amended by Pub. L. 97-448, 
title III, Sec. 309(a)(2), Jan. 12, 1983, 96 Stat. 2408, provided that: 
``The amendment made by subsection (a) [amending this section] shall be 
effective with respect to services furnished on or after October 1, 
1982.''
    Section 113(b)(1) of Pub. L. 97-248 provided that: ``The amendment 
made by subsection (a) [amending this section] is effective with respect 
to services performed on or after October 1, 1982.''
    Amendment by section 128(d)(1) of Pub. L. 97-248 effective Sept. 3, 
1982, see section 128(e)(3) of Pub. L. 97-248, set out as a note under 
section 1395x of this title.


                    Effective Date of 1980 Amendment

    Section 918(a)(2) of Pub. L. 96-499 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to bills 
submitted and requests for payment made on or after such date (not later 
than April 1, 1981) as the Secretary of Health and Human Services 
prescribes by a notice published in the Federal Register.''
    Section 946(c) of Pub. L. 96-499 provided that: ``The amendments 
made by subsections (a) and (b) [amending this section] shall become 
effective with respect to bills submitted or requests for payment made 
on or after July 1, 1981.''
    Section 948(c)(2) of Pub. L. 96-499 provided that: ``The amendment 
made by subsection (b) [amending this section] shall apply with respect 
to cost accounting periods beginning on or after January 1, 1981.''


                    Effective Date of 1977 Amendments

    Amendment by Pub. L. 95-216 effective in the case of items and 
services furnished after Dec. 20, 1977, see section 501(c) of Pub. L. 
95-216, set out as a note under section 1395x of this title.
    Amendment by Pub. L. 95-142 applicable with respect to care and 
services furnished on or after Oct. 25, 1977, see section 2(a)(4) of 
Pub. L. 95-142, set out as a note under section 1395g of this title.


                    Effective Date of 1976 Amendment

    Section 4 of Pub. L. 94-368 provided that: ``The amendments made by 
sections 2 and 3 of this Act [amending this section and provisions set 
out as a note under section 390e of Title 7, Agriculture] shall be 
effective with respect to periods beginning after June 30, 1976; except 
that, for the twelve-month period beginning July 1, 1976, the amendments 
made by section 3 [amending this section and provisions set out as a 
note under section 390e of Title 7, Agriculture] shall be applicable 
with respect to claims filed under part B of title XVIII of the Social 
Security Act [this part] (after June 30, 1976, and before July 1, 1977) 
with a carrier designated pursuant to section 1842 of such Act [this 
section], and processed by such carrier after the appropriate changes 
were made pursuant to such section 3 in the prevailing charge levels for 
such twelve-month period under the third and fourth sentences of section 
1842(b)(3) of the Social Security Act [subsec. (b)(3) of this 
section].''


                    Effective Date of 1974 Amendment

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


                    Effective Date of 1972 Amendment

    Amendment by section 211(c)(3) of Pub. L. 92-603 applicable to 
services furnished with respect to admissions occurring after Dec. 31, 
1972, see section 211(d) of Pub. L. 92-603, set out as a note under 
section 1395f of this title.
    Amendment by section 227(e)(3) of Pub. L. 92-603 applicable with 
respect to accounting periods beginning after June 30, 1973, see section 
227(g) of Pub. L. 92-603, set out as a note under section 1395x of this 
title.
    Section 236(c) of Pub. L. 92-603 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
bills submitted and requests for payments made after the date of the 
enactment of this Act [Oct. 30, 1972]. The amendments made by subsection 
(b) [amending section 1396a of this title] shall be effective January 1, 
1973 (or earlier if the State plan so provides).''
    Section 258(b) of Pub. L. 92-603 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
bills submitted and requests for payment made after March 1968.''
    Section 262(b) of Pub. L. 92-603 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
hearings requested (under the procedures established under section 
1842(b)(3)(C) of the Social Security Act [subsec. (b)(3)(C) of this 
section]) after the date of the enactment of this Act [Oct. 30, 1972].''
    Amendment by section 263(d)(5) of Pub. L. 92-603 with respect to 
collection of premiums applicable to premiums becoming due and payable 
after the fourth month following the month of enactment of Pub. L. 92-
603 which was approved on Oct. 30, 1972, see section 263(f) of Pub. L. 
92-603, set out as a note under section 1395s of this title.
    Amendment by section 281(d) of Pub. L. 92-603 to apply in the case 
of notices sent to individuals after 1968, see section 281(g) of Pub. L. 
92-603, set out as a note under section 1395gg of this title.


                    Effective Date of 1968 Amendment

    Section 125(b) of Pub. L. 90-248 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply with respect 
to claims on which a final determination has not been made on or before 
the date of enactment of this Act [Jan. 2, 1968].''

                          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.


        Implementation of Inherent Reasonableness (IR) Authority

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 223(a), 
(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A-352, 1501A-353, provided 
that:
    ``(a) Limitation on Use.--The Secretary of Health and Human Services 
may not use, or permit fiscal intermediaries or carriers to use, the 
inherent reasonableness authority provided under section 1842(b)(8) of 
the Social Security Act (42 U.S.C. 1395u(b)(8)) until after--
        ``(1) the Comptroller General of the United States releases a 
    report pursuant to the request for such a report made on March 1, 
    1999, regarding the impact of the Secretary's, fiscal 
    intermediaries', and carriers' use of such authority; and
        ``(2) the Secretary has published a notice of final rulemaking 
    in the Federal Register that relates to such authority and that 
    responds to such report and to comments received in response to the 
    Secretary's interim final regulation relating to such authority that 
    was published in the Federal Register on January 7, 1998.
    ``(b) Reevaluation of IR Criteria.--In promulgating the final 
regulation under subsection (a)(2), the Secretary shall--
        ``(1) reevaluate the appropriateness of the criteria included in 
    such interim final regulation for identifying payments which are 
    excessive or deficient; and
        ``(2) take appropriate steps to ensure the use of valid and 
    reliable data when exercising such authority.''


                        Initial Budget Neutrality

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


       Improvements in Administration of Laboratory Tests Benefit

    Section 4554 of Pub. L. 105-33 provided that:
    ``(a) Selection of Regional Carriers.--
        ``(1) In general.--The Secretary of Health and Human Services 
    (in this section referred to as the `Secretary') shall--
            ``(A) divide the United States into no more than 5 regions, 
        and
            ``(B) designate a single carrier for each such region, for 
        the purpose of payment of claims under part B of title XVIII of 
        the Social Security Act [this part] with respect to clinical 
        diagnostic laboratory tests furnished on or after such date (not 
        later than July 1, 1999) as the Secretary specifies.
        ``(2) Designation.--In designating such carriers, the Secretary 
    shall consider, among other criteria--
            ``(A) a carrier's timeliness, quality, and experience in 
        claims processing, and
            ``(B) a carrier's capacity to conduct electronic data 
        interchange with laboratories and data matches with other 
        carriers.
        ``(3) Single data resource.--The Secretary shall select one of 
    the designated carriers to serve as a central statistical resource 
    for all claims information relating to such clinical diagnostic 
    laboratory tests handled by all the designated carriers under such 
    part.
        ``(4) Allocation of claims.--The allocation of claims for 
    clinical diagnostic laboratory tests to particular designated 
    carriers shall be based on whether a carrier serves the geographic 
    area where the laboratory specimen was collected or other method 
    specified by the Secretary.
        ``(5) Secretarial exclusion.--Paragraph (1) shall not apply with 
    respect to clinical diagnostic laboratory tests furnished by 
    physician office laboratories if the Secretary determines that such 
    offices would be unduly burdened by the application of billing 
    responsibilities with respect to more than one carrier.
    ``(b) Adoption of National Policies for Clinical Laboratory Tests 
Benefit.--
        ``(1) In general.--Not later than January 1, 1999, the Secretary 
    shall first adopt, consistent with paragraph (2), national coverage 
    and administrative policies for clinical diagnostic laboratory tests 
    under part B of title XVIII of the Social Security Act [this part], 
    using a negotiated rulemaking process under subchapter III of 
    chapter 5 of title 5, United States Code.
        ``(2) Considerations in design of national policies.--The 
    policies under paragraph (1) shall be designed to promote program 
    integrity and national uniformity and simplify administrative 
    requirements with respect to clinical diagnostic laboratory tests 
    payable under such part in connection with the following:
            ``(A) Beneficiary information required to be submitted with 
        each claim or order for laboratory tests.
            ``(B) The medical conditions for which a laboratory test is 
        reasonable and necessary (within the meaning of section 
        1862(a)(1)(A) of the Social Security Act [section 1395y(a)(1)(A) 
        of this title]).
            ``(C) The appropriate use of procedure codes in billing for 
        a laboratory test, including the unbundling of laboratory 
        services.
            ``(D) The medical documentation that is required by a 
        medicare contractor at the time a claim is submitted for a 
        laboratory test in accordance with section 1833(e) of the Social 
        Security Act [section 1395l(e) of this title].
            ``(E) Recordkeeping requirements in addition to any 
        information required to be submitted with a claim, including 
        physicians' obligations regarding such requirements.
            ``(F) Procedures for filing claims and for providing 
        remittances by electronic media.
            ``(G) Limitation on frequency of coverage for the same tests 
        performed on the same individual.
        ``(3) Changes in laboratory policies pending adoption of 
    national policy.--During the period that begins on the date of the 
    enactment of this Act [Aug. 5, 1997] and ends on the date the 
    Secretary first implements national policies pursuant to regulations 
    promulgated under this subsection, a carrier under such part may 
    implement changes relating to requirements for the submission of a 
    claim for clinical diagnostic laboratory tests.
        ``(4) Use of interim policies.--After the date the Secretary 
    first implements such national policies, the Secretary shall permit 
    any carrier to develop and implement interim policies of the type 
    described in paragraph (1), in accordance with guidelines 
    established by the Secretary, in cases in which a uniform national 
    policy has not been established under this subsection and there is a 
    demonstrated need for a policy to respond to aberrant utilization or 
    provision of unnecessary tests. Except as the Secretary specifically 
    permits, no policy shall be implemented under this paragraph for a 
    period of longer than 2 years.
        ``(5) Interim national policies.--After the date the Secretary 
    first designates regional carriers under subsection (a), the 
    Secretary shall establish a process under which designated carriers 
    can collectively develop and implement interim national policies of 
    the type described in paragraph (1). No such policy shall be 
    implemented under this paragraph for a period of longer than 2 
    years.
        ``(6) Biennial review process.--Not less often than once every 2 
    years, the Secretary shall solicit and review comments regarding 
    changes in the national policies established under this subsection. 
    As part of such biennial review process, the Secretary shall 
    specifically review and consider whether to incorporate or supersede 
    interim policies developed under paragraph (4) or (5). Based upon 
    such review, the Secretary may provide for appropriate changes in 
    the national policies previously adopted under this subsection.
        ``(7) Requirement and notice.--The Secretary shall ensure that 
    any policies adopted under paragraph (3), (4), or (5) shall apply to 
    all laboratory claims payable under part B of title XVIII of the 
    Social Security Act [this part], and shall provide for advance 
    notice to interested parties and a 45-day period in which such 
    parties may submit comments on the proposed change.
    ``(c) Inclusion of Laboratory Representative on Carrier Advisory 
Committees.--The Secretary shall direct that any advisory committee 
established by a carrier to advise such carrier with respect to coverage 
and administrative policies under part B of title XVIII of the Social 
Security Act [this part] shall include an individual to represent the 
independent clinical laboratories and such other laboratories as the 
Secretary deems appropriate. The Secretary shall consider 
recommendations from national and local organizations that represent 
independent clinical laboratories in such selection.''


                    Wholesale Price Study and Report

    Section 4556(c) of Pub. L. 105-33 provided that: ``The Secretary of 
Health and Human Services shall study the effect on the average 
wholesale price of drugs and biologicals of the amendments made by 
subsection (a) [amending this section] and shall report to the 
Committees on Ways and Means and Commerce of the House of 
Representatives and the Committee on Finance of the Senate the result of 
such study not later than July 1, 1999.''


                      Budget Neutrality Adjustment

    Section 13515(b) of Pub. L. 103-66 provided that: ``Notwithstanding 
any other provision of law, the Secretary of Health and Human Services 
shall reduce the following values and amounts for 1994 (to be applied 
for that year and subsequent years) by such uniform percentage as the 
Secretary determines to be required to assure that the amendments made 
by subsection (a) [amending this section and section 1395w-4 of this 
title] will not result in expenditures under part B of title XVIII of 
the Social Security Act [this part] in 1994 that exceed the amount of 
such expenditures that would have been made if such amendments had not 
been made:
        ``(1) The relative values established under section 1848(c) of 
    such Act [section 1395w-4(c) of this title] for services (other than 
    anesthesia services) and, in the case of anesthesia services, the 
    conversion factor established under section 1848 of such Act for 
    such services.
        ``(2) The amounts determined under section 1848(a)(2)(B)(ii)(I) 
    of such Act.
        ``(3) The prevailing charges or fee schedule amounts to be 
    applied under such part for services of a health care practitioner 
    (as defined in section 1842(b)(4)(F)(ii)(I) of such Act [subsec. 
    (b)(4)(F)(ii)(I) of this section], as in effect before the date of 
    the enactment of this Act [Aug. 10, 1993]).''


                             Procedure Codes

    Section 4101(b)(2) of Pub. L. 101-508, as amended by Pub. L. 103-
432, title I, Sec. 126(a)(2), Oct. 31, 1994, 108 Stat. 4414, provided 
that: ``In applying section 1842(b)(16)(B) of the Social Security Act 
[subsec. (b)(16)(B) of this section]:
        ``(A) The codes for the procedures specified in clause (ii) are 
    as follows: Hospital inpatient medical services (HCPCS codes 90200 
    through 90292), consultations (HCPCS codes 90600 through 90654), 
    other visits (HCPCS code 90699), preventive medicine visits (HCPCS 
    codes 90750 through 90764), psychiatric services (HCPCS codes 90801 
    through 90862), emergency care facility services (HCPCS codes 99062 
    through 99065), and critical care services (HCPCS codes 99160 
    through 99174).
        ``(B) The codes for the procedures specified in clause (iii) are 
    as follows: Partial mastectomy (HCPCS code 19160); tendon sheath 
    injections and small joint arthrocentesis (HCPCS codes 20550, 20600, 
    20605, and 20610); femoral fracture and trochanteric fracture 
    treatments (HCPCS codes 27230, 27232, 27234, 27238, 27240, 27242, 
    27246, and 27248); endotracheal intubation (HCPCS code 31500); 
    thoracentesis (HCPCS code 32000); thoracostomy (HCPCS codes 32020, 
    32035, and 32036); aneurysm repair (HCPCS codes 35111); 
    cystourethroscopy (HCPCS code 52340); transurethral fulguration and 
    resection (HCPCS codes 52606 and 52620); tympanoplasty with 
    mastoidectomy (HCPCS code 69645); and ophthalmoscopy (HCPCS codes 
    92250 and 92260).''


     Study of Release of Prepayment Medical Review Screen Parameters

    Section 4111 of Pub. L. 101-508 directed Secretary of Health and 
Human Services to conduct a study of effect of release of medicare 
prepayment medical review screen parameters on physician billings for 
services to which the parameters apply, such study to be based upon the 
release of the screen parameters at a minimum of six carriers, with 
Secretary to report results of study to Congress not later than Oct. 1, 
1992.


 Freeze in Charges for Parenteral and Enteral Nutrients, Supplies, and 
                                Equipment

    Section 13541 of Pub. L. 103-66 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 1994 and 1995, the charges determined to be 
reasonable with respect to such nutrients, supplies, and equipment may 
not exceed the charges determined to be reasonable with respect to such 
nutrients, supplies, and equipment during 1993.''
    Section 4152(d) of Pub. L. 101-508 provided that: ``In determining 
the amount of payment under part B of title XVIII of the Social Security 
Act [this part] for enteral and parenteral nutrients, supplies, and 
equipment furnished during 1991, the charges determined to be reasonable 
with respect to such nutrients, supplies, and equipment may not exceed 
the charges determined to be reasonable with respect to such items for 
1990.''


  Prohibition on Regulations Changing Coverage of Conventional Eyewear

    Section 4153(b)(1) of Pub. L. 101-508 provided that:
    ``(A) Notwithstanding any other provision of law (except as provided 
in subparagraph (B)) the Secretary of Health and Human Services 
(referred to in this subsection as the `Secretary') may not issue any 
regulation that changes the coverage of conventional eyewear furnished 
to individuals (enrolled under part B of title XVIII of the Social 
Security Act [this part]) following cataract surgery with insertion of 
an intraocular lens.
    ``(B) Paragraph (1) shall not apply to any regulation issued for the 
sole purpose of implementing the amendments made by paragraph (2).''


            Directory of Unique Physician Identifier Numbers

    Section 4164(c) of Pub. L. 101-508, as amended by Pub. L. 103-432, 
title I, Sec. 147(f)(7)(B), Oct. 31, 1994, 108 Stat. 4432, provided 
that: ``Not later than March 31, 1991, the Secretary of Health and Human 
Services shall publish, and shall periodically update, a directory of 
the unique physician identification numbers of all physicians providing 
services for which payment may be made under part B of title XVIII of 
the Social Security Act [this part], and shall include in such directory 
the names, provider numbers, and billing addressess [sic] of all listed 
physicians.''


  Treatment of Certain Eye Examination Visits as Primary Care Services

    Section 6102(e)(10) of Pub. L. 101-239 provided that: ``In applying 
section 1842(i)(4) of the Social Security Act [subsec. (i)(4) of this 
section] for services furnished on or after January 1, 1990, 
intermediate and comprehensive office visits for eye examinations and 
treatments (codes 92002 and 92004) shall be considered to be primary 
care services.''


    Delay in Update Until April 1, 1990, and Reduction in Percentage 
                   Increase in Medicare Economic Index

    Section 6107(a) of Pub. L. 101-239 provided that:
    ``(1) In general.--Subject to the amendments made by this section 
[amending this section], any increase or adjustment in customary, 
prevailing, or reasonable charges, fee schedule amounts, maximum 
allowable actual charges, and other limits on actual charges with 
respect to physicians' services and other items and services described 
in paragraph (2) under part B of title XVIII of the Social Security Act 
[this part] which would otherwise occur as of January 1, 1990, shall be 
delayed so as to occur as of April 1, 1990, and, notwithstanding any 
other provision of law, the amount of payment under such part for such 
items and services which are furnished during the period beginning on 
January 1, 1990, and ending on March 31, 1990, shall be determined on 
the same basis as the amount of payment for such services furnished on 
December 31, 1989.
    ``(2) Items and services covered.--The items and services described 
in this paragraph are items and services (other than ambulance services 
and clinical diagnostic laboratory services) for which payment is made 
under part B of title XVIII of the Social Security Act on the basis of a 
reasonable charge or a fee schedule.
    ``(3) Extension of participation agreements and related 
provisions.--Notwithstanding any other provision of law--
        ``(A) subject to the last sentence of this paragraph, each 
    participation agreement in effect on December 31, 1989, under 
    section 1842(h)(1) of the Social Security Act [subsec. (h)(1) of 
    this section] shall remain in effect for the 3-month period 
    beginning on January 1, 1990;
        ``(B) the effective period for such agreements under such 
    section entered into for 1990 shall be the 9-month period beginning 
    on April 1, 1990, and the Secretary of Health and Human Services 
    shall provide an opportunity for physicians and suppliers to enroll 
    as participating physicians and suppliers before April 1, 1990;
        ``(C) instead of publishing, under section 1842(h)(4) of the 
    Social Security Act [subsec. (h)(4) of this section], at the 
    beginning of 1990, directories of participating physicians and 
    suppliers for 1990, the Secretary shall provide for such 
    publication, at the beginning of the 9-month period beginning on 
    April 1, 1990, of such directories of participating physicians and 
    suppliers for such period; and
        ``(D) instead of providing to nonparticipating physicians under 
    section 1842(b)(3)(G) of the Social Security Act [subsec. (b)(3)(G) 
    of this section] at the beginning of 1990, a list of maximum 
    allowable actual charges for 1990, the Secretary shall provide, at 
    the beginning of the 9-month period beginning on April 1, 1990, such 
    physicians such a list for such 9-month period.
An agreement with a participating physician or supplier described in 
subparagraph (A) in effect on December 31, 1989, under section 
1842(h)(1) of the Social Security Act shall not remain in effect for the 
period described in subparagraph (A) if the participating physician or 
supplier requests on or before December 31, 1989, that the agreement be 
terminated.''


State Demonstration Projects on Application of Limitation on Visits Per 
            Month Per Resident on Aggregate Basis for a Team

    Section 6114(e) of Pub. L. 101-239 provided that: ``The Secretary of 
Health and Human Services shall provide for at least 1 demonstration 
project under which, in the application of section 1842(b)(2)(C) of the 
Social Security Act [subsec. (b)(2)(C) of this section] (as added by 
subsection (c)(2) of this section) in one or more States, the limitation 
on the number of visits per month per resident would be applied on an 
average basis over the aggregate total of residents receiving services 
from members of the team.''


Application of Different Performance Standards for Electronic System for 
                        Covered Outpatient Drugs

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


  Delay in Application of Coordination of Benefits With Private Health 
                                Insurance

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


 Extension of Physician Participation Agreements and Related Provisions

    Section 4041(a)(2) of Pub. L. 100-203 provided that: 
``Notwithstanding any other provision of law--
        ``(A) subject to the last sentence of this paragraph, each 
    agreement with a participating physician in effect on December 31, 
    1987, under section 1842(h)(1) of the Social Security Act [subsec. 
    (h)(1) of this section] shall remain in effect for the 3-month 
    period beginning on January 1, 1988;
        ``(B) the effective period for agreements under such section 
    entered into for 1988 shall be the nine-month period beginning on 
    April 1, 1988, and the Secretary shall provide an opportunity for 
    physicians to enroll as participating physicians prior to April 1, 
    1988;
        ``(C) instead of publishing, under section 1842(h)(4) of the 
    Social Security Act [subsec. (h)(4) of this section] at the 
    beginning of 1988, directories of participating physicians for 1988, 
    the Secretary shall provide for such publication, at the beginning 
    of the 9-month period beginning on April 1, 1988, of such 
    directories of participating physicians for such period; and
        ``(D) instead of providing to nonparticipating physicians, under 
    section 1842(b)(3)(G) of the Social Security Act [subsec. (b)(3)(G) 
    of this section] at the beginning of 1988, a list of maximum 
    allowable actual charges for 1988, the Secretary shall provide, at 
    the beginning of the 9-month period beginning on April 1, 1988, to 
    such physicians such a list for such 9-month period.
An agreement with a participating physician in effect on December 31, 
1987, under section 1842(h)(1) of the Social Security Act shall not 
remain in effect for the period described in subparagraph (A) if the 
participating physician requests on or before December 31, 1987, that 
the agreement be terminated.''


               Development of Uniform Relative Value Guide

    Section 4048(b) of Pub. L. 100-203, as amended by Pub. L. 101-508, 
title IV, Sec. 4118(h)(1), Nov. 5, 1990, 104 Stat. 1388-70, provided 
that: ``The Secretary of Health and Human Services, in consultation with 
groups representing physicians who furnish anesthesia services, shall 
establish by regulation a relative value guide for use in all carrier 
localities in making payment for physician anesthesia services furnished 
under part B of title XVIII of the Social Security Act [this part] on 
and after March 1, 1989. Such guide shall be designed so as to result in 
expenditures under such title [this subchapter] for such services in an 
amount that would not exceed the amount of such expenditures which would 
otherwise occur.''
    [Section 4118(h) of Pub. L. 101-508 provided that the amendment by 
that section to section 4048(b) 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.]


           Study of Prevailing Charges for Anesthesia Services

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


                               GAO Studies

    Section 4048(d) of Pub. L. 100-203 provided that:
    ``(1) The Comptroller General shall conduct a study--
        ``(A) to determine the average anesthesia times reported for 
    medicare reimbursement purposes,
        ``(B) to verify those times from patient medical records,
        ``(C) to compare anesthesia times to average surgical times, and
        ``(D) to determine whether the current payments for physician 
    supervision of nurse anesthetists are excessive.
The Comptroller General shall report to Congress, by not later than 
January 1, 1989, on such study and in the report include recommendations 
regarding the appropriateness of the anesthesia times recognized by 
medicare for reimbursement purposes and recommendations regarding 
adjustments of payments for physician supervision of nurse anesthetists.
    ``(2) The Comptroller General shall conduct a study on the impact of 
the amendment made by subsection (a) [amending this section], and shall 
report to Congress on the results of such study by April 1, 1990.''


                Adjustment in Medicare Prevailing Charges

    Section 4051(b) of Pub. L. 100-203 provided that:
    ``(1) Review.--The Secretary of Health and Human Services shall 
review payment levels under part B of title XVIII of the Social Security 
Act [this part] for diagnostic tests (described in section 1861(s)(3) of 
such Act [section 1935x(s)(3) of this title], but excluding clinical 
diagnostic laboratory tests) which are commonly performed by independent 
suppliers, sold as a service to physicians, and billed by such 
physicians, in order to determine the reasonableness of payment amounts 
for such tests (and for associated professional services component of 
such tests). The Secretary may require physicians and suppliers to 
provide such information on the purchase or sale price (net of any 
discounts) for such tests as is necessary to complete the review and 
make the adjustments under this subsection. The Secretary shall also 
review the reasonableness of payment levels for comparable in-office 
diagnostic tests.
    ``(2) Establishment of revised payment screens.--If, as a result of 
such review, the Secretary determines, after notice and opportunity of 
at least 60 days for public comment, that the current prevailing charge 
levels (under the third and fourth sentences of section 1842(b) of the 
Social Security Act [subsec. (b) of this section]) for any such tests or 
associated professional services are excessive, the Secretary shall 
establish such charge levels at levels which, consistent with assuring 
that the test is widely and consistently available to medicare 
beneficiaries, reflect a reasonable price for the test without any 
markup. Alternatively, the Secretary, pursuant to guidelines published 
after notice and opportunity of at least 60 days for public comment, may 
delegate to carriers with contracts under section 1842 of the Social 
Security Act the establishment of new prevailing charge levels under 
this paragraph. When such charge levels are established, the provisions 
of section 1842(j)(1)(D) of such Act shall apply in the same manner as 
they apply to a reduction under section 1842(b)(8)(A) of such Act.''


             Adjustment for Maximum Allowable Actual Charge

    Section 4054(b), formerly Sec. 4053(b), of Pub. L. 100-203, as 
renumbered by Pub. L. 100-360, title IV, Sec. 411(f)(14), July 1, 1988, 
102 Stat. 781, provided that: ``In the case of a physician who did not 
have actual charges under title XVIII of the Social Security Act [this 
subchapter] for a procedure in the calendar quarter beginning on April 
1, 1984, but who establishes to the satisfaction of a carrier that he or 
she had actual charges (whether under such title or otherwise) for the 
procedure performed prior to June 30, 1984, the carrier shall compute 
the maximum allowable actual charge under section 1842(j) of the Social 
Security Act [subsec. (j) of this section] for such procedure performed 
by such physician in 1988 based on such physician's actual charges for 
the procedure.''


     Physician Payment Studies; Definitions of Medical and Surgical 
                               Procedures

    Section 4056(a), formerly Sec. 4055(a), of Pub. L. 100-203, as 
renumbered and amended by Pub. L. 100-360, title IV, Sec. 411(f)(13)(A), 
(14), July 1, 1988, 102 Stat. 781; Pub. L. 101-508, title IV, 
Sec. 4118(g)(4), Nov. 5, 1990, 104 Stat. 1388-70, provided that:
    ``(1) Report on variations in carrier payment practice.--The 
Secretary of Health and Human Services (in this section referred to as 
the `Secretary') shall conduct a study of variations in payment 
practices for physicians' services among the different carriers under 
section 1842 of the Social Security Act [this section]. Such study shall 
examine carrier variations in the services included in global fees and 
pre- and post-operative services included in payment for the operation.
    ``(2) Uniform definitions of procedures for payment purposes.--The 
Secretary shall develop, in consultation with appropriate national 
medical specialty societies and by not later than July 1, 1989, uniform 
definitions of physicians' services (including appropriate 
classification scheme for procedures) which could serve as the basis for 
making payments for such services under part B of title XVIII of the 
Social Security Act [this part]. In developing such definitions, to the 
extent practicable--
        ``(A) ancillary services commonly performed in conjunction with 
    a major procedure would be included with the major procedure;
        ``(B) pre- and post-procedure services would be included in the 
    procedure; and
        ``(C) similar procedures would be listed together if the 
    procedures are similar in resource requirements.''


 Payments for Durable Medical Equipment, Prosthetic Devices, Orthotics, 
          and Prosthetics; 1-Year Freeze on Charge Limitations

    Section 4062(a) of Pub. L. 100-203 provided that:
    ``(1) In general.--In imposing limitations on allowable charges for 
items and services (other than physicians' services) furnished in 1988 
under part B of title XVIII of such Act [this part] and for which 
payment is made on the basis of the reasonable charge for the item or 
service, the Secretary of Health and Human Services shall not impose any 
limitation at a level higher than the same level as was in effect in 
December 1987.
    ``(2) Transition.--The provisions of section 4041(a)(2) (other than 
subparagraph (D) thereof) of this subtitle [set out as a note above] 
shall apply to suppliers of items and services described in paragraph 
(1), and directories of participating suppliers of such items and 
services, in the same manner as such section applies to physicians 
furnishing physicians' services, and directories of participating 
physicians.''


       Special Rule With Respect to Payment for Intraocular Lenses

    Section 4063(d) of Pub. L. 100-203 provided that: ``With respect to 
the establishment of a reasonable charge limit under section 
1842(b)(11)(C)(ii) of the Social Security Act [subsec. (b)(11)(C)(ii) of 
this section], in applying section 1842(j)(1)(D)(i) of such Act, the 
matter beginning with `plus' shall be considered to have been deleted.''


       Study on Cost Effectiveness of Hearing Prior to Hearing by 
 Administrative Law Judge on Carrier Determinations; Report to Congress

    Section 4082(d) of Pub. L. 100-203 provided that: ``The Comptroller 
General shall conduct a study concerning the cost effectiveness of 
requiring hearings with a carrier under part B of title XVIII of the 
Social Security Act [this part] before having a hearing before an 
administrative law judge respecting carrier determinations under that 
part. The Comptroller General shall report to the Congress on the 
results of such study by not later than June 30, 1989.''


                Capacity To Set Geographic Payment Limits

    Section 4085(e) of Pub. L. 100-203 provided that: ``The Secretary of 
Health and Human Services shall develop the capability to implement (for 
services furnished on or after January 1, 1989) geographic limits on 
charges and payments under part B of title XVIII of the Social Security 
Act [this part] for physicians' services based on statewide, regional, 
or national average (or percentile in a distribution) of prevailing 
charges or payment amounts (weighted by frequency of services). Any such 
limits shall take into account adjustments for geographic differences in 
cost of practice and cost of living.''


   Utilization Screens for Physician Services Provided to Patients in 
                        Rehabilitation Hospitals

    Section 4114 of Pub. L. 101-508, as amended by Pub. L. 103-432, 
title I, Sec. 126(g)(4), Oct. 31, 1994, 108 Stat. 4416, provided that: 
``Not later than 180 days after the date of the enactment of this Act 
[Nov. 5, 1990], the Secretary of Health and Human Services shall issue 
guidelines to assure a uniform level of review of physician visits to 
patients of a rehabilitation hospital or unit after the medical review 
screen parameter established under section 4085(h) of the Omnibus Budget 
Reconciliation Act of 1987 [Pub. L. 100-203, set out below] has been 
exceeded.''
    Section 4085(h) of Pub. L. 100-203 provided that:
    ``(1) The Secretary of Health and Human Services shall establish (in 
consultation with appropriate physician groups, including those 
representing rehabilitative medicine) a separate utilization screen for 
physician visits to patients in rehabilitation hospitals and 
rehabilitative units (and patients in long-term care hospitals receiving 
rehabilitation services) to be used by carriers under section 1842 of 
the Social Security Act [this section] in performing functions under 
subsection (a) of such section related to the utilization practices of 
physicians in such hospitals and units.
    ``(2) Not later than 12 months after the date of enactment of this 
Act [Dec. 22, 1987], the Secretary of Health and Human Services shall 
take appropriate steps to implement the utilization screen established 
under paragraph (1).''


           Plan Amendments Not Required Until January 1, 1989

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


                 Amendments in Contracts and Regulations

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


                         Medicare Economic Index

    Section 9331(c)(1), (2), (4)-(6) of Pub. L. 99-509 provided that:
    ``(1) For 1987.--Notwithstanding any other provision of law, for 
purposes of part B of title XVIII of the Social Security Act [this part] 
for physicians' services furnished in 1987, the percentage increase in 
the MEI (as defined in section 1842(b)(4)(E)(ii) of the Social Security 
Act [subsec. (b)(4)(E)(ii) of this section]) shall be 3.2 percent.
    ``(2) Prohibiting retroactive adjustment of medicare economic 
index.--The Secretary of Health and Human Services is not authorized to 
revise the MEI in a manner that provides, for any period before January 
1, 1985, for the substitution of a rental equivalence or rental 
substitution factor for the housing component of the consumer price 
index.''
    ``(4) Study.--The Secretary shall conduct a study of the extent to 
which the MEI appropriately and equitably reflects economic changes in 
the provision of the physicians' services to medicare beneficiaries. In 
conducting such study the Secretary shall consult with appropriate 
experts.
    ``(5) Limitation on changes in mei methodology.--The Secretary shall 
not change the methodology (including the basis and elements) used in 
the MEI from that in effect as of October 1, 1985, until completion of 
the study under paragraph (4). After the completion of the study, the 
Secretary may not change such methodology except after providing notice 
in the Federal Register and opportunity for public comment.
    ``(6) MEI defined.--In this subsection, the term `MEI' means the 
economic index referred to in the fourth sentence of section 1842(b)(3) 
of the Social Security Act [subsec. (b)(3) of this section].''


       Development and Use of HCFA Common Procedure Coding System

    Section 9331(d) of Pub. L. 99-509 provided that:
    ``(1) Not later than July 1, 1989, the Secretary of Health and Human 
Services (in this subsection referred to as the `Secretary'), after 
public notice and opportunity for public comment and after consulation 
[consultation] with appropriate medical and other experts, shall group 
the procedure codes contained in any HCFA Common Procedure Coding System 
for payment purposes to minimize inappropriate increases in the 
intensity or volume of services provided as a result of coding 
distinctions which do not reflect substantial differences in the 
services rendered.
    ``(2) Not later than January 1, 1990, each carrier with which the 
Secretary has entered into a contract under section 1842 of the Social 
Security Act [this section] shall make payments under part B of title 
XVIII of such Act [this part] based on the grouping of procedure codes 
effected under paragraph (1).''


   Measuring Carrier Performance; Carrier Bonuses for Good Performance

    Section 9332(a)(2), (3) of Pub. L. 99-509, as amended by Pub. L. 
100-203, title IV, Sec. 4085(i)(21)(B), Dec. 22, 1987, 101 Stat. 1330-
133, which provided that the Secretary of Health and Human Services was 
to provide, in the standards and criteria established under section 
1842(b)(2) of the Social Security Act [subsec. (b)(2) of this section] 
for contracts under that section, a system to measure a carrier's 
performance of the responsibilities described in sections 1842(b)(3)(H) 
and 1842(h) of such Act and that, of the amounts appropriated for 
administrative activities to carry out part B of title XVIII of the 
Social Security Act [this part], the Secretary of Health and Human 
Services was to provide payments, totaling 1 percent of the total 
payments to carriers for claims processing in any fiscal year, to 
carriers under section 1842 of such Act, to reward such carriers for 
their success in increasing the proportion of physicians in the 
carrier's service area who were participating physicians or in 
increasing the proportion of total payments for physicians' services 
which were payments for such services rendered by participating 
physicians, was repealed by Pub. L. 100-203, title IV, 
Sec. 4041(a)(3)(B)(i), Dec. 22, 1987, 101 Stat. 1330-84.
    Section 9332(a)(4)(B), (C) of Pub. L. 99-509, as amended by Pub. L. 
100-203, title IV, Sec. 4041(a)(3)(B)(ii), (iii), Dec. 22, 1987, 101 
Stat. 1330-84; Pub. L. 100-360, title IV, Sec. 411(f)(1)(C), July 1, 
1988, 102 Stat. 776, provided that:
    ``(B) Performance measures.--The Secretary of Health and Human 
Services shall provide for the establishment of the standards and 
criteria required under the last sentence of section 1842(b)(2) of the 
Social Security Act [subsec. (b)(2) of this section] by not later than 
October 1, 1987, which shall apply to contracts as of October 1, 1987.
    ``(C) Carrier bonuses.--From the amounts appropriated for each 
fiscal year (beginning with fiscal year 1988), the Secretary of Health 
and Human Services shall first provide for payments of bonuses to 
carriers under section 1842(c)(1)(B) of the Social Security Act [subsec. 
(c)(1)(B) of this section] not later than September 30, 1988, to reflect 
performance of carriers during the enrollment period before April 1, 
1988.''


                          Review of Procedures

    Section 9333(c) of Pub. L. 99-509 provided that: ``Not later than 
October 1, 1987, the Secretary of Health and Human Services shall review 
the inherent reasonableness of the reasonable charges for at least 10 of 
the most costly procedures with respect to which payment is made under 
part B of title XVIII of the Social Security Act [this part] (determined 
on the basis of the aggregate annual payments under such part with 
respect to each such procedure).''


                       Ratification of Regulations

    Section 9334(b) of Pub. L. 99-509, as amended by Pub. L. 100-203, 
title IV, Sec. 4045(c)(2)(C), Dec. 22, 1987, 101 Stat. 1330-88, provided 
that:
    ``(1) In general.--The Congress hereby ratifies the final regulation 
of the Secretary of Health and Human Services published on page 35693 of 
volume 51 of the Federal Register on October 7, 1986, relating to 
reasonable charge payment limits for anesthesia services under the 
medicare program.
    ``(2) Patient protections.--In the case of any reduction in the 
reasonable charge for physicians' services effected under the regulation 
described in paragraph (1), the provisions of section 1842(j)(1)(D) of 
the Social Security Act [subsec. (j)(1)(D) of this section] (added by 
the amendment made by subsection (a)(3)) shall apply in the same manner 
and to the same extent as they apply to a reduction in the reasonable 
charge for a physicians' service effected under section 1842(b)(8) of 
such Act.''


   Payment for Parenteral and Enteral Nutrition Supplies and Equipment

    Section 9340 of Pub. L. 99-509 provided that: ``The Secretary of 
Health and Human Services shall apply the sixth sentence of section 
1842(b)(3) of the Social Security Act [subsec. (b)(3) of this section] 
to payment--
        ``(1) for enteral nutrition nutrients, supplies, and equipment 
    and parenteral nutrition supplies and equipment furnished on or 
    after January 1, 1987, and
        ``(2) for parenteral nutrition nutrients furnished on or after 
    October 1, 1987.''


                  Reporting of OPD Services Using HCPCS

    Section 9343(g) of Pub. L. 99-509 provided that: ``Not later than 
July 1, 1987, each fiscal intermediary which processes claims under part 
B of title XVIII of the Social Security Act [this part] shall require 
hospitals, as a condition of payment for outpatient hospital services 
under that part, to report claims for payment for such services under 
such part using a HCFA Common Procedure Coding System.''


            Period for Entering Into Participation Agreements

    Section 9301(b)(3) of Pub. L. 99-272 provided that: ``The Secretary 
of Health and Human Services shall provide, during the month of April 
1986, that physicians and suppliers may enter into an agreement under 
section 1842(h)(1) of the Social Security Act [subsec. (h)(1) of this 
section] for the 8-month period beginning May 1, 1986, or terminate such 
an agreement previously entered into for fiscal year 1986. In the case 
of a physician or supplier who entered into such an agreement for fiscal 
year 1986, the physician or supplier shall be deemed to have entered 
into such agreement for such 8-month period and for each succeeding year 
unless the physician or supplier terminates such agreement before the 
beginning of the respective period. At the beginning of such 8-month 
period, the Secretary shall publish a new directory (described in 
section 1842(h)(4) of that Act [subsec. (h)(4) of this section], as 
redesignated by subsection (c)(3)(D) of this section) of participating 
physicians and suppliers.''


          Transitional Provisions for Medicare Part B Payments

    Section 9301(d)(5) of Pub. L. 99-272 provided that: 
``Notwithstanding any other provision of law, for purposes of making 
payment under part B of title XVIII of the Social Security Act [this 
part], customary and prevailing charges (and the lowest charges 
determined under the sixth sentence of section 1842(b)(3) of such Act 
[subsec. (b)(3) of this section]) for items and services furnished 
during the period beginning on October 1, 1986, and ending on December 
31, 1986, shall be determined on the same basis as for items and 
services furnished on September 30, 1986.''


Computation of Customary Charges for Certain Former Hospital-Compensated 
                               Physicians

    Section 9304(b) of Pub. L. 99-272 provided that:
    ``(1) In applying section 1842(b) of the Social Security Act 
[subsec. (b) of this section] to payment for physicians' services 
performed during the 8-month period beginning May 1, 1986, in the case 
of a physician who at anytime during the period beginning on October 31, 
1982, and ending on January 31, 1985, was a hospital-compensated 
physician (as defined in paragraph (3)) but who, as of February 1, 1985, 
was no longer a hospital-compensated physician, the physician's 
customary charges shall--
        ``(A) be based upon the physician's actual charges billed during 
    the 12-month period ending on March 31, 1985, and
        ``(B) in the case of a physician who was not a participating 
    physician (as defined in section 1842(h)(1) of the Social Security 
    Act [subsec. (h)(1) of this section]) on September 30, 1985, and who 
    is not such a physician on May 1, 1986, be deflated (to take into 
    account the legislative freeze on actual charges for 
    nonparticipating physicians' services) by multiplying the 
    physician's customary charges by .85.
    ``(2) In applying section 1842(b) of the Social Security Act 
[subsec. (b) of this section] to payment for physicians' services 
performed during the 8-month period beginning May 1, 1986, in the case 
of a physician who during the period beginning on February 1, 1985, and 
ending on December 31, 1986, changes from being a hospital-compensated 
physician to not being a hospital-compensated physician, the physician's 
customary charges shall be determined in the same manner as if the 
physician were considered to be a new physician.
    ``(3) In this subsection, the term `hospital-compensated physician' 
means, with respect to services furnished to patients of a hospital, a 
physician who is compensated by the hospital for the furnishing of 
physicians' services for which payment may be made under this part.''


           Extension of Medicare Physician Payment Provisions

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


  Simplification of Procedures With Respect to Claims and Payments for 
                  Clinical Diagnostic Laboratory Tests

    Section 2303(h) of Pub. L. 98-369 provided that: ``The Secretary of 
Health and Human Services shall simplify the procedures under section 
1842 of the Social Security Act [this section] with respect to claims 
and payments for clinical diagnostic laboratory tests so as to reduce 
unnecessary paperwork while assuring that sufficient information is 
supplied to identify instances of fraud and abuse.''


  Study of Amounts Billed for Physician Services and Paid by Carriers 
       Under Subsection (b)(7) of This Section; Report to Congress

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


  Replacement of Agency, Organization, or Carrier Processing Medicare 
 Claims; Number of Agreements and Contracts Authorized for Fiscal Years 
                            1985 Through 1993

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


                          Rules and Regulations

    Section 113(b)(2) of Pub. L. 97-248 provided that: ``The Secretary 
of Health and Human Services shall first issue such final regulations 
(whether on an interim or other basis) before October 1, 1982, as may be 
necessary to implement the amendment made by subsection (a) [amending 
this section] on a timely basis. If such regulations are promulgated on 
an interim final basis, the Secretary shall take such steps as may be 
necessary to provide opportunity for public comment, and appropriate 
revision based thereon, so as to provide that such regulations are not 
on an interim basis later than January 31, 1983.''


            Report on Reimbursement of Clinical Laboratories

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


     Prevailing Charge Levels for Fiscal Year Beginning July 1, 1975

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


   Report by Health Insurance Benefits Advisory Council on Methods of 
             Reimbursement of Physicians for Their Services

    Section 224(b) of Pub. L. 92-603 directed Health Insurance Benefits 
Advisory Council to conduct a study of methods of reimbursement for 
physicians' services under Medicare with respect to fees, extent of 
assignments accepted by physicians, and share of physician-fee costs 
which Medicare program does not pay and submit such study to Congress by 
Jan. 1, 1973.

                  Section Referred to in Other Sections

    This section is referred to in sections 238m, 254n, 254t, 704, 
1320a-3, 1320a-7a, 1320a-7b, 1320c-2, 1320c-3, 1395a, 1395k, 1395l, 
1395m, 1395t, 1395v, 1395w-4, 1395w-27, 1395y, 1395cc, 1395gg, 1395mm, 
1395pp, 1395ss, 1395vv, 1395ddd, 1395fff, 1396b, 1396m, 1397d of this 
title; title 2 section 906; title 5 section 8904; title 25 section 
1616m.
