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[CITE: 42USC1395x]

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

    For purposes of this subchapter--

(a) Spell of illness

    The term ``spell of illness'' with respect to any individual means a 
period of consecutive days--
        (1) beginning with the first day (not included in a previous 
    spell of illness) (A) on which such individual is furnished 
    inpatient hospital services, inpatient critical access hospital 
    services or extended care services, and (B) which occurs in a month 
    for which he is entitled to benefits under part A of this 
    subchapter, and
        (2) ending with the close of the first period of 60 consecutive 
    days thereafter on each of which he is neither an inpatient of a 
    hospital or critical access hospital nor an inpatient of a facility 
    described in section 1396r(a)(2) of this title or subsection (y)(1) 
    of this section.

(b) Inpatient hospital services

    The term ``inpatient hospital services'' means the following items 
and services furnished to an inpatient of a hospital and (except as 
provided in paragraph (3)) by the hospital--
        (1) bed and board;
        (2) such nursing services and other related services, such use 
    of hospital facilities, and such medical social services as are 
    ordinarily furnished by the hospital for the care and treatment of 
    inpatients, and such drugs, biologicals, supplies, appliances, and 
    equipment, for use in the hospital, as are ordinarily furnished by 
    such hospital for the care and treatment of inpatients; and
        (3) such other diagnostic or therapeutic items or services, 
    furnished by the hospital or by others under arrangements with them 
    made by the hospital, as are ordinarily furnished to inpatients 
    either by such hospital or by others under such arrangements;

excluding, however--
        (4) medical or surgical services provided by a physician, 
    resident, or intern, services described by subsection (s)(2)(K) of 
    this section, certified nurse-midwife services, qualified 
    psychologist services, and services of a certified registered nurse 
    anesthetist; and
        (5) the services of a private-duty nurse or other private-duty 
    attendant.

Paragraph (4) shall not apply to services provided in a hospital by--
        (6) an intern or a resident-in-training under a teaching program 
    approved by the Council on Medical Education of the American Medical 
    Association or, in the case of an osteopathic hospital, approved by 
    the Committee on Hospitals of the Bureau of Professional Education 
    of the American Osteopathic Association, or, in the case of services 
    in a hospital or osteopathic hospital by an intern or resident-in-
    training in the field of dentistry, approved by the Council on 
    Dental Education of the American Dental Association, or in the case 
    of services in a hospital or osteopathic hospital by an intern or 
    resident-in-training in the field of podiatry, approved by the 
    Council on Podiatric Medical Education of the American Podiatric 
    Medical Association; or
        (7) a physician where the hospital has a teaching program 
    approved as specified in paragraph (6), if (A) the hospital elects 
    to receive any payment due under this subchapter for reasonable 
    costs of such services, and (B) all physicians in such hospital 
    agree not to bill charges for professional services rendered in such 
    hospital to individuals covered under the insurance program 
    established by this subchapter.

(c) Inpatient psychiatric hospital services

    The term ``inpatient psychiatric hospital services'' means inpatient 
hospital services furnished to an inpatient of a psychiatric hospital.

(d) Repealed. Pub. L. 98-369, div. B, title III, Sec. 2335(b)(1), July 
        18, 1984, 98 Stat. 1090

(e) Hospital

    The term ``hospital'' (except for purposes of sections 1395f(d), 
1395f(f), and 1395n(b) of this title, subsection (a)(2) of this section, 
paragraph (7) of this subsection, and subsection (i) of this section) 
means an institution which--
        (1) is primarily engaged in providing, by or under the 
    supervision of physicians, to inpatients (A) diagnostic services and 
    therapeutic services for medical diagnosis, treatment, and care of 
    injured, disabled, or sick persons, or (B) rehabilitation services 
    for the rehabilitation of injured, disabled, or sick persons;
        (2) maintains clinical records on all patients;
        (3) has bylaws in effect with respect to its staff of 
    physicians;
        (4) has a requirement that every patient with respect to whom 
    payment may be made under this subchapter must be under the care of 
    a physician, except that a patient receiving qualified psychologist 
    services (as defined in subsection (ii) of this section) may be 
    under the care of a clinical psychologist with respect to such 
    services to the extent permitted under State law;
        (5) provides 24-hour nursing service rendered or supervised by a 
    registered professional nurse, and has a licensed practical nurse or 
    registered professional nurse on duty at all times; except that 
    until January 1, 1979, the Secretary is authorized to waive the 
    requirement of this paragraph for any one-year period with respect 
    to any institution, insofar as such requirement relates to the 
    provision of twenty-four-hour nursing service rendered or supervised 
    by a registered professional nurse (except that in any event a 
    registered professional nurse must be present on the premises to 
    render or supervise the nursing service provided, during at least 
    the regular daytime shift), where immediately preceding such one-
    year period he finds that--
            (A) such institution is located in a rural area and the 
        supply of hospital services in such area is not sufficient to 
        meet the needs of individuals residing therein,
            (B) the failure of such institution to qualify as a hospital 
        would seriously reduce the availability of such services to such 
        individuals, and
            (C) such institution has made and continues to make a good 
        faith effort to comply with this paragraph, but such compliance 
        is impeded by the lack of qualified nursing personnel in such 
        area;

        (6)(A) has in effect a hospital utilization review plan which 
    meets the requirements of subsection (k) of this section and (B) has 
    in place a discharge planning process that meets the requirements of 
    subsection (ee) of this section;
        (7) in the case of an institution in any State in which State or 
    applicable local law provides for the licensing of hospitals, (A) is 
    licensed pursuant to such law or (B) is approved, by the agency of 
    such State or locality responsible for licensing hospitals, as 
    meeting the standards established for such licensing;
        (8) has in effect an overall plan and budget that meets the 
    requirements of subsection (z) of this section; and
        (9) meets such other requirements as the Secretary finds 
    necessary in the interest of the health and safety of individuals 
    who are furnished services in the institution.

For purposes of subsection (a)(2) of this section, such term includes 
any institution which meets the requirements of paragraph (1) of this 
subsection. For purposes of sections 1395f(d) and 1395n(b) of this title 
(including determination of whether an individual received inpatient 
hospital services or diagnostic services for purposes of such sections), 
section 1395f(f)(2) of this title, and subsection (i) of this section, 
such term includes any institution which (i) meets the requirements of 
paragraphs (5) and (7) of this subsection, (ii) is not primarily engaged 
in providing the services described in subsection (j)(1)(A) of this 
section and (iii) is primarily engaged in providing, by or under the 
supervision of individuals referred to in paragraph (1) of subsection 
(r) of this section, to inpatients diagnostic services and therapeutic 
services for medical diagnosis, treatment, and care of injured, 
disabled, or sick persons, or rehabilitation services for the 
rehabilitation of injured, disabled, or sick persons. For purposes of 
section 1395f(f)(1) of this title, such term includes an institution 
which (i) is a hospital for purposes of sections 1395f(d), 1395f(f)(2), 
and 1395n(b) of this title and (ii) is accredited by the Joint 
Commission on Accreditation of Hospitals, or is accredited by or 
approved by a program of the country in which such institution is 
located if the Secretary finds the accreditation or comparable approval 
standards of such program to be essentially equivalent to those of the 
Joint Commission on Accreditation of Hospitals. Notwithstanding the 
preceding provisions of this subsection, such term shall not, except for 
purposes of subsection (a)(2) of this section, include any institution 
which is primarily for the care and treatment of mental diseases unless 
it is a psychiatric hospital (as defined in subsection (f) of this 
section). The term ``hospital'' also includes a religious nonmedical 
health care institution (as defined in subsection (ss)(1) of this 
section), but only with respect to items and services ordinarily 
furnished by such institution to inpatients, and payment may be made 
with respect to services provided by or in such an institution only to 
such extent and under such conditions, limitations, and requirements (in 
addition to or in lieu of the conditions, limitations, and requirements 
otherwise applicable) as may be provided in regulations consistent with 
section 1395i-5 of this title. For provisions deeming certain 
requirements of this subsection to be met in the case of accredited 
institutions, see section 1395bb of this title. The term ``hospital'' 
also includes a facility of fifty beds or less which is located in an 
area determined by the Secretary to meet the definition relating to a 
rural area described in subparagraph (A) of paragraph (5) of this 
subsection and which meets the other requirements of this subsection, 
except that--
        (A) with respect to the requirements for nursing services 
    applicable after December 31, 1978, such requirements shall provide 
    for temporary waiver of the requirements, for such period as the 
    Secretary deems appropriate, where (i) the facility's failure to 
    fully comply with the requirements is attributable to a temporary 
    shortage of qualified nursing personnel in the area in which the 
    facility is located, (ii) a registered professional nurse is present 
    on the premises to render or supervise the nursing service provided 
    during at least the regular daytime shift, and (iii) the Secretary 
    determines that the employment of such nursing personnel as are 
    available to the facility during such temporary period will not 
    adversely affect the health and safety of patients;
        (B) with respect to the health and safety requirements 
    promulgated under paragraph (9), such requirements shall be applied 
    by the Secretary to a facility herein defined in such manner as to 
    assure that personnel requirements take into account the 
    availability of technical personnel and the educational 
    opportunities for technical personnel in the area in which such 
    facility is located, and the scope of services rendered by such 
    facility; and the Secretary, by regulations, shall provide for the 
    continued participation of such a facility where such personnel 
    requirements are not fully met, for such period as the Secretary 
    determines that (i) the facility is making good faith efforts to 
    fully comply with the personnel requirements, (ii) the employment by 
    the facility of such personnel as are available to the facility will 
    not adversely affect the health and safety of patients, and (iii) if 
    the Secretary has determined that because of the facility's waiver 
    under this subparagraph the facility should limit its scope of 
    services in order not to adversely affect the health and safety of 
    the facility's patients, the facility is so limiting the scope of 
    services it provides; and
        (C) with respect to the fire and safety requirements promulgated 
    under paragraph (9), the Secretary (i) may waive, for such period as 
    he deems appropriate, specific provisions of such requirements which 
    if rigidly applied would result in unreasonable hardship for such a 
    facility and which, if not applied, would not jeopardize the health 
    and safety of patients, and (ii) may accept a facility's compliance 
    with all applicable State codes relating to fire and safety in lieu 
    of compliance with the fire and safety requirements promulgated 
    under paragraph (9), if he determines that such State has in effect 
    fire and safety codes, imposed by State law, which adequately 
    protect patients.

The term ``hospital'' does not include, unless the context otherwise 
requires, a critical access hospital (as defined in subsection (mm)(1) 
of this section).

(f) Psychiatric hospital

    The term ``psychiatric hospital'' means an institution which--
        (1) is primarily engaged in providing, by or under the 
    supervision of a physician, psychiatric services for the diagnosis 
    and treatment of mentally ill persons;
        (2) satisfies the requirements of paragraphs (3) through (9) of 
    subsection (e) of this section;
        (3) maintains clinical records on all patients and maintains 
    such records as the Secretary finds to be necessary to determine the 
    degree and intensity of the treatment provided to individuals 
    entitled to hospital insurance benefits under part A of this 
    subchapter; and
        (4) meets such staffing requirements as the Secretary finds 
    necessary for the institution to carry out an active program of 
    treatment for individuals who are furnished services in the 
    institution.

In the case of an institution which satisfies paragraphs (1) and (2) of 
the preceding sentence and which contains a distinct part which also 
satisfies paragraphs (3) and (4) of such sentence, such distinct part 
shall be considered to be a ``psychiatric hospital''.

(g) Outpatient occupational therapy services

    The term ``outpatient occupational therapy services'' has the 
meaning given the term ``outpatient physical therapy services'' in 
subsection (p) of this section, except that ``occupational'' shall be 
substituted for ``physical'' each place it appears therein.

(h) Extended care services

    The term ``extended care services'' means the following items and 
services furnished to an inpatient of a skilled nursing facility and 
(except as provided in paragraphs (3), (6), and (7)) by such skilled 
nursing facility--
        (1) nursing care provided by or under the supervision of a 
    registered professional nurse;
        (2) bed and board in connection with the furnishing of such 
    nursing care;
        (3) physical or occupational therapy or speech-language 
    pathology services furnished by the skilled nursing facility or by 
    others under arrangements with them made by the facility;
        (4) medical social services;
        (5) such drugs, biologicals, supplies, appliances, and 
    equipment, furnished for use in the skilled nursing facility, as are 
    ordinarily furnished by such facility for the care and treatment of 
    inpatients;
        (6) medical services provided by an intern or resident-in-
    training of a hospital with which the facility has in effect a 
    transfer agreement (meeting the requirements of subsection (l) of 
    this section), under a teaching program of such hospital approved as 
    provided in the last sentence of subsection (b) of this section, and 
    other diagnostic or therapeutic services provided by a hospital with 
    which the facility has such an agreement in effect; and
        (7) such other services necessary to the health of the patients 
    as are generally provided by skilled nursing facilities, or by 
    others under arrangements with them made by the facility;

excluding, however, any item or service if it would not be included 
under subsection (b) of this section if furnished to an inpatient of a 
hospital.

(i) Post-hospital extended care services

    The term ``post-hospital extended care services'' means extended 
care services furnished an individual after transfer from a hospital in 
which he was an inpatient for not less than 3 consecutive days before 
his discharge from the hospital in connection with such transfer. For 
purposes of the preceding sentence, items and services shall be deemed 
to have been furnished to an individual after transfer from a hospital, 
and he shall be deemed to have been an inpatient in the hospital 
immediately before transfer therefrom, if he is admitted to the skilled 
nursing facility (A) within 30 days after discharge from such hospital, 
or (B) within such time as it would be medically appropriate to begin an 
active course of treatment, in the case of an individual whose condition 
is such that skilled nursing facility care would not be medically 
appropriate within 30 days after discharge from a hospital; and an 
individual shall be deemed not to have been discharged from a skilled 
nursing facility if, within 30 days after discharge therefrom, he is 
admitted to such facility or any other skilled nursing facility.

(j) Skilled nursing facility

    The term ``skilled nursing facility'' has the meaning given such 
term in section 1395i-3(a) of this title.

(k) Utilization review

    A utilization review plan of a hospital or skilled nursing facility 
shall be considered sufficient if it is applicable to services furnished 
by the institution to individuals entitled to insurance benefits under 
this subchapter and if it provides--
        (1) for the review, on a sample or other basis, of admissions to 
    the institution, the duration of stays therein, and the professional 
    services (including drugs and biologicals) furnished, (A) with 
    respect to the medical necessity of the services, and (B) for the 
    purpose of promoting the most efficient use of available health 
    facilities and services;
        (2) for such review to be made by either (A) a staff committee 
    of the institution composed of two or more physicians (of which at 
    least two must be physicians described in subsection (r)(1) of this 
    section), with or without participation of other professional 
    personnel, or (B) a group outside the institution which is similarly 
    composed and (i) which is established by the local medical society 
    and some or all of the hospitals and skilled nursing facilities in 
    the locality, or (ii) if (and for as long as) there has not been 
    established such a group which serves such institution, which is 
    established in such other manner as may be approved by the 
    Secretary;
        (3) for such review, in each case of inpatient hospital services 
    or extended care services furnished to such an individual during a 
    continuous period of extended duration, as of such days of such 
    period (which may differ for different classes of cases) as may be 
    specified in regulations, with such review to be made as promptly as 
    possible, after each day so specified, and in no event later than 
    one week following such day; and
        (4) for prompt notification to the institution, the individual, 
    and his attending physician of any finding (made after opportunity 
    for consultation to such attending physician) by the physician 
    members of such committee or group that any further stay in the 
    institution is not medically necessary.

The review committee must be composed as provided in clause (B) of 
paragraph (2) rather than as provided in clause (A) of such paragraph in 
the case of any hospital or skilled nursing facility where, because of 
the small size of the institution, or (in the case of a skilled nursing 
facility) because of lack of an organized medical staff, or for such 
other reason or reasons as may be included in regulations, it is 
impracticable for the institution to have a properly functioning staff 
committee for the purposes of this subsection. If the Secretary 
determines that the utilization review procedures established pursuant 
to subchapter XIX of this chapter are superior in their effectiveness to 
the procedures required under this section, he may, to the extent that 
he deems it appropriate, require for purposes of this subchapter that 
the procedures established pursuant to subchapter XIX of this chapter be 
utilized instead of the procedures required by this section.

(l) Agreements for transfer between skilled nursing facilities and 
        hospitals

    A hospital and a skilled nursing facility shall be considered to 
have a transfer agreement in effect if, by reason of a written agreement 
between them or (in case the two institutions are under common control) 
by reason of a written undertaking by the person or body which controls 
them, there is reasonable assurance that--
        (1) transfer of patients will be effected between the hospital 
    and the skilled nursing facility whenever such transfer is medically 
    appropriate as determined by the attending physician; and
        (2) there will be interchange of medical and other information 
    necessary or useful in the care and treatment of individuals 
    transferred between the institutions, or in determining whether such 
    individuals can be adequately cared for otherwise than in either of 
    such institutions.

Any skilled nursing facility which does not have such an agreement in 
effect, but which is found by a State agency (of the State in which such 
facility is situated) with which an agreement under section 1395aa of 
this title is in effect (or, in the case of a State in which no such 
agency has an agreement under section 1395aa of this title, by the 
Secretary) to have attempted in good faith to enter into such an 
agreement with a hospital sufficiently close to the facility to make 
feasible the transfer between them of patients and the information 
referred to in paragraph (2), shall be considered to have such an 
agreement in effect if and for so long as such agency (or the Secretary, 
as the case may be) finds that to do so is in the public interest and 
essential to assuring extended care services for persons in the 
community who are eligible for payments with respect to such services 
under this subchapter.

(m) Home health services

    The term ``home health services'' means the following items and 
services furnished to an individual, who is under the care of a 
physician, by a home health agency or by others under arrangements with 
them made by such agency, under a plan (for furnishing such items and 
services to such individual) established and periodically reviewed by a 
physician, which items and services are, except as provided in paragraph 
(7), provided on a visiting basis in a place of residence used as such 
individual's home--
        (1) part-time or intermittent nursing care provided by or under 
    the supervision of a registered professional nurse;
        (2) physical or occupational therapy or speech-language 
    pathology services;
        (3) medical social services under the direction of a physician;
        (4) to the extent permitted in regulations, part-time or 
    intermittent services of a home health aide who has successfully 
    completed a training program approved by the Secretary;
        (5) medical supplies (including catheters, catheter supplies, 
    ostomy bags, and supplies related to ostomy care, and a covered 
    osteoporosis drug (as defined in subsection (kk) of this section), 
    but excluding other drugs and biologicals) and durable medical 
    equipment while under such a plan;
        (6) in the case of a home health agency which is affiliated or 
    under common control with a hospital, medical services provided by 
    an intern or resident-in-training of such hospital, under a teaching 
    program of such hospital approved as provided in the last sentence 
    of subsection (b) of this section; and
        (7) any of the foregoing items and services which are provided 
    on an outpatient basis, under arrangements made by the home health 
    agency, at a hospital or skilled nursing facility, or at a 
    rehabilitation center which meets such standards as may be 
    prescribed in regulations, and--
            (A) the furnishing of which involves the use of equipment of 
        such a nature that the items and services cannot readily be made 
        available to the individual in such place of residence, or
            (B) which are furnished at such facility while he is there 
        to receive any such item or service described in clause (A),

    but not including transportation of the individual in connection 
    with any such item or service;

excluding, however, any item or service if it would not be included 
under subsection (b) of this section if furnished to an inpatient of a 
hospital. For purposes of paragraphs (1) and (4), the term ``part-time 
or intermittent services'' means skilled nursing and home health aide 
services furnished any number of days per week as long as they are 
furnished (combined) less than 8 hours each day and 28 or fewer hours 
each week (or, subject to review on a case-by-case basis as to the need 
for care, less than 8 hours each day and 35 or fewer hours per week). 
For purposes of sections 1395f(a)(2)(C) and 1395n(a)(2)(A) of this 
title, ``intermittent'' means skilled nursing care that is either 
provided or needed on fewer than 7 days each week, or less than 8 hours 
of each day for periods of 21 days or less (with extensions in 
exceptional circumstances when the need for additional care is finite 
and predictable).

(n) Durable medical equipment

    The term ``durable medical equipment'' includes iron lungs, oxygen 
tents, hospital beds, and wheelchairs (which may include a power-
operated vehicle that may be appropriately used as a wheelchair, but 
only where the use of such a vehicle is determined to be necessary on 
the basis of the individual's medical and physical condition and the 
vehicle meets such safety requirements as the Secretary may prescribe) 
used in the patient's home (including an institution used as his home 
other than an institution that meets the requirements of subsection 
(e)(1) of this section or section 1395i-3(a)(1) of this title), whether 
furnished on a rental basis or purchased, and includes blood-testing 
strips and blood glucose monitors for individuals with diabetes without 
regard to whether the individual has Type I or Type II diabetes or to 
the individual's use of insulin (as determined under standards 
established by the Secretary in consultation with the appropriate 
organizations); except that such term does not include such equipment 
furnished by a supplier who has used, for the demonstration and use of 
specific equipment, an individual who has not met such minimum training 
standards as the Secretary may establish with respect to the 
demonstration and use of such specific equipment. With respect to a 
seat-lift chair, such term includes only the seat-lift mechanism and 
does not include the chair.

(o) Home health agency

    The term ``home health agency'' means a public agency or private 
organization, or a subdivision of such an agency or organization, 
which--
        (1) is primarily engaged in providing skilled nursing services 
    and other therapeutic services;
        (2) has policies, established by a group of professional 
    personnel (associated with the agency or organization), including 
    one or more physicians and one or more registered professional 
    nurses, to govern the services (referred to in paragraph (1)) which 
    it provides, and provides for supervision of such services by a 
    physician or registered professional nurse;
        (3) maintains clinical records on all patients;
        (4) in the case of an agency or organization in any State in 
    which State or applicable local law provides for the licensing of 
    agencies or organizations of this nature, (A) is licensed pursuant 
    to such law, or (B) is approved, by the agency of such State or 
    locality responsible for licensing agencies or organizations of this 
    nature, as meeting the standards established for such licensing;
        (5) has in effect an overall plan and budget that meets the 
    requirements of subsection (z) of this section;
        (6) meets the conditions of participation specified in section 
    1395bbb(a) of this title and such other conditions of participation 
    as the Secretary may find necessary in the interest of the health 
    and safety of individuals who are furnished services by such agency 
    or organization;
        (7) provides the Secretary with a surety bond--
            (A) effective for a period of 4 years (as specified by the 
        Secretary) or in the case of a change in the ownership or 
        control of the agency (as determined by the Secretary) during or 
        after such 4-year period, an additional period of time that the 
        Secretary determines appropriate, such additional period not to 
        exceed 4 years from the date of such change in ownership or 
        control;
            (B) in a form specified by the Secretary; and
            (C) for a year in the period described in subparagraph (A) 
        in an amount that is equal to the lesser of $50,000 or 10 
        percent of the aggregate amount of payments to the agency under 
        this subchapter and subchapter XIX of this chapter for that 
        year, as estimated by the Secretary; and

        (8) meets such additional requirements (including conditions 
    relating to bonding or establishing of escrow accounts as the 
    Secretary finds necessary for the financial security of the program) 
    as the Secretary finds necessary for the effective and efficient 
    operation of the program;

except that for purposes of part A of this subchapter such term shall 
not include any agency or organization which is primarily for the care 
and treatment of mental diseases. The Secretary may waive the 
requirement of a surety bond under paragraph (7) in the case of an 
agency or organization that provides a comparable surety bond under 
State law.

(p) Outpatient physical therapy services

    The term ``outpatient physical therapy services'' means physical 
therapy services furnished by a provider of services, a clinic, 
rehabilitation agency, or a public health agency, or by others under an 
arrangement with, and under the supervision of, such provider, clinic, 
rehabilitation agency, or public health agency to an individual as an 
outpatient--
        (1) who is under the care of a physician (as defined in 
    paragraph (1), (3), or (4) of subsection (r) of this section), and
        (2) with respect to whom a plan prescribing the type, amount, 
    and duration of physical therapy services that are to be furnished 
    such individual has been established by a physician (as so defined) 
    or by a qualified physical therapist and is periodically reviewed by 
    a physician (as so defined);

excluding, however--
        (3) any item or service if it would not be included under 
    subsection (b) of this section if furnished to an inpatient of a 
    hospital; and
        (4) any such service--
            (A) if furnished by a clinic or rehabilitation agency, or by 
        others under arrangements with such clinic or agency, unless 
        such clinic or rehabilitation agency--
                (i) provides an adequate program of physical therapy 
            services for outpatients and has the facilities and 
            personnel required for such program or required for the 
            supervision of such a program, in accordance with such 
            requirements as the Secretary may specify,
                (ii) has policies, established by a group of 
            professional personnel, including one or more physicians 
            (associated with the clinic or rehabilitation agency) and 
            one or more qualified physical therapists, to govern the 
            services (referred to in clause (i)) it provides,
                (iii) maintains clinical records on all patients,
                (iv) if such clinic or agency is situated in a State in 
            which State or applicable local law provides for the 
            licensing of institutions of this nature, (I) is licensed 
            pursuant to such law, or (II) is approved by the agency of 
            such State or locality responsible for licensing 
            institutions of this nature, as meeting the standards 
            established for such licensing; and
                (v) meets such other conditions relating to the health 
            and safety of individuals who are furnished services by such 
            clinic or agency on an outpatient basis, as the Secretary 
            may find necessary, and provides the Secretary on a 
            continuing basis with a surety bond in a form specified by 
            the Secretary and in an amount that is not less than 
            $50,000, or

            (B) if furnished by a public health agency, unless such 
        agency meets such other conditions relating to health and safety 
        of individuals who are furnished services by such agency on an 
        outpatient basis, as the Secretary may find necessary.

The term ``outpatient physical therapy services'' also includes physical 
therapy services furnished an individual by a physical therapist (in his 
office or in such individual's home) who meets licensing and other 
standards prescribed by the Secretary in regulations, otherwise than 
under an arrangement with and under the supervision of a provider of 
services, clinic, rehabilitation agency, or public health agency, if the 
furnishing of such services meets such conditions relating to health and 
safety as the Secretary may find necessary. In addition, such term 
includes physical therapy services which meet the requirements of the 
first sentence of this subsection except that they are furnished to an 
individual as an inpatient of a hospital or extended care facility. The 
term ``outpatient physical therapy services'' also includes speech-
language pathology services furnished by a provider of services, a 
clinic, rehabilitation agency, or by a public health agency, or by 
others under an arrangement with, and under the supervision of, such 
provider, clinic, rehabilitation agency, or public health agency to an 
individual as an outpatient, subject to the conditions prescribed in 
this subsection. Nothing in this subsection shall be construed as 
requiring, with respect to outpatients who are not entitled to benefits 
under this subchapter, a physical therapist to provide outpatient 
physical therapy services only to outpatients who are under the care of 
a physician or pursuant to a plan of care established by a physician. 
The Secretary may waive the requirement of a surety bond under paragraph 
(4)(A)(v) in the case of a clinic or agency that provides a comparable 
surety bond under State law.

(q) Physicians' services

    The term ``physicians' services'' means professional services 
performed by physicians, including surgery, consultation, and home, 
office, and institutional calls (but not including services described in 
subsection (b)(6) of this section).

(r) Physician

    The term ``physician'', when used in connection with the performance 
of any function or action, means (1) a doctor of medicine or osteopathy 
legally authorized to practice medicine and surgery by the State in 
which he performs such function or action (including a physician within 
the meaning of section 1301(a)(7) of this title), (2) a doctor of dental 
surgery or of dental medicine who is legally authorized to practice 
dentistry by the State in which he performs such function and who is 
acting within the scope of his license when he performs such functions, 
(3) a doctor of podiatric medicine for the purposes of subsections (k), 
(m), (p)(1), and (s) of this section and sections 1395f(a), 
1395k(a)(2)(F)(ii), and 1395n of this title but only with respect to 
functions which he is legally authorized to perform as such by the State 
in which he performs them, (4) a doctor of optometry, but only for 
purposes of subsection (p)(1) of this section and with respect to the 
provision of items or services described in subsection (s) of this 
section which he is legally authorized to perform as a doctor of 
optometry by the State in which he performs them, or (5) a chiropractor 
who is licensed as such by the State (or in a State which does not 
license chiropractors as such, is legally authorized to perform the 
services of a chiropractor in the jurisdiction in which he performs such 
services), and who meets uniform minimum standards promulgated by the 
Secretary, but only for the purpose of subsections (s)(1) and (s)(2)(A) 
of this section and only with respect to treatment by means of manual 
manipulation of the spine (to correct a subluxation) which he is legally 
authorized to perform by the State or jurisdiction in which such 
treatment is provided. For the purposes of section 1395y(a)(4) of this 
title and subject to the limitations and conditions provided in the 
previous sentence, such term includes a doctor of one of the arts, 
specified in such previous sentence, legally authorized to practice such 
art in the country in which the inpatient hospital services (referred to 
in such section 1395y(a)(4) of this title) are furnished.

(s) Medical and other health services

    The term ``medical and other health services'' means any of the 
following items or services:
        (1) physicians' services;
        (2)(A) services and supplies (including drugs and biologicals 
    which cannot, as determined in accordance with regulations, be self-
    administered) furnished as an incident to a physician's professional 
    service, of kinds which are commonly furnished in physicians' 
    offices and are commonly either rendered without charge or included 
    in the physicians' bills;
        (B) hospital services (including drugs and biologicals which 
    cannot, as determined in accordance with regulations, be self-
    administered) incident to physicians' services rendered to 
    outpatients and partial hospitalization services incident to such 
    services;
        (C) diagnostic services which are--
            (i) furnished to an individual as an outpatient by a 
        hospital or by others under arrangements with them made by a 
        hospital, and
            (ii) ordinarily furnished by such hospital (or by others 
        under such arrangements) to its outpatients for the purpose of 
        diagnostic study;

        (D) outpatient physical therapy services and outpatient 
    occupational therapy services;
        (E) rural health clinic services and Federally qualified health 
    center services;
        (F) home dialysis supplies and equipment, self-care home 
    dialysis support services, and institutional dialysis services and 
    supplies;
        (G) antigens (subject to quantity limitations prescribed in 
    regulations by the Secretary) prepared by a physician, as defined in 
    subsection (r)(1) of this section, for a particular patient, 
    including antigens so prepared which are forwarded to another 
    qualified person (including a rural health clinic) for 
    administration to such patient, from time to time, by or under the 
    supervision of another such physician;
        (H)(i) services furnished pursuant to a contract under section 
    1395mm of this title to a member of an eligible organization by a 
    physician assistant or by a nurse practitioner (as defined in 
    subsection (aa)(5) of this section) and such services and supplies 
    furnished as an incident to his service to such a member as would 
    otherwise be covered under this part if furnished by a physician or 
    as an incident to a physician's service; and
        (ii) services furnished pursuant to a risk-sharing contract 
    under section 1395mm(g) of this title to a member of an eligible 
    organization by a clinical psychologist (as defined by the 
    Secretary) or by a clinical social worker (as defined in subsection 
    (hh)(2) of this section), and such services and supplies furnished 
    as an incident to such clinical psychologist's services or clinical 
    social worker's services to such a member as would otherwise be 
    covered under this part if furnished by a physician or as an 
    incident to a physician's service;
        (I) blood clotting factors, for hemophilia patients competent to 
    use such factors to control bleeding without medical or other 
    supervision, and items related to the administration of such 
    factors, subject to utilization controls deemed necessary by the 
    Secretary for the efficient use of such factors;
        (J) prescription drugs used in immunosuppressive therapy 
    furnished, to an individual who receives an organ transplant for 
    which payment is made under this subchapter, but only in the case of 
    drugs furnished--
            (i) before 1995, within 12 months after the date of the 
        transplant procedure,
            (ii) during 1995, within 18 months after the date of the 
        transplant procedure,
            (iii) during 1996, within 24 months after the date of the 
        transplant procedure,
            (iv) during 1997, within 30 months after the date of the 
        transplant procedure, and
            (v) during any year after 1997, within 36 months after the 
        date of the transplant procedure plus such additional number of 
        months (if any) provided under section 1395k(b)of this title;

        (K)(i) services which would be physicians' services if furnished 
    by a physician (as defined in subsection (r)(1) of this section) and 
    which are performed by a physician assistant (as defined in 
    subsection (aa)(5) of this section) under the supervision of a 
    physician (as so defined) and which the physician assistant is 
    legally authorized to perform by the State in which the services are 
    performed, and such services and supplies furnished as incident to 
    such services as would be covered under subparagraph (A) if 
    furnished incident to a physician's professional service; and \1\ 
    but only if no facility or other provider charges or is paid any 
    amounts with respect to the furnishing of such services,\2\
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    \1\ So in original. The word ``and'' probably should not appear.
    \2\ So in original. Probably should be followed by ``and''.
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        (ii) services which would be physicians' services if furnished 
    by a physician (as defined in subsection (r)(1) of this section) and 
    which are performed by a nurse practitioner or clinical nurse 
    specialist (as defined in subsection (aa)(5) of this section) 
    working in collaboration (as defined in subsection (aa)(6) of this 
    section) with a physician (as defined in subsection (r)(1) of this 
    section) which the nurse practitioner or clinical nurse specialist 
    is legally authorized to perform by the State in which the services 
    are performed, and such services and supplies furnished as an 
    incident to such services as would be covered under subparagraph (A) 
    if furnished incident to a physician's professional service, but 
    only if no facility or other provider charges or is paid any amounts 
    with respect to the furnishing of such services;
        (L) certified nurse-midwife services;
        (M) qualified psychologist services;
        (N) clinical social worker services (as defined in subsection 
    (hh)(2) of this section);
        (O) erythropoietin for dialysis patients competent to use such 
    drug without medical or other supervision with respect to the 
    administration of such drug, subject to methods and standards 
    established by the Secretary by regulation for the safe and 
    effective use of such drug, and items related to the administration 
    of such drug;
        (P) prostate cancer screening tests (as defined in subsection 
    (oo) of this section);
        (Q) an oral drug (which is approved by the Federal Food and Drug 
    Administration) prescribed for use as an anticancer chemotherapeutic 
    agent for a given indication, and containing an active ingredient 
    (or ingredients), which is the same indication and active ingredient 
    (or ingredients) as a drug which the carrier determines would be 
    covered pursuant to subparagraph (A) or (B) if the drug could not be 
    self-administered;
        (R) colorectal cancer screening tests (as defined in subsection 
    (pp) of this section); and \1\
        (S) diabetes outpatient self-management training services (as 
    defined in subsection (qq) of this section); and
        (T) an oral drug (which is approved by the Federal Food and Drug 
    Administration) prescribed for use as an acute anti-emetic used as 
    part of an anticancer chemotherapeutic regimen if the drug is 
    administered by a physician (or as prescribed by a physician)--
            (i) for use immediately before, at, or within 48 hours after 
        the time of the administration of the anticancer 
        chemotherapeutic agent; and
            (ii) as a full replacement for the anti-emetic therapy which 
        would otherwise be administered intravenously;

        (3) diagnostic X-ray tests (including tests under the 
    supervision of a physician, furnished in a place of residence used 
    as the patient's home, if the performance of such tests meets such 
    conditions relating to health and safety as the Secretary may find 
    necessary and including diagnostic mammography if conducted by a 
    facility that has a certificate (or provisional certificate) issued 
    under section 354 of the Public Health Service Act [42 U.S.C. 
    263b]), diagnostic laboratory tests, and other diagnostic tests;
        (4) X-ray, radium, and radioactive isotope therapy, including 
    materials and services of technicians;
        (5) surgical dressings, and splints, casts, and other devices 
    used for reduction of fractures and dislocations;
        (6) durable medical equipment;
        (7) ambulance service where the use of other methods of 
    transportation is contraindicated by the individual's condition, but 
    only to the extent provided in regulations;
        (8) prosthetic devices (other than dental) which replace all or 
    part of an internal body organ (including colostomy bags and 
    supplies directly related to colostomy care), including replacement 
    of such devices, and including one pair of conventional eyeglasses 
    or contact lenses furnished subsequent to each cataract surgery with 
    insertion of an intraocular lens;
        (9) leg, arm, back, and neck braces, and artificial legs, arms, 
    and eyes, including replacements if required because of a change in 
    the patient's physical condition;
        (10)(A) pneumococcal vaccine and its administration and, subject 
    to section 4071(b) of the Omnibus Budget Reconciliation Act of 1987, 
    influenza vaccine and its administration; and
        (B) hepatitis B vaccine and its administration, furnished to an 
    individual who is at high or intermediate risk of contracting 
    hepatitis B (as determined by the Secretary under regulations);
        (11) services of a certified registered nurse anesthetist (as 
    defined in subsection (bb) of this section);
        (12) subject to section 4072(e) of the Omnibus Budget 
    Reconciliation Act of 1987, extra-depth shoes with inserts or custom 
    molded shoes with inserts for an individual with diabetes, if--
            (A) the physician who is managing the individual's diabetic 
        condition (i) documents that the individual has peripheral 
        neuropathy with evidence of callus formation, a history of pre-
        ulcerative calluses, a history of previous ulceration, foot 
        deformity, or previous amputation, or poor circulation, and (ii) 
        certifies that the individual needs such shoes under a 
        comprehensive plan of care related to the individual's diabetic 
        condition;
            (B) the particular type of shoes are prescribed by a 
        podiatrist or other qualified physician (as established by the 
        Secretary); and
            (C) the shoes are fitted and furnished by a podiatrist or 
        other qualified individual (such as a pedorthist or orthotist, 
        as established by the Secretary) who is not the physician 
        described in subparagraph (A) (unless the Secretary finds that 
        the physician is the only such qualified individual in the 
        area);

        (13) screening mammography (as defined in subsection (jj) of 
    this section);
        (14) screening pap smear and screening pelvic exam; and
        (15) bone mass measurement (as defined in subsection (rr) of 
    this section).

No diagnostic tests performed in any laboratory, including a laboratory 
that is part of a rural health clinic, or a hospital (which, for 
purposes of this sentence, means an institution considered a hospital 
for purposes of section 1395f(d) of this title) shall be included within 
paragraph (3) unless such laboratory--
        (16) if situated in any State in which State or applicable local 
    law provides for licensing of establishments of this nature, (A) is 
    licensed pursuant to such law, or (B) is approved, by the agency of 
    such State or locality responsible for licensing establishments of 
    this nature, as meeting the standards established for such 
    licensing; and
        (17)(A) meets the certification requirements under section 353 
    of the Public Health Service Act [42 U.S.C. 263a]; and
        (B) meets such other conditions relating to the health and 
    safety of individuals with respect to whom such tests are performed 
    as the Secretary may find necessary.

There shall be excluded from the diagnostic services specified in 
paragraph (2)(C) any item or service (except services referred to in 
paragraph (1)) which would not be included under subsection (b) of this 
section if it were furnished to an inpatient of a hospital. None of the 
items and services referred to in the preceding paragraphs (other than 
paragraphs (1) and (2)(A)) of this subsection which are furnished to a 
patient of an institution which meets the definition of a hospital for 
purposes of section 1395f(d) of this title shall be included unless such 
other conditions are met as the Secretary may find necessary relating to 
health and safety of individuals with respect to whom such items and 
services are furnished.

(t) Drugs and biologicals

    (1) The term ``drugs'' and the term ``biologicals'', except for 
purposes of subsection (m)(5) of this section and paragraph (2), include 
only such drugs and biologicals, respectively, as are included (or 
approved for inclusion) in the United States Pharmacopoeia, the National 
Formulary, or the United States Homeopathic Pharmacopoeia, or in New 
Drugs or Accepted Dental Remedies (except for any drugs and biologicals 
unfavorably evaluated therein), or as are approved by the pharmacy and 
drug therapeutics committee (or equivalent committee) of the medical 
staff of the hospital furnishing such drugs and biologicals for use in 
such hospital.
    (2)(A) For purposes of paragraph (1), the term ``drugs'' also 
includes any drugs or biologicals used in an anticancer chemotherapeutic 
regimen for a medically accepted indication (as described in 
subparagraph (B)).
    (B) In subparagraph (A), the term ``medically accepted indication'', 
with respect to the use of a drug, includes any use which has been 
approved by the Food and Drug Administration for the drug, and includes 
another use of the drug if--
        (i) the drug has been approved by the Food and Drug 
    Administration; and
        (ii)(I) such use is supported by one or more citations which are 
    included (or approved for inclusion) in one or more of the following 
    compendia: the American Hospital Formulary Service-Drug Information, 
    the American Medical Association Drug Evaluations, the United States 
    Pharmacopoeia-Drug Information, and other authoritative compendia as 
    identified by the Secretary, unless the Secretary has determined 
    that the use is not medically appropriate or the use is identified 
    as not indicated in one or more such compendia, or
        (II) the carrier involved determines, based upon guidance 
    provided by the Secretary to carriers for determining accepted uses 
    of drugs, that such use is medically accepted based on supportive 
    clinical evidence in peer reviewed medical literature appearing in 
    publications which have been identified for purposes of this 
    subclause by the Secretary.

The Secretary may revise the list of compendia in clause (ii)(I) as is 
appropriate for identifying medically accepted indications for drugs.

(u) Provider of services

    The term ``provider of services'' means a hospital, critical access 
hospital, skilled nursing facility, comprehensive outpatient 
rehabilitation facility, home health agency, hospice program, or, for 
purposes of section 1395f(g) and section 1395n(e) of this title, a fund.

(v) Reasonable costs

    (1)(A) The reasonable cost of any services shall be the cost 
actually incurred, excluding therefrom any part of incurred cost found 
to be unnecessary in the efficient delivery of needed health services, 
and shall be determined in accordance with regulations establishing the 
method or methods to be used, and the items to be included, in 
determining such costs for various types or classes of institutions, 
agencies, and services; except that in any case to which paragraph (2) 
or (3) applies, the amount of the payment determined under such 
paragraph with respect to the services involved shall be considered the 
reasonable cost of such services. In prescribing the regulations 
referred to in the preceding sentence, the Secretary shall consider, 
among other things, the principles generally applied by national 
organizations or established prepayment organizations (which have 
developed such principles) in computing the amount of payment, to be 
made by persons other than the recipients of services, to providers of 
services on account of services furnished to such recipients by such 
providers. Such regulations may provide for determination of the costs 
of services on a per diem, per unit, per capita, or other basis, may 
provide for using different methods in different circumstances, may 
provide for the use of estimates of costs of particular items or 
services, may provide for the establishment of limits on the direct or 
indirect overall incurred costs or incurred costs of specific items or 
services or groups of items or services to be recognized as reasonable 
based on estimates of the costs necessary in the efficient delivery of 
needed health services to individuals covered by the insurance programs 
established under this subchapter, and may provide for the use of 
charges or a percentage of charges where this method reasonably reflects 
the costs. Such regulations shall (i) take into account both direct and 
indirect costs of providers of services (excluding therefrom any such 
costs, including standby costs, which are determined in accordance with 
regulations to be unnecessary in the efficient delivery of services 
covered by the insurance programs established under this subchapter) in 
order that, under the methods of determining costs, the necessary costs 
of efficiently delivering covered services to individuals covered by the 
insurance programs established by this subchapter will not be borne by 
individuals not so covered, and the costs with respect to individuals 
not so covered will not be borne by such insurance programs, and (ii) 
provide for the making of suitable retroactive corrective adjustments 
where, for a provider of services for any fiscal period, the aggregate 
reimbursement produced by the methods of determining costs proves to be 
either inadequate or excessive.
    (B) In the case of extended care services, the regulations under 
subparagraph (A) shall not include provision for specific recognition of 
a return on equity capital.
    (C) Where a hospital has an arrangement with a medical school under 
which the faculty of such school provides services at such hospital, an 
amount not in excess of the reasonable cost of such services to the 
medical school shall be included in determining the reasonable cost to 
the hospital of furnishing services--
        (i) for which payment may be made under part A of this 
    subchapter, but only if--
            (I) payment for such services as furnished under such 
        arrangement would be made under part A of this subchapter to the 
        hospital had such services been furnished by the hospital, and
            (II) such hospital pays to the medical school at least the 
        reasonable cost of such services to the medical school, or

        (ii) for which payment may be made under part B of this 
    subchapter, but only if such hospital pays to the medical school at 
    least the reasonable cost of such services to the medical school.

    (D) Where (i) physicians furnish services which are either inpatient 
hospital services (including services in conjunction with the teaching 
programs of such hospital) by reason of paragraph (7) of subsection (b) 
of this section or for which entitlement exists by reason of clause (II) 
of section 1395k(a)(2)(B)(i) of this title, and (ii) such hospital (or 
medical school under arrangement with such hospital) incurs no actual 
cost in the furnishing of such services, the reasonable cost of such 
services shall (under regulations of the Secretary) be deemed to be the 
cost such hospital or medical school would have incurred had it paid a 
salary to such physicians rendering such services approximately 
equivalent to the average salary paid to all physicians employed by such 
hospital (or if such employment does not exist, or is minimal in such 
hospital, by similar hospitals in a geographic area of sufficient size 
to assure reasonable inclusion of sufficient physicians in development 
of such average salary).
    (E) Such regulations may, in the case of skilled nursing facilities 
in any State, provide for the use of rates, developed by the State in 
which such facilities are located, for the payment of the cost of 
skilled nursing facility services furnished under the State's plan 
approved under subchapter XIX of this chapter (and such rates may be 
increased by the Secretary on a class or size of institution or on a 
geographical basis by a percentage factor not in excess of 10 percent to 
take into account determinable items or services or other requirements 
under this subchapter not otherwise included in the computation of such 
State rates), if the Secretary finds that such rates are reasonably 
related to (but not necessarily limited to) analyses undertaken by such 
State of costs of care in comparable facilities in such State. 
Notwithstanding the previous sentence, such regulations with respect to 
skilled nursing facilities shall take into account (in a manner 
consistent with subparagraph (A) and based on patient-days of services 
furnished) the costs (including the costs of services required to attain 
or maintain the highest practicable physical, mental, and psychosocial 
well-being of each resident eligible for benefits under this subchapter) 
of such facilities complying with the requirements of subsections (b), 
(c), and (d) of section 1395i-3 of this title (including the costs of 
conducting nurse aide training and competency evaluation programs and 
competency evaluation programs).
    (F) Such regulations shall require each provider of services (other 
than a fund) to make reports to the Secretary of information described 
in section 1320a(a) of this title in accordance with the uniform 
reporting system (established under such section) for that type of 
provider.
    (G)(i) In any case in which a hospital provides inpatient services 
to an individual that would constitute post-hospital extended care 
services if provided by a skilled nursing facility and a quality control 
and peer review organization (or, in the absence of such a qualified 
organization, the Secretary or such agent as the Secretary may 
designate) determines that inpatient hospital services for the 
individual are not medically necessary but post-hospital extended care 
services for the individual are medically necessary and such extended 
care services are not otherwise available to the individual (as 
determined in accordance with criteria established by the Secretary) at 
the time of such determination, payment for such services provided to 
the individual shall continue to be made under this subchapter at the 
payment rate described in clause (ii) during the period in which--
        (I) such post-hospital extended care services for the individual 
    are medically necessary and not otherwise available to the 
    individual (as so determined),
        (II) inpatient hospital services for the individual are not 
    medically necessary, and
        (III) the individual is entitled to have payment made for post-
    hospital extended care services under this subchapter,

except that if the Secretary determines that there is not an excess of 
hospital beds in such hospital and (subject to clause (iv)) there is not 
an excess of hospital beds in the area of such hospital, such payment 
shall be made (during such period) on the basis of the amount otherwise 
payable under part A with respect to inpatient hospital services.
    (ii)(I) Except as provided in subclause (II), the payment rate 
referred to in clause (i) is a rate equal to the estimated adjusted 
State-wide average rate per patient-day paid for services provided in 
skilled nursing facilities under the State plan approved under 
subchapter XIX of this chapter for the State in which such hospital is 
located, or, if the State in which the hospital is located does not have 
a State plan approved under subchapter XIX of this chapter, the 
estimated adjusted State-wide average allowable costs per patient-day 
for extended care services under this subchapter in that State.
    (II) If a hospital has a unit which is a skilled nursing facility, 
the payment rate referred to in clause (i) for the hospital is a rate 
equal to the lesser of the rate described in subclause (I) or the 
allowable costs in effect under this subchapter for extended care 
services provided to patients of such unit.
    (iii) Any day on which an individual receives inpatient services for 
which payment is made under this subparagraph shall, for purposes of 
this chapter (other than this subparagraph), be deemed to be a day on 
which the individual received inpatient hospital services.
    (iv) In determining under clause (i), in the case of a public 
hospital, whether or not there is an excess of hospital beds in the area 
of such hospital, such determination shall be made on the basis of only 
the public hospitals (including the hospital) which are in the area of 
the hospital and which are under common ownership with that hospital.
    (H) In determining such reasonable cost with respect to home health 
agencies, the Secretary may not include--
        (i) any costs incurred in connection with bonding or 
    establishing an escrow account by any such agency as a result of the 
    surety bond requirement described in subsection (o)(7) of this 
    section and the financial security requirement described in 
    subsection (o)(8) of this section;
        (ii) in the case of home health agencies to which the surety 
    bond requirement described in subsection (o)(7) of this section and 
    the financial security requirement described in subsection (o)(8) of 
    this section apply, any costs attributed to interest charged such an 
    agency in connection with amounts borrowed by the agency to repay 
    overpayments made under this subchapter to the agency, except that 
    such costs may be included in reasonable cost if the Secretary 
    determines that the agency was acting in good faith in borrowing the 
    amounts;
        (iii) in the case of contracts entered into by a home health 
    agency after December 5, 1980, for the purpose of having services 
    furnished for or on behalf of such agency, any cost incurred by such 
    agency pursuant to any such contract which is entered into for a 
    period exceeding five years; and
        (iv) in the case of contracts entered into by a home health 
    agency before December 5, 1980, for the purpose of having services 
    furnished for or on behalf of such agency, any cost incurred by such 
    agency pursuant to any such contract, which determines the amount 
    payable by the home health agency on the basis of a percentage of 
    the agency's reimbursement or claim for reimbursement for services 
    furnished by the agency, to the extent that such cost exceeds the 
    reasonable value of the services furnished on behalf of such agency.

    (I) In determining such reasonable cost, the Secretary may not 
include any costs incurred by a provider with respect to any services 
furnished in connection with matters for which payment may be made under 
this subchapter and furnished pursuant to a contract between the 
provider and any of its subcontractors which is entered into after 
December 5, 1980, and the value or cost of which is $10,000 or more over 
a twelve-month period unless the contract contains a clause to the 
effect that--
        (i) until the expiration of four years after the furnishing of 
    such services pursuant to such contract, the subcontractor shall 
    make available, upon written request by the Secretary, or upon 
    request by the Comptroller General, or any of their duly authorized 
    representatives, the contract, and books, documents and records of 
    such subcontractor that are necessary to certify the nature and 
    extent of such costs, and
        (ii) if the subcontractor carries out any of the duties of the 
    contract through a subcontract, with a value or cost of $10,000 or 
    more over a twelve-month period, with a related organization, such 
    subcontract shall contain a clause to the effect that until the 
    expiration of four years after the furnishing of such services 
    pursuant to such subcontract, the related organization shall make 
    available, upon written request by the Secretary, or upon request by 
    the Comptroller General, or any of their duly authorized 
    representatives, the subcontract, and books, documents and records 
    of such organization that are necessary to verify the nature and 
    extent of such costs.

The Secretary shall prescribe in regulation \3\ criteria and procedures 
which the Secretary shall use in obtaining access to books, documents, 
and records under clauses required in contracts and subcontracts under 
this subparagraph.
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    \3\ So in original. Probably should be ``regulations''.
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    (J) Such regulations may not provide for any inpatient routine 
salary cost differential as a reimbursable cost for hospitals and 
skilled nursing facilities.
    (K)(i) The Secretary shall issue regulations that provide, to the 
extent feasible, for the establishment of limitations on the amount of 
any costs or charges that shall be considered reasonable with respect to 
services provided on an outpatient basis by hospitals (other than bona 
fide emergency services as defined in clause (ii)) or clinics (other 
than rural health clinics), which are reimbursed on a cost basis or on 
the basis of cost related charges, and by physicians utilizing such 
outpatient facilities. Such limitations shall be reasonably related to 
the charges in the same area for similar services provided in 
physicians' offices. Such regulations shall provide for exceptions to 
such limitations in cases where similar services are not generally 
available in physicians' offices in the area to individuals entitled to 
benefits under this subchapter.
    (ii) For purposes of clause (i), the term ``bona fide emergency 
services'' means services provided in a hospital emergency room after 
the sudden onset of a medical condition manifesting itself by acute 
symptoms of sufficient severity (including severe pain) such that the 
absence of immediate medical attention could reasonably be expected to 
result in--
        (I) placing the patient's health in serious jeopardy;
        (II) serious impairment to bodily functions; or
        (III) serious dysfunction of any bodily organ or part.

    (L)(i) The Secretary, in determining the amount of the payments that 
may be made under this subchapter with respect to services furnished by 
home health agencies, may not recognize as reasonable (in the efficient 
delivery of such services) costs for the provision of such services by 
an agency to the extent these costs exceed (on the aggregate for the 
agency) for cost reporting periods beginning on or after--
        (I) July 1, 1985, and before July 1, 1986, 120 percent of the 
    mean of the labor-related and nonlabor per visit costs for 
    freestanding home health agencies,
        (II) July 1, 1986, and before July 1, 1987, 115 percent of such 
    mean,
        (III) July 1, 1987, and before October 1, 1997, 112 percent of 
    such mean,
        (IV) October 1, 1997, and before October 1, 1998, 105 percent of 
    the median of the labor-related and nonlabor per visit costs for 
    freestanding home health agencies, or
        (V) October 1, 1998, 106 percent of such median.

    (ii) Effective for cost reporting periods beginning on or after July 
1, 1986, such limitations shall be applied on an aggregate basis for the 
agency, rather than on a discipline specific basis. The Secretary may 
provide for such exemptions and exceptions to such limitation as he 
deems appropriate.
    (iii) Not later than July 1, 1991, and annually thereafter (but not 
for cost reporting periods beginning on or after July 1, 1994, and 
before July 1, 1996, or on or after July 1, 1997, and before October 1, 
1997), the Secretary shall establish limits under this subparagraph for 
cost reporting periods beginning on or after such date by utilizing the 
area wage index applicable under section 1395ww(d)(3)(E) of this title 
and determined using the survey of the most recent available wages and 
wage-related costs of hospitals located in the geographic area in which 
the home health service is furnished (determined without regard to 
whether such hospitals have been reclassified to a new geographic area 
pursuant to section 1395ww(d)(8)(B) of this title, a decision of the 
Medicare Geographic Classification Review Board under section 
1395ww(d)(10) of this title, or a decision of the Secretary).
    (iv) In establishing limits under this subparagraph for cost 
reporting periods beginning after September 30, 1997, the Secretary 
shall not take into account any changes in the home health market 
basket, as determined by the Secretary, with respect to cost reporting 
periods which began on or after July 1, 1994, and before July 1, 1996.
    (v) For services furnished by home health agencies for cost 
reporting periods beginning on or after October 1, 1997, subject to 
clause (viii)(I), the Secretary shall provide for an interim system of 
limits. Payment shall not exceed the costs determined under the 
preceding provisions of this subparagraph or, if lower, the product of--
        (I) an agency-specific per beneficiary annual limitation 
    calculated based 75 percent on 98 percent of the reasonable costs 
    (including nonroutine medical supplies) for the agency's 12-month 
    cost reporting period ending during fiscal year 1994, and based 25 
    percent on 98 percent of the standardized regional average of such 
    costs for the agency's census division, as applied to such agency, 
    for cost reporting periods ending during fiscal year 1994, such 
    costs updated by the home health market basket index; and
        (II) the agency's unduplicated census count of patients 
    (entitled to benefits under this subchapter) for the cost reporting 
    period subject to the limitation.

    (vi) For services furnished by home health agencies for cost 
reporting periods beginning on or after October 1, 1997, the following 
rules apply:
        (I) For new providers and those providers without a 12-month 
    cost reporting period ending in fiscal year 1994 subject to clauses 
    (viii)(II) and (viii)(III), the per beneficiary limitation shall be 
    equal to the median of these limits (or the Secretary's best 
    estimates thereof) applied to other home health agencies as 
    determined by the Secretary. A home health agency that has altered 
    its corporate structure or name shall not be considered a new 
    provider for this purpose.
        (II) For beneficiaries who use services furnished by more than 
    one home health agency, the per beneficiary limitations shall be 
    prorated among the agencies.

    (vii)(I) Not later than January 1, 1998, the Secretary shall 
establish per visit limits applicable for fiscal year 1998, and not 
later than April 1, 1998, the Secretary shall establish per beneficiary 
limits under clause (v)(I) for fiscal year 1998.
    (II) Not later than August 1 of each year (beginning in 1998) the 
Secretary shall establish the limits applicable under this subparagraph 
for services furnished during the fiscal year beginning October 1 of the 
year.
    (viii)(I) In the case of a provider with a 12-month cost reporting 
period ending in fiscal year 1994, if the limit imposed under clause (v) 
(determined without regard to this subclause) for a cost reporting 
period beginning during or after fiscal year 1999 is less than the 
median described in clause (vi)(I) (but determined as if any reference 
in clause (v) to ``98 percent'' were a reference to ``100 percent''), 
the limit otherwise imposed under clause (v) for such provider and 
period shall be increased by \1/3\ of such difference.
    (II) Subject to subclause (IV), for new providers and those 
providers without a 12-month cost reporting period ending in fiscal year 
1994, but for which the first cost reporting period begins before fiscal 
year 1999, for cost reporting periods beginning during or after fiscal 
year 1999, the per beneficiary limitation described in clause (vi)(I) 
shall be equal to the median described in such clause (determined as if 
any reference in clause (v) to ``98 percent'' were a reference to ``100 
percent'').
    (III) Subject to subclause (IV), in the case of a new provider for 
which the first cost reporting period begins during or after fiscal year 
1999, the limitation applied under clause (vi)(I) (but only with respect 
to such provider) shall be equal to 75 percent of the median described 
in clause (vi)(I).
    (IV) In the case of a new provider or a provider without a 12-month 
cost reporting period ending in fiscal year 1994, subclause (II) shall 
apply, instead of subclause (III), to a home health agency which filed 
an application for home health agency provider status under this 
subchapter before September 15, 1998, or which was approved as a branch 
of its parent agency before such date and becomes a subunit of the 
parent agency or a separate agency on or after such date.
    (V) Each of the amounts specified in subclauses (I) through (III) 
are such amounts as adjusted under clause (iii) to reflect variations in 
wages among different areas.
    (ix) Notwithstanding the per beneficiary limit under clause (viii), 
if the limit imposed under clause (v) (determined without regard to this 
clause) for a cost reporting period beginning during or after fiscal 
year 2000 is less than the median described in clause (vi)(I) (but 
determined as if any reference in clause (v) to ``98 percent'' were a 
reference to ``100 percent''), the limit otherwise imposed under clause 
(v) for such provider and period shall be increased by 2 percent.
    (x) Notwithstanding any other provision of this subparagraph, in 
updating any limit under this subparagraph by a home health market 
basket index for cost reporting periods beginning during each of fiscal 
years 2000, 2001, 2002, and 2003, the update otherwise provided shall be 
reduced by 1.1 percentage points.
    (M) Such regulations shall provide that costs respecting care 
provided by a provider of services, pursuant to an assurance under title 
VI or XVI of the Public Health Service Act [42 U.S.C. 291 et seq., 300q 
et seq.] that the provider will make available a reasonable volume of 
services to persons unable to pay therefor, shall not be allowable as 
reasonable costs.
    (N) In determining such reasonable costs, costs incurred for 
activities directly related to influencing employees respecting 
unionization may not be included.
    (O)(i) In establishing an appropriate allowance for depreciation and 
for interest on capital indebtedness with respect to an asset of a 
provider of services which has undergone a change of ownership, such 
regulations shall provide, except as provided in clause (iii), that the 
valuation of the asset after such change of ownership shall be the 
historical cost of the asset, as recognized under this subchapter, less 
depreciation allowed, to the owner of record as of August 5, 1997 (or, 
in the case of an asset not in existence as of August 5, 1997, the first 
owner of record of the asset after August 5, 1997).
    (ii) Such regulations shall not recognize, as reasonable in the 
provision of health care services, costs (including legal fees, 
accounting and administrative costs, travel costs, and the costs of 
feasibility studies) attributable to the negotiation or settlement of 
the sale or purchase of any capital asset (by acquisition or merger) for 
which any payment has previously been made under this subchapter.
    (iii) In the case of the transfer of a hospital from ownership by a 
State to ownership by a nonprofit corporation without monetary 
consideration, the basis for capital allowances to the new owner shall 
be the book value of the hospital to the State at the time of the 
transfer.
    (P) If such regulations provide for the payment for a return on 
equity capital (other than with respect to costs of inpatient hospital 
services), the rate of return to be recognized, for determining the 
reasonable cost of services furnished in a cost reporting period, shall 
be equal to the average of the rates of interest, for each of the months 
any part of which is included in the period, on obligations issued for 
purchase by the Federal Hospital Insurance Trust Fund.
    (Q) Except as otherwise explicitly authorized, the Secretary is not 
authorized to limit the rate of increase on allowable costs of approved 
medical educational activities.
    (R) In determining such reasonable cost, costs incurred by a 
provider of services representing a beneficiary in an unsuccessful 
appeal of a determination described in section 1395ff(b) of this title 
shall not be allowable as reasonable costs.
    (S)(i) Such regulations shall not include provision for specific 
recognition of any return on equity capital with respect to hospital 
outpatient departments.
    (ii)(I) Such regulations shall provide that, in determining the 
amount of the payments that may be made under this subchapter with 
respect to all the capital-related costs of outpatient hospital 
services, the Secretary shall reduce the amounts of such payments 
otherwise established under this subchapter by 15 percent for payments 
attributable to portions of cost reporting periods occurring during 
fiscal year 1990, by 15 percent for payments attributable to portions of 
cost reporting periods occurring during fiscal year 1991, and by 10 
percent for payments attributable to portions of cost reporting periods 
occurring during fiscal years 1992 through 1999 and until the first date 
that the prospective payment system under section 1395l(t) of this title 
is implemented.
    (II) The Secretary shall reduce the reasonable cost of outpatient 
hospital services (other than the capital-related costs of such 
services) otherwise determined pursuant to section 1395l(a)(2)(B)(i)(I) 
of this title by 5.8 percent for payments attributable to portions of 
cost reporting periods occurring during fiscal years 1991 through 1999 
and until the first date that the prospective payment system under 
section 1395l(t) of this title is implemented.
    (III) Subclauses (I) and (II) shall not apply to payments with 
respect to the costs of hospital outpatient services provided by any 
hospital that is a sole community hospital (as defined in section 
1395ww(d)(5)(D)(iii) of this title \4\ or a critical access hospital (as 
defined in subsection (mm)(1) of this section).
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    \4\ So in original. Probably should be followed by a closing 
parenthesis.
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    (IV) In applying subclauses (I) and (II) to services for which 
payment is made on the basis of a blend amount under section 
1395l(i)(3)(A)(ii) or 1395l(n)(1)(A)(ii) of this title, the costs 
reflected in the amounts described in sections 1395l(i)(3)(B)(i)(I) and 
1395l(n)(1)(B)(i)(I) of this title, respectively, shall be reduced in 
accordance with such subclause.\5\
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    \5\ So in original. Probably should be ``subclauses.''
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    (T) In determining such reasonable costs for hospitals, no reduction 
in copayments under section 1395l(t)(5)(B) \6\ of this title shall be 
treated as a bad debt and the amount of bad debts otherwise treated as 
allowable costs which are attributable to the deductibles and 
coinsurance amounts under this subchapter shall be reduced--
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    \6\ See References in Text note below.
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        (i) for cost reporting periods beginning during fiscal year 
    1998, by 25 percent of such amount otherwise allowable,
        (ii) for cost reporting periods beginning during fiscal year 
    1999, by 40 percent of such amount otherwise allowable, and
        (iii) for cost reporting periods beginning during a subsequent 
    fiscal year, by 45 percent of such amount otherwise allowable.

    (U) In determining the reasonable cost of ambulance services (as 
described in subsection (s)(7) of this section) provided during fiscal 
year 1998, during fiscal year 1999, and during so much of fiscal year 
2000 as precedes January 1, 2000, the Secretary shall not recognize the 
costs per trip in excess of costs recognized as reasonable for ambulance 
services provided on a per trip basis during the previous fiscal year 
(after application of this subparagraph), 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 fiscal year involved reduced by 1.0 percentage 
point. For ambulance services provided after June 30, 1998, the 
Secretary may provide that claims for such services must include a code 
(or codes) under a uniform coding system specified by the Secretary that 
identifies the services furnished.
    (2)(A) If the bed and board furnished as part of inpatient hospital 
services (including inpatient tuberculosis hospital services and 
inpatient psychiatric hospital services) or post-hospital extended care 
services is in accommodations more expensive than semi-private 
accommodations, the amount taken into account for purposes of payment 
under this subchapter with respect to such services may not exceed the 
amount that would be taken into account with respect to such services if 
furnished in such semi-private accommodations unless the more expensive 
accommodations were required for medical reasons.
    (B) Where a provider of services which has an agreement in effect 
under this subchapter furnishes to an individual items or services which 
are in excess of or more expensive than the items or services with 
respect to which payment may be made under part A or part B of this 
subchapter, as the case may be, the Secretary shall take into account 
for purposes of payment to such provider of services only the items or 
services with respect to which such payment may be made.
    (3) If the bed and board furnished as part of inpatient hospital 
services (including inpatient tuberculosis hospital services and 
inpatient psychiatric hospital services) or post-hospital extended care 
services is in accommodations other than, but not more expensive than, 
semi-private accommodations and the use of such other accommodations 
rather than semi-private accommodations was neither at the request of 
the patient nor for a reason which the Secretary determines is 
consistent with the purposes of this subchapter, the amount of the 
payment with respect to such bed and board under part A of this 
subchapter shall be the amount otherwise payable under this subchapter 
for such bed and board furnished in semi-private accommodations minus 
the difference between the charge customarily made by the hospital or 
skilled nursing facility for bed and board in semi-private 
accommodations and the charge customarily made by it for bed and board 
in the accommodations furnished.
    (4) If a provider of services furnishes items or services to an 
individual which are in excess of or more expensive than the items or 
services determined to be necessary in the efficient delivery of needed 
health services and charges are imposed for such more expensive items or 
services under the authority granted in section 1395cc(a)(2)(B)(ii),\7\ 
of this title, the amount of payment with respect to such items or 
services otherwise due such provider in any fiscal period shall be 
reduced to the extent that such payment plus such charges exceed the 
cost actually incurred for such items or services in the fiscal period 
in which such charges are imposed.
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    \7\ See References in Text note below.
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    (5)(A) Where physical therapy services, occupational therapy 
services, speech therapy services, or other therapy services or services 
of other health-related personnel (other than physicians) are furnished 
under an arrangement with a provider of services or other organization, 
specified in the first sentence of subsection (p) of this section 
(including through the operation of subsection (g) of this section) the 
amount included in any payment to such provider or other organization 
under this subchapter as the reasonable cost of such services (as 
furnished under such arrangements) shall not exceed an amount equal to 
the salary which would reasonably have been paid for such services 
(together with any additional costs that would have been incurred by the 
provider or other organization) to the person performing them if they 
had been performed in an employment relationship with such provider or 
other organization (rather than under such arrangement) plus the cost of 
such other expenses (including a reasonable allowance for traveltime and 
other reasonable types of expense related to any differences in 
acceptable methods of organization for the provision of such therapy) 
incurred by such person, as the Secretary may in regulations determine 
to be appropriate.
    (B) Notwithstanding the provisions of subparagraph (A), if a 
provider of services or other organization specified in the first 
sentence of subsection (p) of this section requires the services of a 
therapist on a limited part-time basis, or only to perform intermittent 
services, the Secretary may make payment on the basis of a reasonable 
rate per unit of service, even though such rate is greater per unit of 
time than salary related amounts, where he finds that such greater 
payment is, in the aggregate, less than the amount that would have been 
paid if such organization had employed a therapist on a full- or part-
time salary basis.
    (6) For purposes of this subsection, the term, ``semi-private 
accommodations'' means two-bed, three-bed, or four-bed accommodations.
    (7)(A) For limitation on Federal participation for capital 
expenditures which are out of conformity with a comprehensive plan of a 
State or areawide planning agency, see section 1320a-1 of this title.
    (B) For further limitations on reasonable cost and determination of 
payment amounts for operating costs of inpatient hospital services and 
waivers for certain States, see section 1395ww of this title.
    (C) For provisions restricting payment for provider-based 
physicians' services and for payments under certain percentage 
arrangements, see section 1395xx of this title.
    (D) For further limitations on reasonable cost and determination of 
payment amounts for routine service costs of skilled nursing facilities, 
see subsections (a) through (c) of section 1395yy of this title.
    (8) Items unrelated to patient care.--Reasonable costs do not 
include costs for the following--
        (i) entertainment, including tickets to sporting and other 
    entertainment events;
        (ii) gifts or donations;
        (iii) personal use of motor vehicles;
        (iv) costs for fines and penalties resulting from violations of 
    Federal, State, or local laws; and
        (v) education expenses for spouses or other dependents of 
    providers of services, their employees or contractors.

(w) Arrangements for certain services; payments pursuant to arrangements 
        for utilization review activities

    (1) The term ``arrangements'' is limited to arrangements under which 
receipt of payment by the hospital, critical access hospital, skilled 
nursing facility, home health agency, or hospice program (whether in its 
own right or as agent), with respect to services for which an individual 
is entitled to have payment made under this subchapter, discharges the 
liability of such individual or any other person to pay for the 
services.
    (2) Utilization review activities conducted, in accordance with the 
requirements of the program established under part B of subchapter XI of 
this chapter with respect to services furnished by a hospital or 
critical access hospital to patients insured under part A of this 
subchapter or entitled to have payment made for such services under part 
B of this subchapter or under a State plan approved under subchapter XIX 
of this chapter, by a quality control and peer review organization 
designated for the area in which such hospital or critical access 
hospital is located shall be deemed to have been conducted pursuant to 
arrangements between such hospital or critical access hospital and such 
organization under which such hospital or critical access hospital is 
obligated to pay to such organization, as a condition of receiving 
payment for hospital or critical access hospital services so furnished 
under this part or under such a State plan, such amount as is reasonably 
incurred and requested (as determined under regulations of the 
Secretary) by such organization in conducting such review activities 
with respect to services furnished by such hospital or critical access 
hospital to such patients.

(x) State and United States

    The terms ``State'' and ``United States'' have the meaning given to 
them by subsections (h) and (i), respectively, of section 410 of this 
title.

(y) Extended care in religious nonmedical health care institutions

    (1) The term ``skilled nursing facility'' also includes a religious 
nonmedical health care institution (as defined in subsection (ss)(1) of 
this section), but only (except for purposes of subsection (a)(2) of 
this section) with respect to items and services ordinarily furnished by 
such an institution to inpatients, and payment may be made with respect 
to services provided by or in such an institution only to such extent 
and under such conditions, limitations, and requirements (in addition to 
or in lieu of the conditions, limitations, and requirements otherwise 
applicable) as may be provided in regulations consistent with section 
1395i-5 of this title.
    (2) Notwithstanding any other provision of this subchapter, payment 
under part A of this subchapter may not be made for services furnished 
an individual in a skilled nursing facility to which paragraph (1) 
applies unless such individual elects, in accordance with regulations, 
for a spell of illness to have such services treated as post-hospital 
extended care services for purposes of such part; and payment under part 
A of this subchapter may not be made for post-hospital extended care 
services--
        (A) furnished an individual during such spell of illness in a 
    skilled nursing facility to which paragraph (1) applies after--
            (i) such services have been furnished to him in such a 
        facility for 30 days during such spell, or
            (ii) such services have been furnished to him during such 
        spell in a skilled nursing facility to which such paragraph does 
        not apply; or

        (B) furnished an individual during such spell of illness in a 
    skilled nursing facility to which paragraph (1) does not apply after 
    such services have been furnished to him during such spell in a 
    skilled nursing facility to which such paragraph applies.

    (3) The amount payable under part A of this subchapter for post-
hospital extended care services furnished an individual during any spell 
of illness in a skilled nursing facility to which paragraph (1) applies 
shall be reduced by a coinsurance amount equal to one-eighth of the 
inpatient hospital deductible for each day before the 31st day on which 
he is furnished such services in such a facility during such spell (and 
the reduction under this paragraph shall be in lieu of any reduction 
under section 1395e(a)(3) of this title).
    (4) For purposes of subsection (i) of this section, the 
determination of whether services furnished by or in an institution 
described in paragraph (1) constitute post-hospital extended care 
services shall be made in accordance with and subject to such 
conditions, limitations, and requirements as may be provided in 
regulations.

(z) Institutional planning

    An overall plan and budget of a hospital, skilled nursing facility, 
comprehensive outpatient rehabilitation facility, or home health agency 
shall be considered sufficient if it--
        (1) provides for an annual operating budget which includes all 
    anticipated income and expenses related to items which would, under 
    generally accepted accounting principles, be considered income and 
    expense items (except that nothing in this paragraph shall require 
    that there be prepared, in connection with any budget, an item-by-
    item identification of the components of each type of anticipated 
    expenditure or income);
        (2)(A) provides for a capital expenditures plan for at least a 
    3-year period (including the year to which the operating budget 
    described in paragraph (1) is applicable) which includes and 
    identifies in detail the anticipated sources of financing for, and 
    the objectives of, each anticipated expenditure in excess of 
    $600,000 (or such lesser amount as may be established by the State 
    under section 1320a-1(g)(1) of this title in which the hospital is 
    located) related to the acquisition of land, the improvement of 
    land, buildings, and equipment, and the replacement, modernization, 
    and expansion of the buildings and equipment which would, under 
    generally accepted accounting principles, be considered capital 
    items;
        (B) provides that such plan is submitted to the agency 
    designated under section 1320a-1(b) of this title, or if no such 
    agency is designated, to the appropriate health planning agency in 
    the State (but this subparagraph shall not apply in the case of a 
    facility exempt from review under section 1320a-1 of this title by 
    reason of section 1320a-1(j) of this title);
        (3) provides for review and updating at least annually; and
        (4) is prepared, under the direction of the governing body of 
    the institution or agency, by a committee consisting of 
    representatives of the governing body, the administrative staff, and 
    the medical staff (if any) of the institution or agency.

(aa) Rural health clinic services and Federally qualified health center 
        services

    (1) The term ``rural health clinic services'' means--
        (A) physicians' services and such services and supplies as are 
    covered under subsection (s)(2)(A) of this section if furnished as 
    an incident to a physician's professional service and items and 
    services described in subsection (s)(10) of this section,
        (B) such services furnished by a physician assistant or a nurse 
    practitioner (as defined in paragraph (5)), by a clinical 
    psychologist (as defined by the Secretary) or by a clinical social 
    worker (as defined in subsection (hh)(1) of this section),,\8\ and 
    such services and supplies furnished as an incident to his service 
    as would otherwise be covered if furnished by a physician or as an 
    incident to a physician's service, and
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    \8\ So in original.
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        (C) in the case of a rural health clinic located in an area in 
    which there exists a shortage of home health agencies, part-time or 
    intermittent nursing care and related medical supplies (other than 
    drugs and biologicals) furnished by a registered professional nurse 
    or licensed practical nurse to a homebound individual under a 
    written plan of treatment (i) established and periodically reviewed 
    by a physician described in paragraph (2)(B), or (ii) established by 
    a nurse practitioner or physician assistant and periodically 
    reviewed and approved by a physician described in paragraph (2)(B),

when furnished to an individual as an outpatient of a rural health 
clinic.
    (2) The term ``rural health clinic'' means a facility which--
        (A) is primarily engaged in furnishing to outpatients services 
    described in subparagraphs (A) and (B) of paragraph (1);
        (B) in the case of a facility which is not a physician-directed 
    clinic, has an arrangement (consistent with the provisions of State 
    and local law relative to the practice, performance, and delivery of 
    health services) with one or more physicians (as defined in 
    subsection (r)(1)) of this section under which provision is made for 
    the periodic review by such physicians of covered services furnished 
    by physician assistants and nurse practitioners, the supervision and 
    guidance by such physicians of physician assistants and nurse 
    practitioners, the preparation by such physicians of such medical 
    orders for care and treatment of clinic patients as may be 
    necessary, and the availability of such physicians for such referral 
    of and consultation for patients as is necessary and for advice and 
    assistance in the management of medical emergencies; and, in the 
    case of a physician-directed clinic, has one or more of its staff 
    physicians perform the activities accomplished through such an 
    arrangement;
        (C) maintains clinical records on all patients;
        (D) has arrangements with one or more hospitals, having 
    agreements in effect under section 1395cc of this title, for the 
    referral and admission of patients requiring inpatient services or 
    such diagnostic or other specialized services as are not available 
    at the clinic;
        (E) has written policies, which are developed with the advice of 
    (and with provision for review of such policies from time to time 
    by) a group of professional personnel, including one or more 
    physicians and one or more physician assistants or nurse 
    practitioners, to govern those services described in paragraph (1) 
    which it furnishes;
        (F) has a physician, physician assistant, or nurse practitioner 
    responsible for the execution of policies described in subparagraph 
    (E) and relating to the provision of the clinic's services;
        (G) directly provides routine diagnostic services, including 
    clinical laboratory services, as prescribed in regulations by the 
    Secretary, and has prompt access to additional diagnostic services 
    from facilities meeting requirements under this subchapter;
        (H) in compliance with State and Federal law, has available for 
    administering to patients of the clinic at least such drugs and 
    biologicals as are determined by the Secretary to be necessary for 
    the treatment of emergency cases (as defined in regulations) and has 
    appropriate procedures or arrangements for storing, administering, 
    and dispensing any drugs and biologicals;
        (I) has a quality assessment and performance improvement 
    program, and appropriate procedures for review of utilization of 
    clinic services, as the Secretary may specify;
        (J) has a nurse practitioner, a physician assistant, or a 
    certified nurse-midwife (as defined in subsection (gg) of this 
    section) available to furnish patient care services not less than 50 
    percent of the time the clinic operates; and
        (K) meets such other requirements as the Secretary may find 
    necessary in the interest of the health and safety of the 
    individuals who are furnished services by the clinic.

For the purposes of this subchapter, such term includes only a facility 
which (i) is located in an area that is not an urbanized area (as 
defined by the Bureau of the Census) and in which there are insufficient 
numbers of needed health care practitioners (as determined by the 
Secretary), and that, within the previous 3-year period, has been 
designated by the chief executive officer of the State and certified by 
the Secretary as an area with a shortage of personal health services or 
designated by the Secretary either (I) as an area with a shortage of 
personal health services under section 330(b)(3) \9\ or 1302(7) [42 
U.S.C. 300e-1(7)] of the Public Health Service Act, (II) as a health 
professional shortage area described in section 332(a)(1)(A) of that Act 
[42 U.S.C. 254e(a)(1)(A)] because of its shortage of primary medical 
care manpower, (III) as a high impact area described in section 
329(a)(5) \9\ of that Act, or (IV) as an area which includes a 
population group which the Secretary determines has a health manpower 
shortage under section 332(a)(1)(B) of that Act [42 U.S.C. 
254e(a)(1)(B)], (ii) has filed an agreement with the Secretary by which 
it agrees not to charge any individual or other person for items or 
services for which such individual is entitled to have payment made 
under this subchapter, except for the amount of any deductible or 
coinsurance amount imposed with respect to such items or services (not 
in excess of the amount customarily charged for such items and services 
by such clinic), pursuant to subsections (a) and (b) of section 1395l of 
this title, (iii) employs a physician assistant or nurse practitioner, 
and (iv) is not a rehabilitation agency or a facility which is primarily 
for the care and treatment of mental diseases. A facility that is in 
operation and qualifies as a rural health clinic under this subchapter 
or subchapter XIX of this chapter and that subsequently fails to satisfy 
the requirement of clause (i) shall be considered, for purposes of this 
subchapter and subchapter XIX of this chapter, as still satisfying the 
requirement of such clause if it is determined, in accordance with 
criteria established by the Secretary in regulations, to be essential to 
the delivery of primary care services that would otherwise be 
unavailable in the geographic area served by the clinic. If a State 
agency has determined under section 1395aa(a) of this title that a 
facility is a rural health clinic and the facility has applied to the 
Secretary for approval as such a clinic, the Secretary shall notify the 
facility of the Secretary's approval or disapproval not later than 60 
days after the date of the State agency determination or the application 
(whichever is later).
---------------------------------------------------------------------------
    \9\ See References in Text note below.
---------------------------------------------------------------------------
    (3) The term ``Federally qualified health center services'' means--
        (A) services of the type described in subparagraphs (A) through 
    (C) of paragraph (1), and
        (B) preventive primary health services that a center is required 
    to provide under sections 329, 330, and 340 \9\ of the Public Health 
    Service Act,

when furnished to an individual as an outpatient of a Federally 
qualified health center and, for this purpose, any reference to a rural 
health clinic or a physician described in paragraph (2)(B) is deemed a 
reference to a Federally qualified health center or a physician at the 
center, respectively.
    (4) The term ``Federally qualified health center'' means an entity 
which--
        (A)(i) is receiving a grant under section 330 (other than 
    subsection (h)) of the Public Health Service Act [42 U.S.C. 254b], 
    or
        (ii)(I) is receiving funding from such a grant under a contract 
    with the recipient of such a grant, and (II) meets the requirements 
    to receive a grant under section 330 (other than subsection (h)) of 
    such Act [42 U.S.C. 254b];
        (B) based on the recommendation of the Health Resources and 
    Services Administration within the Public Health Service, is 
    determined by the Secretary to meet the requirements for receiving 
    such a grant;
        (C) was treated by the Secretary, for purposes of part B of this 
    subchapter, as a comprehensive Federally funded health center as of 
    January 1, 1990; or
        (D) is an outpatient health program or facility operated by a 
    tribe or tribal organization under the Indian Self-Determination Act 
    [25 U.S.C. 450f et seq.] or by an urban Indian organization 
    receiving funds under title V of the Indian Health Care Improvement 
    Act [25 U.S.C. 1651 et seq.].

    (5)(A) The term ``physician assistant'' and the term ``nurse 
practitioner'' mean, for purposes of this subchapter, a physician 
assistant or nurse practitioner who performs such services as such 
individual is legally authorized to perform (in the State in which the 
individual performs such services) in accordance with State law (or the 
State regulatory mechanism provided by State law), and who meets such 
training, education, and experience requirements (or any combination 
thereof) as the Secretary may prescribe in regulations.
    (B) The term ``clinical nurse specialist'' means, for purposes of 
this subchapter, an individual who--
        (i) is a registered nurse and is licensed to practice nursing in 
    the State in which the clinical nurse specialist services are 
    performed; and
        (ii) holds a master's degree in a defined clinical area of 
    nursing from an accredited educational institution.

    (6) The term ``collaboration'' means a process in which a nurse 
practitioner works with a physician to deliver health care services 
within the scope of the practitioner's professional expertise, with 
medical direction and appropriate supervision as provided for in jointly 
developed guidelines or other mechanisms as defined by the law of the 
State in which the services are performed.
    (7)(A) The Secretary shall waive for a 1-year period the 
requirements of paragraph (2) that a rural health clinic employ a 
physician assistant, nurse practitioner or certified nurse midwife or 
that such clinic require such providers to furnish services at least 50 
percent of the time that the clinic operates for any facility that 
requests such waiver if the facility demonstrates that the facility has 
been unable, despite reasonable efforts, to hire a physician assistant, 
nurse practitioner, or certified nurse-midwife in the previous 90-day 
period.
    (B) The Secretary may not grant such a waiver under subparagraph (A) 
to a facility if the request for the waiver is made less than 6 months 
after the date of the expiration of any previous such waiver for the 
facility, or if the facility has not yet been determined to meet the 
requirements (including subparagraph (J) of the first sentence of 
paragraph (2)) of a rural health clinic.
    (C) A waiver which is requested under this paragraph shall be deemed 
granted unless such request is denied by the Secretary within 60 days 
after the date such request is received.

(bb) Services of a certified registered nurse anesthetist

    (1) The term ``services of a certified registered nurse 
anesthetist'' means anesthesia services and related care furnished by a 
certified registered nurse anesthetist (as defined in paragraph (2)) 
which the nurse anesthetist is legally authorized to perform as such by 
the State in which the services are furnished.
    (2) The term ``certified registered nurse anesthetist'' means a 
certified registered nurse anesthetist licensed by the State who meets 
such education, training, and other requirements relating to anesthesia 
services and related care as the Secretary may prescribe. In prescribing 
such requirements the Secretary may use the same requirements as those 
established by a national organization for the certification of nurse 
anesthetists. Such term also includes, as prescribed by the Secretary, 
an anesthesiologist assistant.

(cc) Comprehensive outpatient rehabilitation facility services

    (1) The term ``comprehensive outpatient rehabilitation facility 
services'' means the following items and services furnished by a 
physician or other qualified professional personnel (as defined in 
regulations by the Secretary) to an individual who is an outpatient of a 
comprehensive outpatient rehabilitation facility under a plan (for 
furnishing such items and services to such individual) established and 
periodically reviewed by a physician--
        (A) physicians' services;
        (B) physical therapy, occupational therapy, speech-language 
    pathology services, and respiratory therapy;
        (C) prosthetic and orthotic devices, including testing, fitting, 
    or training in the use of prosthetic and orthotic devices;
        (D) social and psychological services;
        (E) nursing care provided by or under the supervision of a 
    registered professional nurse;
        (F) drugs and biologicals which cannot, as determined in 
    accordance with regulations, be self-administered;
        (G) supplies and durable medical equipment; and
        (H) such other items and services as are medically necessary for 
    the rehabilitation of the patient and are ordinarily furnished by 
    comprehensive outpatient rehabilitation facilities,

excluding, however, any item or service if it would not be included 
under subsection (b) of this section if furnished to an inpatient of a 
hospital. In the case of physical therapy, occupational therapy, and 
speech pathology services, there shall be no requirement that the item 
or service be furnished at any single fixed location if the item or 
service is furnished pursuant to such plan and payments are not 
otherwise made for the item or service under this subchapter.
    (2) The term ``comprehensive outpatient rehabilitation facility'' 
means a facility which--
        (A) is primarily engaged in providing (by or under the 
    supervision of physicians) diagnostic, therapeutic, and restorative 
    services to outpatients for the rehabilitation of injured, disabled, 
    or sick persons;
        (B) provides at least the following comprehensive outpatient 
    rehabilitation services: (i) physicians' services (rendered by 
    physicians, as defined in subsection (r)(1) of this section, who are 
    available at the facility on a full- or part-time basis); (ii) 
    physical therapy; and (iii) social or psychological services;
        (C) maintains clinical records on all patients;
        (D) has policies established by a group of professional 
    personnel (associated with the facility), including one or more 
    physicians defined in subsection (r)(1) of this section to govern 
    the comprehensive outpatient rehabilitation services it furnishes, 
    and provides for the carrying out of such policies by a full- or 
    part-time physician referred to in subparagraph (B)(i);
        (E) has a requirement that every patient must be under the care 
    of a physician;
        (F) in the case of a facility in any State in which State or 
    applicable local law provides for the licensing of facilities of 
    this nature (i) is licensed pursuant to such law, or (ii) is 
    approved by the agency of such State or locality, responsible for 
    licensing facilities of this nature, as meeting the standards 
    established for such licensing;
        (G) has in effect a utilization review plan in accordance with 
    regulations prescribed by the Secretary;
        (H) has in effect an overall plan and budget that meets the 
    requirements of subsection (z) of this section;
        (I) provides the Secretary on a continuing basis with a surety 
    bond in a form specified by the Secretary and in an amount that is 
    not less than $50,000; and
        (J) meets such other conditions of participation as the 
    Secretary may find necessary in the interest of the health and 
    safety of individuals who are furnished services by such facility, 
    including conditions concerning qualifications of personnel in these 
    facilities.

The Secretary may waive the requirement of a surety bond under 
subparagraph (I) in the case of a facility that provides a comparable 
surety bond under State law.

(dd) Hospice care; hospice program; definitions; certification; waiver 
        by Secretary

    (1) The term ``hospice care'' means the following items and services 
provided to a terminally ill individual by, or by others under 
arrangements made by, a hospice program under a written plan (for 
providing such care to such individual) established and periodically 
reviewed by the individual's attending physician and by the medical 
director (and by the interdisciplinary group described in paragraph 
(2)(B)) of the program--
        (A) nursing care provided by or under the supervision of a 
    registered professional nurse,
        (B) physical or occupational therapy, or speech-language 
    pathology services,
        (C) medical social services under the direction of a physician,
        (D)(i) services of a home health aide who has successfully 
    completed a training program approved by the Secretary and (ii) 
    homemaker services,
        (E) medical supplies (including drugs and biologicals) and the 
    use of medical appliances, while under such a plan,
        (F) physicians' services,
        (G) short-term inpatient care (including both respite care and 
    procedures necessary for pain control and acute and chronic symptom 
    management) in an inpatient facility meeting such conditions as the 
    Secretary determines to be appropriate to provide such care, but 
    such respite care may be provided only on an intermittent, 
    nonroutine, and occasional basis and may not be provided 
    consecutively over longer than five days,
        (H) counseling (including dietary counseling) with respect to 
    care of the terminally ill individual and adjustment to his death, 
    and
        (I) any other item or service which is specified in the plan and 
    for which payment may otherwise be made under this subchapter.

The care and services described in subparagraphs (A) and (D) may be 
provided on a 24-hour, continuous basis only during periods of crisis 
(meeting criteria established by the Secretary) and only as necessary to 
maintain the terminally ill individual at home.
    (2) The term ``hospice program'' means a public agency or private 
organization (or a subdivision thereof) which--
        (A)(i) is primarily engaged in providing the care and services 
    described in paragraph (1) and makes such services available (as 
    needed) on a 24-hour basis and which also provides bereavement 
    counseling for the immediate family of terminally ill individuals,
        (ii) provides for such care and services in individuals' homes, 
    on an outpatient basis, and on a short-term inpatient basis, 
    directly or under arrangements made by the agency or organization, 
    except that--
            (I) the agency or organization must routinely provide 
        directly substantially all of each of the services described in 
        subparagraphs (A), (C), and (H) of paragraph (1), except as 
        otherwise provided in paragraph (5), and
            (II) in the case of other services described in paragraph 
        (1) which are not provided directly by the agency or 
        organization, the agency or organization must maintain 
        professional management responsibility for all such services 
        furnished to an individual, regardless of the location or 
        facility in which such services are furnished; and

        (iii) provides assurances satisfactory to the Secretary that the 
    aggregate number of days of inpatient care described in paragraph 
    (1)(G) provided in any 12-month period to individuals who have an 
    election in effect under section 1395d(d) of this title with respect 
    to that agency or organization does not exceed 20 percent of the 
    aggregate number of days during that period on which such elections 
    for such individuals are in effect;
        (B) has an interdisciplinary group of personnel which--
            (i) includes at least--
                (I) one physician (as defined in subsection (r)(1) of 
            this section),
                (II) one registered professional nurse, and
                (III) one social worker,

        employed by or, in the case of a physician described in 
        subclause (I), under contract with the agency or organization, 
        and also includes at least one pastoral or other counselor,
            (ii) provides (or supervises the provision of) the care and 
        services described in paragraph (1), and
            (iii) establishes the policies governing the provision of 
        such care and services;

        (C) maintains central clinical records on all patients;
        (D) does not discontinue the hospice care it provides with 
    respect to a patient because of the inability of the patient to pay 
    for such care;
        (E)(i) utilizes volunteers in its provision of care and services 
    in accordance with standards set by the Secretary, which standards 
    shall ensure a continuing level of effort to utilize such 
    volunteers, and (ii) maintains records on the use of these 
    volunteers and the cost savings and expansion of care and services 
    achieved through the use of these volunteers;
        (F) in the case of an agency or organization in any State in 
    which State or applicable local law provides for the licensing of 
    agencies or organizations of this nature, is licensed pursuant to 
    such law; and
        (G) meets such other requirements as the Secretary may find 
    necessary in the interest of the health and safety of the 
    individuals who are provided care and services by such agency or 
    organization.

    (3)(A) An individual is considered to be ``terminally ill'' if the 
individual has a medical prognosis that the individual's life expectancy 
is 6 months or less.
    (B) The term ``attending physician'' means, with respect to an 
individual, the physician (as defined in subsection (r)(1) of this 
section), who may be employed by a hospice program, whom the individual 
identifies as having the most significant role in the determination and 
delivery of medical care to the individual at the time the individual 
makes an election to receive hospice care.
    (4)(A) An entity which is certified as a provider of services other 
than a hospice program shall be considered, for purposes of 
certification as a hospice program, to have met any requirements under 
paragraph (2) which are also the same requirements for certification as 
such other type of provider. The Secretary shall coordinate surveys for 
determining certification under this subchapter so as to provide, to the 
extent feasible, for simultaneous surveys of an entity which seeks to be 
certified as a hospice program and as a provider of services of another 
type.
    (B) Any entity which is certified as a hospice program and as a 
provider of another type shall have separate provider agreements under 
section 1395cc of this title and shall file separate cost reports with 
respect to costs incurred in providing hospice care and in providing 
other services and items under this subchapter.
    (5)(A) The Secretary may waive the requirements of paragraph 
(2)(A)(ii)(I) for an agency or organization with respect to all or part 
of the nursing care described in paragraph (1)(A) if such agency or 
organization--
        (i) is located in an area which is not an urbanized area (as 
    defined by the Bureau of the Census);
        (ii) was in operation on or before January 1, 1983; and
        (iii) has demonstrated a good faith effort (as determined by the 
    Secretary) to hire a sufficient number of nurses to provide such 
    nursing care directly.

    (B) Any waiver, which is in such form and containing such 
information as the Secretary may require and which is requested by an 
agency or organization under subparagraph (A) or (C), shall be deemed to 
be granted unless such request is denied by the Secretary within 60 days 
after the date such request is received by the Secretary. The granting 
of a waiver under subparagraph (A) or (C) shall not preclude the 
granting of any subsequent waiver request should such a waiver again 
become necessary.
    (C) The Secretary may waive the requirements of paragraph (2)(A)(i) 
and (2)(A)(ii) for an agency or organization with respect to the 
services described in paragraph (1)(B) and, with respect to dietary 
counseling, paragraph (1)(H), if such agency or organization--
        (i) is located in an area which is not an urbanized area (as 
    defined by the Bureau of Census), and
        (ii) demonstrates to the satisfaction of the Secretary that the 
    agency or organization has been unable, despite diligent efforts, to 
    recruit appropriate personnel.

(ee) Discharge planning process

    (1) A discharge planning process of a hospital shall be considered 
sufficient if it is applicable to services furnished by the hospital to 
individuals entitled to benefits under this subchapter and if it meets 
the guidelines and standards established by the Secretary under 
paragraph (2).
    (2) The Secretary shall develop guidelines and standards for the 
discharge planning process in order to ensure a timely and smooth 
transition to the most appropriate type of and setting for post-hospital 
or rehabilitative care. The guidelines and standards shall include the 
following:
        (A) The hospital must identify, at an early stage of 
    hospitalization, those patients who are likely to suffer adverse 
    health consequences upon discharge in the absence of adequate 
    discharge planning.
        (B) Hospitals must provide a discharge planning evaluation for 
    patients identified under subparagraph (A) and for other patients 
    upon the request of the patient, patient's representative, or 
    patient's physician.
        (C) Any discharge planning evaluation must be made on a timely 
    basis to ensure that appropriate arrangements for post-hospital care 
    will be made before discharge and to avoid unnecessary delays in 
    discharge.
        (D) A discharge planning evaluation must include an evaluation 
    of a patient's likely need for appropriate post-hospital services, 
    including hospice services, and the availability of those services, 
    including the availability of home health services through 
    individuals and entities that participate in the program under this 
    subchapter and that serve the area in which the patient resides and 
    that request to be listed by the hospital as available.
        (E) The discharge planning evaluation must be included in the 
    patient's medical record for use in establishing an appropriate 
    discharge plan and the results of the evaluation must be discussed 
    with the patient (or the patient's representative).
        (F) Upon the request of a patient's physician, the hospital must 
    arrange for the development and initial implementation of a 
    discharge plan for the patient.
        (G) Any discharge planning evaluation or discharge plan required 
    under this paragraph must be developed by, or under the supervision 
    of, a registered professional nurse, social worker, or other 
    appropriately qualified personnel.
        (H) Consistent with section 1395a of this title, the discharge 
    plan shall--
            (i) not specify or otherwise limit the qualified provider 
        which may provide post-hospital home health services, and
            (ii) identify (in a form and manner specified by the 
        Secretary) any entity to whom the individual is referred in 
        which the hospital has a disclosable financial interest (as 
        specified by the Secretary consistent with section 
        1395cc(a)(1)(S) of this title) or which has such an interest in 
        the hospital.

    (3) With respect to a discharge plan for an individual who is 
enrolled with a Medicare+Choice organization under a Medicare+Choice 
plan and is furnished inpatient hospital services by a hospital under a 
contract with the organization--
        (A) the discharge planning evaluation under paragraph (2)(D) is 
    not required to include information on the availability of home 
    health services through individuals and entities which do not have a 
    contract with the organization; and
        (B) notwithstanding subparagraph (H)(i) \10\, the plan may 
    specify or limit the provider (or providers) of post-hospital home 
    health services or other post-hospital services under the plan.
---------------------------------------------------------------------------
    \10\ So in original. Probably should be ``paragraph (2)(H)(i)''.
---------------------------------------------------------------------------

(ff) Partial hospitalization services

    (1) The term ``partial hospitalization services'' means the items 
and services described in paragraph (2) prescribed by a physician and 
provided under a program described in paragraph (3) under the 
supervision of a physician pursuant to an individualized, written plan 
of treatment established and periodically reviewed by a physician (in 
consultation with appropriate staff participating in such program), 
which plan sets forth the physician's diagnosis, the type, amount, 
frequency, and duration of the items and services provided under the 
plan, and the goals for treatment under the plan.
    (2) The items and services described in this paragraph are--
        (A) individual and group therapy with physicians or 
    psychologists (or other mental health professionals to the extent 
    authorized under State law),
        (B) occupational therapy requiring the skills of a qualified 
    occupational therapist,
        (C) services of social workers, trained psychiatric nurses, and 
    other staff trained to work with psychiatric patients,
        (D) drugs and biologicals furnished for therapeutic purposes 
    (which cannot, as determined in accordance with regulations, be 
    self-administered),
        (E) individualized activity therapies that are not primarily 
    recreational or diversionary,
        (F) family counseling (the primary purpose of which is treatment 
    of the individual's condition),
        (G) patient training and education (to the extent that training 
    and educational activities are closely and clearly related to 
    individual's care and treatment),
        (H) diagnostic services, and
        (I) such other items and services as the Secretary may provide 
    (but in no event to include meals and transportation);

that are reasonable and necessary for the diagnosis or active treatment 
of the individual's condition, reasonably expected to improve or 
maintain the individual's condition and functional level and to prevent 
relapse or hospitalization, and furnished pursuant to such guidelines 
relating to frequency and duration of services as the Secretary shall by 
regulation establish (taking into account accepted norms of medical 
practice and the reasonable expectation of patient improvement).
    (3)(A) A program described in this paragraph is a program which is 
furnished by a hospital to its outpatients or by a community mental 
health center (as defined in subparagraph (B)), and which is a distinct 
and organized intensive ambulatory treatment service offering less than 
24-hour-daily care.
    (B) For purposes of subparagraph (A), the term ``community mental 
health center'' means an entity--
        (i) providing the services described in section 1916(c)(4) of 
    the Public Health Service Act [42 U.S.C. 300x-4(c)(4)]; and
        (ii) meeting applicable licensing or certification requirements 
    for community mental health centers in the State in which it is 
    located.

(gg) Certified nurse-midwife services

    (1) The term ``certified nurse-midwife services'' means such 
services furnished by a certified nurse-midwife (as defined in paragraph 
(2)) and such services and supplies furnished as an incident to the 
nurse-midwife's service which the certified nurse-midwife is legally 
authorized to perform under State law (or the State regulatory mechanism 
provided by State law) as would otherwise be covered if furnished by a 
physician or as an incident to a physicians' service.
    (2) The term ``certified nurse-midwife'' means a registered nurse 
who has successfully completed a program of study and clinical 
experience meeting guidelines prescribed by the Secretary, or has been 
certified by an organization recognized by the Secretary.

(hh) Clinical social worker; clinical social worker services

    (1) The term ``clinical social worker'' means an individual who--
        (A) possesses a master's or doctor's degree in social work;
        (B) after obtaining such degree has performed at least 2 years 
    of supervised clinical social work; and
        (C)(i) is licensed or certified as a clinical social worker by 
    the State in which the services are performed, or
        (ii) in the case of an individual in a State which does not 
    provide for licensure or certification--
            (I) has completed at least 2 years or 3,000 hours of post-
        master's degree supervised clinical social work practice under 
        the supervision of a master's level social worker in an 
        appropriate setting (as determined by the Secretary), and
            (II) meets such other criteria as the Secretary establishes.

    (2) The term ``clinical social worker services'' means services 
performed by a clinical social worker (as defined in paragraph (1)) for 
the diagnosis and treatment of mental illnesses (other than services 
furnished to an inpatient of a hospital and other than services 
furnished to an inpatient of a skilled nursing facility which the 
facility is required to provide as a requirement for participation) 
which the clinical social worker is legally authorized to perform under 
State law (or the State regulatory mechanism provided by State law) of 
the State in which such services are performed as would otherwise be 
covered if furnished by a physician or as an incident to a physician's 
professional service.

(ii) Qualified psychologist services

    The term ``qualified psychologist services'' means such services and 
such services and supplies furnished as an incident to his service 
furnished by a clinical psychologist (as defined by the Secretary) which 
the psychologist is legally authorized to perform under State law (or 
the State regulatory mechanism provided by State law) as would otherwise 
be covered if furnished by a physician or as an incident to a 
physician's service.

(jj) Screening mammography

    The term ``screening mammography'' means a radiologic procedure 
provided to a woman for the purpose of early detection of breast cancer 
and includes a physician's interpretation of the results of the 
procedure.

(kk) Covered osteoporosis drug

    The term ``covered osteoporosis drug'' means an injectable drug 
approved for the treatment of post-menopausal osteoporosis provided to 
an individual by a home health agency if, in accordance with regulations 
promulgated by the Secretary--
        (1) the individual's attending physician certifies that the 
    individual has suffered a bone fracture related to post-menopausal 
    osteoporosis and that the individual is unable to learn the skills 
    needed to self-administer such drug or is otherwise physically or 
    mentally incapable of self-administering such drug; and
        (2) the individual is confined to the individual's home (except 
    when receiving items and services referred to in subsection (m)(7) 
    of this section).

(ll) Speech-language pathology services; audiology services

    (1) The term ``speech-language pathology services'' means such 
speech, language, and related function assessment and rehabilitation 
services furnished by a qualified speech-language pathologist as the 
speech-language pathologist is legally authorized to perform under State 
law (or the State regulatory mechanism provided by State law) as would 
otherwise be covered if furnished by a physician.
    (2) The term ``audiology services'' means such hearing and balance 
assessment services furnished by a qualified audiologist as the 
audiologist is legally authorized to perform under State law (or the 
State regulatory mechanism provided by State law), as would otherwise be 
covered if furnished by a physician.
    (3) In this subsection:
        (A) The term ``qualified speech-language pathologist'' means an 
    individual with a master's or doctoral degree in speech-language 
    pathology who--
            (i) is licensed as a speech-language pathologist by the 
        State in which the individual furnishes such services, or
            (ii) in the case of an individual who furnishes services in 
        a State which does not license speech-language pathologists, has 
        successfully completed 350 clock hours of supervised clinical 
        practicum (or is in the process of accumulating such supervised 
        clinical experience), performed not less than 9 months of 
        supervised full-time speech-language pathology services after 
        obtaining a master's or doctoral degree in speech-language 
        pathology or a related field, and successfully completed a 
        national examination in speech-language pathology approved by 
        the Secretary.

        (B) The term ``qualified audiologist'' means an individual with 
    a master's or doctoral degree in audiology who--
            (i) is licensed as an audiologist by the State in which the 
        individual furnishes such services, or
            (ii) in the case of an individual who furnishes services in 
        a State which does not license audiologists, has successfully 
        completed 350 clock hours of supervised clinical practicum (or 
        is in the process of accumulating such supervised clinical 
        experience), performed not less than 9 months of supervised 
        full-time audiology services after obtaining a master's or 
        doctoral degree in audiology or a related field, and 
        successfully completed a national examination in audiology 
        approved by the Secretary.

(mm) Critical access hospital; critical access hospital services

    (1) The term ``critical access hospital'' means a facility certified 
by the Secretary as a critical access hospital under section 1395i-4(e) 
of this title.
    (2) The term ``inpatient critical access hospital services'' means 
items and services, furnished to an inpatient of a critical access 
hospital by such facility, that would be inpatient hospital services if 
furnished to an inpatient of a hospital by a hospital.
    (3) The term ``outpatient critical access hospital services'' means 
medical and other health services furnished by a critical access 
hospital on an outpatient basis.

(nn) Screening pap smear; screening pelvic exam

    (1) The term ``screening pap smear'' means a diagnostic laboratory 
test consisting of a routine exfoliative cytology test (Papanicolaou 
test) provided to a woman for the purpose of early detection of cervical 
or vaginal cancer and includes a physician's interpretation of the 
results of the test, if the individual involved has not had such a test 
during the preceding 3 years, or during the preceding year in the case 
of a woman described in paragraph (3).
    (2) The term ``screening pelvic exam'' means a pelvic examination 
provided to a woman if the woman involved has not had such an 
examination during the preceding 3 years, or during the preceding year 
in the case of a woman described in paragraph (3), and includes a 
clinical breast examination.
    (3) A woman described in this paragraph is a woman who--
        (A) is of childbearing age and has had a test described in this 
    subsection during any of the preceding 3 years that indicated the 
    presence of cervical or vaginal cancer or other abnormality; or
        (B) is at high risk of developing cervical or vaginal cancer (as 
    determined pursuant to factors identified by the Secretary).

(oo) Prostate cancer screening tests

    (1) The term ``prostate cancer screening test'' means a test that 
consists of any (or all) of the procedures described in paragraph (2) 
provided for the purpose of early detection of prostate cancer to a man 
over 50 years of age who has not had such a test during the preceding 
year.
    (2) The procedures described in this paragraph are as follows:
        (A) A digital rectal examination.
        (B) A prostate-specific antigen blood test.
        (C) For years beginning after 2002, such other procedures as the 
    Secretary finds appropriate for the purpose of early detection of 
    prostate cancer, taking into account changes in technology and 
    standards of medical practice, availability, effectiveness, costs, 
    and such other factors as the Secretary considers appropriate.

(pp) Colorectal cancer screening tests

    (1) The term ``colorectal cancer screening test'' means any of the 
following procedures furnished to an individual for the purpose of early 
detection of colorectal cancer:
        (A) Screening fecal-occult blood test.
        (B) Screening flexible sigmoidoscopy.
        (C) In the case of an individual at high risk for colorectal 
    cancer, screening colonoscopy.
        (D) Such other tests or procedures, and modifications to tests 
    and procedures under this subsection, with such frequency and 
    payment limits, as the Secretary determines appropriate, in 
    consultation with appropriate organizations.

    (2) In paragraph (1)(C), an ``individual at high risk for colorectal 
cancer'' is an individual who, because of family history, prior 
experience of cancer or precursor neoplastic polyps, a history of 
chronic digestive disease condition (including inflammatory bowel 
disease, Crohn's Disease, or ulcerative colitis), the presence of any 
appropriate recognized gene markers for colorectal cancer, or other 
predisposing factors, faces a high risk for colorectal cancer.

(qq) Diabetes outpatient self-management training services

    (1) The term ``diabetes outpatient self-management training 
services'' means educational and training services furnished (at such 
times as the Secretary determines appropriate) to an individual with 
diabetes by a certified provider (as described in paragraph (2)(A)) in 
an outpatient setting by an individual or entity who meets the quality 
standards described in paragraph (2)(B), but only if the physician who 
is managing the individual's diabetic condition certifies that such 
services are needed under a comprehensive plan of care related to the 
individual's diabetic condition to ensure therapy compliance or to 
provide the individual with necessary skills and knowledge (including 
skills related to the self-administration of injectable drugs) to 
participate in the management of the individual's condition.
    (2) In paragraph (1)--
        (A) a ``certified provider'' is a physician, or other individual 
    or entity designated by the Secretary, that, in addition to 
    providing diabetes outpatient self-management training services, 
    provides other items or services for which payment may be made under 
    this subchapter; and
        (B) a physician, or such other individual or entity, meets the 
    quality standards described in this paragraph if the physician, or 
    individual or entity, meets quality standards established by the 
    Secretary, except that the physician or other individual or entity 
    shall be deemed to have met such standards if the physician or other 
    individual or entity meets applicable standards originally 
    established by the National Diabetes Advisory Board and subsequently 
    revised by organizations who participated in the establishment of 
    standards by such Board, or is recognized by an organization that 
    represents individuals (including individuals under this subchapter) 
    with diabetes as meeting standards for furnishing the services.

(rr) Bone mass measurement

    (1) The term ``bone mass measurement'' means a radiologic or 
radioisotopic procedure or other procedure approved by the Food and Drug 
Administration performed on a qualified individual (as defined in 
paragraph (2)) for the purpose of identifying bone mass or detecting 
bone loss or determining bone quality, and includes a physician's 
interpretation of the results of the procedure.
    (2) For purposes of this subsection, the term ``qualified 
individual'' means an individual who is (in accordance with regulations 
prescribed by the Secretary)--
        (A) an estrogen-deficient woman at clinical risk for 
    osteoporosis;
        (B) an individual with vertebral abnormalities;
        (C) an individual receiving long-term glucocorticoid steroid 
    therapy;
        (D) an individual with primary hyperparathyroidism; or
        (E) an individual being monitored to assess the response to or 
    efficacy of an approved osteoporosis drug therapy.

    (3) The Secretary shall establish such standards regarding the 
frequency with which a qualified individual shall be eligible to be 
provided benefits for bone mass measurement under this subchapter.

(ss) Religious nonmedical health care institution

    (1) The term ``religious nonmedical health care institution'' means 
an institution that--
        (A) is described in subsection (c)(3) of section 501 of the 
    Internal Revenue Code of 1986 and is exempt from taxes under 
    subsection (a) of such section;
        (B) is lawfully operated under all applicable Federal, State, 
    and local laws and regulations;
        (C) provides only nonmedical nursing items and services 
    exclusively to patients who choose to rely solely upon a religious 
    method of healing and for whom the acceptance of medical health 
    services would be inconsistent with their religious beliefs;
        (D) provides such nonmedical items and services exclusively 
    through nonmedical nursing personnel who are experienced in caring 
    for the physical needs of such patients;
        (E) provides such nonmedical items and services to inpatients on 
    a 24-hour basis;
        (F) on the basis of its religious beliefs, does not provide 
    through its personnel or otherwise medical items and services 
    (including any medical screening, examination, diagnosis, prognosis, 
    treatment, or the administration of drugs) for its patients;
        (G)(i) is not owned by, under common ownership with, or has an 
    ownership interest in, a provider of medical treatment or services;
        (ii) is not affiliated with--
            (I) a provider of medical treatment or services, or
            (II) an individual who has an ownership interest in a 
        provider of medical treatment or services;

        (H) has in effect a utilization review plan which--
            (i) provides for the review of admissions to the 
        institution, of the duration of stays therein, of cases of 
        continuous extended duration, and of the items and services 
        furnished by the institution,
            (ii) requires that such reviews be made by an appropriate 
        committee of the institution that includes the individuals 
        responsible for overall administration and for supervision of 
        nursing personnel at the institution,
            (iii) provides that records be maintained of the meetings, 
        decisions, and actions of such committee, and
            (iv) meets such other requirements as the Secretary finds 
        necessary to establish an effective utilization review plan;

        (I) provides the Secretary with such information as the 
    Secretary may require to implement section 1395i-5 of this title, 
    including information relating to quality of care and coverage 
    determinations; and
        (J) meets such other requirements as the Secretary finds 
    necessary in the interest of the health and safety of individuals 
    who are furnished services in the institution.

    (2) To the extent that the Secretary finds that the accreditation of 
an institution by a State, regional, or national agency or association 
provides reasonable assurances that any or all of the requirements of 
paragraph (1) are met or exceeded, the Secretary may treat such 
institution as meeting the condition or conditions with respect to which 
the Secretary made such finding.
    (3)(A)(i) In administering this subsection and section 1395i-5 of 
this title, the Secretary shall not require any patient of a religious 
nonmedical health care institution to undergo medical screening, 
examination, diagnosis, prognosis, or treatment or to accept any other 
medical health care service, if such patient (or legal representative of 
the patient) objects thereto on religious grounds.
    (ii) Clause (i) shall not be construed as preventing the Secretary 
from requiring under section 1395i-5(a)(2) of this title the provision 
of sufficient information regarding an individual's condition as a 
condition for receipt of benefits under part A of this subchapter for 
services provided in such an institution.
    (B)(i) In administering this subsection and section 1395i-5 of this 
title, the Secretary shall not subject a religious nonmedical health 
care institution or its personnel to any medical supervision, 
regulation, or control, insofar as such supervision, regulation, or 
control would be contrary to the religious beliefs observed by the 
institution or such personnel.
    (ii) Clause (i) shall not be construed as preventing the Secretary 
from reviewing items and services billed by the institution to the 
extent the Secretary determines such review to be necessary to determine 
whether such items and services were not covered under part A of this 
subchapter, are excessive, or are fraudulent.
    (4)(A) For purposes of paragraph (1)(G)(i), an ownership interest of 
less than 5 percent shall not be taken into account.
    (B) For purposes of paragraph (1)(G)(ii), none of the following 
shall be considered to create an affiliation:
        (i) An individual serving as an uncompensated director, trustee, 
    officer, or other member of the governing body of a religious 
    nonmedical health care institution.
        (ii) An individual who is a director, trustee, officer, 
    employee, or staff member of a religious nonmedical health care 
    institution having a family relationship with an individual who is 
    affiliated with (or has an ownership interest in) a provider of 
    medical treatment or services.
        (iii) An individual or entity furnishing goods or services as a 
    vendor to both providers of medical treatment or services and 
    religious nonmedical health care institutions.

(tt) Post-institutional home health services; home health spell of 
        illness

    (1) The term ``post-institutional home health services'' means home 
health services furnished to an individual--
        (A) after discharge from a hospital or rural primary care \11\ 
    hospital in which the individual was an inpatient for not less than 
    3 consecutive days before such discharge if such home health 
    services were initiated within 14 days after the date of such 
    discharge; or
---------------------------------------------------------------------------
    \11\ So in original. Probably should be ``critical access''.
---------------------------------------------------------------------------
        (B) after discharge from a skilled nursing facility in which the 
    individual was provided post-hospital extended care services if such 
    home health services were initiated within 14 days after the date of 
    such discharge.

    (2) The term ``home health spell of illness'' with respect to any 
individual means a period of consecutive days--
        (A) beginning with the first day (not included in a previous 
    home health spell of illness) (i) on which such individual is 
    furnished post-institutional home health services, and (ii) which 
    occurs in a month for which the individual is entitled to benefits 
    under part A of this subchapter, and
        (B) ending with the close of the first period of 60 consecutive 
    days thereafter on each of which the individual is neither an 
    inpatient of a hospital or rural primary care \11\ hospital nor an 
    inpatient of a facility described in section 1395i-3(a)(1) of this 
    title or subsection (y)(1) of this section nor provided home health 
    services.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1861, as added Pub. L. 89-97, 
title I, Sec. 102(a), July 30, 1965, 79 Stat. 313; amended Pub. L. 89-
713, Sec. 7, Nov. 2, 1966, 80 Stat. 1111; Pub. L. 90-248, title I, 
Secs. 127(a), 129(a), (b), (c)(9)(C), (10), (11), 132(a), 133(a), (b), 
134(a), 143(a), 144(a)-(d), Jan. 2, 1968, 81 Stat. 846-850, 852, 857, 
858; Pub. L. 91-690, Jan. 12, 1971, 84 Stat. 2074; Pub. L. 92-603, title 
II, Secs. 211(b), (c)(2), 221(c)(4), 223(a)-(d), (f), 227(a), (c), 
(d)(1), (f), 234(a)-(f), 237(c), 244(c), 246(b), 248, 249(b), 251(a)(1), 
(b)(1), (c), 252(a), 256(b), 264(a), 265, 267, 273(a), 276(a), 278(a) 
(4)-(15), (b)(6), (10), (11), (13), 283(a), Oct. 30, 1972, 86 Stat. 
1383, 1384, 1389, 1393, 1394, 1404-1407, 1412, 1413, 1416, 1423-1426, 
1445-1447, 1449-1454, 1456; Pub. L. 94-182, title I, Secs. 102, 106(a), 
112(a)(1), Dec. 31, 1975, 89 Stat. 1051, 1052, 1055; Pub. L. 95-142, 
Secs. 3(a)(2), 5(m), 19(b)(1), 21(a), Oct. 25, 1977, 91 Stat. 1178, 
1191, 1204, 1207; Pub. L. 95-210, Sec. 1(d), (g), (h), Dec. 13, 1977, 91 
Stat. 1485, 1487, 1488; Pub. L. 95-216, title V, Sec. 501(a), Dec. 20, 
1977, 91 Stat. 1564; Pub. L. 95-292, Sec. 4(d), June 13, 1978, 92 Stat. 
315; Pub. L. 96-499, title IX, Secs. 902(a)(1), 915(a), 930(k)-(n), (p), 
931(c), (d), 933(c)-(e), 936(a), 937(a), 938(a), 948(a)(1), 949, 950, 
951(a), (b), 952(a), formerly 952, Dec. 5, 1980, 94 Stat. 2612, 2623, 
2632, 2633, 2635, 2639, 2640, 2643, 2645, 2646; Pub. L. 96-611, 
Sec. 1(a)(1), (b)(3), Dec. 28, 1980, 94 Stat. 3566; Pub. L. 97-35, title 
XXI, Secs. 2102(a), 2114, 2121(c), (d), 2141(a), 2142(a), 2143(a), 
2144(a), 2193(c)(9), Aug. 13, 1981, 95 Stat. 787, 796-799, 828; Pub. L. 
97-248, title I, Secs. 101(a)(2), (d), 102(a), 103(a), 105(a), 106(a), 
107(a), 108(a)(2), 109(b), 114(b), 122(d), 127(1), 128(a)(1), (d)(2), 
148(b), Sept. 3, 1982, 96 Stat. 335-339, 350, 359, 366, 367, 394; Pub. 
L. 97-448, title III, Sec. 309(a)(4), Jan. 12, 1983, 96 Stat. 2408; Pub. 
L. 98-21, title VI, Secs. 602(d), 607(b)(2), (d), Apr. 20, 1983, 97 
Stat. 163, 171, 172; Pub. L. 98-369, div. B, title III, Secs. 2314(a), 
2318(a), (b), 2319(a), 2321(e), 2322(a), 2323(a), 2324(a), 2335(b), 
2340(a), 2341(a), (c), 2342(a), 2343(a), (b), 2354(b)(18)-(29), July 18, 
1984, 98 Stat. 1079, 1081, 1082, 1085, 1086, 1090, 1093, 1094, 1101; 
Pub. L. 98-617, Sec. 3(a)(4), (b)(7), Nov. 8, 1984, 98 Stat. 3295, 3296; 
Pub. L. 99-272, title IX, Secs. 9107(b), 9110(a), 9202(i)(1), 
9219(b)(1)(B), (3)(A), Apr. 7, 1986, 100 Stat. 160, 162, 177, 182, 183; 
Pub. L. 99-509, title IX, Secs. 9305(c)(1), (2), 9313(a)(2), 9315(a), 
9320(b), (c), (f), 9335(c)(1), 9336(a), 9337(d), 9338(a), Oct. 21, 1986, 
100 Stat. 1989, 2002, 2005, 2013, 2015, 2030, 2033, 2034; Pub. L. 100-
203, title IV, Secs. 4009(e)(1), (f), 4021(a), 4026(a)(1), 4039(b), 
4064(e)(1), 4065(a), 4070(b)(1), (2), 4071(a), 4072(a), 4073(a), (c), 
4074(a), (b), 4075(a), 4076(a), 4077(a)(1), (b)(1), (4), formerly (5), 
4078, 4084(c)(1), 4085(i)(9)-(14), 4201(a)(1), (b)(1), (d)(1), (2), (5), 
formerly (d), Dec. 22, 1987, 101 Stat. 1330-57, 1330-58, 1330-67, 1330-
74, 1330-81, 1330-111, 1330-112, 1330-114, 1330-116, 1330-118 to 1330-
121, 1330-132, 1330-133, 1330-160, 1330-174, as amended Pub. L. 100-360, 
title IV, Sec. 411(h)(4)(D), (5)-(7)(A), (E), (F), (i)(3), (4)(C)(iii), 
(l)(1)(B), (C), July 1, 1988, 102 Stat. 787-789, 801, as amended Pub. L. 
100-485, title VI, Sec. 608(d)(27)(B), Oct. 13, 1988, 102 Stat. 2422; 
Pub. L. 100-360, title I, Sec. 104(d)(4), title II, Secs. 202(a), 
203(b), (e)(1), 204(a), 205(b), 206(a), title IV, Sec. 411(d)(1)(B)(i), 
(5)(A), (g)(3)(H), (h)(1)(B), (2), (3)(A), July 1, 1988, 102 Stat. 689, 
702, 721, 725, 730, 731, 773, 774, 785, 786; Pub. L. 100-485, title VI, 
Sec. 608(d)(6)(A), (23)(B), Oct. 13, 1988, 102 Stat. 2414, 2421; Pub. L. 
100-647, title VIII, Secs. 8423(a), 8424(a), Nov. 10, 1988, 102 Stat. 
3803; Pub. L. 101-234, title I, Sec. 101(a), title II, Sec. 201(a), Dec. 
13, 1989, 103 Stat. 1979, 1981; Pub. L. 101-239, title VI, 
Secs. 6003(g)(3)(A), (C)(i), (D)(x), 6110, 6112(e)(1), 6113(a)-(b)(2), 
6114(a), (d), 6115(a), 6116(a)(1), 6131(a)(2), 6141(a), 6213(a)-(c), 
Dec. 19, 1989, 103 Stat. 2151-2153, 2213, 2215-2219, 2221, 2225, 2250, 
2251; Pub. L. 101-508, title IV, Secs. 4008(h)(2)(A)(i), 4151(a), 
(b)(1), 4152(a)(2), 4153(b)(2)(A), 4155(a), (d), 4156(a), 4157(a), 
4161(a)(1), (2), (5), (b)(1), (2), 4162(a), 4163(a), 4201(d)(1), 
4207(d)(1), formerly 4027(d)(1), Nov. 5, 1990, 104 Stat. 1388-48, 1388-
71, 1388-72, 1388-74, 1388-84, 1388-86 to 1388-88, 1388-93 to 1388-96, 
1388-104, 1388-120, renumbered Pub. L. 103-432, title I, Sec. 160(d)(4), 
Oct. 31, 1994, 108 Stat. 4444; Pub. L. 101-597, title IV, 
Sec. 401(c)(2), Nov. 16, 1990, 104 Stat. 3035; Pub. L. 103-66, title 
XIII, Secs. 13503(c)(1)(A), 13521, 13522, 13553(a), (b), 13554(a), 
13556(a), 13564(a)(2), (b)(1), 13565, 13566(b), Aug. 10, 1993, 107 Stat. 
578, 586, 591, 592, 607; Pub. L. 103-432, title I, Secs. 102(g)(4), 104, 
107(a), 145(b), 146(a), (b), 147(e)(1), (4), (5), (f)(3), (4)(A), 
(6)(A), (B), (E), 158(a)(1), Oct. 31, 1994, 108 Stat. 4404, 4405, 4407, 
4427-4432, 4442; Pub. L. 104-299, Sec. 4(b)(1), Oct. 11, 1996, 110 Stat. 
3645; Pub. L. 105-33, title IV, Secs. 4102(a), (c), 4103(a), 4104(a)(1), 
4105(a)(1), (b)(1), 4106(a), 4201(c)(1), (2), 4205(b)(1), (c)(1), 
(d)(1)-(3)(A), 4312(b)(1), (2), (d), (e), 4320, 4321(a), 4404(a), 
4432(b)(5)(D), (E), 4444(a), 4445, 4446, 4451, 4454(a)(1), 4511(a)(1)-
(2)(B), (d), 4512(a), 4513(a), 4522, 4531(a)(1), 4557(a), 4601(a), 
4602(a)-(c), 4604(b), 4611(b), 4612(a), Aug. 5, 1997, 111 Stat. 360-362, 
366, 367, 373, 376, 377, 386, 387, 394, 400, 421-426, 442-444, 450, 463, 
466, 472, 474; Pub. L. 105-277, div. J, title V, Sec. 5101(a), (b), 
(d)(1), Oct. 21, 1998, 112 Stat. 2681-913, 2681-914; Pub. L. 106-113, 
div. B, Sec. 1000(a)(6) [title II, Secs. 201(k), 221(b)(1), 227(a), 
title III, Secs. 303(a), 304(a), 321(k)(7)-(9), title V, Sec. 521], Nov. 
29, 1999, 113 Stat. 1536, 1501A-341, 1501A-351, 1501A-354, 1501A-360, 
1501A-361, 1501A-367, 1501A-386.)

                       References in Text

    Parts A and B of this subchapter, referred to in text, are 
classified to section 1395c et seq. and section 1395j et seq., 
respectively, of this title.
    Section 4071(b) of the Omnibus Budget Reconciliation Act of 1987, 
referred to in subsec. (s)(10)(A), is section 4071(b) of Pub. L. 100-
203, which is set out as a note below.
    Section 4072(e) of the Omnibus Budget Reconciliation Act of 1987, 
referred to in subsec. (s)(12), is section 4072(e) of Pub. L. 100-203, 
which is set out as a note below.
    The Public Health Service Act, referred to in subsec. (v)(1)(M), is 
act July 1, 1944, ch. 373, 58 Stat. 682, as amended, which is classified 
generally to chapter 6A (Sec. 201 et seq.) of this title. Titles VI and 
XVI of the Public Health Service Act are classified generally to 
subchapters IV (Sec. 291 et seq.) and XIV (Sec. 300q et seq.), 
respectively, of chapter 6A of this title. For complete classification 
of this Act to the Code, see Short Title note set out under section 201 
of this title and Tables.
    Section 1395l(t)(5)(B) of this title, referred to in subsec. 
(v)(1)(T), was redesignated section 1395l(t)(8)(B) of this title by Pub. 
L. 106-113, div. B, Sec. 1000(a)(6) [title II, Secs. 201(a)(1), 
202(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-336, 1501A-342.
    Section 1395cc(a)(2)(B)(ii) of this title, referred to in subsec. 
(v)(4), was repealed by Pub. L. 101-239, title VI, Sec. 6017(2), Dec. 
19, 1989, 103 Stat. 2165.
    Part B of subchapter XI of this chapter, referred to in subsec. 
(w)(2), is classified to section 1320c et seq. of this title.
    Sections 329 and 330 of the Public Health Service Act, referred to 
in subsec. (aa)(2), (3)(B), were sections 329 and 330 of act July 1, 
1944, which were classified, respectively, to sections 254b and 254c of 
this title and were omitted in the general amendment of subpart I 
(Sec. 254b et seq.) of part D of subchapter II of chapter 6A of this 
title by Pub. L. 104-299, Sec. 2, Oct. 11, 1996, 110 Stat. 3626. 
Sections 2 and 3(a) of Pub. L. 104-299 enacted new sections 330 and 330A 
of act July 1, 1944, which are classified, respectively, to sections 
254b and 254c of this title.
    Section 340 of the Public Health Service Act, referred to in subsec. 
(aa)(3)(B), was section 340 of act July 1, 1944, which was classified to 
section 256 of this title prior to repeal by Pub. L. 104-299, 
Sec. 4(a)(3), Oct. 11, 1996, 110 Stat. 3645.
    The Indian Self-Determination Act, referred to in subsec. 
(aa)(4)(D), is title I of Pub. L. 93-638, Jan. 4, 1975, 88 Stat. 2206, 
as amended, which is classified principally to part A (Sec. 450f et 
seq.) of subchapter II of chapter 14 of Title 25, Indians. For complete 
classification of this Act to the Code, see Short Title note set out 
under section 450 of Title 25 and Tables.
    The Indian Health Care Improvement Act, referred to in subsec. 
(aa)(4)(D), is Pub. L. 94-437, Sept. 30, 1976, 90 Stat. 1400, as 
amended. Title V of the Act is classified generally to subchapter IV 
(Sec. 1651 et seq.) of chapter 18 of Title 25. For complete 
classification of this Act to the Code, see Short Title note set out 
under section 1601 of Title 25 and Tables.
    The Internal Revenue Code of 1986, referred to in subsec. 
(ss)(1)(A), is classified generally to Title 26, Internal Revenue Code.


                               Amendments

    1999--Subsec. (o)(7). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 304(a)], amended par. (7) generally. Prior to amendment, par. (7) 
read as follows: ``provides the Secretary on a continuing basis with a 
surety bond in a form specified by the Secretary and in an amount that 
is not less than $50,000; and''.
    Subsec. (p)(1). Pub. L. 106-113, Sec. 1000(a)(6) [title II, 
Sec. 221(b)(1)(A)], substituted ``, (3), or (4)'' for ``or (3)''.
    Subsec. (r)(4). Pub. L. 106-113, Sec. 1000(a)(6) [title II, 
Sec. 221(b)(1)(B)], inserted ``for purposes of subsection (p)(1) of this 
section and'' after ``but only''.
    Subsec. (s)(2)(J)(v). Pub. L. 106-113, Sec. 1000(a)(6) [title II, 
Sec. 227(a)], inserted before semicolon at end ``plus such additional 
number of months (if any) provided under section 1395k(b) of this 
title''.
    Subsec. (s)(2)(T)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(7)], substituted semicolon for period at end.
    Subsec. (v)(1)(L)(ix), (x). Pub. L. 106-113, Sec. 1000(a)(6) [title 
III, Sec. 303(a)], added cl. (ix) and redesignated former cl. (ix) as 
(x).
    Subsec. (v)(1)(S)(ii)(I), (II). Pub. L. 106-113, Sec. 1000(a)(6) 
[title II, Sec. 201(k)], substituted ``and until the first date that the 
prospective payment system under section 1395l(t) of this title is 
implemented'' for ``and during fiscal year 2000 before January 1, 
2000''.
    Subsec. (aa)(2)(I). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(8)], substituted semicolon for comma at end and realigned 
margins.
    Subsec. (ee)(3). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 521], added par. (3).
    Subsec. (ss)(1)(G)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(9)(B)], which directed substitution of ``or'' for ``of'', 
was executed by making the substitution for ``of'' the second time 
appearing to reflect the probable intent of Congress.
    Pub. L. 106-113, Sec. 1000(a)(6) [title III, Sec. 321(k)(9)(A)], 
substituted ``owned'' for ``owed''.
    1998--Subsec. (v)(1)(L)(i)(III) to (V). Pub. L. 105-277, 
Sec. 5101(b), in subcl. (III) struck out ``or'' at end, in subcl. (IV) 
inserted ``and before October 1, 1998,'' after ``1997,'' and substituted 
``, or'' for period at end, and added subcl. (V).
    Subsec. (v)(1)(L)(v). Pub. L. 105-277, Sec. 5101(a)(1), inserted 
``subject to clause (viii)(I),'' before ``the Secretary'' in 
introductory provisions.
    Subsec. (v)(1)(L)(vi)(I). Pub. L. 105-277, Sec. 5101(a)(2), inserted 
``subject to clauses (viii)(II) and (viii)(III)'' after ``1994''.
    Subsec. (v)(1)(L)(viii). Pub. L. 105-277, Sec. 5101(a)(3), added cl. 
(viii).
    Subsec. (v)(1)(L)(ix). Pub. L. 105-277, Sec. 5101(d)(1), added cl. 
(ix).
    1997--Subsec. (a). Pub. L. 105-33, Sec. 4201(c)(1), substituted 
``critical access'' for ``rural primary care'' in pars. (1) and (2).
    Subsec. (b)(4). Pub. L. 105-33, Sec. 4511(a)(2)(B), substituted 
``subsection (s)(2)(K)'' for ``clauses (i) or (iii) of subsection 
(s)(2)(K)''.
    Subsec. (e). Pub. L. 105-33, Sec. 4454(a)(1)(A), in fifth sentence 
after par. (9), substituted ``includes a religious nonmedical health 
care institution (as defined in subsection (ss)(1) of this section),'' 
for ``includes a Christian Science sanatorium operated, or listed and 
certified, by the First Church of Christ, Scientist, Boston, 
Massachusetts,'' and inserted ``consistent with section 1395i-5 of this 
title'' before the period.
    Pub. L. 105-33, Sec. 4201(c)(1), substituted ``critical access'' for 
``rural primary care'' in last sentence.
    Subsec. (h). Pub. L. 105-33, Sec. 4432(b)(5)(D)(i), substituted 
``paragraphs (3), (6), and (7)'' for ``paragraphs (3) and (6)'' in 
introductory provisions.
    Subsec. (h)(7). Pub. L. 105-33, Sec. 4432(b)(5)(D)(ii), inserted ``, 
or by others under arrangements with them made by the facility'' after 
``skilled nursing facilities''.
    Subsec. (m). Pub. L. 105-33, Sec. 4612(a), inserted at end of 
closing provisions ``For purposes of paragraphs (1) and (4), the term 
`part-time or intermittent services' means skilled nursing and home 
health aide services furnished any number of days per week as long as 
they are furnished (combined) less than 8 hours each day and 28 or fewer 
hours each week (or, subject to review on a case-by-case basis as to the 
need for care, less than 8 hours each day and 35 or fewer hours per 
week). For purposes of sections 1395f(a)(2)(C) and 1395n(a)(2)(A) of 
this title, `intermittent' means skilled nursing care that is either 
provided or needed on fewer than 7 days each week, or less than 8 hours 
of each day for periods of 21 days or less (with extensions in 
exceptional circumstances when the need for additional care is finite 
and predictable).''
    Subsec. (n). Pub. L. 105-33, Sec. 4105(b)(1), inserted before 
semicolon in first sentence ``, and includes blood-testing strips and 
blood glucose monitors for individuals with diabetes without regard to 
whether the individual has Type I or Type II diabetes or to the 
individual's use of insulin (as determined under standards established 
by the Secretary in consultation with the appropriate organizations)''.
    Subsec. (o). Pub. L. 105-33, Sec. 4312(b)(1)(D), inserted at end of 
closing provisions ``The Secretary may waive the requirement of a surety 
bond under paragraph (7) in the case of an agency or organization that 
provides a comparable surety bond under State law.''
    Subsec. (o)(7), (8). Pub. L. 105-33, Sec. 4312(b)(1)(A)-(C), added 
par. (7) and redesignated former par. (7) as (8).
    Subsec. (p). Pub. L. 105-33, Sec. 4312(e)(2), inserted at end of 
closing provisions ``The Secretary may waive the requirement of a surety 
bond under paragraph (4)(A)(v) in the case of a clinic or agency that 
provides a comparable surety bond under State law.''
    Subsec. (p)(4)(A)(v). Pub. L. 105-33, Sec. 4312(e)(1), inserted 
``and provides the Secretary on a continuing basis with a surety bond in 
a form specified by the Secretary and in an amount that is not less than 
$50,000,'' after ``as the Secretary may find necessary,''.
    Subsec. (r)(5). Pub. L. 105-33, Sec. 4513(a), struck out 
``demonstrated by x-ray to exist'' following ``(to correct a 
subluxation''.
    Subsec. (s)(2)(K)(i). Pub. L. 105-33, Secs. 4511(a)(2)(A)(i), 
4512(a), struck out ``(I) in a hospital, skilled nursing facility, or 
nursing facility (as defined in section 1396r(a) of this title), (II) as 
an assistant at surgery, or (III) in a rural area (as defined in section 
1395ww(d)(2)(D) of this title) that is designated, under section 
332(a)(1)(A) of the Public Health Service Act, as a health professional 
shortage area,'' after ``physician (as so defined)'' and inserted at end 
``and such services and supplies furnished as incident to such services 
as would be covered under subparagraph (A) if furnished incident to a 
physician's professional service; and but only if no facility or other 
provider charges or is paid any amounts with respect to the furnishing 
of such services,''.
    Subsec. (s)(2)(K)(ii). Pub. L. 105-33, Sec. 4511(a)(1), amended cl. 
(ii) generally. Prior to amendment, cl. (ii) read as follows: ``services 
which would be physicians' services if furnished by a physician (as 
defined in subsection (r)(1) of this section) and which are performed by 
a nurse practitioner (as defined in subsection (aa)(5) of this section) 
working in collaboration (as defined in subsection (aa)(6) of this 
section) with a physician (as defined in subsection (r)(1) of this 
section) in a skilled nursing facility or nursing facility (as defined 
in section 1396r(a) of this title) which the nurse practitioner is 
legally authorized to perform by the State in which the services are 
performed,''.
    Subsec. (s)(2)(K)(iii), (iv). Pub. L. 105-33, 
Sec. 4511(a)(2)(A)(ii), struck out cls. (iii) and (iv) which read as 
follows:
    ``(iii) services which would be physicians' services if furnished by 
a physician (as defined in subsection (r)(1) of this section) and which 
are performed by a nurse practitioner or clinical nurse specialist (as 
defined in subsection (aa)(5) of this section) working in collaboration 
(as defined in subsection (aa)(6) of this section) with a physician (as 
defined in subsection (r)(1) of this section) in a rural area (as 
defined in section 1395ww(d)(2)(D) of this title) which the nurse 
practitioner or clinical nurse specialist is authorized to perform by 
the State in which the services are performed, and such services and 
supplies furnished as an incident to such services as would be covered 
under subparagraph (A) if furnished as an incident to a physician's 
professional service, and
    ``(iv) such services and supplies furnished as an incident to 
services described in clause (i) or (ii) as would be covered under 
subparagraph (A) if furnished as an incident to a physician's 
professional service;''.
    Subsec. (s)(2)(N) to (P). Pub. L. 105-33, Sec. 4103(a)(1), struck 
out ``and'' at end of subpars. (N) and (O) and added subpar. (P).
    Subsec. (s)(2)(R). Pub. L. 105-33, Sec. 4104(a)(1)(A), added subpar. 
(R).
    Subsec. (s)(2)(S). Pub. L. 105-33, Sec. 4105(a)(1)(A), added subpar. 
(S).
    Subsec. (s)(2)(T). Pub. L. 105-33, Sec. 4557(a), added subpar. (T).
    Subsec. (s)(12)(C). Pub. L. 105-33, Sec. 4106(a)(1)(A), struck out 
``and'' at end.
    Subsec. (s)(14). Pub. L. 105-33, Sec. 4102(c), inserted ``and 
screening pelvic exam'' after ``screening pap smear''.
    Subsec. (s)(15) to (17). Pub. L. 105-33, Sec. 4106(a)(1)(B)-(D), 
added par. (15) and redesignated former pars. (15) and (16) as (16) and 
(17), respectively.
    Subsec. (u). Pub. L. 105-33, Sec. 4201(c)(1), substituted ``critical 
access'' for ``rural primary care''.
    Subsec. (v)(1)(H)(i). Pub. L. 105-33, Sec. 4312(b)(2)(A), 
substituted ``the surety bond requirement described in subsection (o)(7) 
of this section and the financial security requirement described in 
subsection (o)(8) of this section'' for ``the financial security 
requirement described in subsection (o)(7) of this section''.
    Subsec. (v)(1)(H)(ii). Pub. L. 105-33, Sec. 4312(b)(2)(B), 
substituted ``the surety bond requirement described in subsection (o)(7) 
of this section and the financial security requirement described in 
subsection (o)(8) of this section apply'' for ``the financial security 
requirement described in subsection (o)(7) of this section applies''.
    Subsec. (v)(1)(L)(i). Pub. L. 105-33, Sec. 4602(a)(5), struck out 
closing provisions which read as follows: ``of the mean of the labor-
related and nonlabor per visit costs for free standing home health 
agencies.''
    Subsec. (v)(1)(L)(i)(I). Pub. L. 105-33, Sec. 4602(a)(1), (2), 
inserted ``of the mean of the labor-related and nonlabor per visit costs 
for freestanding home health agencies'' before comma at end and 
realigned margins.
    Subsec. (v)(1)(L)(i)(II). Pub. L. 105-33, Sec. 4602(a)(1), (3), 
substituted ``of such mean,'' for ``, or'' at end and realigned margins.
    Subsec. (v)(1)(L)(i)(III). Pub. L. 105-33, Sec. 4602(a)(1), (4), 
inserted ``and before October 1, 1997,'' after ``July 1, 1987,'', 
substituted ``of such mean, or'' for comma at end, and realigned 
margins.
    Subsec. (v)(1)(L)(i)(IV). Pub. L. 105-33, Sec. 4602(a)(5), added 
subcl. (IV).
    Subsec. (v)(1)(L)(iii). Pub. L. 105-33, Sec. 4604(b), substituted 
``service is furnished'' for ``agency is located''.
    Pub. L. 105-33, Sec. 4602(b), inserted ``, or on or after July 1, 
1997, and before October 1, 1997'' after ``July 1, 1996''.
    Subsec. (v)(1)(L)(iv). Pub. L. 105-33, Sec. 4601(a), added cl. (iv).
    Subsec. (v)(1)(L)(v) to (vii). Pub. L. 105-33, Sec. 4602(c), added 
cls. (v) to (vii).
    Subsec. (v)(1)(O)(i). Pub. L. 105-33, Sec. 4404(a)(1), struck out 
``and (if applicable) a return on equity capital'' after ``capital 
indebtedness'' and substituted ``provider of services'' for ``hospital 
or skilled nursing facility'', ``clause (iii)'' for ``clause (iv)'', and 
``the historical cost of the asset, as recognized under this subchapter, 
less depreciation allowed, to the owner of record as of August 5, 1997 
(or, in the case of an asset not in existence as of August 5, 1997, the 
first owner of record of the asset after August 5, 1997).'' for ``the 
lesser of the allowable acquisition cost of such asset to the owner of 
record as of July 18, 1984 (or, in the case of an asset not in existence 
as of such date, the first owner of record of the asset after such 
date), or the acquisition cost of such asset to the new owner.''
    Subsec. (v)(1)(O)(ii) to (iv). Pub. L. 105-33, Sec. 4404(a)(2), (3), 
redesignated cls. (iii) and (iv) as (ii) and (iii), respectively, and 
struck out former cl. (ii) which read as follows: ``Such regulations 
shall provide for recapture of depreciation in the same manner as 
provided under the regulations in effect on June 1, 1984.''
    Subsec. (v)(1)(S)(ii)(I), (II). Pub. L. 105-33, Sec. 4522, 
substituted ``through 1999 and during fiscal year 2000 before January 1, 
2000'' for ``through 1998''.
    Subsec. (v)(1)(S)(ii)(III). Pub. L. 105-33, Sec. 4201(c)(1), 
substituted ``critical access'' for ``rural primary care''.
    Subsec. (v)(1)(T). Pub. L. 105-33, Sec. 4451, added subpar. (T).
    Subsec. (v)(1)(U). Pub. L. 105-33, Sec. 4531(a)(1), added subpar. 
(U).
    Subsec. (v)(7)(D). Pub. L. 105-33, Sec. 4432(b)(5)(E), inserted 
``subsections (a) through (c) of'' before ``section 1395yy of this 
title''.
    Subsec. (v)(8). Pub. L. 105-33, Sec. 4320, added par. (8).
    Subsec. (w). Pub. L. 105-33, Sec. 4201(c)(1), substituted ``critical 
access'' for ``rural primary care'' wherever appearing.
    Subsec. (y). Pub. L. 105-33, Sec. 4454(a)(1)(B)(i), substituted 
``Extended care in religious nonmedical health care institutions'' for 
``Post-hospital extended care in Christian Science skilled nursing 
facilities'' in heading.
    Subsec. (y)(1). Pub. L. 105-33, Sec. 4454(a)(1)(B)(iii), which 
directed the amendment of this subsec. by inserting ``consistent with 
section 1395i-5 of this title'' before the period, was executed by 
making the insertion in par. (1) to reflect the probable intent of 
Congress.
    Pub. L. 105-33, Sec. 4454(a)(1)(B)(ii), substituted ``includes a 
religious nonmedical health care institution (as defined in subsection 
(ss)(1) of this section),'' for ``includes a Christian Science 
sanatorium operated, or listed and certified, by the First Church of 
Christ, Scientist, Boston, Massachusetts,''.
    Subsec. (aa)(2). Pub. L. 105-33, Sec. 4205(d)(3)(A), in second 
sentence of concluding provisions inserted before period at end ``if it 
is determined, in accordance with criteria established by the Secretary 
in regulations, to be essential to the delivery of primary care services 
that would otherwise be unavailable in the geographic area served by the 
clinic''.
    Pub. L. 105-33, Sec. 4205(d)(1), (2), in cl. (i) of first sentence 
of concluding provisions substituted ``Bureau of the Census) and in 
which there are insufficient numbers of needed health care practitioners 
(as determined by the Secretary), and that, within the previous 3-year 
period, has been designated'' for ``Bureau of the Census) and that is 
designated'' and ``personal health services or designated by the 
Secretary'' for ``personal health services, or that is designated by the 
Secretary''.
    Subsec. (aa)(2)(I). Pub. L. 105-33, Sec. 4205(b)(1), amended subpar. 
(I) generally. Prior to amendment, subpar. (I) read as follows: ``has 
appropriate procedures for review of utilization of clinic services to 
the extent that the Secretary determines to be necessary and 
feasible;''.
    Subsec. (aa)(5). Pub. L. 105-33, Sec. 4511(d), designated existing 
provisions as subpar. (A), substituted ``The term `physician assistant' 
and the term `nurse practitioner' mean, for purposes of this subchapter, 
a physician assistant or nurse practitioner who performs'' for ``The 
term `physician assistant', the term `nurse practitioner', and the term 
`clinical nurse specialist' mean, for purposes of this subchapter, a 
physician assistant, nurse practitioner, or clinical nurse specialist 
who performs'', and added subpar. (B).
    Subsec. (aa)(7)(B). Pub. L. 105-33, Sec. 4205(c)(1), inserted before 
period at end ``, or if the facility has not yet been determined to meet 
the requirements (including subparagraph (J) of the first sentence of 
paragraph (2)) of a rural health clinic''.
    Subsec. (cc)(2). Pub. L. 105-33, Sec. 4312(d)(4), inserted 
concluding provisions.
    Subsec. (cc)(2)(I), (J). Pub. L. 105-33, Sec. 4312(d)(1)-(3), added 
subpar. (I) and redesignated former subpar. (I) as (J).
    Subsec. (dd)(1)(I). Pub. L. 105-33, Sec. 4444(a), added subpar. (I).
    Subsec. (dd)(2)(A)(ii)(I). Pub. L. 105-33, Sec. 4445(1), substituted 
``subparagraphs (A), (C), and (H)'' for ``subparagraphs (A), (C), (F), 
and (H)''.
    Subsec. (dd)(2)(B)(i). Pub. L. 105-33, Sec. 4445(2), in concluding 
provisions, inserted ``or, in the case of a physician described in 
subclause (I), under contract with'' after ``employed by''.
    Subsec. (dd)(5)(B). Pub. L. 105-33, Sec. 4446(1), inserted ``or 
(C)'' after ``subparagraph (A)'' in two places.
    Subsec. (dd)(5)(C). Pub. L. 105-33, Sec. 4446(2), added subpar. (C).
    Subsec. (ee)(2)(D). Pub. L. 105-33, Sec. 4321(a)(1), inserted before 
period at end ``, including the availability of home health services 
through individuals and entities that participate in the program under 
this subchapter and that serve the area in which the patient resides and 
that request to be listed by the hospital as available''.
    Subsec. (ee)(2)(H). Pub. L. 105-33, Sec. 4321(a)(2), added subpar. 
(H).
    Subsec. (mm). Pub. L. 105-33, Sec. 4201(c)(2), amended heading and 
text of subsec. (mm) generally. Prior to amendment, text read as 
follows:
    ``(1) The term `rural primary care hospital' means a facility 
designated by the Secretary as a rural primary care hospital under 
section 1395i-4(i)(2) of this title.
    ``(2) The term `inpatient rural primary care hospital services' 
means items and services, furnished to an inpatient of a rural primary 
care hospital by such a hospital, that would be inpatient hospital 
services if furnished to an inpatient of a hospital by a hospital.
    ``(3) The term `outpatient rural primary care hospital services' 
means medical and other health services furnished by a rural primary 
care hospital.''
    Subsec. (nn). Pub. L. 105-33, Sec. 4102(a), substituted ``Screening 
pap smear; screening pelvic exam'' for ``Screening pap smear'' in 
heading, designated existing provisions as par. (1), inserted ``or 
vaginal'' after ``cervical'' in two places, substituted ``3 years, or 
during the preceding year in the case of a woman described in paragraph 
(3).'' for ``3 years (or such shorter period as the Secretary may 
specify in the case of a woman who is at high risk of developing 
cervical or vaginal cancer (as determined pursuant to factors identified 
by the Secretary)).'', and added pars. (2) and (3).
    Subsec. (oo). Pub. L. 105-33, Sec. 4103(a)(2), added subsec. (oo).
    Subsec. (pp). Pub. L. 105-33, Sec. 4104(a)(1)(B), added subsec. 
(pp).
    Subsec. (qq). Pub. L. 105-33, Sec. 4105(a)(1)(B), added subsec. 
(qq).
    Subsec. (rr). Pub. L. 105-33, Sec. 4106(a)(2), added subsec. (rr).
    Subsec. (ss). Pub. L. 105-33, Sec. 4454(a)(1)(C), added subsec. 
(ss).
    Subsec. (tt). Pub. L. 105-33, Sec. 4611(b), added subsec. (tt).
    1996--Subsec. (aa)(4)(A)(i). Pub. L. 104-299 substituted ``section 
330 (other than subsection (h))'' for ``section 329, 330, or 340''.
    Subsec. (aa)(4)(A)(ii)(II). Pub. L. 104-299 which directed amendment 
of subcl. (I) by substituting ``section 330 (other than subsection 
(h))'' for ``section 329, 330, or 340'', was executed to subcl. (II) to 
reflect the probable intent of Congress.
    1994--Subsec. (a)(1). Pub. L. 103-432, Sec. 102(g)(4)(A), 
substituted ``inpatient hospital services, inpatient rural primary care 
hospital services'' for ``inpatient hospital services''.
    Subsec. (a)(2). Pub. L. 103-432, Sec. 102(g)(4)(B), substituted 
``hospital or rural primary care hospital'' for ``hospital''.
    Subsec. (b)(3). Pub. L. 103-432, Sec. 147(f)(3), made technical 
amendment to Pub. L. 101-508, Sec. 4157(a). See 1990 Amendment note 
below.
    Subsec. (b)(4). Pub. L. 103-432, Sec. 147(f)(3), made technical 
amendment to Pub. L. 101-508, Sec. 4157(a). See 1990 Amendment note 
below.
    Pub. L. 103-432, Sec. 147(e)(4), substituted ``clauses (i) or (iii) 
of subsection (s)(2)(K) of this section'' for ``subsection (s)(2)(K)(i) 
of this section''.
    Subsec. (e)(4). Pub. L. 103-432, Sec. 104, substituted ``physician, 
except that a patient receiving qualified psychologist services (as 
defined in subsection (ii) of this section) may be under the care of a 
clinical psychologist with respect to such services to the extent 
permitted under State law;'' for ``physician;''.
    Subsec. (h)(3). Pub. L. 103-432, Sec. 146(b)(1), substituted ``or 
occupational therapy or speech-language pathology services'' for ``, 
occupational, or speech therapy''.
    Subsec. (m)(2). Pub. L. 103-432, Sec. 146(b)(2), substituted ``or 
occupational therapy or speech-language pathology services'' for ``, 
occupational, or speech therapy''.
    Subsec. (m)(5). Pub. L. 103-432, Sec. 147(f)(6)(B)(ii), substituted 
``and a covered osteoporosis drug (as defined in subsection (kk) of this 
section), but excluding other drugs'' for ``but excluding drugs''.
    Subsec. (p). Pub. L. 103-432, Sec. 146(b)(3), substituted ``speech-
language pathology services'' for ``speech pathology services'' after 
``term `outpatient physical therapy services' also includes'' in third 
sentence of closing provisions.
    Subsec. (s)(2)(K)(iii). Pub. L. 103-432, Sec. 147(e)(1), made an 
amendment identical to that made by Pub. L. 101-508, Sec. 4161(a)(5)(A), 
substituting ``subsection (aa)(5)'' for ``subsection (aa)(3)'' and 
``subsection (aa)(6)'' for ``subsection (aa)(4)''.
    Subsec. (s)(2)(N). Pub. L. 103-432, Sec. 147(f)(6)(B)(iii)(I), 
inserted ``and'' at end.
    Subsec. (s)(2)(O), (P). Pub. L. 103-432, Sec. 147(f)(6)(B)(iii)(II), 
redesignated subpar. (P) as (O) and struck out former subpar. (O) which 
read as follows: ``a covered osteoporosis drug and its administration 
(as defined in subsection (jj) of this section) furnished on or after 
January 1, 1991, and on or before December 31, 1995; and''.
    Subsec. (s)(3). Pub. L. 103-432, Sec. 145(b), inserted ``and 
including diagnostic mammography if conducted by a facility that has a 
certificate (or provisional certificate) issued under section 354 of the 
Public Health Service Act'' after ``necessary''.
    Subsec. (v)(1)(L)(iii). Pub. L. 103-432, Sec. 158(a)(1), substituted 
``and determined using the survey of the most recent available wages and 
wage-related costs of hospitals'' for ``as of such date to hospitals''.
    Subsec. (aa)(2). Pub. L. 103-432, Sec. 147(f)(4)(A), in last 
sentence of closing provisions, substituted ``approval as such a 
clinic'' for ``certification as such a clinic'' and ``Secretary's 
approval or disapproval'' for ``the Secretary's approval or disapproval 
of the certification''.
    Subsec. (aa)(5). Pub. L. 103-432, Sec. 147(e)(5), substituted ``this 
subchapter'' for ``this chapter''.
    Subsec. (cc)(1)(B). Pub. L. 103-432, Sec. 146(b)(4), substituted 
``speech-language pathology services'' for ``speech pathology 
services''.
    Subsec. (dd)(1)(B). Pub. L. 103-432, Sec. 146(b)(5), substituted 
``therapy, or speech-language pathology services'' for ``therapy or 
speech-language pathology''.
    Subsec. (ee)(2)(D). Pub. L. 103-432, Sec. 107(a), inserted ``, 
including hospice services,'' after ``post-hospital services''.
    Subsec. (jj). Pub. L. 103-432, Sec. 147(f)(6)(E), redesignated 
subsec. (jj), defining ``covered osteoporosis drug'', as (kk).
    Pub. L. 103-432, Sec. 147(f)(6)(A), (B)(i), amended subsec. (jj), 
defining ``covered osteoporosis drug'', in introductory provisions, by 
striking out ``a bone fracture related to'' before ``post-menopausal 
osteoporosis'' and substituting ``individual by a home health agency 
if'' for ``individual if'', and in par. (1), by substituting 
``individual has suffered a bone fracture related to post-menopausal 
osteoporosis and that the individual'' for ``patient''.
    Subsec. (kk). Pub. L. 103-432, Sec. 147(f)(6)(E), redesignated 
subsec. (jj), defining ``covered osteoporosis drug'', as (kk).
    Subsec. (ll). Pub. L. 103-432, Sec. 146(a), added subsec. (ll).
    1993--Subsec. (s)(2)(J). Pub. L. 103-66, Sec. 13565, substituted 
``subchapter, but only in the case of drugs furnished--'' and cls. (i) 
to (v) for ``subchapter, within 1 year after the date of the transplant 
procedure;''.
    Subsec. (s)(2)(P). Pub. L. 103-66, Sec. 13566(b), substituted 
``dialysis'' for ``home dialysis'' and realigned margin.
    Subsec. (s)(2)(Q). Pub. L. 103-66, Sec. 13553(a), added subpar. (Q).
    Subsec. (t). Pub. L. 103-66, Sec. 13553(b), designated existing 
provisions as par. (1), inserted ``and paragraph (2)'', and added par. 
(2).
    Subsec. (v)(1)(B). Pub. L. 103-66, Sec. 13503(c)(1), amended subpar. 
(B) generally. Prior to amendment, subpar. (B) read as follows: ``Such 
regulations in the case of extended care services furnished by 
proprietary facilities shall include provision for specific recognition 
of a reasonable return on equity capital, including necessary working 
capital, invested in the facility and used in the furnishing of such 
services, in lieu of other allowances to the extent that they reflect 
similar items. The rate of return recognized pursuant to the preceding 
sentence for determining the reasonable cost of any services furnished 
in any cost reporting period shall be equal to the average of the rates 
of interest, for each of the months any part of which is included in the 
period, on obligations issued for purchase by the Federal Hospital 
Insurance Trust Fund.''
    Subsec. (v)(1)(L)(ii). Pub. L. 103-66, Sec. 13564(b)(1), struck out 
``, with appropriate adjustment for administrative and general costs of 
hospital-based agencies'' after ``discipline specific basis''.
    Subsec. (v)(1)(L)(iii). Pub. L. 103-66, Sec. 13564(a)(2), 
substituted ``thereafter (but not for cost reporting periods beginning 
on or after July 1, 1994, and before July 1, 1996)'' for ``thereafter''.
    Subsec. (v)(1)(S)(ii)(I). Pub. L. 103-66, Sec. 13521, substituted 
``fiscal years 1992 through 1998'' for ``fiscal year 1992, 1993, 1994, 
or 1995''.
    Subsec. (v)(1)(S)(ii)(II). Pub. L. 103-66, Sec. 13522, substituted 
``fiscal years 1991 through 1998'' for ``fiscal years 1991, 1992, 1993, 
1994, or 1995''.
    Subsec. (aa)(4)(D). Pub. L. 103-66, Sec. 13556(a), added subpar. 
(D).
    Subsec. (gg)(2). Pub. L. 103-66, Sec. 13554(a), substituted a period 
for ``, and performs services in the area of management of the care of 
mothers and babies throughout the maternity cycle.''
    1990--Subsec. (b)(3). Pub. L. 101-508, Sec. 4157(a)(1), as amended 
by Pub. L. 103-432, Sec. 147(f)(3), struck out ``(including clinical 
psychologist (as defined by the Secretary))'' after ``the hospital or by 
others''.
    Subsec. (b)(4). Pub. L. 101-508, Sec. 4157(a)(2), as amended by Pub. 
L. 103-432, Sec. 147(f)(3), substituted ``, services described by 
subsection (s)(2)(K)(i) of this section, certified nurse-midwife 
services, qualified psychologist services, and services of a certified 
registered nurse anesthetist; and'' for ``and anesthesia services 
provided by a certified registered nurse anesthetist; and''.
    Subsec. (n). Pub. L. 101-508, Sec. 4152(a)(2), inserted at end 
``With respect to a seat-lift chair, such term includes only the seat-
lift mechanism and does not include the chair.''
    Subsec. (s)(2)(E). Pub. L. 101-508, Sec. 4161(a)(1), inserted ``and 
Federally qualified health center services'' after ``clinic services''.
    Subsec. (s)(2)(H)(i). Pub. L. 101-508, Sec. 4161(a)(5)(A), 
substituted ``subsection (aa)(5)'' for ``subsection (aa)(3)''.
    Subsec. (s)(2)(K)(i). Pub. L. 101-597 substituted ``health 
professional shortage area'' for ``health manpower shortage area''.
    Pub. L. 101-508, Sec. 4161(a)(5)(A), substituted ``subsection 
(aa)(5)'' for ``subsection (aa)(3)''.
    Subsec. (s)(2)(K)(ii). Pub. L. 101-508, Sec. 4161(a)(5)(A), 
substituted ``subsection (aa)(5)'' for ``subsection (aa)(3)'' and 
``subsection (aa)(6)'' for ``subsection (aa)(4)''.
    Subsec. (s)(2)(K)(iii). Pub. L. 101-508, Sec. 4161(a)(5)(A), 
substituted ``subsection (aa)(5)'' for ``subsection (aa)(3)'' and 
``subsection (aa)(6)'' for ``subsection (aa)(4)''.
    Pub. L. 101-508, Sec. 4155(a)(3), added cl. (iii). Former cl. (iii) 
redesignated (iv).
    Subsec. (s)(2)(K)(iv). Pub. L. 101-508, Sec. 4155(a)(2), 
redesignated cl. (iii) as (iv).
    Subsec. (s)(2)(O). Pub. L. 101-508, Sec. 4156(a)(1), added subpar. 
(O).
    Subsec. (s)(2)(P). Pub. L. 101-508, Sec. 4201(d)(1), added subpar. 
(P).
    Subsec. (s)(8). Pub. L. 101-508, Sec. 4153(b)(2)(A), inserted ``, 
and including one pair of conventional eyeglasses or contact lenses 
furnished subsequent to each cataract surgery with insertion of an 
intraocular lens'' after ``such devices''.
    Subsec. (s)(13). Pub. L. 101-508, Sec. 4163(a)(1), added par. (13).
    Subsec. (v)(1)(E). Pub. L. 101-508, Sec. 4008(h)(2)(A)(i), 
substituted ``the costs (including the costs of services required to 
attain or maintain the highest practicable physical, mental, and 
psychosocial well-being of each resident eligible for benefits under 
this subchapter) of such facilities'' for ``the costs of such 
facilities'' in second sentence.
    Subsec. (v)(1)(L)(iii). Pub. L. 101-508, Sec. 4207(d)(1), formerly 
Sec. 4027(d)(1), as renumbered by Pub. L. 103-432, Sec. 160(d)(4), 
amended cl. (iii) generally. Prior to amendment, cl. (iii) read as 
follows: ``In establishing limits under this subparagraph, the Secretary 
shall--
        ``(I) utilize a wage index that is based on verified wage data 
    obtained from home health agencies, and
        ``(II) base such limits on the most recent verified wage data 
    available, which data may be for cost reporting periods beginning no 
    earlier than July 1, 1985.
In the case of a home health agency that refuses to provide data, or 
deliberately provides false data, respecting wages for purposes of this 
clause upon the request of the Secretary, the Secretary may withhold up 
to 5 percent of the amount of the payments otherwise payable to the 
agency under this subchapter until such date as the Secretary determines 
that such data has been satisfactorily provided.''
    Subsec. (v)(1)(S)(ii)(I). Pub. L. 101-508, Sec. 4151(a)(1), inserted 
before period at end ``, by 15 percent for payments attributable to 
portions of cost reporting periods occurring during fiscal year 1991, 
and by 10 percent for payments attributable to portions of cost 
reporting periods occurring during fiscal year 1992, 1993, 1994, or 
1995''.
    Subsec. (v)(1)(S)(ii)(II). Pub. L. 101-508, Sec. 4151(b)(1)(D), 
added subcl. (II). Former subcl. (II) redesignated (III).
    Pub. L. 101-508, Sec. 4151(b)(1)(A), substituted ``Subclauses (I) 
and (II)'' for ``Subclause (I)'' and ``costs of hospital outpatient 
services provided by any hospital'' for ``capital-related costs of any 
hospital''.
    Pub. L. 101-508, Sec. 4151(a)(2), substituted ``section 
1395ww(d)(5)(D)(iii) of this title or a rural primary care hospital (as 
defined in subsection (mm)(1) of this section)'' for ``section 
1395ww(d)(5)(D)(iii) of this title)''.
    Subsec. (v)(1)(S)(ii)(III). Pub. L. 101-508, Sec. 4151(b)(1)(C), 
redesignated former subcl. (II) as (III). Former subcl. (III) 
redesignated (IV).
    Pub. L. 101-508, Sec. 4151(b)(1)(B), substituted ``subclauses (I) 
and (II)'' for ``subclause (I)'' and ``the costs reflected'' for 
``capital-related costs reflected''.
    Subsec. (v)(1)(S)(ii)(IV). Pub. L. 101-508, Sec. 4151(b)(1)(C), 
redesignated subcl. (III) as (IV).
    Subsec. (aa). Pub. L. 101-508, Sec. 4161(a)(2)(A), inserted ``and 
Federally qualified health center services'' after ``clinic services'' 
in heading.
    Subsec. (aa)(1)(B). Pub. L. 101-508, Sec. 4161(a)(5)(B), substituted 
``paragraph (5)'' for ``paragraph (3)''.
    Subsec. (aa)(2). Pub. L. 101-597 substituted ``health professional 
shortage area'' for ``health manpower shortage area'' in second 
sentence.
    Pub. L. 101-508, Sec. 4161(b)(1), inserted at end ``If a State 
agency has determined under section 1395aa(a) of this title that a 
facility is a rural health clinic and the facility has applied to the 
Secretary for certification as such a clinic, the Secretary shall notify 
the facility of the the Secretary's approval or disapproval of the 
certification not later than 60 days after the date of the State agency 
determination or the application (whichever is later).''
    Subsec. (aa)(3). Pub. L. 101-508, Sec. 4161(a)(2)(C), added par. 
(3). Former par. (3) redesignated (5).
    Pub. L. 101-508, Sec. 4161(a)(2)(B), which directed amendment of 
par. (3) by substituting ``the previous provisions of this subsection'' 
for ``paragraphs (1) and (2)'', could not be executed because the words 
``paragraphs (1) and (2)'' did not appear after amendment by Pub. L. 
101-508, Sec. 4155(d). See below.
    Pub. L. 101-508, Sec. 4155(d), substituted ``The term `physician 
assistant', the term `nurse practitioner', and the term `clinical nurse 
specialist' mean, for purposes of this chapter, a physician assistant, 
nurse practitioner, or clinical nurse specialist who performs'' for 
``The term `physician assistant' and the term `nurse practitioner' mean, 
for the purposes of paragraphs (1) and (2), a physician assistant or 
nurse practitioner who performs''.
    Subsec. (aa)(4) to (6). Pub. L. 101-508, Sec. 4161(a)(2)(B), (C), 
added par. (4) and redesignated former pars. (3) and (4) as (5) and (6), 
respectively.
    Subsec. (aa)(7). Pub. L. 101-508, Sec. 4161(b)(2), added par. (7).
    Subsec. (ff)(3). Pub. L. 101-508, Sec. 4162(a), designated existing 
provision as subpar. (A), substituted ``outpatients or by a community 
mental health center (as defined in subparagraph (B)),'' for 
``outpatients'', and added subpar. (B).
    Subsec. (jj). Pub. L. 101-508, Sec. 4163(a)(2), added subsec. (jj) 
defining ``screening mammography''.
    Pub. L. 101-508, Sec. 4156(a)(2), added subsec. (jj) defining 
``covered osteoporosis drug''.
    1989--Subsec. (a). Pub. L. 101-234, Sec. 101(a), repealed Pub. L. 
100-360, Sec. 104(d)(4)(A), 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. (e). Pub. L. 101-239, Sec. 6003(g)(3)(D)(x)(I), inserted at 
end ``The term `hospital' does not include, unless the context otherwise 
requires, a rural primary care hospital (as defined in subsection 
(mm)(1) of this section).''
    Pub. L. 101-234, Sec. 101(a), repealed Pub. L. 100-360, 
Sec. 104(d)(4)(B), 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. (i). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 104(d)(4)(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. (m). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 206(a), 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. (m)(5). Pub. L. 101-239, Sec. 6112(e)(1), amended par. (5) 
generally. Prior to amendment, par. (5) read as follows: ``medical 
supplies (other than drugs and biologicals) and durable medical 
equipment, while under such a plan;''.
    Subsec. (s). Pub. L. 101-239, Sec. 6141(a)(1), substituted ``, 
including a laboratory that is part of'' for ``which is independent of a 
physician's office, a laboratory not independent of a physician's office 
that has a volume of clinical diagnostic laboratory tests exceeding 
5,000 per year,'' in provisions following par. (14).
    Subsec. (s)(2)(H)(ii). Pub. L. 101-239, Sec. 6113(b)(2)(A), 
substituted ``subsection (hh)(2)'' for ``subsection (hh)''.
    Subsec. (s)(2)(J). Pub. L. 101-239, Sec. 6114(a)(1), struck out 
``and'' at end.
    Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 202(a)(1), and provided that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, see 1988 Amendment note below.
    Subsec. (s)(2)(K). Pub. L. 101-239, Sec. 6114(a)(2), added cl. (ii), 
redesignated former cl. (ii) as (iii), and substituted ``to services 
described in clause (i) or (ii)'' for ``to such services'' in cl. (iii).
    Subsec. (s)(2)(N). Pub. L. 101-239, Sec. 6113(b)(1), added subpar. 
(N).
    Subsec. (s)(12). Pub. L. 101-239, Sec. 6131(a)(2), inserted ``with 
inserts'' after ``custom molded shoes'' in introductory provisions.
    Subsec. (s)(13). Pub. L. 101-234, Sec. 201(a), which repealed Pub. 
L. 100-360, Sec. 204(a)(1)(B)-(D), and directed that the provisions of 
law amended or repealed by such section are restored or revived as if 
such section had not been enacted, was executed by striking out par. 
(13) as added by Pub. L. 100-360, Sec. 204(a)(1)(B)-(D), but former par. 
(13) which was redesignated (14) was not restored in view of intervening 
redesignation as (15) by Pub. L. 101-239, Sec. 6115(a)(1)(C), see 1988 
Amendment note below.
    Subsec. (s)(14). Pub. L. 101-239, Sec. 6115(a)(1)(A), (B), (D), 
added par. (14). Former par. (14) redesignated (15).
    Pub. L. 101-234, Sec. 201(a), which repealed Pub. L. 100-360, 
Sec. 204(a)(1)(A), and directed that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, was not executed in view of intervening redesignation 
of par. (14) as (15) by Pub. L. 101-239, Sec. 6115(a)(1)(C), see 1988 
Amendment note below.
    Subsec. (s)(15). Pub. L. 101-239, Sec. 6115(a)(1)(C), redesignated 
par. (14) as (15). Former par. (15) redesignated (16).
    Pub. L. 101-234, Sec. 201(a), which repealed Pub. L. 100-360, 
Sec. 204(a)(1)(A), and directed that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, was not executed in view of intervening redesignation 
of par. (15) as (16) by Pub. L. 101-239, Sec. 6115(a)(1)(C), see 1988 
Amendment note below.
    Subsec. (s)(16). Pub. L. 101-239, Sec. 6141(a)(2), (3), added 
subpar. (A) and designated existing provisions as subpar. (B).
    Pub. L. 101-239, Sec. 6115(a)(1)(C), redesignated par. (15) as (16).
    Subsec. (t). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 202(a)(2), 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. (u). Pub. L. 101-239, Sec. 6003(g)(3)(C)(i), inserted 
``rural primary care hospital,'' after ``hospital,''.
    Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, 
Sec. 203(e)(1), and provided that the provisions of law amended or 
repealed by such section are restored or revived as if such section had 
not been enacted, see 1988 Amendment note below.
    Subsec. (v)(1)(G)(i). Pub. L. 101-234, Sec. 101(a), repealed Pub. L. 
100-360, Sec. 104(d)(4)(D), 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. (v)(1)(S). Pub. L. 101-239, Sec. 6110, designated existing 
provisions as cl. (i) and added cl. (ii).
    Subsec. (v)(2)(A), (3). Pub. L. 101-234, Sec. 101(a), repealed Pub. 
L. 100-360, Sec. 104(d)(4)(D), 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. (w)(1). Pub. L. 101-239, Sec. 6003(g)(3)(D) (x)(II), 
inserted ``rural primary care hospital,'' after ``hospital,''.
    Subsec. (w)(2). Pub. L. 101-239, Sec. 6003(g)(3)(D) (x)(III), 
substituted ``hospital or rural primary care hospital'' for ``hospital'' 
in six places.
    Subsec. (y). Pub. L. 101-234, Sec. 101(a), repealed Pub. L. 100-360, 
Sec. 104(d)(4)(E), 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. (aa)(1)(B). Pub. L. 101-239, Sec. 6213(b), substituted ``(as 
defined in paragraph (3)), by'' for ``(as defined in paragraph (3)), or 
by'' and inserted ``or by a clinical social worker (as defined in 
subsection (hh)(1) of this section),'' after ``Secretary)''.
    Subsec. (aa)(2). Pub. L. 101-239, Sec. 6213(c), in second sentence 
substituted ``designated by the chief executive officer of the State and 
certified by the Secretary as an area with a shortage of personal health 
services, or that is designated by the Secretary'' for ``designated by 
the Secretary'', ``section 330(b)(3) or 1302(7) of the Public Health 
Service Act,'' for ``section 1302(7) of the Public Health Service Act 
or'', and ``medical care manpower, (III) as a high impact area described 
in section 329(a)(5) of that Act, or (IV) as an area which includes a 
population group which the Secretary determines has a health manpower 
shortage under section 332(a)(1)(B) of that Act,'' for ``medical care 
manpower,''.
    Subsec. (aa)(2)(J), (K). Pub. L. 101-239, Sec. 6213(a), added 
subpar. (J) and redesignated former subpar. (J) as (K).
    Subsec. (aa)(4). Pub. L. 101-239, Sec. 6114(d), added par. (4).
    Subsec. (hh). Pub. L. 101-239, Sec. 6113(b)(2)(B), inserted ``; 
clinical social worker services'' after ``social worker'' in heading, 
redesignated existing provisions as par. (1), redesignated former pars. 
(1) to (3) as subpars. (A) to (C), respectively, in subpar. (C), 
redesignated former subpars. (A) and (B) as cls. (i) and (ii), 
respectively, in cl. (ii), redesignated former cls. (i) and (ii) as 
subcls. (I) and (II), respectively, and added par. (2).
    Subsec. (ii). Pub. L. 101-239, Sec. 6113(a), struck out ``on-site at 
a community mental health center (as such term is used in the Public 
Health Service Act), and such services that are necessarily furnished 
off-site (other than at an off-site office of such psychologist) as part 
of a treatment plan because of the inability of the individual furnished 
such services to travel to the center by reason of physical or mental 
impairment, because of institutionalization, or because of similar 
circumstances of the individual,'' after ``as defined by the 
Secretary)''.
    Subsecs. (jj) to (ll). Pub. L. 101-234, Sec. 201(a), repealed Pub. 
L. 100-360, Secs. 203(b), 204(a)(2), 205(b), 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. (mm). Pub. L. 101-239, Sec. 6003(g)(3)(A), added subsec. 
(mm).
    Subsec. (mm)(3). Pub. L. 101-239, Sec. 6116(a)(1), added par. (3).
    Subsec. (nn). Pub. L. 101-239, Sec. 6115(a)(2), added subsec. (nn).
    1988--Subsec. (a). Pub. L. 100-360, Sec. 104(d)(4)(A), struck out 
subsec. (a) which defined ``spell of illness''.
    Subsec. (a)(2). Pub. L. 100-360, Sec. 411(l)(1)(B)(i), (ii), 
redesignated and amended Pub. L. 100-203, Sec. 4201(d)(1), see 1987 
Amendment note below.
    Subsec. (e). Pub. L. 100-360, Sec. 104(d)(4)(B), substituted ``and 
paragraph (7) of this subsection'' for ``paragraph (7) of this 
subsection, and subsection (i) of this section'' in introductory 
provisions, struck out second sentence which read as follows: ``For 
purposes of subsection (a)(2) of this section, such term includes any 
institution which meets the requirements of paragraph (1) of this 
subsection.'', substituted ``and section 1395f(f)(2) of this title'' for 
``section 1395f(f)(2) of this title, and subsection (i) of this 
section'' in third sentence, and struck out ``, except for purposes of 
subsection (a)(2) of this section,'' after ``such term shall not'' in 
fifth sentence.
    Subsec. (i). Pub. L. 100-360, Sec. 104(d)(4)(C), struck out subsec. 
(i) which defined ``post-hospital extended care services''.
    Subsec. (m). Pub. L. 100-360, Sec. 206(a), inserted at end ``For 
purposes of paragraphs (1) and (4) and sections 1395f(a)(2)(C) and 
1395n(a)(2)(A) of this title, nursing care and home health aide services 
shall be considered to be provided or needed on an `intermittent' basis 
if they are provided or needed less than 7 days each week and, in the 
case they are provided or needed for 7 days each week, if they are 
provided or needed for a period of up to 38 consecutive days.''
    Subsec. (n). Pub. L. 100-360, Sec. 411(l)(1)(C), as added by Pub. L. 
100-485, Sec. 608(d)(27)(B), added Pub. L. 100-203, Sec. 4201(d)(5), see 
1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(l)(1)(B)(iii), added Pub. L. 100-203, 
Sec. 4201(d)(2), see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 411(d)(1)(B)(i), inserted ``; except that such 
term does not include such equipment furnished by a supplier who has 
used, for the demonstration and use of specific equipment, an individual 
who has not met such minimum training standards as the Secretary may 
establish with respect to the demonstration and use of such specific 
equipment'' before period at end.
    Subsec. (p). Pub. L. 100-647, Sec. 8424(a), inserted at end 
``Nothing in this subsection shall be construed as requiring, with 
respect to outpatients who are not entitled to benefits under this 
subchapter, a physical therapist to provide outpatient physical therapy 
services only to outpatients who are under the care of a physician or 
pursuant to a plan of care established by a physician.''
    Subsec. (s). Pub. L. 100-360, Sec. 411(g)(3)(H), inserted a comma 
before ``year'' in provisions immediately preceding par. (13).
    Subsec. (s)(2)(H)(ii). Pub. L. 100-360, Sec. 411(h)(5)(A), amended 
Pub. L. 100-203, Sec. 4074(a), see 1987 Amendment note below.
    Subsec. (s)(2)(J). Pub. L. 100-360, Sec. 202(a)(1), amended subpar. 
(J) generally, substituting ``covered outpatient drugs (as defined in 
subsection (t) of this section); and'' for former provision which 
related to prescription drugs used in immunosuppressive therapy.
    Subsec. (s)(2)(K)(i). Pub. L. 100-360, Sec. 411(h)(6), amended Pub. 
L. 100-203, Sec. 4076(a), see 1987 Amendment note below.
    Subsec. (s)(2)(K)(i)(I). Pub. L. 100-485, Sec. 608(d)(23)(B), 
substituted ``nursing facility (as defined in section 1396r(a) of this 
title)'' for ``intermediate care facility (as defined in section 
1396d(c) of this title)''.
    Subsec. (s)(2)(M). Pub. L. 100-360, Sec. 411(h)(7)(A), made 
technical amendment to directory language of Pub. L. 100-203, 
Sec. 4077(b)(1), see 1987 Amendment note below.
    Subsec. (s)(10)(A). Pub. L. 100-360, Sec. 411(h)(2), inserted ``, 
subject to section 4071(b) of the Omnibus Budget Reconciliation Act of 
1987,'' before ``influenza vaccine''.
    Subsec. (s)(12). Pub. L. 100-360, Sec. 411(h)(3)(A), inserted 
``subject to section 4072(e) of the Omnibus Budget Reconciliation Act of 
1987,'' in introductory provisions.
    Subsec. (s)(13). Pub. L. 100-360, Sec. 204(a)(1)(B)-(D), added par. 
(13) relating to screening mammography (as defined in subsection (kk) of 
this section). Former par. (13) redesignated (14).
    Subsec. (s)(14). Pub. L. 100-360, Sec. 204(a)(1)(A), redesignated 
par. (13) as (14). Former par. (14) redesignated (15).
    Subsec. (s)(15). Pub. L. 100-360, Sec. 411(i)(4)(C)(iii), amended 
directory language of Pub. L. 100-203, Sec. 4085(i)(11), to correct an 
error, see 1987 Amendment note below.
    Pub. L. 100-360, Sec. 204(a)(1)(A), redesignated par. (14) as (15).
    Subsec. (s)(16). Pub. L. 100-360, Sec. 411(i)(4)(C)(iii), amended 
directory language of Pub. L. 100-203, Sec. 4085(i)(11), to correct an 
error, see 1987 Amendment note below.
    Subsec. (t). Pub. L. 100-360, Sec. 202(a)(2), designated existing 
provisions as par. (1), inserted ``and paragraph (2)'', and added pars. 
(2) to (4) defining ``covered outpatient drug'' and ``covered home IV 
drug''.
    Subsec. (u). Pub. L. 100-360, Sec. 203(e)(1), inserted ``home 
intravenous drug therapy provider,'' after ``hospice program,''.
    Subsec. (v)(1)(G)(i). Pub. L. 100-360, Sec. 104(d)(4)(D), struck out 
``post-hospital'' before ``extended care services'' in four places.
    Subsec. (v)(1)(L)(iii). Pub. L. 100-360, Sec. 411(d)(5)(A), 
substituted ``verified'' for ``audited'' in subcls. (I) and (II) and 
inserted at end ``In the case of a home health agency that refuses to 
provide data, or deliberately provides false data, respecting wages for 
purposes of this clause upon the request of the Secretary, the Secretary 
may withhold up to 5 percent of the amount of the payments otherwise 
payable to the agency under this subchapter until such date as the 
Secretary determines that such data has been satisfactorily provided.''
    Subsec. (v)(2)(A), (3). Pub. L. 100-360, Sec. 104(d)(4)(D), struck 
out ``post-hospital'' before ``extended care services''.
    Subsec. (y). Pub. L. 100-360, Sec. 104(d)(4)(E)(i), substituted 
``Extended care'' for ``Post-hospital extended care'' in heading.
    Subsec. (y)(1). Pub. L. 100-360, Sec. 104(d)(4)(E)(ii), struck out 
``(except for purposes of subsection (a)(2) of this section)'' after 
``Massachusetts, but only''.
    Subsec. (y)(2). Pub. L. 100-360, Sec. 104(d)(4)(E)(i), (iii), (iv), 
struck out ``post-hospital'' before ``extended care services'' in two 
places, substituted ``year'' for ``spell of illness'' and ``spell'' 
wherever each appeared, and substituted ``45 days'' for ``30 days''.
    Subsec. (y)(3). Pub. L. 100-360, Sec. 104(d)(4)(E)(i), (iii), (v), 
struck out ``post-hospital'' before ``extended care services'' and 
substituted ``year'' for ``spell of illness'', ``the coinsurance amount 
established under section 1395e(a)(3)(C) of this title for each day 
before the 46th day'' for ``one-eighth of the inpatient hospital 
deductible for each day before the 31st day'', and ``year'' for 
``spell''.
    Subsec. (y)(4). Pub. L. 100-360, Sec. 104(d)(4)(E)(vi), struck out 
par. (4) which provided that certain determinations about services 
provided by an institution described in par. (1) be made under 
regulations.
    Subsec. (bb)(2). Pub. L. 100-360, Sec. 411(i)(3), added Pub. L. 100-
203, Sec. 4084(c)(1), see 1987 Amendment note below.
    Subsec. (ff). Pub. L. 100-360, Sec. 411(h)(1)(B)(i), inserted 
heading.
    Subsec. (ff)(3). Pub. L. 100-360, Sec. 411(h)(1)(B)(ii), substituted 
``furnished by a hospital to its outpatients'' for ``hospital-based or 
hospital-affiliated (as defined by the Secretary)''.
    Subsec. (gg). Pub. L. 100-360, Sec. 411(h)(4)(D), amended Pub. L. 
100-203, Sec. 4073(c), see 1987 Amendment note below.
    Subsec. (hh). Pub. L. 100-360, Sec. 411(h)(5)(B), amended Pub. L. 
100-203, Sec. 4074(b), see 1987 Amendment note below.
    Subsec. (ii). Pub. L. 100-647, Sec. 8423(a), inserted ``on-site'' 
before ``at a community mental health center'' and ``, and such services 
that are necessarily furnished off-site (other than at an off-site 
office of such psychologist) as part of a treatment plan because of the 
inability of the individual furnished such services to travel to the 
center by reason of physical or mental impairment, because of 
institutionalization, or because of similar circumstances of the 
individual,'' after ``Public Health Service Act)''.
    Pub. L. 100-360, Sec. 411(h)(7)(E), (F), redesignated and amended 
Pub. L. 100-203, Sec. 4077(b)(4), see 1987 Amendment note below.
    Subsec. (jj). Pub. L. 100-485, Sec. 608(d)(6)(A), inserted heading.
    Pub. L. 100-360, Sec. 203(b), added subsec. (jj) relating to home 
intravenous drug therapy services.
    Subsec. (kk). Pub. L. 100-360, Sec. 204(a)(2), added subsec. (kk) 
relating to screening mammography.
    Subsec. (ll). Pub. L. 100-360, Sec. 205(b), added subsec. (ll) 
relating to in-home care furnished to chronically dependent individual.
    1987--Subsec. (a)(2). Pub. L. 100-203, Sec. 4201(d)(1), formerly 
Sec. 4201(d), as redesignated and amended by Pub. L. 100-360, 
Sec. 411(l)(1)(B)(i), (ii), substituted ``facility described in section 
1396i-3(a)(1) of this title or subsection (y)(1) of this section'' for 
``skilled nursing facility''.
    Subsec. (b)(3). Pub. L. 100-203, Sec. 4009(e)(1), inserted 
``(including clinical psychologist (as defined by the Secretary))'' 
before ``under arrangements''.
    Subsec. (b)(4). Pub. L. 100-203, Sec. 4085(i)(9), substituted ``and 
anesthesia'' for ``, anesthesia'' and ``certified registered nurse'' for 
``certified certified registered nurse''.
    Subsec. (b)(6). Pub. L. 100-203, Sec. 4039(b)(2), substituted 
``Council on Podiatric Medical Education of the American Podiatric 
Medical Association'' for ``Council on Podiatry Education of the 
American Podiatry Association''.
    Subsec. (e)(4). Pub. L. 100-203, Sec. 4009(f), inserted ``with 
respect to whom payment may be made under this subchapter'' after 
``patient''.
    Subsec. (g). Pub. L. 100-203, Sec. 4085(i)(10), made technical 
amendment to heading.
    Subsec. (j). Pub. L. 100-203, Sec. 4201(a)(1), amended subsec. 
generally, substituting provision defining ``skilled nursing facility'' 
as having the meaning given such term in section 1395i-3(a) of this 
title for provision defining ``skilled nursing facility'' as, except for 
purposes of subsec. (a)(2) of this section, an institution or a distinct 
part of an institution which has in effect a transfer agreement, meeting 
the requirements of subsec. (l) of this section, with one or more 
hospitals having agreements in effect under section 1395cc of this title 
and which meet a specified list of criteria.
    Subsec. (n). Pub. L. 100-203, Sec. 4201(d)(2), (5), as added by Pub. 
L. 100-360, Sec. 411(l)(1)(B)(iii), and Pub. L. 100-360, 
Sec. 411(l)(1)(C), as added by Pub. L. 100-485, Sec. 608(d)(27)(B), made 
similar amendments, resulting in the substitution of ``subsection (e)(1) 
of this section or section 1395i-3(a)(1) of this title'' for 
``subsection (e)(1) or (j)(1) of this section'' in introductory 
provisions.
    Subsec. (o)(6). Pub. L. 100-203, Sec. 4021(a), inserted ``the 
conditions of participation specified in section 1395bbb(a) of this 
title and'' after ``meets''.
    Subsec. (r)(3). Pub. L. 100-203, Sec. 4039(b)(1), substituted 
``subsections (k), (m), (p)(1), and (s) of this section and sections 
1395f(a), 1395k(a)(2)(F)(ii), and 1395n of this title'' for ``subsection 
(s) of this section'', and struck out ``; and for the purposes of 
subsections (k), (m), and (p)(1) of this section and sections 1395f(a), 
1395k(a)(2)(F)(ii), and 1395n of this title but only if his performance 
of functions under subsections (k), (m), and (p)(1) of this section and 
sections 1395f(a), 1395k(a)(2)(F)(ii), and 1395n of this title is 
consistent with the policy of the institution or agency with respect to 
which he performs them and with the functions which he is legally 
authorized to perform''.
    Subsec. (s). Pub. L. 100-203, Sec. 4085(i)(11), substituted in 
closing provisions ``which would not be included under subsection (b) of 
this section if it were furnished to an inpatient of a hospital.'' for 
``which--'' before par. (15) and struck out pars. (15) and (16).
    Pub. L. 100-203, Sec. 4064(e)(1), inserted ``a laboratory not 
independent of a physician's office that has a volume of clinical 
diagnostic laboratory tests exceeding 5,000 per year'' in provisions 
preceding par. (13).
    Subsec. (s)(2)(B). Pub. L. 100-203, Sec. 4070(b)(1), inserted ``and 
partial hospitalization services incident to such services'' before 
semicolon.
    Subsec. (s)(2)(H)(ii). Pub. L. 100-203, Sec. 4074(a), as amended by 
Pub. L. 100-360, Sec. 411(h)(5)(A), inserted ``or by a clinical social 
worker (as defined in subsection (hh) of this section)'' after 
``clinical psychologist (as defined by the Secretary)'', and substituted 
``incident to such clinical psychologist's services or clinical social 
worker's services'' for ``incident to his services''.
    Subsec. (s)(2)(J). Pub. L. 100-203, Sec. 4075(a), substituted 
``prescription drugs used in immunosuppressive therapy'' for 
``immunosuppressive drugs''.
    Subsec. (s)(2)(K)(i). Pub. L. 100-203, Sec. 4076(a), as amended by 
Pub. L. 100-360, Sec. 411(h)(6), inserted ``(I)'' and substituted ``, 
(II) as an assistant at surgery, or (III) in a rural area (as defined in 
section 1395ww(d)(2)(D) of this title) that is designated, under section 
332(a)(1)(A) of the Public Health Service Act, as a health manpower 
shortage area,'' for ``or as an assistant at surgery''.
    Subsec. (s)(2)(L). Pub. L. 100-203, Sec. 4073(a), added subpar. (L).
    Subsec. (s)(2)(M). Pub. L. 100-203, Sec. 4077(b)(1), as amended by 
Pub. L. 100-360, Sec. 411(h)(7)(A), added subpar. (M).
    Subsec. (s)(10)(A). Pub. L. 100-203, Sec. 4071(a), inserted ``and 
influenza vaccine and its administration'' before semicolon.
    Subsec. (s)(12). Pub. L. 100-203, Sec. 4072(a), added par. (12). 
Former par. (12) redesignated (13).
    Subsec. (s)(13), (14). Pub. L. 100-203, Sec. 4072(a)(1), 
redesignated pars. (12) and (13) as (13) and (14), respectively. Former 
par. (14) redesignated (15).
    Subsec. (s)(15). Pub. L. 100-203, Sec. 4085(i)(11), as amended by 
Pub. L. 100-360, Sec. 411(i)(4)(C)(iii), struck out par. (15) which read 
as follows: ``would not be included under subsection (b) of this section 
if it were furnished to an inpatient of a hospital; or''.
    Pub. L. 100-203, Sec. 4072(a)(1), redesignated par. (14) as (15). 
Former par. (15) redesignated (16).
    Subsec. (s)(16). Pub. L. 100-203, Sec. 4085(i)(11), as amended by 
Pub. L. 100-360, Sec. 411(i)(4)(C)(iii), struck out par. (16) which read 
as follows: ``is furnished under arrangements referred to in such 
paragraph (2)(C) unless furnished in the hospital or in other facilities 
operated by or under the supervision of the hospital or its organized 
medical staff.''
    Pub. L. 100-203, Sec. 4072(a)(1), redesignated par. (15) as (16).
    Subsec. (v)(1)(E). Pub. L. 100-203, Sec. 4201(b)(1), inserted at end 
``Notwithstanding the previous sentence, such regulations with respect 
to skilled nursing facilities shall take into account (in a manner 
consistent with subparagraph (A) and based on patient-days of services 
furnished) the costs of such facilities complying with the requirements 
of subsections (b), (c), and (d) of section 1395i-3 of this title 
(including the costs of conducting nurse aide training and competency 
evaluation programs and competency evaluation programs).''
    Subsec. (v)(1)(L)(iii). Pub. L. 100-203, Sec. 4026(a)(1), added cl. 
(iii).
    Subsec. (v)(1)(S). Pub. L. 100-203, Sec. 4065(a), added subpar. (S).
    Subsec. (v)(5)(A). Pub. L. 100-203, Sec. 4085(i)(12), substituted 
``subsection (p)'' and ``subsection (g)'' for ``section 1861(p)'' and 
``section 1861(g)'', respectively.
    Subsec. (aa)(1)(B). Pub. L. 100-203, Sec. 4077(a)(1), substituted 
``physician assistant or a nurse practitioner (as defined in paragraph 
(3)), or by a clinical psychologist (as defined by the Secretary),'' for 
``physician assistant or by a nurse practitioner''.
    Subsec. (bb). Pub. L. 100-203, Sec. 4085(i)(13), made technical 
amendment to heading.
    Subsec. (bb)(2). Pub. L. 100-203, Sec. 4084(c)(1), as added by Pub. 
L. 100-360, Sec. 411(i)(3), inserted at end ``Such term also includes, 
as prescribed by the Secretary, an anesthesiologist assistant.''
    Subsec. (cc)(1). Pub. L. 100-203, Sec. 4078, inserted provision at 
end relating to location requirements in case of physical therapy, 
occupational therapy, and speech pathology services.
    Subsec. (ee). Pub. L. 100-203, Sec. 4085(i)(14), made technical 
amendment to heading.
    Subsec. (ff). Pub. L. 100-203, Sec. 4070(b)(2), added subsec. (ff).
    Subsec. (gg). Pub. L. 100-203, Sec. 4073(c), as amended by Pub. L. 
100-360, Sec. 411(h)(4)(D), added subsec. (gg).
    Subsec. (hh). Pub. L. 100-203, Sec. 4074(b), as amended by Pub. L. 
100-360, Sec. 411(h)(5)(B), added subsec. (hh).
    Subsec. (ii). Pub. L. 100-203, Sec. 4077(b)(4), formerly 
Sec. 4077(b)(5), as redesignated and amended by Pub. L. 100-360, 
Sec. 411(h)(7)(E), (F), added subsec. (ii).
    1986--Subsec. (b)(4). Pub. L. 99-509, Sec. 9320(f), inserted before 
the semicolon at end ``, anesthesia services provided by a certified 
registered nurse anesthetist''.
    Subsec. (e)(6). Pub. L. 99-509, Sec. 9305(c)(1), inserted ``(A)'' 
after ``(6)'' and cl. (B).
    Subsec. (g). Pub. L. 99-509, Sec. 9337(d)(1), added subsec. (g).
    Subsec. (n). Pub. L. 99-272, Sec. 9219(b)(1)(B), substituted ``as 
his home'' for ``at his home''.
    Subsec. (r)(4). Pub. L. 99-509, Sec. 9336(a), amended cl. (4) 
generally. Prior to amendment, cl. (4) read as follows: ``a doctor of 
optometry who is legally authorized to practice optometry by the State 
in which he performs such function, but only with respect to services 
related to the condition of aphakia, or''.
    Subsec. (s)(2)(D). Pub. L. 99-509, Sec. 9337(d)(2), inserted ``and 
outpatient occupational therapy services''.
    Subsec. (s)(2)(J). Pub. L. 99-509, Sec. 9335(c)(1), added subpar. 
(J).
    Subsec. (s)(2)(K). Pub. L. 99-509, Sec. 9338(a), added subpar. (K).
    Subsec. (s)(11) to (15). Pub. L. 99-509, Sec. 9320(b), added par. 
(11) and redesignated former pars. (11) to (14) as (12) to (15), 
respectively.
    Subsec. (v)(1)(B). Pub. L. 99-272, Sec. 9107(b)(2), substituted 
``any cost reporting period shall be equal to'' for ``any fiscal period 
shall not exceed one and one-half times'' and ``the period'' for ``such 
fiscal period''.
    Subsec. (v)(1)(G)(i). Pub. L. 99-272, Sec. 9219(b)(3)(A), inserted 
``on the basis of'' after ``(during such period)'' in provisions 
following subcl. (III).
    Subsec. (v)(1)(L). Pub. L. 99-509, Sec. 9315(a), inserted ``(i)'' 
after ``(L)'', struck out ``the 75th percentile of such costs per visit 
for free standing home health agencies, or, in the judgment of the 
Secretary, such lower percentile or such comparable or lower limit 
(based on or related to the mean of the costs of such agencies or 
otherwise) as the Secretary may determine.'', and substituted in lieu 
``for cost reporting periods beginning on or after--
        ``(I) July 1, 1985, and before July 1, 1986, 120 percent,
        ``(II) July 1, 1986, and before July 1, 1987, 115 percent, or
        ``(III) July 1, 1987, 112 percent,
of the mean of the labor-related and nonlabor per visit costs for free 
standing home health agencies.
    ``(ii) Effective for cost reporting periods beginning on or after 
July 1, 1986, such limitations shall be applied on an aggregate basis 
for the agency, rather than on a discipline specific basis, with 
appropriate adjustment for administrative and general costs of hospital-
based agencies.''
    Subsec. (v)(1)(O)(i). Pub. L. 99-272, Sec. 9110(a)(1), inserted ``, 
except as provided in clause (iv),'' after ``such regulations shall 
provide''.
    Subsec. (v)(1)(O)(iv). Pub. L. 99-272, Sec. 9110(a)(2), added cl. 
(iv).
    Subsec. (v)(1)(P). Pub. L. 99-272, Sec. 9107(b)(1), added subpar. 
(P).
    Subsec. (v)(1)(Q). Pub. L. 99-272, Sec. 9202(i)(1), added subpar. 
(Q).
    Subsec. (v)(1)(R). Pub. L. 99-509, Sec. 9313(a)(2), added subpar. 
(R).
    Subsec. (v)(5)(A). Pub. L. 99-509, Sec. 9337(d)(3), inserted 
``(including through the operation of subsection (g) of this section)'' 
after ``subsection (p) of this section''.
    Subsec. (bb). Pub. L. 99-509, Sec. 9320(c), added subsec. (bb).
    Subsec. (ee). Pub. L. 99-509, Sec. 9305(c)(2), added subsec. (ee).
    1984--Subsec. (d). Pub. L. 98-369, Sec. 2335(b)(1), struck out 
subsec. (d) which defined ``inpatient tuberculosis hospital services'' 
as inpatient hospital services furnished to an inpatient of a 
tuberculosis hospital.
    Subsec. (e). Pub. L. 98-369, Sec. 2335(b)(2), struck out ``or 
tuberculosis unless it is a tuberculosis hospital (as defined in 
subsection (g) of this section) or'' before ``unless it is a psychiatric 
hospital'' in provisions following par. (9).
    Subsec. (f). Pub. L. 98-369, Sec. 2340(a), struck out par. (5) which 
provided that ``psychiatric hospital'' meant an institution which was 
accredited by the Joint Commission on Accreditation of Hospitals, and 
struck out ``if the institution is accredited by the Joint Commission on 
Accreditation of Hospitals or if such distinct part meets requirements 
equivalent to such accreditation requirements as determined by the 
Secretary'' in concluding provisions.
    Subsec. (g). Pub. L. 98-369, Sec. 2335(b)(1), struck out subsec. (g) 
which defined ``tuberculosis hospital''.
    Subsec. (j). Pub. L. 98-369, Sec. 2335(b)(3), in provisions 
following par. (15), struck out ``or tuberculosis'' after ``treatment of 
mental diseases''.
    Subsec. (j)(2). Pub. L. 98-369, Sec. 2354(b)(18), substituted 
``provision for'' for ``provision of''.
    Subsec. (j)(13). Pub. L. 98-369, Sec. 2354(b)(19), substituted ``an 
institution'' for ``a nursing home''.
    Subsec. (m)(5). Pub. L. 98-369, Sec. 2321(e)(1), which directed the 
substitution of ``and durable medical equipment'' for ``, and the use of 
medical applicances'' was executed by making the substitution for ``, 
and the use of medical appliances'' as the probable intent of Congress.
    Subsec. (n). Pub. L. 98-369, Sec. 2321(e)(3), added subsec. (n).
    Subsec. (p)(1). Pub. L. 98-369, Sec. 2341(a), substituted 
``paragraph (1) or (3) of subsection (r) of this section'' for 
``subsection (r)(1) of this section''.
    Subsec. (p)(2). Pub. L. 98-369, Sec. 2342(a), substituted ``by a 
physician as so defined) or by a qualified physical therapist and is 
periodically reviewed by a physician (as so defined)'' for ``, and is 
periodically reviewed, by a physician (as so defined)''.
    Subsec. (r)(3). Pub. L. 98-617, Sec. 3(b)(7), substituted ``under 
subsections (k), (m), and (p)(1) of this section and sections 1395f(a), 
1395k(a)(2)(F)(ii), and 1395n of this title'' for ``under subsections 
(k) and (m) and sections 1395f(a) and 1395n of this title'' before ``is 
consistent with the policy''.
    Pub. L. 98-369, Sec. 2341(c), substituted ``for the purposes of 
subsections (k), (m), and (p)(1) of this section'' for ``for the 
purposes of subsections (k) and (m) of this section'', and substituted 
``sections 1395f(a), 1395k(a)(2)(F)(ii), and 1395n of this title but 
only if'' for ``sections 1395f(a) and 1395n of this title but only if''.
    Subsec. (s)(2)(H). Pub. L. 98-369, Sec. 2322(a), designated existing 
provisions as cl. (i) and added cl. (ii).
    Subsec. (s)(2)(I). Pub. L. 98-369, Sec. 2324(a), added subpar. (I).
    Subsec. (s)(6). Pub. L. 98-369, Sec. 2321(e)(2), struck out 
provision which included iron lungs, oxygen tents, etc. with durable 
medical equipment. See subsec. (n) of this section.
    Subsec. (s)(10). Pub. L. 98-369, Sec. 2323(a), designated existing 
provisions as subpar. (A) and added subpar. (B).
    Subsec. (u). Pub. L. 98-369, Sec. 2354(b)(20), struck out ``or'' 
before ``home health agency''.
    Subsec. (v)(1)(B). Pub. L. 98-369, Sec. 2354(b)(21)(A), realigned 
margin of subpar. (B).
    Subsec. (v)(1)(C). Pub. L. 98-369, Sec. 2354(b)(21)(B), realigned 
margins of subpar. (C).
    Subsec. (v)(1)(C)(i). Pub. L. 98-369, Sec. 2354(b)(22), inserted a 
dash after ``but only if''.
    Subsec. (v)(1)(D). Pub. L. 98-369, Sec. 2354(b)(21)(B), realigned 
margin of subpar. (D).
    Pub. L. 98-369, Sec. 2354(b)(21)(C), inserted a comma after 
``section 1395k(a)(2)(B)(i) of this title''.
    Subsec. (v)(1)(E). Pub. L. 98-369, Sec. 2319(a)(1), struck out cl. 
(i) which directed that such regulations provide that any determination 
of reasonable cost with respect to services provided by hospital-based 
skilled nursing facilities be made on the basis of a single standard 
based on the reasonableness of costs incurred by free standing skilled 
nursing facilities, subject to such adjustments as deemed appropriate by 
the Secretary, and struck out the designation ``(ii)''.
    Pub. L. 98-369, Sec. 2354(b)(23), as amended by Pub. L. 98-617, 
Sec. 3(a)(4), substituted ``use'' for ``uses''.
    Subsec. (v)(1)(I)(i), (ii). Pub. L. 98-369, Sec. 2354(b)(24), 
substituted ``by the Secretary, or upon request by the Comptroller 
General'' for ``to the Secretary, or upon request to the Comptroller 
General''.
    Subsec. (v)(1)(K). Pub. L. 98-369, Sec. 2318(a), (b), designated 
existing provisions as cl. (i), substituted therein ``as defined in 
clause (ii)'' for ``provided in an emergency room'', and added cl. (ii).
    Subsec. (v)(1)(O). Pub. L. 98-369, Sec. 2314(a), added subpar. (O).
    Subsec. (v)(3). Pub. L. 98-369, Sec. 2354(b)(25), substituted 
``semi-private'' for ``semiprivate'' after ``furnished in''.
    Subsec. (v)(7)(D). Pub. L. 98-369, Sec. 2319(a)(2), added subpar. 
(D).
    Subsec. (z)(2). Pub. L. 98-369, Sec. 2354(b)(26), substituted 
``paragraph (1)'' for ``subparagraph (1)''.
    Subsec. (aa)(2)(I). Pub. L. 98-369, Sec. 2354(b)(27), substituted 
``utilization'' for ``ultilization''.
    Subsec. (cc)(1)(F). Pub. L. 98-369, Sec. 2354(b)(28), substituted 
``self-administered'' for ``self administered''.
    Subsec. (cc)(1)(G). Pub. L. 98-369, Sec. 2321(e)(4), substituted 
``and durable medical equipment'' for ``, appliances, and equipment, 
including the purchase or rental of equipment''.
    Subsec. (cc)(2)(F). Pub. L. 98-369, Sec. 2354(b)(29), substituted 
``standards established'' for ``standard establishment''.
    Subsec. (dd)(2)(A)(ii)(I). Pub. L. 98-369, Sec. 2343(a), inserted 
``except as otherwise provided in paragraph (5),''.
    Subsec. (dd)(5). Pub. L. 98-369, Sec. 2343(b), added par. (5).
    1983--Subsec. (v)(1)(G)(i). Pub. L. 98-21, Sec. 602(d)(1), 
substituted ``the amount otherwise payable under part A with respect 
to'' for ``on the basis of the reasonable cost of'' in provisions 
following subcl. (III).
    Subsec. (v)(2)(A). Pub. L. 98-21, Sec. 602(d)(2), substituted ``the 
amount that would be taken into account with respect to'' for ``an 
amount equal to the reasonable cost of''.
    Subsec. (v)(2)(B). Pub. L. 98-21, Sec. 602(d)(3), struck out ``the 
equivalent of the reasonable cost of'' after ``only''.
    Subsec. (v)(3). Pub. L. 98-21, Sec. 602(d)(4), substituted ``the 
amount otherwise payable under this subchapter for such bed and board 
furnished in semiprivate accommodations'' for ``the reasonable cost of 
such bed and board furnished in semiprivate accommodations (determined 
pursuant to paragraph (1))''.
    Subsec. (v)(7)(C). Pub. L. 97-448 amended directory language of Pub. 
L. 97-248, Sec. 109(b)(2), to correct typographical error, and did not 
involve any change in text. See 1982 Amendment note below.
    Subsec. (z)(2). Pub. L. 98-21, Sec. 607(d), designated existing 
provisions as subpar. (A) and added subpar. (B).
    Pub. L. 98-21, Sec. 607(b)(2), substituted ``$600,000 (or such 
lesser amount as may be established by the State under section 1320a-
1(g)(1) of this title in which the hospital is located)'' for 
``$100,000''.
    1982--Subsec. (e)(C). Pub. L. 97-248, Sec. 128(d)(2), substituted 
``(i) may'' for ``may (i),''.
    Subsec. (s)(2)(H). Pub. L. 97-248, Sec. 114(b), added subpar. (H).
    Subsec. (u). Pub. L. 97-248, Sec. 122(d)(1), inserted ``hospice 
program,'' after ``home health agency,''.
    Subsec. (v)(1)(E). Pub. L. 97-248, Sec. 102(a), struck out 
provisions that this subparagraph would not apply to any skilled nursing 
facility that either was a distinct part of or directly operated by a 
hospital or was in a close, formal satellite relationship with a 
participating hospital, and in the case of the latter, the reasonable 
cost of any services furnished by such facility as determined by the 
Secretary under this subsection would not exceed 150 percent of the 
costs determined by the application of this subparagraph, redesignated 
the remainder as cl. (ii), and added cl. (i).
    Subsec. (v)(1)(G)(i). Pub. L. 97-248, Sec. 148(b), substituted 
``quality control and peer review organization'' for ``Professional 
Standards Review Organization''.
    Subsec. (v)(1)(H)(iii). Pub. L. 97-248, Sec. 109(b)(1), struck out 
``(I)'' and ``, or (II) which determines the amount payable by the home 
health agency on the basis of a percentage of the agency's reimbursement 
or claim for reimbursement for services furnished by the agency''.
    Subsec. (v)(1)(I). Pub. L. 97-248, Sec. 127(1), amended directory 
language of Pub. L. 96-499, Sec. 952, by inserting ``(a)'' after 
``952'', and did not involve any change in text. See 1980 Amendment note 
below.
    Subsec. (v)(1)(J). Pub. L. 97-248, Sec. 103(a), substituted 
provisions that cost regulations may not provide for any inpatient 
routine salary cost differential as a reimbursable cost for hospitals 
and skilled nursing facilities for provisions that such regulations 
would provide that an inpatient routine nursing salary cost differential 
would be allowable as a reimbursable cost of hospitals, at a rate not to 
exceed 5 percent, to be applied under the same methodology used for the 
nursing salary cost differential for the month of April 1981.
    Subsec. (v)(1)(L). Pub. L. 97-248, Sec. 101(a)(2), struck out cl. 
(i) which provided that the Secretary, in determining the amount of the 
payments that could be made under this subchapter with respect to 
routine operating costs for the provision of general inpatient hospital 
services, could not recognize as reasonable, routine operating costs for 
the provision of general inpatient hospital services by a hospital to 
the extent these costs exceeded 108 percent of the mean of such routine 
operating costs per diem for hospitals, or, in the judgment of the 
Secretary, such lower percentage or such comparable or lower limit as 
the Secretary could determine, and struck out ``(ii)''.
    Pub. L. 97-248, Sec. 105(a), inserted ``free standing'' after 
``costs per visit for''.
    Subsec. (v)(1)(M). Pub. L. 97-248, Sec. 106(a), added subpar. (M).
    Subsec. (v)(1)(N). Pub. L. 97-248, Sec. 107(a), added subpar. (N).
    Subsec. (v)(7). Pub. L. 97-248, Sec. 101(d), redesignated existing 
provisions as subpar. (A) and added subpar. (B).
    Subsec. (v)(7)(C). Pub. L. 97-248, Sec. 108(a)(2), added subpar. 
(C).
    Pub. L. 97-248, Sec. 109(b)(2), as amended by Pub. L. 97-448, 
Sec. 309(a)(4), inserted ``and for payments under certain percentage 
arrangements''.
    Subsec. (w)(1). Pub. L. 97-248, Sec. 122(d)(2), substituted ``home 
health agency, or hospice program'' for ``or home health agency''.
    Subsec. (w)(2). Pub. L. 97-248, Sec. 148(b), substituted ``quality 
control and peer review organization'' for ``Professional Standards 
Review Organization''.
    Subsec. (cc)(1). Pub. L. 97-248, Sec. 128(a)(1), substituted 
``inpatient'' for ``outpatient'' in provisions following subpar. (H).
    Subsec. (dd). Pub. L. 97-248, Sec. 122(d)(3), added subsec. (dd).
    1981--Subsec. (u). Pub. L. 97-35, Sec. 2121(c), struck out 
``detoxification facility,'' after ``home health agency,''.
    Subsec. (v)(1)(G)(i). Pub. L. 97-35, Sec. 2102(a)(1), substituted 
``there is not an excess of hospital beds in such hospital and (subject 
to clause (iv)) there is not an excess of hospital beds in the area of 
such hospital'' for ``the hospital had (during the immediately preceding 
calendar year) an average daily occupancy rate of 80 percent or more'' 
in provision following subcl. (III).
    Pub. L. 97-35, Sec. 2114, substituted ``the Secretary or such agent 
as the Secretary may designate'' for ``an organization or agency with 
review responsibility as is otherwise provided for under part A of 
subchapter XI of this chapter'' in provision preceding subcl. (I).
    Subsec. (v)(1)(G)(iv). Pub. L. 97-35, Sec. 2102(a)(2), substituted 
provisions that the determination under cl. (i) of this subparagraph, in 
the case of a public hospital, whether or not there is an excess of 
hospital beds in the area of such hospital, be made on the basis of only 
the public hospitals which are in the area of the hospital and which are 
under common ownership with that hospital for provisions that public 
hospitals under common ownership may elect to be treated as a single 
hospital, and beginning two years after the date this subparagraph is 
first applied with respect to a hospital, the Secretary, to the extent 
feasible, shall not treat as an inpatient an individual with respect to 
whom payment was made to the hospital only because of this subparagraph 
or section 1396a(h) of this title for such determination.
    Subsec. (v)(1)(J). Pub. L. 97-35, Sec. 2141(a), added subpar. (J).
    Subsec. (v)(1)(K). Pub. L. 97-35, Sec. 2142(a), added subpar. (K).
    Subsec. (v)(1)(L). Pub. L. 97-35, Sec. 2143(a), added subpar. (L).
    Pub. L. 97-35, Sec. 2144(a), designated existing provisions as cl. 
(i) and added cl. (ii).
    Subsec. (w)(2). Pub. L. 97-35, Sec. 2193(c)(9), substituted 
``subchapter XIX of this chapter'' for ``subchapter V or XIX of this 
chapter''.
    Subsec. (bb). Pub. L. 97-35, Sec. 2121(d), struck out subsec. (bb) 
which defined ``alcohol detoxification facility services'' and 
``detoxification facility''.
    1980--Subsec. (b)(7). Pub. L. 96-499, Sec. 948(a)(1), provided that 
par. (4) was not to apply to services provided in a hospital by a 
physician where the hospital had a teaching program approved as 
specified in par. (6) if the hospital elected to receive payment for 
reasonable costs of such services and all physicians in such hospital 
agreed not to bill charges for professional services rendered in such 
hospital to individuals covered under the insurance program established 
by this subchapter.
    Subsec. (e). Pub. L. 96-499, Sec. 930(k), substituted ``subsection 
(i)'' for ``subsections (i) and (n)'' in text preceding par. (1) and in 
text following par. (9).
    Pub. L. 96-499, Sec. 949, in text following par. (9), inserted 
provision defining ``hospital'' as a facility of fifty beds or less 
located in an area determined by the Secretary to meet definition 
relating to a rural area described in subpar. (A) of par. (5) and 
prescribing exceptions to such definition.
    Subsec. (i). Pub. L. 96-499, Sec. 950, substituted ``30 days'' for 
``14 days'' in three places and struck out former cl. (B) which related 
to admission to skilled nursing facilities within 28 days after hospital 
discharge of an individual unable to be admitted to such facilities 
within 14 days because of a shortage of appropriate bed space, and 
redesignated former cl. (C) as (B).
    Subsec. (j)(13). Pub. L. 96-499, Sec. 915(a), substituted ``such 
edition (as is specified by the Secretary in regulations) of the Life 
Safety Code of the National Fire Protection Association'' for ``the Life 
Safety Code of the National Fire Protection Association (23rd edition, 
1973)''.
    Subsec. (k)(2)(A). Pub. L. 96-499, Sec. 951(b), inserted ``(of which 
at least two must be physicians described in subsection (r)(1) of this 
section)'' after ``two or more physicians''.
    Subsec. (m)(4). Pub. L. 96-499, Sec. 930(l), inserted ``who has 
successfully completed a training program approved by the Secretary'' 
after ``health aide''.
    Subsec. (n). Pub. L. 96-499, Sec. 930(m), struck out subsec. (n) 
which defined ``post-hospital home health services''.
    Subsec. (o). Pub. L. 96-499, Sec. 930(n)(2), in provisions following 
par. (7), struck out provision that ``home health agency'' was not to 
include a private organization which was not a nonprofit organization 
exempt from Federal income taxation under section 501 of title 26 unless 
it were licensed pursuant to State law and met such additional standards 
and requirements as prescribed by regulations.
    Subsec. (o)(7). Pub. L. 96-499, Sec. 930(n)(1), added par. (7).
    Subsec. (r)(2). Pub. L. 96-499, Sec. 936(a), amended cl. (2) 
generally to expand definition of ``physician'' to include doctors of 
dental surgery or dental medicine acting within the scope of their 
licenses.
    Subsec. (r)(3). Pub. L. 96-499, Sec. 951(a), substituted provisions 
relating to doctors of podiatric medicine for provisions relating to 
doctors of podiatry and surgical chiropody.
    Subsec. (r)(4). Pub. L. 96-499, Sec. 937(a), substituted ``services 
related to the condition of aphakia'' for ``establishing the necessity 
for prosthetic lenses''.
    Subsec. (s)(2)(G). Pub. L. 96-499, Sec. 938(a), added subpar. (G).
    Subsec. (s)(10) to (14). Pub. L. 96-611, Sec. 1(a)(1), added par. 
(10) and redesignated former pars. (10) to (13) as (11) to (14), 
respectively.
    Subsec. (u). Pub. L. 96-499, Sec. 933(c), inserted ``comprehensive 
outpatient rehabilitation facility,'' after ``nursing facility''.
    Pub. L. 96-499, Sec. 931(c), inserted ``detoxification facility,''.
    Subsec. (v)(1)(G). Pub. L. 96-499, Sec. 902(a)(1), added subpar. 
(G).
    Subsec. (v)(1)(H). Pub. L. 96-499, Sec. 930(p), added subpar. (H).
    Subsec. (v)(1)(I). Pub. L. 96-499, Sec. 952(a), formerly Sec. 952, 
as redesignated by Pub. L. 97-248, Sec. 127(1), added subpar. (I).
    Subsec. (z). Pub. L. 96-499, Sec. 933(d), which purported to 
substitute ``skilled nursing facility, comprehensive outpatient 
rehabilitation facility,'' for ``extended care facility,'' was executed 
by inserting ``comprehensive outpatient rehabilitation facility,'' after 
``skilled nursing facility,'' as the probable intent of Congress, in 
view of the substitution of ``skilled nursing facility'' for ``extended 
care facility'' by section 278(b)(6) of Pub. L. 92-603.
    Subsec. (aa)(1)(A). Pub. L. 96-611, Sec. 1(b)(3), inserted reference 
to items and services described in subsection (s)(10) of this section.
    Subsec. (bb). Pub. L. 96-499, Sec. 931(d), added subsec. (bb).
    Subsec. (cc). Pub. L. 96-499, Sec. 933(e), added subsec. (cc).
    1978--Subsec. (s)(2)(F). Pub. L. 95-292 added subpar. (F).
    1977--Subsec. (j)(11). Pub. L. 95-142, Sec. 3(a)(2), substituted 
provisions relating to compliance with requirements of section 1320a-3 
of this title, for provisions relating disclosure of ownership, 
corporate status, etc., information to the Secretary or his delegate.
    Subsec. (j)(13). Pub. L. 95-142, Sec. 21(a), struck out ``; and'' 
after ``nursing facilities''.
    Subsec. (j)(14). Pub. L. 95-142, Sec. 21(a), added par. (14).
    Subsec. (s). Pub. L. 95-210, Sec. 1(g), (h), added subpar. (E) of 
par. (2) and in provisions following par. (9) inserted ``, a rural 
health clinic,'' after ``independent of a physician's office''.
    Subsec. (s)(6). Pub. L. 95-216 inserted ``(which may include a 
power-operated vehicle that may be appropriately used as a wheelchair, 
but only where the use of such a vehicle is determined to be necessary 
on the basis of the individual's medical and physical condition and the 
vehicle meets such safety requirements as the Secretary may prescribe)'' 
after ``wheelchairs''.
    Subsec. (v)(1)(F). Pub. L. 95-142, Sec. 19(b)(1), added subpar. (F).
    Subsec. (w)(2). Pub. L. 95-142, Sec. 5(m), inserted ``part B of this 
subchapter or under'' after ``or entitled to have payment made for such 
services under''.
    Subsec. (aa). Pub. L. 95-210, Sec. 1(d), added subsec. (aa).
    1975--Subsec. (e)(5). Pub. L. 94-182, Sec. 102, substituted 
``January 1, 1979'' for ``January 1, 1976''.
    Subsec. (j)(13). Pub. L. 94-182, Sec. 106(a), substituted ``23d 
edition, 1973'' for ``21st edition, 1967''.
    Subsec. (w). Pub. L. 94-182, Sec. 112(a)(1), designated existing 
provisions as par. (1) and added par. (2).
    1972--Subsec. (a)(2). Pub. L. 92-603, Sec. 278(a)(4), substituted 
``skilled nursing facility'' for ``extended care facility'' and ``a'' 
for ``an''.
    Subsec. (b)(6). Pub. L. 92-603, Secs. 227(a), 276(a), redesignated 
existing second sentence of subsec. (b) as par. (6) and in subsec. 
(b)(6) as so designated inserted reference to services in a hospital or 
osteopathic hospital by an intern or resident-in-training in the field 
of podiatry, approved by the Council on Podiatry Education of the 
American Podiatry Association.
    Subsec. (b)(7). Pub. L. 92-603, Sec. 227(a), added par. (7).
    Subsec. (e). Pub. L. 92-603, Sec. 211(b), inserted reference to 
section 1395f(f) of this title in the provisions preceding par. (1), 
inserted reference to sections 1395f(f)(2) of this title after ``For 
purposes of sections 1395f(d) and 1395n(b) of this title (including 
determination of whether an individual received inpatient hospital 
services or diagnostic services for purposes of such sections),'', and 
inserted provisions for accreditation by the Joint Commission on 
Accreditation of Hospitals.
    Subsec. (e)(8). Pub. L. 92-603, Sec. 234(a), added par. (8). Former 
par. (8) redesignated (9).
    Subsec. (e)(9). Pub. L. 92-603, Secs. 234(a), 244(c), redesignated 
former par. (8) as (9) and struck out provisions requiring that other 
requirements not be higher than the comparable requirements prescribed 
for the accreditation of hospitals by the Joint Commission on 
Accreditation of Hospitals.
    Subsecs. (f)(2), (g)(2). Pub. L. 92-603, Sec. 234(b), (c), inserted 
reference to par. (9) of subsec. (e) of this section.
    Subsec. (h). Pub. L. 92-603, Sec. 278(a)(5), substituted ``skilled 
nursing facility'' for ``extended care facility'', ``skilled nursing 
facilities'' for ``extended care facilities'' and ``a'' for ``an''.
    Subsec. (i). Pub. L. 92-603, Secs. 248, 278(a)(6), (b)(10), extended 
the class of persons qualifying to be deemed as having been an inpatient 
in a hospital immediately before transfer therefrom by designating as 
clause (A) the existing requirement that the person have been admitted 
to the skilled nursing facility within 14 days after discharge from such 
hospital and adding cls. (B) and (C) and substituted ``skilled nursing 
facility'' for ``extended care facility''.
    Subsec. (j). Pub. L. 92-603, Sec. 278(a)(7), substituted ``skilled 
nursing facility'' for ``extended care facility'' in provisions 
preceding par. (1).
    Subsec. (j)(10). Pub. L. 92-603, Sec. 234(d), added par. (10). 
Former par. (10) redesignated par. (11) by section 234(d)(2) of Pub. L. 
92-603 and again redesignated par. (15) by section 246(b)(2) of Pub. L. 
92-603.
    Subsec. (j)(11) to (13). Pub. L. 92-603, Sec. 246(b)(3), added pars. 
(11) to (13).
    Subsec. (j)(15). Pub. L. 92-603, Secs. 234(d), 246(b)(2), (4), 265, 
267, 278(b)(13), redesignated former par. (10) as (11), amended par. 
(11) as thus redesignated by inserting provisions that the Secretary 
shall not require as a condition of participation that medical social 
services be furnished in any such institution, redesignated such par. 
(11) as thus amended as par. (15), and inserted provision that all 
information concerning skilled nursing facilities required to be filed 
with the Secretary be made available to Federal and state employees for 
purposes consistent with the effective administration of programs 
established under subchapters XVIII and XIX and inserted provision for 
the waiver of the registered nurse requirement in skilled nursing 
facilities in rural areas.
    Subsec. (k). Pub. L. 92-603, Secs. 237(c), 278(a)(8), inserted 
provisions authorizing the Secretary to utilize the procedures 
established under subchapter XIX of this chapter if such procedures were 
determined to be superior in their effectiveness and substituted 
``skilled nursing facility'' for ``extended care facility'', ``skilled 
nursing facilities'' for ``extended care facilities'', and ``a'' for 
``an''.
    Subsec. (l). Pub. L. 92-603, Sec. 278(a)(9), substituted ``skilled 
nursing facility'' for ``extended care facility'' and ``a'' for ``an''.
    Subsec. (m)(7). Pub. L. 92-603, Sec. 278(a)(10), substituted 
``skilled nursing facility'' for ``extended care facility''.
    Subsec. (n). Pub. L. 92-603, Sec. 278(a)(11), substituted ``skilled 
nursing facility'' for ``extended care facility'' and ``a'' for ``an''.
    Subsec. (o)(5), (6). Pub. L. 92-603, Sec. 234(e), added par. (5) and 
redesignated former par. (5) as (6).
    Subsec. (p). Pub. L. 92-603, Secs. 251(a)(1), (b)(1), 283(a), 
inserted provisions covering physical therapy services of a licensed 
physical therapist other than under an arrangement with and under the 
supervision of a provider of services, clinic, rehabilitation agency, or 
public health agency, inserted ``In addition, such term includes 
physical therapy services which meet the requirements of the first 
sentence of this subsection except that they are furnished to an 
individual as an inpatient of a hospital or extended care facility'', 
and extended definition of ``outpatient physical therapy services'' to 
include outpatient speech pathology services.
    Subsec. (q). Pub. L. 92-603, Sec. 227(f), substituted ``subsection 
(b)(6) of this section'' for ``the last sentence of subsection (b) of 
this section'' in parenthetical phrase.
    Subsec. (r). Pub. L. 92-603, Secs. 211(c)(2), 256(b), 264(a), 
273(a), inserted ``or (C) the certification required by section 
1395x(a)(2)(E) of this title,'' inserted provision so as to include 
doctors in one of the specified arts legally authorized to practice such 
art in the country in which inpatient hospital services referred to in 
section 1395y(a)(4) are furnished, added cl. (4) covering doctors of 
optometry who are legally authorized to practice optometry by the State 
in which they perform such functions, but only with respect to 
establishing the necessity for prosthetic lenses, and added cl. (5) 
providing for the inclusion of chiropractor services.
    Subsec. (s)(8). Pub. L. 92-603, Sec. 252(a), inserted (including 
colostomy bags and supplies directly related to colostomy care)'' after 
``organ''.
    Subsec. (u). Pub. L. 92-603, Secs. 227(d)(1), 278(a)(12), 
substituted ``skilled nursing facility, or home health agency, or, for 
purposes of sections 1395(g) and 1395n(e) of this title, a fund.'' for 
``extended care facility, or home health agency.''.
    Subsec. (v)(1). Pub. L. 92-603, Secs. 223(a), (b), (c), (d), 
227(c)(1), (2), (3), (4), 249(b), 278(b)(11), inserted definition of the 
costs of services, inserted provision that the regulation for the 
establishment of limits on the direct or indirect overall incurred costs 
or incurred costs of specific items or services or groups of items or 
services to be recognized as reasonably based on estimates of the costs 
necessary in the efficient delivery of needed health services to 
individuals covered by the insurance programs established under this 
subchapter, inserted parenthetical provisions covering exclusion of 
costs, substituted ``the necessary costs of efficiently delivering 
covered services covered by the insurance programs'' for ``the costs 
with respect to individuals covered by the insurance programs'', 
designated existing provisions as subpars. (A) and (B), and added 
subpars. (C), (D), and (E), and substituted ``skilled nursing 
facilities'' for ``extended care facilities''.
    Subsec. (v)(3). Pub. L. 92-603, Sec. 278(a)(13), substituted 
``skilled nursing facility'' for ``extended care facility''.
    Subsec. (v)(4). Pub. L. 92-603, Sec. 223(f), added par. (4). Former 
par. (4) redesignated (6).
    Subsec. (v)(5). Pub. L. 92-603, Sec. 251(c), added par. (5).
    Subsec. (v)(6). Pub. L. 92-603, Secs. 223(f), 251(c), redesignated 
former par. (4) as (6).
    Subsec. (v)(7). Pub. L. 92-603, Secs. 221(c)(4), 223(b), 251(c), 
added par. (7).
    Subsecs. (w), (y). Pub. L. 92-603, Sec. 278(a)(14), (15), 
substituted ``skilled nursing facility'' for ``extended care facility'' 
and ``a'' for ``an''.
    Subsec. (z). Pub. L. 92-603, Secs. 234(b), 278(b)(6), added subsec. 
(z) and substituted ``skilled nursing facility'' for ``extended care 
facility''.
    1971--Subsec. (e)(5). Pub. L. 91-690 authorized the Secretary, until 
January 1, 1976, to waive the requirement relating to the provision of 
24 hour nursing service rendered or supervised by a registered 
professional nurse.
    1968--Subsec. (e). Pub. L. 90-248, Sec. 129(c)(9)(C), inserted 
reference to section 1395n(b) in first and third sentences and inserted 
``or diagnostic services'' after ``hospital services'' in third 
sentence.
    Pub. L. 90-248, Sec. 143(a), in second sentence after par. (8), 
changed definition of hospitals for purposes of making payments for 
emergency hospital services by deleting provision that hospital meet 
requirements of pars. (1) to (4), by requiring that such hospitals have 
full-time nursing services, be licensed as a hospital, and be primarily 
engaged in providing not nursing care and related services but medical 
or rehabilitative care by or under the supervision of a doctor of 
medicine or osteopathy.
    Subsec. (p). Pub. L. 90-248, Secs. 129(c)(10), 133(b), struck out 
definition of ``outpatient hospital diagnostic services'' and inserted 
definition of ``outpatient physical therapy services'', respectively.
    Subsec. (r)(3). Pub. L. 90-248, Sec. 127(a), added cl. (3).
    Subsec. (s). Pub. L. 90-248, Sec. 144(a)-(c), struck out ``(unless 
they would otherwise constitute inpatient hospital services, extended 
care services, or home health services)'' after ``items or services'' in 
text preceding par. (1), inserted after ``hospital'' in sentence 
following par. (9) ``which, for purposes of this sentence, means an 
institution considered a hospital for purposes of section 1395f(d) of 
this title)'', and inserted sentence following par. (13) providing that 
medical and other health services (other than physicians' services and 
services incident to physicians' services) furnished a patient of a 
facility which meets the definition of a hospital for emergency services 
will be covered under the medical insurance program only if such 
facility satisfies such health and safety requirements as are 
appropriate for the item or service furnished as the Secretary may 
determine are necessary.
    Subsec. (s)(2)(A) to (C). Pub. L. 90-248, Sec. 129(a), designated 
existing provisions as subpars. (A) and (B) and added subpar. (C).
    Subsec. (s)(2)(D). Pub. L. 90-248, Sec. 133(a), added subpar. (D).
    Subsec. (s)(3). Pub. L. 90-248, Sec. 134(a), included in medical and 
other health services diagnostic X-ray tests furnished in the patient's 
home under the supervision of a physician if the tests meet such health 
and safety conditions as the Secretary finds necessary.
    Subsec. (s)(6). Pub. L. 90-248, Sec. 132(a), provided that payments 
may be made with respect to expenses incurred in the purchase as well as 
in the rental of durable medical equipment.
    Pub. L. 90-248, Sec. 144(d), inserted ``other than in institution 
that meets the requirements of subsection (e)(1) or (j)(1) of this 
section''.
    Subsec. (s)(12), (13). Pub. L. 90-248, Sec. 129(b), added pars. (12) 
and (13) which excluded from the diagnostic services referred to in par. 
(2)(C) (other than physician's services) certain items or service.
    Subsec. (y)(3). Pub. L. 90-248, Sec. 129(c)(11), substituted 
``1395e(a)(3)'' for ``1395e(a)(4)''.
    1966--Subsec. (v)(1). Pub. L. 89-713 inserted provisions which 
required that, in the case of extended care services furnished by 
proprietary facilities, the regulations include provision for specific 
recognition of a reasonable return on equity capital and which placed a 
limitation on the rate of return of one and one-half times the average 
of the rates of interest on obligations issued for purchase by the 
Federal Hospital Insurance Trust Fund.


                    Effective Date of 1999 Amendment

    Amendment by section 1000(a)(6) [title II, Sec. 201(k)] of Pub. L. 
106-113 effective as if included in enactment of the Balanced Budget Act 
of 1997, Pub. L. 105-33, except as otherwise provided, see 
Sec. 1000(a)(6) [title II, Sec. 201(m)] of Pub. L. 106-113, set out as a 
note under section 1395l of this title.
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 221(b)(2)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-351, provided that: ``The 
amendments made by paragraph (1) [amending this section] apply to 
services furnished on or after January 1, 2000.''
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 303(c)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-361, provided that: ``The 
amendments made by this section [amending this section and section 
1395fff of this title] shall apply to services furnished by home health 
agencies for cost reporting periods beginning on or after October 1, 
1999.''
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 304(c)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-361, provided that: ``The 
amendments made by this section [amending this section and enacting 
section 1320b-7f of this title] take effect on the date of the enactment 
of this Act [Nov. 29, 1999], and in applying section 1861(o)(7) of the 
Social Security Act (42 U.S.C. 1395x(o)(7)), as amended by subsection 
(a), the Secretary of Health and Human Services may take into account 
the previous period for which a home health agency had a surety bond in 
effect under such section before such date.''
    Amendment by section 1000(a)(6) [title III, Sec. 321(k)(7)-(9)] 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 4102(a), (c) of Pub. L. 105-33 applicable to 
items and services furnished on or after Jan. 1, 1998, see section 
4102(e) of Pub. L. 105-33, set out as a note under section 1395l of this 
title.
    Amendment by section 4103(a) of Pub. L. 105-33 applicable to items 
and services furnished on or after Jan. 1, 2000, see section 4103(e) of 
Pub. L. 105-33, set out as a note under section 1395l of this title.
    Amendment by section 4104(a)(1) of Pub. L. 105-33 applicable to 
items and services furnished on or after Jan. 1, 1998, see section 
4104(e) of Pub. L. 105-33, set out as a note under section 1395l of this 
title.
    Amendment by section 4105(a)(1), (b)(1) of Pub. L. 105-33 applicable 
to items and services furnished on or after July 1, 1998, see section 
4105(d)(1) of Pub. L. 105-33, set out as a note under section 1395m of 
this title.
    Section 4106(d) of Pub. L. 105-33 provided that: ``The amendments 
made by this section [amending this section and sections 1395w-4, 
1395aa, 1396a, and 1396n of this title] shall apply to bone mass 
measurements performed on or after July 1, 1998.''
    Amendment by section 4201(c)(1), (2) of Pub. L. 105-33 applicable to 
services furnished on or after Oct. 1, 1997, see section 4201(d) of Pub. 
L. 105-33, set out as a note under section 1395f of this title.
    Section 4205(b)(2) of Pub. L. 105-33 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall take effect on 
January 1, 1998.''
    Section 4205(c)(2) of Pub. L. 105-33 provided that: ``The amendment 
made by paragraph (1) [amending this section] applies to waiver requests 
made on or after January 1, 1998.''
    Section 4205(d)(4) of Pub. L. 105-33 provided that:
    ``(A) In general.--Except as otherwise provided, the amendments made 
by the preceding paragraphs [amending this section and section 1395u of 
this title] take effect on the date of the enactment of this Act [Aug. 
5, 1997].
    ``(B) Current rural health clinics.--The amendments made by the 
preceding paragraphs take effect, with respect to entities that are 
rural health clinics under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) on the date of enactment of this Act, on the date 
of the enactment of this Act [sic].
    ``(C) Grandfathered clinics.--
        ``(i) In general.--The amendment made by paragraph (3)(A) 
    [amending this section] shall take effect on the effective date of 
    regulations issued by the Secretary under clause (ii).
        ``(ii) Regulations.--The Secretary shall issue final regulations 
    implementing paragraph (3)(A) that shall take effect no later than 
    January 1, 1999.''
    Amendment by section 4312(d), (e) of Pub. L. 105-33 effective Aug. 
5, 1997, and may be applied with respect to items and services furnished 
on or after Jan. 1, 1998, see section 4312(f)(3) of Pub. L. 105-33, set 
out as a note under section 1395m of this title.
    Section 4312(f)(2) of Pub. L. 105-33 provided that: ``The amendments 
made by subsection (b) [amending this section] shall apply to home 
health agencies with respect to services furnished on or after January 
1, 1998. The Secretary of Health and Human Services shall modify 
participation agreements under section 1866(a)(1) of the Social Security 
Act (42 U.S.C. 1395cc(a)(1)) with respect to home health agencies to 
provide for implementation of such amendments on a timely basis.''
    Section 4321(d)(1) of Pub. L. 105-33 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to discharges 
occurring on or after the date which is 90 days after the date of the 
enactment of this Act [Aug. 5, 1997].''
    Section 4404(b) of Pub. L. 105-33 provided that: ``The amendments 
made by subsection (a) [amending this section] apply to changes of 
ownership that occur after the third month beginning after the date of 
enactment of this section [Aug. 5, 1997].''
    Amendment by section 4432(b)(5)(D), (E) 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.
    Section 4444(b) of Pub. L. 105-33 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply with respect 
to items or services furnished on or after April 1, 1998.''
    Amendment by sections 4445 and 4446 of Pub. L. 105-33 applicable to 
benefits provided on or after Aug. 5, 1997, except as otherwise 
provided, see section 4449 of Pub. L. 105-33, set out as a note under 
section 1395d of this title.
    Amendment by section 4454(a)(1) of Pub. L. 105-33 effective Aug. 5, 
1997, and applicable to items and services furnished on or after such 
date, with provision that Secretary of Health and Human Services issue 
regulations to carry out such amendment by not later than July 1, 1998, 
see section 4454(d) of Pub. L. 105-33, set out as an Effective Date note 
under section 1395i-5 of this title.
    Amendment by section 4511(a)(1)-(2)(B), (d) of Pub. L. 105-33 
applicable to services furnished and supplies provided on and after Jan. 
1, 1998, see section 4511(e) of Pub. L. 105-33, set out as a note under 
section 1395k of this title.
    Amendment by section 4512(a) of Pub. L. 105-33 applicable 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.
    Section 4513(b) of Pub. L. 105-33 provided that: ``The amendment 
made by subsection (a) [amending this section] applies to services 
furnished on or after January 1, 2000.''
    Section 4557(b) of Pub. L. 105-33 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to items and 
services furnished on or after January 1, 1998.''
    Section 4604(c) of Pub. L. 105-33 provided that: ``The amendments 
made by this section [amending this section and section 1395bbb of this 
title] apply to cost reporting periods beginning on or after October 1, 
1997.''
    Amendment by section 4611(b) 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.
    Section 4612(b) of Pub. L. 105-33 provided that: ``The amendment 
made by subsection (a) [amending this section] applies to services 
furnished on or after October 1, 1997.''


                    Effective Date of 1996 Amendment

    Amendment by Pub. L. 104-299 effective Oct. 1, 1996, see section 5 
of Pub. L. 104-299, as amended, set out as a note under section 233 of 
this title.


                    Effective Date of 1994 Amendment

    Section 107(b) of Pub. L. 103-432 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 one year after the date of the enactment of this Act [Oct. 31, 
1994].''
    Amendment by section 145(b) of Pub. L. 103-432 applicable to 
mammography furnished by the facility on and after the first date that 
the certificate requirements of section 263b(b) of this title apply to 
such mammography conducted by such facility, see section 145(d) of Pub. 
L. 103-432, set out as a note under section 1395m of this title.
    Section 146(c) of Pub. L. 103-432 provided that: ``The amendments 
made by this section [amending this section] shall take effect on 
January 1, 1995.''
    Amendment by section 147(e)(1), (4), (5), (f)(3), (4)(A), (6)(A), 
(B), (E) of Pub. L. 103-432 effective as if included in the enactment of 
Pub. L. 101-508, see section 147(g) of Pub. L. 103-432, set out as a 
note under section 1320a-3a of this title.
    Section 158(a)(2) of Pub. L. 103-432 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply with respect 
to cost reporting periods beginning on or after July 1, 1996.''


                    Effective Date of 1993 Amendment

    Section 13503(c)(2) of Pub. L. 103-66 provided that: ``The 
amendments made by paragraph (1) [amending this section and section 
1395oo of this title] shall take effect October 1, 1993.''
    Section 13553(c) of Pub. L. 103-66 provided that: ``The amendments 
made by subsections (a) and (b) [amending this section] shall apply to 
items furnished on or after January 1, 1994.''
    Section 13554(b) of Pub. L. 103-66 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after January 1, 1994.''
    Section 13556(b) of Pub. L. 103-66 provided that: ``The amendments 
made by subsection (a) [amending this section] shall take effect as if 
included in the enactment of section 4161(a)(2)(C) of OBRA-1990 [Pub. L. 
101-508].''
    Section 13564(b)(2) of Pub. L. 103-66 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to cost 
reporting periods beginning on or after October 1, 1993.''
    Section 13566(c) of Pub. L. 103-66 provided that: ``The amendments 
made by this section [amending this section and section 1395rr of this 
title] shall apply to erythropoietin furnished on or after January 1, 
1994.''


                    Effective Date of 1990 Amendment

    Amendment by section 4008(h)(2)(A)(i) of Pub. L. 101-508 effective 
as if included in the enactment of the Omnibus Budget Reconciliation Act 
of 1987, Pub. L. 100-203, see section 4008(h)(2)(P) of Pub. L. 101-508, 
set out as a note under section 1395i-3 of this title.
    Amendment by section 4152(a)(2) of Pub. L. 101-508 applicable to 
items furnished on or after Jan. 1, 1991, see section 4152(a)(3) of Pub. 
L. 101-508, set out as a note under section 1395m of this title.
    Section 4153(b)(2)(C) of Pub. L. 101-508 provided that: ``The 
amendments made by subparagraphs (A) and (B) [amending this section and 
section 1395y of this title] shall apply to items furnished on or after 
January 1, 1991.''
    Amendment by section 4155(a), (d) 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.
    Amendment by section 4157(a) of Pub. L. 101-508 applicable to 
services furnished on or after Jan. 1, 1991, see section 4157(d) of Pub. 
L. 101-508, set out as a note under section 1395k of this title.
    Amendment by section 4161(a)(1), (2), (5) of Pub. L. 101-508 
applicable to services furnished on or after Oct. 1, 1991, see section 
4161(a)(8) of Pub. L. 101-508, set out as a note under section 1395k of 
this title.
    Section 4161(b)(5) of Pub. L. 101-508 provided that: ``This 
subsection [amending this section and section 1395oo of this title and 
enacting provisions set out as a note below] shall take effect on 
October 1, 1991, except that the amendment made by paragraph (4) 
[amending section 1395oo of this title] shall apply to cost reports for 
periods beginning on or after October 1, 1991.''
    Amendment by section 4162(a) of Pub. L. 101-508 applicable with 
respect to partial hospitalization services provided on or after Oct. 1, 
1991, see section 4162(c) of Pub. L. 101-508, set out as a note under 
section 1395k of this title.
    Amendment by section 4163(a) of Pub. L. 101-508 applicable to 
screening mammography performed on or after Jan. 1, 1991, see section 
4163(e) of Pub. L. 101-508, set out as a note under section 1395l of 
this title.
    Section 4201(d)(3)[(4)] of Pub. L. 101-508 provided that: ``The 
amendments made by paragraphs (1) and (2) [amending this section and 
section 1395rr of this title] shall apply to items and services 
furnished on or after July 1, 1991.''
    Section 4207(d)(4), formerly 4027(d)(3), of Pub. L. 101-508, as 
renumbered and amended by Pub. L. 103-432, title I, Sec. 160(d)(4), 
(10), Oct. 31, 1994, 108 Stat. 4444, provided that: ``The amendment made 
by paragraph (1) [amending this section] shall apply with respect to 
home health agency cost reporting periods beginning on or after July 1, 
1991.''


                    Effective Date of 1989 Amendments

    Amendment by section 6112(e)(1) of Pub. L. 101-239 applicable with 
respect to items furnished on or after Jan. 1, 1990, see section 
6112(e)(4) of Pub. L. 101-239, set out as a note under section 1395m of 
this title.
    Amendment by section 6113(a)-(b)(2) of Pub. L. 101-239 applicable to 
services furnished on or after July 1, 1990, see section 6113(e) of Pub. 
L. 101-239, set out as a note under section 1395l of this title.
    Amendment by section 6114(a), (d) of Pub. L. 101-239 applicable to 
services furnished on or after Apr. 1, 1990, see section 6114(f) of Pub. 
L. 101-239, set out as a note under section 1395u of this title.
    Section 6115(d) of Pub. L. 101-239 provided that: ``The amendments 
made by this section [amending this section and sections 1395y, 1395aa, 
1395bb, 1396a, and 1396n of this title] shall apply to screening pap 
smears performed on or after July 1, 1990.''
    Amendment by section 6131(a)(2) of Pub. L. 101-239 applicable with 
respect to therapeutic shoes and inserts furnished on or after July 1, 
1989, with additional provisions regarding applicability of the increase 
under section 1395l(o)(2)(C) of this title, see section 6131(c) of Pub. 
L. 101-239, set out as a note under section 1395l of this title.
    Section 6141(b) of Pub. L. 101-239 provided that: ``The amendments 
made by subsection (a) [amending this section] shall take effect on the 
date of the enactment of this Act [Dec. 19, 1989].''
    Section 6213(d) of Pub. L. 101-239, as amended by Pub. L. 101-508, 
title IV, Sec. 4207(k)(4), formerly Sec. 4027(k)(4), Nov. 5, 1990, 104 
Stat. 1388-125, renumbered Pub. L. 103-432, title I, Sec. 160(d)(4), 
Oct. 31, 1994, 108 Stat. 4444, provided that: ``The amendments made by 
subsections (a) through (c) of this section [amending this section] 
shall apply to services furnished on or after October 1, 1989.''
    Amendment by section 101(a) of Pub. L. 101-234 effective Jan. 1, 
1990, see section 101(d) of Pub. L. 101-234, set out as a note under 
section 1395c 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.


                    Effective Date of 1988 Amendment

    Section 8423(b) of Pub. L. 100-647 provided that: ``The amendments 
made by subsection (a) [amending this section] shall be effective with 
respect to services furnished on or after January 1, 1989.''
    Section 8424(b) of Pub. L. 100-647 provided that: ``The amendment 
made by subsection (a) [amending this section] shall become effective 
with respect to services provided after December 31, 1988.''
    Amendment by Pub. L. 100-485 effective as if included in the 
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note 
under section 704 of this title.
    Amendment by section 104(d)(4) of Pub. L. 100-360 effective Jan. 1, 
1989, except as otherwise provided, and applicable to inpatient hospital 
deductible for 1989 and succeeding years, to care and services furnished 
on or after Jan. 1, 1989, to premiums for January 1989 and succeeding 
months, and to blood or blood cells furnished on or after Jan. 1, 1989, 
see section 104(a) of Pub. L. 100-360, set out as a note under section 
1395d of this title.
    Amendment by section 202(a) of Pub. L. 100-360 applicable to items 
dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub. L. 
100-360, set out as a note under section 1395u of this title.
    Amendment by section 203(b), (e)(1) of Pub. L. 100-360 applicable to 
items and services furnished on or after Jan. 1, 1990, see section 
203(g) of Pub. L. 100-360, set out as a note under section 1320c-3 of 
this title.
    Amendment by section 204(a) of Pub. L. 100-360 applicable to 
screening mammography performed on or after Jan. 1, 1990, see section 
204(e) of Pub. L. 100-360, set out as a note under section 1395m of this 
title.
    Amendment by section 205(b) of Pub. L. 100-360 applicable to items 
and services furnished on or after Jan. 1, 1990, see section 205(f) of 
Pub. L. 100-360, set out as a note under section 1395k of this title.
    Section 206(b) of Pub. L. 100-360, which provided that the amendment 
of this section by section 206(a) of Pub. L. 100-360 applied to services 
furnished in cases of initial periods of home health services beginning 
on or after January 1, 1990, was repealed by Pub. L. 101-234, title II, 
Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(d)(5)(A), (g)(3)(H), (h)(1)(B)-(3)(A), (4)(D), 
(5)-(7)(A), (E), (F), (i)(3), (4)(C)(iii), (l)(1)(B), (C) 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.
    Section 411(d)(1)(B)(ii) of Pub. L. 100-360 provided that: ``The 
amendment made by clause (i) [amending this section] shall apply to 
equipment furnished on or after the effective date provided in section 
4021(c) of OBRA [Pub. L. 100-203, set out below].''


                    Effective Date of 1987 Amendment

    Section 4009(e)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply with respect 
to services furnished on or after April 1, 1988.''
    Section 4021(c) of Pub. L. 100-203 provided that: ``Except as 
otherwise provided, the amendments made by subsections (a) and (b) 
[enacting section 1395bbb of this title and amending this section] shall 
apply to home health agencies as of the first day of the 18th calendar 
month that begins after the date of the enactment of this Act [Dec. 22, 
1987].''
    Section 4026(a)(2) of Pub. L. 100-203, as amended by Pub. L. 100-
360, title IV, Sec. 411(d)(5)(B), July 1, 1988, 102 Stat. 775, provided 
that: ``The amendment made by paragraph (1) [amending this section] 
shall apply to cost reporting periods beginning on or after July 1, 
1989.''
    Section 4064(e)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to diagnostic 
tests performed on or after January 1, 1990.''
    Section 4065(c) of Pub. L. 100-203 provided that: ``The amendments 
made by this section [amending this section and section 1395rr of this 
title] shall become effective on January 1, 1988.''
    Section 4070(c)(2) of Pub. L. 100-203 provided that:
    ``(A) The amendments made by subsection (b) [amending this section 
and sections 1395l and 1395n of this title] shall become effective on 
the date of enactment of this Act [Dec. 22, 1987].
    ``(B) The Secretary of Health and Human Services shall implement the 
amendments made by subsection (b) so as to ensure that there is no 
additional cost to the medicare program by reason of such amendments.''
    Section 4071(b) of Pub. L. 100-203 provided that:
    ``(1) The provisions of subsection (e) of section 4072 of this 
subpart [section 4072(e) of Pub. L. 100-203, set out below] shall apply 
to this section [amending this section] in the same manner as it applies 
to section 4072. [Amendments became effective pursuant to final report 
dated Apr. 26, 1993. See Cong. Rec., vol. 139, p. H2595, Daily Issue, 
Ex. Comm. 1254.]
    ``(2) In conducting the demonstration project pursuant to paragraph 
(1), in order to determine the cost effectiveness of including influenza 
vaccine in the medicare program, the Secretary of Health and Human 
Services is required to conduct a demonstration of the provision of 
influenza vaccine as a service for medicare beneficiaries and to expend 
$25,000,000 each year of the demonstration project for this purpose. In 
conducting this demonstration, the Secretary is authorized to purchase 
in bulk influenza vaccine and to distribute it in a manner to make it 
widely available to medicare beneficiaries, to develop projects to 
provide vaccine in the same manner as other covered medicare services in 
large scale demonstration projects, including statewide projects, and to 
engage in other appropriate use of moneys to provide influenza vaccine 
to medicare beneficiaries and evaluate the cost effectiveness of its 
use. In determining cost effectiveness, the Secretary shall consider the 
direct cost of the vaccine, the utilization of vaccine which might 
otherwise not have occurred, the costs of illnesses and nursing home 
days avoided, and other relevant factors, except that extended life for 
beneficiaries shall not be considered to reduce the cost effectiveness 
of the vaccine.''
    Section 4072(e) of Pub. L. 100-203 provided that:
    ``(1) The amendments made by this section [amending this section and 
sections 1395l, 1395y, 1395aa, 1395bb, 1396a, and 1396n of this title] 
shall become effective (if at all) in accordance with paragraph (2).
    ``(2)(A) The Secretary of Health and Human Services (in this 
paragraph referred to as the `Secretary'), shall establish a 
demonstration project to begin on October 1, 1988, to test the cost-
effectiveness of furnishing therapeutic shoes under the medicare program 
to the extent provided under the amendments made by this section to a 
sample group of medicare beneficiaries.
    ``(B)(i) The demonstration project under subparagraph (A) shall be 
conducted for an initial period of 24 months. Not later than October 1, 
1990, the Secretary shall report to the Congress on the results of such 
project. If the Secretary finds, on the basis of existing data, that 
furnishing therapeutic shoes under the medicare program to the extent 
provided under the amendments made by this section is cost-effective, 
the Secretary shall include such finding in such report, such project 
shall be discontinued, and the amendments made by this section shall 
become effective on November 1, 1990.
    ``(ii) If the Secretary determines that such finding cannot be made 
on the basis of existing data, such project shall continue for an 
additional 24 months. Not later than April 1, 1993, the Secretary shall 
submit a final report to the Congress on the results of such project. 
The amendments made by this section shall become effective on the first 
day of the first month to begin after such report is submitted to the 
Congress unless the report contains a finding by the Secretary that 
furnishing therapeutic shoes under the medicare program to the extent 
provided under the amendments made by this section is not cost-effective 
(in which case the amendments made by this section shall not become 
effective).''
    [Amendments by section 4072 of Pub. L. 100-203 became effective 
pursuant to final report dated Apr. 26, 1993. See Cong. Rec., vol. 139, 
p. H2595, Daily Issue, Ex. Comm. 1252.]
    Amendment by section 4073(a), (c) of Pub. L. 100-203 effective with 
respect to services performed on or after July 1, 1988, see section 
4073(e) of Pub. L. 100-203, set out as a note under section 1395k of 
this title.
    Section 4074(c) of Pub. L. 100-203 provided that: ``The amendments 
made by this section [amending this section] shall be effective with 
respect to services performed on or after January 1, 1988.''
    Section 4075(b) of Pub. L. 100-203 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to drugs 
dispensed on or after the date of the enactment of this Act [Dec. 22, 
1987].''
    Section 4076(b) of Pub. L. 100-203 provided that: ``The amendments 
made by this section [amending this section] shall apply with respect to 
services furnished on or after January 1, 1989.''
    Section 4077(a)(2) of Pub. L. 100-203 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective with 
respect to services furnished on or after the date of enactment of this 
Act [Dec. 22, 1987].''
    Amendment by section 4077(b)(1), (4) of Pub. L. 100-203 effective 
with respect to services performed on or after July 1, 1988, see section 
4077(b)(5) of Pub. L. 100-203, as amended, set out as a note under 
section 1395k of this title.
    Amendment by section 4084(c)(1) of Pub. L. 100-203 applicable to 
services furnished after Dec. 31, 1988, see section 4084(c)(3) of Pub. 
L. 100-203, as added, set out as a note under section 1395l of this 
title.
    Amendments by section 4201(a)(1), (b)(1), (d)(1), (2), (5) of Pub. 
L. 100-203 applicable to services furnished on or after Oct. 1, 1990, 
without regard to whether regulations to implement such amendments are 
promulgated by such date, except as otherwise specifically provided in 
section 1395i-3 of this title, see section 4204(a) of Pub. L. 100-203, 
as amended, set out as an Effective Date note under section 1395i-3 of 
this title.


                    Effective Date of 1986 Amendments

    Section 9305(c)(4) of Pub. L. 99-509 provided that: ``The amendments 
made by this subsection [amending this section and section 1395bb of 
this title] shall apply to hospitals as of one year after the date of 
the enactment of this Act [Oct. 21, 1986].''
    Section 9313(a)(3) of Pub. L. 99-509 provided that: ``The amendments 
made by this paragraph [probably means ``this subsection'' which amended 
this section and section 1395ff of this title] take effect on the date 
of the enactment of this Act [Oct. 21, 1986].''
    Amendment by section 9320(b), (c), (f) 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 9335(c)(2) of Pub. L. 99-509 provided that: ``The amendments 
made by paragraph (1) [amending this section] shall apply to 
immunosuppressive drugs furnished on or after January 1, 1987.''
    Section 9336(b) of Pub. L. 99-509 provided that: ``The amendment 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after April 1, 1987.''
    Amendment by section 9337(d) of Pub. L. 99-509 applicable to 
expenses incurred for outpatient occupational therapy services furnished 
on or after July 1, 1987, see section 9337(e) of Pub. L. 99-509, set out 
as a note under section 1395k of this title.
    Section 9338(f) of Pub. L. 99-509 provided that: ``The amendments 
made by this section [amending this section and section 1395u of this 
title] shall apply to services furnished on or after January 1, 1987.''
    Section 9107(c)(2) of Pub. L. 99-272 provided that: ``The amendments 
made by subsection (b) [amending this section] shall apply to cost 
reporting periods beginning on or after October 1, 1985.''
    Section 9110(b) of Pub. L. 99-272 provided that: ``The amendments 
made by subsection (a) [amending this section] shall be applied as 
though they were originally included in the Deficit Reduction Act of 
1984 [Pub. L. 98-369].''
    Section 9202(i)(2) of Pub. L. 99-272 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to cost 
reporting periods beginning on or after July 1, 1985.''
    Amendment by section 9219(b)(1)(B) of Pub. L. 99-272 effective as if 
originally included in the Deficit Reduction Act of 1984, Pub. L. 98-
369, see section 9219(b)(1)(D) of Pub. L. 99-272, set out as a note 
under section 1395u of this title.
    Section 9219(b)(3)(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 the Social Security 
Amendments of 1983 [Pub. L. 98-21].''


                    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.
    Section 2314(c)(1), (2) of Pub. L. 98-369 provided that:
    ``(1) Clause (i) of section 1861(v)(1)(O) of the Social Security Act 
[subsec. (v)(1)(O)(i) of this section] shall not apply to changes of 
ownership of assets pursuant to an enforceable agreement entered into 
before the date of the enactment of this Act [July 18, 1984].
    ``(2) Clause (iii) of section 1861(v)(1)(O) of such Act [subsec. 
(v)(1)(O)(iii) of this section] shall apply to costs incurred on or 
after the date of the enactment of this Act.''
    Section 2318(c) of Pub. L. 98-369 provided that: ``The amendments 
made by this section [amending this section] shall apply to services 
furnished on or after the date of the enactment of this Act [July 18, 
1984].''
    Amendment by section 2319(a) of Pub. L. 98-369 applicable to cost 
reporting periods beginning on or after July 1, 1984, see section 
2319(c) of Pub. L. 98-369, set out as an Effective Date note under 
section 1395yy of this title.
    Amendment by section 2321(e) of Pub. L. 98-369 applicable to items 
and services furnished on or after July 18, 1984, see section 2321(g) of 
Pub. L. 98-369, set out as a note under section 1395f of this title.
    Section 2322(b) of Pub. L. 98-369 provided that: ``The amendments 
made by subsection (a) [amending this section] shall be effective with 
respect to services furnished on or after the date of the enactment of 
this Act [July 18, 1984].''
    Amendment by section 2323(a) of Pub. L. 98-369 applicable to 
services furnished on or after Sept. 1, 1984, see section 2323(d) of 
Pub. L. 98-369, set out as a note under section 1395l of this title.
    Section 2324(b) of Pub. L. 98-369 provided that: ``The amendments 
made by subsection (a) [amending this section] shall be effective with 
respect to items and services purchased on or after the date of the 
enactment of this Act [July 18, 1984].''
    Amendment by section 2335(b) of Pub. L. 98-369 effective July 18, 
1984, see section 2335(g) of Pub. L. 98-369, set out as a note under 
section 1395f of this title.
    Section 2340(c) of Pub. L. 98-369 provided that: ``The amendments 
made by this section [amending this section and section 1396d of this 
title] shall become effective on the date of the enactment of this Act 
[July 18, 1984].''
    Amendment by section 2341(a), (c) of Pub. L. 98-369 applicable to 
services furnished on or after July 18, 1984, see section 2341(d) of 
Pub. L. 98-369, set out as a note under section 1395k of this title.
    Amendment by section 2342(a) of Pub. L. 98-369 applicable to plans 
of care established on or after July 18, 1984, see section 2342(c) of 
Pub. L. 98-369, set out as a note under section 1395n of this title.
    Section 2343(c) of Pub. L. 98-369 provided that: ``The amendments 
made by subsections (a) and (b) [amending this section] shall become 
effective on the date of the enactment of this Act [July 18, 1984].''
    Amendment by section 2354(b)(18)-(29) 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.


                    Effective Date of 1983 Amendments

    Amendment by section 602(d) of Pub. L. 98-21 applicable to items and 
services furnished by or under arrangement with a hospital beginning 
with its first cost reporting period that begins on or after Oct. 1, 
1983, any change in a hospital's cost reporting period made after 
November 1982 to be recognized for such purposes only if the Secretary 
finds good cause therefor, see section 604(a)(1) of Pub. L. 98-21, set 
out as a note under section 1395ww of this title.
    Amendment by Pub. L. 97-448 effective as if originally included in 
the provision of the Tax Equity and Fiscal Responsibility Act of 1982, 
Pub. L. 97-248, to which such amendment relates, see section 309(c)(1) 
of Pub. L. 97-448, set out as a note under section 426 of this title.


                    Effective Date of 1982 Amendment

    Amendment by section 101(a)(2) of Pub. L. 97-248 applicable to cost 
reporting periods beginning on or after Oct. 1, 1982, see section 
101(b)(1) of Pub. L. 97-248, set out as an Effective Date note under 
section 1395ww of this title.
    Section 102(b) of Pub. L. 97-248, as amended by Pub. L. 98-21, title 
VI, Sec. 605(a), Apr. 20, 1983, 97 Stat. 169, provided that: ``The 
amendment made by subsection (a) [amending this section] shall be 
effective with respect to cost reporting periods beginning on or after 
October 1, 1983.''
    Section 103(b) of Pub. L. 97-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be effective with 
respect to cost reporting periods ending after September 30, 1982, but 
in the case of any cost reporting period beginning before October 1, 
1982, any reduction in payments under title XVIII of the Social Security 
Act [this subchapter] to a hospital or skilled nursing facility 
resulting from such amendment shall be imposed only in proportion to the 
part of the period which occurs after September 30, 1982.''
    Section 105(b) of Pub. L. 97-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be effective with 
respect to cost reporting periods beginning on or after the date of the 
enactment of this Act [Sept. 3, 1982].''
    Section 106(b) of Pub. L. 97-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be effective with 
respect to any costs incurred under title XVIII of the Social Security 
Act [this subchapter], except that it shall not apply to costs which 
have been allowed prior to the date of the enactment of this Act [Sept. 
3, 1982] pursuant to the final court order affirmed by a United States 
Court of Appeals.''
    Section 107(b) of Pub. L. 97-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be effective with 
respect to costs incurred after the date of the enactment of this Act 
[Sept. 3, 1982].''
    Amendment by section 109(b)(2) of Pub. L. 97-248 effective Sept. 3, 
1982, see section 109(c)(1) of Pub. L. 97-248, set out as a note under 
section 1395xx of this title.
    Section 109(c)(3) of Pub. L. 97-248 provided that: ``The amendment 
made by subsection (b)(1) [amending this section] shall not apply to 
contracts entered into before the date of the enactment of this Act 
[Sept. 3, 1982].''
    Amendment by section 122(d) of Pub. L. 97-248 applicable to hospice 
care provided on or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 
97-248, as amended, set out as a note under section 1395c of this title.
    Section 128(e) of Pub. L. 97-248, as amended by Pub. L. 99-514, 
Sec. 2, Oct. 22, 1986, 100 Stat. 2095, provided that:
    ``(1) Any amendment to the Omnibus Budget Reconciliaton 
[Reconciliation] Act of 1981 [Pub. L. 97-35] made by this section 
[amending provisions set out as notes under sections 426 and 1395x of 
this title] shall be effective as if it had been originally included in 
the provision of the Omnibus Budget Reconciliation Act of 1981 to which 
such amendment relates.
    ``(2) Except as otherwise provided in this section, any amendment to 
the Social Security Act [this chapter] or the Internal Revenue Code of 
1986 [formerly I.R.C. 1954] [Title 26, Internal Revenue Code] made by 
this section (other than subsection (d)) [amending this section and 
sections 1395y, 1395cc, and 1395uu of this title and section 162 of 
Title 26] shall be effective as if it had been originally included as a 
part of that provision of the Social Security Act or Internal Revenue 
Code of 1986 to which it relates, as such provision of such Act or Code 
was amended by the Omnibus Budget Reconciliaton [Reconciliation] Act of 
1981 [Pub. L. 97-35].
    ``(3) The amendments made by subsection (d) [amending this section 
and sections 1395u, 1395bb, 1395cc, and 1395gg of this title] shall take 
effect upon enactment [Sept. 3, 1982].''
    Amendment by section 148(b) of Pub. L. 97-248 effective with respect 
to contracts entered into or renewed on or after Sept. 3, 1982, see 
section 149 of Pub. L. 97-248, set out as an Effective Date note under 
section 1320c of this title.


                    Effective Date of 1981 Amendment

    Section 2102(b)(1) of Pub. L. 97-35 provided that: ``The amendments 
made by subsection (a) [amending this section], shall apply to services 
provided on or after the first day of the first month beginning after 
the date of the enactment of this Act [Aug. 13, 1981].''
    Amendment by section 2121(c), (d) of Pub. L. 97-35 applicable to 
services furnished in detoxification facilities for inpatient stays 
beginning on or after the tenth day after Aug. 13, 1981, see section 
2121(i) of Pub. L. 97-35, set out as a note under section 1395d of this 
title.
    Section 2141(c) of Pub. L. 97-35 provided that:
    ``(1) Subject to paragraph (2), the amendment made by subsection (a) 
[amending this section] shall apply to cost reporting periods ending 
after September 30, 1981.
    ``(2) In the case of a cost reporting period beginning before 
October 1, 1981, any reduction in payments resulting from the amendment 
made by subsection (a) shall be imposed only in proportion to the part 
of the period that occurs after September 30, 1981.''
    Section 2143(b) of Pub. L. 97-35, as amended by Pub. L. 97-248, 
title I, Sec. 128(c)(1), Sept. 3, 1982, 96 Stat. 367, provided that:
    ``(1) Subject to paragraph (2), the amendment made by subsection (a) 
[amending this section] shall apply to cost reporting periods ending 
after September 30, 1981.
    ``(2) In the case of a cost reporting period beginning before 
October 1, 1981, any reduction in payments resulting from the amendment 
made by subsection (a) shall be imposed only in proportion to the part 
of the period that occurs after September 30, 1981.''
    Section 2144(b) of Pub. L. 97-35 provided that:
    ``(1) Subject to paragraph (2), the amendment made by subsection (a) 
[amending this section] shall apply to cost reporting periods ending 
after September 30, 1981.
    ``(2) In the case of a cost reporting period beginning before 
October 1, 1981, any reduction in payments resulting from the amendment 
made by subsection (a) shall be imposed only in proportion to the part 
of the period that occurs after September 30, 1981.''
    For effective date, savings, and transitional provisions relating to 
amendment by section 2193(c)(9) of Pub. L. 97-35, see section 2194 of 
Pub. L. 97-35, set out as a note under section 701 of this title.


                    Effective Date of 1980 Amendments

    Amendment by Pub. L. 96-611 effective July 1, 1981, and applicable 
to services furnished on or after that date, see section 2 of Pub. L. 
96-611, set out as a note under section 1395l of this title.
    Section 902(c) of Pub. L. 96-499 provided that: ``The amendments 
made by this section [amending this section and sections 1320c-7 and 
1396a of this title] shall become effective on the date of [probably 
should be ``on''] which final regulations, promulgated by the Secretary 
to implement such amendments, are first issued; and those regulations 
shall be issued not later than the first day of the sixth month 
following the month in which this Act is enacted [December 1980].''
    Section 930(s) of Pub. L. 96-499 provided that:
    ``(1) the amendments made by this section [amending this section, 
sections 426, 1395c, 1395d, 1395f, 1395h, 1395k, 1395l, and 1395n of 
this title, and section 231f of Title 45, Railroads, and repealing 
section 1395m of this title] shall become effective with respect to 
services furnished on or after July 1, 1981, except that the amendments 
made by subsections (n)(1) and (o) [amending this section and section 
1395h of this title] shall become effective on the date of the enactment 
of this Act [Dec. 5, 1980].
    ``(2) The Secretary of Health and Human Services shall take 
administrative action to assure that improvements, in accordance with 
the amendment made by subsection (n)(1) [amending this section], will be 
made not later than June 30, 1981.''
    Amendment by section 931(c), (d) of Pub. L. 96-499 effective Apr. 1, 
1981, see section 931(e) of Pub. L. 96-499, set out as a note under 
section 1395d of this title.
    Amendment by section 933(c)-(e) of Pub. L. 96-499 effective with 
respect to a comprehensive outpatient rehabilitation facility's first 
accounting period beginning on or after July 1, 1981, see section 933(h) 
of Pub. L. 96-499, set out as a note under section 1395k of this title.
    Amendment by section 936(a) of Pub. L. 96-499 applicable with 
respect to services provided on or after July 1, 1981, see section 
936(d) of Pub. L. 96-499, set out as a note under section 1395f of this 
title.
    Section 937(c) of Pub. L. 96-499, as amended by Pub. L. 98-369, div. 
B, title III, Sec. 2354(c)(1)(B), July 18, 1984, 98 Stat. 1102, provided 
that: ``The amendment made by subsection (a) [amending this section] 
shall apply to services furnished on or after July 1, 1981.''
    Section 938(b) of Pub. L. 96-499 provided that: ``The amendments 
made by subsection (a) [amending this section] shall apply to services 
furnished on or after January 1, 1981.''
    Section 948(c)(1) of Pub. L. 96-499 provided that: ``The amendments 
made by subsection (a) [amending this section and section 1395k of this 
title] shall apply with respect to cost accounting periods beginning on 
or after October 1, 1978. A hospital's election under section 
1861(b)(7)(A) of the Social Security Act [subsec. (b)(7)(A) of this 
section] (as administered in accordance with section 15 of Public Law 
93-233) as of September 30, 1978, shall constitute such hospital's 
election under such section (as amended by subsection (a)(1)) on and 
after October 1, 1978, until otherwise provided by the hospital.''
    Section 951(c) of Pub. L. 96-499 provided that: ``The amendments 
made by this section [amending this section] shall take effect on 
January 1, 1981.''


                    Effective Date of 1978 Amendment

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


                    Effective Date of 1977 Amendments

    Section 501(c) of Pub. L. 95-216 provided that: ``The amendments 
made by this section [amending this section and section 1395u of this 
title] shall be effective in the case of items and services furnished 
after the date of the enactment of this Act [Dec. 20, 1977].''
    Amendment by Pub. L. 95-210 applicable to services rendered on or 
after the first day of the third calendar month which begins after Dec. 
31, 1977, see section 1(j) of Pub. L. 95-210, set out as a note under 
section 1395k of this title.
    Amendment by section 3(a)(2) of Pub. L. 95-142 effective Oct. 25, 
1977, see section 3(e) of Pub. L. 95-142, set out as an Effective Date 
note under section 1320a-3 of this title.
    Amendment by section 19(b)(1) of Pub. L. 95-142 effective with 
respect to operation of a hospital, skilled nursing facility, or 
intermediate care facility on and after the first day of its first 
fiscal year which begins after the end of the six-month period beginning 
on the date a uniform reporting system is established under section 
1320a(a) of this title for that type of health services facility, except 
that for other types of facilities or organizations effective with 
respect to operations on and after the first day of its first fiscal 
year which begins after such date as the Secretary determines to be 
appropriate for the implementation of the reporting requirement for that 
type of facility or organization, see section 19(c)(2) of Pub. L. 95-
142, set out as a note under section 1396a of this title.
    Section 21(c)(1) of Pub. L. 95-142 provided that: ``The amendments 
made by subsection (a) [amending this section] shall be effective on the 
first day of the first calendar quarter which begins more than six 
months after the date of enactment of this Act [Oct. 25, 1977].''


                    Effective Date of 1975 Amendment

    Section 106(b) of Pub. L. 94-182 provided that: ``Subject to 
subsection (c) [enacting provisions set out below], the amendment made 
by subsection (a) [amending this section] shall be effective on the 
first day of the sixth month which begins after the date of enactment of 
this Act [Dec. 31, 1975].''
    Section 112(d) of Pub. L. 94-182 provided that: ``The amendments 
made by this section [amending this section and sections 1320c-17 and 
1395g of this title] shall be effective with respect to utilization 
review activities conducted on and after the first day of the first 
month which begins more than 30 days after the date of enactment of this 
Act [Dec. 31, 1975].''


                    Effective Date of 1972 Amendment

    Amendment by section 211(b), (c)(2) 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.
    Section 223(h) of Pub. L. 92-603 provided that: ``The amendments 
made by this section [amending this section and section 1395cc of this 
title] shall be effective with respect to accounting periods beginning 
after December 31, 1972.''
    Section 227(g) of Pub. L. 92-603 provided that: ``The amendments 
made by this section [amending this section and sections 1395f, 1395k, 
1395n, 1395u, and 1395cc of this title] shall apply with respect to 
accounting periods beginning after June 30, 1973.''
    Section 234(i) of Pub. L. 92-603 provided that: ``The amendments 
made by this section [amending this section and sections 1395f, 1395z, 
and 1395bb of this title] shall apply with respect to any provider of 
services for fiscal years (of such provider) beginning after the fifth 
month following the month in which this Act is enacted [October 1972].''
    Section 246(c) of Pub. L. 92-603 provided that: ``The amendments 
made by this section [amending this section and section 1396 of this 
title] shall be effective July 1, 1973.''
    Section 251(d) of Pub. L. 92-603, as amended by Pub. L. 93-233, 
Sec. 17(a), Dec. 31, 1973, 87 Stat. 967, provided that:
    ``(1) The amendments made by subsection (a) [amending this section 
and sections 1395l and 1395k of this title] shall apply with respect to 
services furnished on or after July 1, 1973.
    ``(2) The amendments made by subsection (b) [amending this section 
and section 1395n of this title] shall apply with respect to services 
furnished on or after the date of enactment of this Act [Oct. 30, 1972].
    ``(3) The amendments made by subsection (c) [amending this section] 
shall be effective with respect to accounting periods beginning after 
the month in which there are promulgated, by the Secretary of Health, 
Education, and Welfare, final regulations implementing the provisions of 
section 1861(v)(5) of the Social Security Act [subsec. (v)(5) of this 
section].''
    Section 252(b) of Pub. L. 92-603 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply only with respect 
to items furnished on or after the date of the enactment of this Act 
[Oct. 30, 1972].''
    Amendment by section 256(b) of Pub. L. 92-603 applicable with 
respect to admissions occurring after the second month following the 
month of enactment of Pub. L. 92-603 which was approved on Oct. 30, 
1972, see section 256(d) of Pub. L. 92-603, set out as a note under 
section 1395f of this title.
    Section 264(b) of Pub. L. 92-603 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply only with respect 
to services performed on or after the date of the enactment of this Act 
[Oct. 30, 1972].''
    Section 273(b) of Pub. L. 92-603 provided that: ``The amendments 
made by this section [amending this section] shall be effective with 
respect to services furnished after June 30, 1973.''
    Section 276(b) of Pub. L. 92-603 provided that: ``The amendment made 
by this section [amending this section] shall apply with respect to 
accounting periods beginning after December 31, 1972.''
    Amendment by section 283(a) of Pub. L. 92-603 to apply with respect 
to services rendered after Dec. 31, 1972, see section 283(c) of Pub. L. 
92-603, set out as a note under section 1395n of this title.


                    Effective Date of 1968 Amendment

    Section 127(c) of Pub. L. 90-248 provided that: ``The amendments 
made by subsections (a) and (b) [amending this section and section 1395y 
of this title] shall apply with respect to services furnished after 
December 31, 1967.''
    Amendment by section 129(a), (b), (c)(9)(C), (10), (11) of Pub. L. 
90-248 applicable with respect to services furnished after Mar. 31, 
1968, see section 129(d) of Pub. L. 90-248, set out as a note under 
section 1395d of this title.
    Amendment by section 132(a) of Pub. L. 90-248 applicable with 
respect to items purchased after Dec. 31, 1967, see section 132(c) of 
Pub. L. 90-248, set out as a note under section 1395l of this title.
    Amendment by section 133(a), (b) of Pub. L. 90-248 applicable with 
respect to services furnished after June 30, 1968, see section 133(g) of 
Pub. L. 90-248, set out as a note under section 1395k of this title.
    Section 134(b) of Pub. L. 90-248 provided that: ``The amendment made 
by subsection (a) [amending this section] shall apply with respect to 
services furnished after December 31, 1967.''
    Amendment by section 143(a) of Pub. L. 90-248 effective July 1, 
1966, see section 143(d) of Pub. L. 90-248, set out as a note under 
section 1395d of this title.
    Section 144(e) of Pub. L. 90-248 provided that: ``The amendments 
made by this section [amending this section] shall apply with respect to 
services furnished after March 31, 1968.''


                    Effective Date of 1966 Amendment

    Amendment by Pub. L. 89-713 effective Nov. 2, 1966, see section 6 of 
Pub. L. 89-713, set out as a note under section 6091 of Title 26, 
Internal Revenue Code.


         Prompt Implementation of Amendments by Pub. L. 105-277

    Pub. L. 105-277, div. J, title V, Sec. 5101(i), Oct. 21, 1998, 112 
Stat. 2681-916, provided that:
    ``(1) In general.--The Secretary of Health and Human Services shall 
promptly issue (without regard to chapter 8 of title 5, United States 
Code) such regulations or program memoranda as may be necessary to 
effect the amendments made by this section [amending this section, 
sections 1395r and 1395fff of this title, and provisions set out as 
notes under section 1395fff of this title] for cost reporting periods 
beginning during fiscal year 1999.
    ``(2) Use of payment amounts and limits from published tables.--
        ``(A) Per beneficiary limits.--In effecting the amendments made 
    by subsection (a) [amending this section] for cost reporting periods 
    beginning in fiscal year 1999, the `median' referred to in section 
    1861(v)(1)(L)(vi)(I) of the Social Security Act [subsec. 
    (v)(1)(L)(vi)(I) of this section] for such periods shall be the 
    national standardized per beneficiary limitation specified in Table 
    3C published in the Federal Register on August 11, 1998 (63 FR 
    42926) and the `standardized regional average of such costs' 
    referred to in section 1861(v)(1)(L)(v)(I) of such Act [subsec. 
    (v)(1)(L)(v)(I) of this section] for a census division shall be the 
    sum of the labor and nonlabor components of the standardized per 
    beneficiary limitation for that census division specified in Table 
    3B published in the Federal Register on that date (63 FR 42926) (or 
    in Table 3D as so published with respect to Puerto Rico and Guam), 
    and adjusted to reflect variations in wages among different 
    geographic areas as specified in Tables 4a and 4b published in the 
    Federal Register on that date (63 FR 42926-42933).
        ``(B) Per visit limits.--In effecting the amendments made by 
    subsection (b) [amending this section] for cost reporting periods 
    beginning in fiscal year 1999, the limits determined under section 
    1861(v)(1)(L)(i)(V) of such Act [subsec. (v)(1)(L)(i)(V) of this 
    section] for cost reporting periods beginning during such fiscal 
    year shall be equal to the per visit limits as specified in Table 3A 
    published in the Federal Register on August 11, 1998 (63 FR 42925) 
    and as subsequently corrected, multiplied by \106/105\, and adjusted 
    to reflect variations in wages among different geographic areas as 
    specified in Tables 4a and 4b published in the Federal Register on 
    August 11, 1998 (63 FR 42926-42933).''


                Conforming References to Previous Part C

    Section 4002(f)(1) of Pub. L. 105-33 provided that: ``Any reference 
in law (in effect before the date of the enactment of this Act [Aug. 5, 
1997]) to part C of title XVIII of the Social Security Act [part C of 
this subchapter] is deemed a reference to part D of such title [this 
part] (as in effect after such date).''


   Deadline for Publication of Determination on Coverage of Screening 
                              Barium Enema

    Section 4104(a)(2) of Pub. L. 105-33 provided that: ``Not later than 
the earlier of the date that is January 1, 1998, or 90 days after the 
date of the enactment of this Act [Aug. 5, 1997], the Secretary of 
Health and Human Services shall publish notice in the Federal Register 
with respect to the determination under paragraph (1)(D) of section 
1861(pp) of the Social Security Act (42 U.S.C. 1395x(pp)), as added by 
paragraph (1), on the coverage of a screening barium enema as a 
colorectal cancer screening test under such section.''


    Establishment of Outcome Measures for Beneficiaries With Diabetes

    Section 4105(c) of Pub. L. 105-33 provided that:
    ``(1) In general.--The Secretary of Health and Human Services, in 
consultation with appropriate organizations, shall establish outcome 
measures, including glysolated hemoglobin (past 90-day average blood 
sugar levels), for purposes of evaluating the improvement of the health 
status of medicare beneficiaries with diabetes mellitus.
    ``(2) Recommendations for modifications to screening benefits.--
Taking into account information on the health status of medicare 
beneficiaries with diabetes mellitus as measured under the outcome 
measures established under paragraph (1), the Secretary shall from time 
to time submit recommendations to Congress regarding modifications to 
the coverage of services for such beneficiaries under the medicare 
program.''


                       Vaccines Outreach Expansion

    Section 4107 of Pub. L. 105-33 provided that:
    ``(a) Extension of Influenza and Pneumococcal Vaccination 
Campaign.--In order to increase utilization of pneumococcal and 
influenza vaccines in medicare beneficiaries, the Influenza and 
Pneumococcal Vaccination Campaign carried out by the Health Care 
Financing Administration in conjunction with the Centers for Disease 
Control and Prevention and the National Coalition for Adult 
Immunization, is extended until the end of fiscal year 2002.
    ``(b) Authorization of Appropriation.--There are hereby authorized 
to be appropriated for each of fiscal years 1998 through 2002, 
$8,000,000 for the Campaign described in subsection (a). Of the amount 
so authorized to be appropriated in each fiscal year, 60 percent of the 
amount so appropriated shall be payable from the Federal Hospital 
Insurance Trust Fund, and 40 percent shall be payable from the Federal 
Supplementary Medical Insurance Trust Fund.''


                Study on Preventive and Enhanced Benefits

    Section 4108 of Pub. L. 105-33 provided that:
    ``(a) Study.--The Secretary of Health and Human Services shall 
request the National Academy of Sciences, and as appropriate in 
conjunction with the United States Preventive Services Task Force, to 
analyze the expansion or modification of preventive or other benefits 
provided to medicare beneficiaries under title XVIII of the Social 
Security Act [this subchapter]. The analysis shall consider both the 
short term and long term benefits, and costs to the medicare program, of 
such expansion or modification.
    ``(b) Report.--
        ``(1) Initial report.--Not later than 2 years after the date of 
    the enactment of this Act [Aug. 5, 1997], the Secretary shall submit 
    a report on the findings of the analysis conducted under subsection 
    (a) to the Committee on Ways and Means and the Committee on Commerce 
    of the House of Representatives and the Committee on Finance of the 
    Senate.
        ``(2) Contents.--Such report shall include specific findings 
    with respect to coverage of at least the following benefits:
            ``(A) Nutrition therapy services, including parenteral and 
        enteral nutrition and including the provision of such services 
        by a registered dietitian.
            ``(B) Skin cancer screening.
            ``(C) Medically necessary dental care.
            ``(D) Routine patient care costs for beneficiaries enrolled 
        in approved clinical trial programs.
            ``(E) Elimination of time limitation for coverage of 
        immunosuppressive drugs for transplant patients.
        ``(3) Funding.--From funds appropriated to the Department of 
    Health and Human Services for fiscal years 1998 and 1999, the 
    Secretary shall provide for such funding as the Secretary determines 
    necessary for the conduct of the study by the National Academy of 
    Sciences under this section.''


                         Utilization Guidelines

    Section 4513(c) of Pub. L. 105-33 provided that: ``The Secretary of 
Health and Human Services shall develop and implement utilization 
guidelines relating to the coverage of chiropractic services under part 
B of title XVIII of the Social Security Act [part B of this subchapter] 
in cases in which a subluxation has not been demonstrated by X-ray to 
exist.''


 Authorizing Payment for Paramedic Intercept Service Providers in Rural 
                               Communities

    Pub. L. 105-33, title IV, Sec. 4531(c), Aug. 5, 1997, 111 Stat. 452, 
as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV, 
Sec. 412(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A-377, provided that: 
``In promulgating regulations to carry out section 1861(s)(7) of the 
Social Security Act (42 U.S.C. 1395x(s)(7)) with respect to the coverage 
of ambulance service, the Secretary of Health and Human Services may 
include coverage of advanced life support services (in this subsection 
referred to as `ALS intercept services') provided by a paramedic 
intercept service provider in a rural area if the following conditions 
are met:
        ``(1) The ALS intercept services are provided under a contract 
    with one or more volunteer ambulance services and are medically 
    necessary based on the health condition of the individual being 
    transported.
        ``(2) The volunteer ambulance service involved--
            ``(A) is certified as qualified to provide ambulance service 
        for purposes of such section,
            ``(B) provides only basic life support services at the time 
        of the intercept, and
            ``(C) is prohibited by State law from billing for any 
        services.
        ``(3) The entity supplying the ALS intercept services--
            ``(A) is certified as qualified to provide such services 
        under the medicare program under title XVIII of the Social 
        Security Act [this subchapter], and
            ``(B) bills all recipients who receive ALS intercept 
        services from the entity, regardless of whether or not such 
        recipients are medicare beneficiaries.
For purposes of this subsection, an area shall be treated as a rural 
area if it is designated as a rural area by any law or regulation of the 
State or if it is located in a rural census tract of a metropolitan 
statistical area (as determined under the most recent Goldsmith 
Modification, originally published in the Federal Register on February 
27, 1992 (57 Fed. Reg. 6725)).''
    [Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV, Sec. 412(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-377, provided that: ``The amendment 
made by subsection (a) [amending section 4531(c) of Pub. L. 105-33, set 
out above] takes effect on January 1, 2000, and applies to ALS intercept 
services furnished on or after such date.'']


   No Exceptions Permitted Based on Amendment to Subsection (v)(1)(L)

    Section 4601(b) of Pub. L. 105-33 provided that: ``The Secretary of 
Health and Human Services shall not consider the amendment made by 
subsection (a) [amending this section] in making any exemptions and 
exceptions pursuant to section 1861(v)(1)(L)(ii) of the Social Security 
Act (42 U.S.C. 1395x(v)(1)(L)(ii)).''


                    Study on Definition of Homebound

    Section 4613 of Pub. L. 105-33 provided that:
    ``(a) Study.--The Secretary of Health and Human Services shall 
conduct a study of the criteria that should be applied, and the method 
of applying such criteria, in the determination of whether an individual 
is homebound for purposes of qualifying for receipt of benefits for home 
health services under the medicare program. Such criteria shall include 
the extent and circumstances under which a person may be absent from the 
home but nonetheless qualify.
    ``(b) Report.--Not later than October 1, 1998, the Secretary shall 
submit a report to Congress on the study conducted under subsection (a). 
The report shall include specific recommendations on such criteria and 
methods.''


        Revisions of Coverage for Immunosuppressive Drug Therapy

    Section 160(c) of Pub. L. 103-432 provided that: ``The Secretary of 
Health and Human Services may administer section 1861(s)(2)(J) of the 
Social Security Act (42 U.S.C. 1395x(s)(2)(J)) in a manner such that the 
months of coverage of drugs described in such section are provided 
consecutively, so long as the total number of months of coverage 
provided is the same as the number of months described in such 
section.''


        Freeze in Per Visit Cost Limits for Home Health Services

    Section 13564(a)(1) of Pub. L. 103-66 provided that: ``The Secretary 
of Health and Human Services shall not provide for any change in the per 
visit cost limits for home health services under section 1861(v)(1)(L) 
of such Act [subsec. (v)(1)(L) of this section] for cost reporting 
periods beginning on or after July 1, 1994, and before July 1, 1996, 
except as may be necessary to take into account the amendment made by 
subsection (b)(1) [amending this section]. The effect of the preceding 
sentence shall not be considered by the Secretary in making adjustments 
pursuant to section 1861(v)(1)(L)(ii) of such Act to the payment limits 
for such services during such cost reporting periods.''


      Study and Report on Effects of Coverage of Osteoporosis Drugs

    Section 4156(b) of Pub. L. 101-508 directed Secretary of Health and 
Human Services to conduct a study analyzing effects of coverage of 
osteoporosis drugs under part B of this subchapter on health of 
individuals enrolled under such part and utilization of inpatient 
hospital and extended care services by such individuals, and, by not 
later than Oct. 1, 1994, to submit a report to Congress on such study, 
which was to include recommendations regarding expansion of coverage 
under the medicare program of items and services for individuals with 
post-menopausal osteoporosis as the Secretary considered appropriate.


 Productivity Screening Guidelines Application to Staff in Rural Health 
                                 Clinics

    Section 4161(b)(3) of Pub. L. 101-508 provided that: ``In employing 
any screening guideline in determining the productivity of physicians, 
physician assistants, nurse practitioners, and certified nurse-midwives 
in a rural health clinic, the Secretary of Health and Human Services 
shall provide that the guideline shall take into account the combined 
services of such staff (and not merely the service within each class of 
practitioner).''


   Development of Prospective Payment System for Home Health Services

    Section 4207(c), formerly 4027(c), of Pub. L. 101-508, as renumbered 
and amended by Pub. L. 103-432, title I, Sec. 160(d)(4), (9), Oct. 31, 
1994, 108 Stat. 4444; Pub. L. 105-362, title VI, Sec. 601(b)(2), Nov. 
10, 1998, 112 Stat. 3286, directed Secretary of Health and Human 
Services to develop a proposal to modify the current system under which 
payment is made for home health services under this subchapter or a 
proposal to replace such system with a system under which such payments 
would be made on the basis of prospectively determined rates, with 
Secretary to submit to Congress by not later than Apr. 1, 1993, the 
research findings upon which the proposal was to be based, and directed 
Prospective Payment Assessment Commission to submit to Congress by not 
later than Mar. 1, 1994, an analysis of and comments on the proposal.


                   Application of Budget-Neutral Basis

    Section 4207(d)(2), formerly 4027(d)(2), of Pub. L. 101-508, as 
renumbered by Pub. L. 103-432, title I, Sec. 160(d)(4), Oct. 31, 1994, 
108 Stat. 4444, provided that: ``In updating the wage index for 
establishing limits under section 1861(v)(1)(L)(iii) of the Social 
Security Act [subsec. (v)(1)(L)(iii) of this section], the Secretary 
shall ensure that aggregate payments to home health agencies under title 
XVIII of such Act [this subchapter] will be no greater or lesser than 
such payments would have been without regard to such update.''


 Transition Provisions for Determining Reasonable Costs for Home Health 
                             Agency Services

    Section 4207(d)(3), formerly 4027(d)(3), of Pub. L. 101-508, as 
renumbered by Pub. L. 103-432, title I, Sec. 160(d)(4), Oct. 31, 1994, 
108 Stat. 4444, provided that, notwithstanding subsec. (v)(1)(L)(iii) of 
this section, the Secretary of Health and Human Services was to, in 
determining the limits of reasonable costs under this subchapter with 
respect to services furnished by a home health agency, utilize a wage 
index equal to (1) for cost reporting periods beginning on or after July 
1, 1991, and on or before June 30, 1992, a combined area wage index 
consisting of 67 percent of the area wage index applicable to such home 
health agency, determined using the survey of the 1982 wages and wage-
related costs of hospitals in the United States, and 33 percent of the 
area wage index applicable to hospitals located in the geographic area 
in which the home health agency was located, determined using the survey 
of the 1988 wages and wage-related costs of hospitals in the United 
States, and (2) for cost reporting periods beginning on or after July 1, 
1992, and on or before June 30, 1993, a combined area wage index 
consisting of 33 percent of the area wage index applicable to such home 
health agency, determined using the survey of the 1982 wages and wage-
related costs of hospitals in the United States, and 67 percent of the 
area wage index applicable to hospitals located in the geographic area 
in which the home health agency was located, determined using the survey 
of the 1988 wages and wage-related costs of hospitals in the United 
States.


        Permitting Dentist To Serve as Hospital Medical Director

    Section 6025 of Pub. L. 101-239 provided that: ``Notwithstanding the 
requirement that the responsibility for organization and conduct of the 
medical staff of an institution be assigned only to a doctor of medicine 
or osteopathy in order for the institution to participate as a hospital 
under the medicare program, an institution that has a doctor of dental 
surgery or of dental medicine serving as its medical director shall be 
considered to meet such requirement if the laws of the State in which 
the institution is located permit a doctor of dental surgery or of 
dental medicine to serve as the medical staff director of a hospital.''


     Recognition of Costs of Certain Hospital-Based Nursing Schools

    Section 6205(a)(1)(A) of Pub. L. 101-239 provided that: ``The 
reasonable costs incurred by a hospital in training students of a 
hospital-based nursing school shall be allowable as reasonable costs 
under title XVIII of the Social Security Act [this subchapter] and 
reimbursed under such title on the same basis as if they were allowable 
direct costs of a hospital-operated educational program (other than an 
approved graduate medical education program) if, before June 15, 1989, 
and thereafter, the hospital demonstrates that for each year, it incurs 
at least 50 percent of the costs of training nursing students at such 
school, the nursing school and the hospital share some common board 
members, and all instruction is provided at the hospital or, if in 
another building, a building on the immediate grounds of the hospital.''
    [Section 6205(a)(2) of Pub. L. 101-239 provided that: ``Paragraph 
(1)(A) [set out above] shall apply with respect to cost reporting 
periods beginning on or after the date of the enactment of this Act 
[Dec. 19, 1989] and on or before the date on which the Secretary issues 
regulations pursuant to subsection (b)(2)(A) [set out as a note under 
section 1395ww of this title].'']


            Dissemination of Rural Health Clinic Information

    Section 6213(e) of Pub. L. 101-239 directed Secretary of Health and 
Human Services, not later than 60 days after Dec. 19, 1989, in 
consultation with the Director of the Office of Rural Health Policy, to 
disseminate to health care facilities and to the chief executive 
officer, chief health officer, and chief human services officer of each 
State, applications and other necessary information to enable such a 
facility to apply for designation as a rural health clinic for the 
purposes of this subchapter and subchapter XIX of this chapter.


         Treatment of Certain Facilities as Rural Health Clinics

    Section 6213(f) of Pub. L. 101-239 provided that: ``The Secretary of 
Health and Human Services shall not deny certification of a facility as 
a rural health clinic under section 1861(aa)(2) of the Social Security 
Act [subsec. (aa)(2) of this section] if the facility is located on an 
island and would otherwise be qualified to be certified as such a 
facility but for the requirement that the services of a physician 
assistant or nurse practitioner be provided in the facility.''


Continued Use of Home Health Wage Index in Effect Prior to July 1, 1989, 
                        Until After July 1, 1991

    Section 6222 of Pub. L. 101-239 provided that: ``Notwithstanding the 
requirement of section 1861(v)(1)(L)(iii) of the Social Security Act 
[subsec. (v)(1)(L)(iii) of this section], the Secretary of Health and 
Human Services shall, in determining the limits of reasonable costs 
under title XVIII of the Social Security Act [this subchapter] with 
respect to services furnished by home health agencies, continue to 
utilize the wage index that was in effect for cost reporting periods 
beginning before July 1, 1989, until cost reporting periods beginning on 
or after July 1, 1991.''


 Payment for Medical Escort or Medical Attendant on Commercial Airliner 
                                 Allowed

    Section 8427 of Pub. L. 100-647 provided that:
    ``(a) In General.--The Secretary of Health and Human Services shall 
provide that in cases where (as of the date of the enactment of this Act 
[Nov. 10, 1988]) transportation on a commercial airliner is covered 
under section 1861(s)(7) of the Social Security Act [subsec. (s)(7) of 
this section], the Secretary shall also provide for payment for 
medically necessary services of a medical escort or medical attendant.
    ``(b) Effective Period.--Subsection (a) shall apply to payment for 
services furnished during the 5-year period beginning on July 1, 1989.''


         Skilled Nursing Facility; Access and Visitation Rights

    Section 411(l)(2)(E) of Pub. L. 100-360 provided that: ``Effective 
as of the date of the enactment of this Act [July 1, 1988] and until the 
effective date of section 1819(c) of such Act [see Effective Date note 
set out under section 1395i-3 of this title], section 1861(j) of the 
Social Security Act [subsec. (j) of this section] is deemed to include 
the requirement described in section 1819(c)(3)(A) of such Act [section 
1395i-3(c)(3)(A) of this title] (as added by section 4201(a)(3) of 
OBRA).''


  Moratorium on Prior Authorization for Home Health and Post-Hospital 
                         Extended Care Services

    Section 4039(e) of Pub. L. 100-203 provided that: ``The Secretary of 
Health and Human Services shall not implement any voluntary or mandatory 
program of prior authorization for home health services, extended care 
services, or post-hospital extended care services under part A or B of 
title XVIII of the Social Security Act [part A or B of this subchapter] 
at any time prior to six months after the date on which the Congress 
receives the report required under section 9305(k)(4) of the Omnibus 
Budget Reconciliation Act of 1986 [section 9305(k)(4) of Pub. L. 99-509, 
set out below].''


   Delay in Publishing Regulations With Respect To Deeming Status of 
                                Entities

    Section 4039(f) of Pub. L. 100-203 provided that: ``The Secretary of 
Health and Human Services (in this subsection referred to as the 
`Secretary') shall not deem any entity to be a provider of services (as 
defined in section 1861(u) of the Social Security Act [subsec. (u) of 
this section]) for purposes of title XVIII of such Act [this 
subchapter]--
        ``(1) on any date prior to 6 months after the date on which the 
    Secretary has published a proposed rule with respect to the deeming 
    of the entity, and
        ``(2) until the Secretary publishes a final rule with respect to 
    the deeming of the entity.''


           Development of Uniform Needs Assessment Instrument

    Section 9305(h) of Pub. L. 99-509 directed Secretary of Health and 
Human Services to develop a uniform needs assessment instrument that 
could be used by discharge planners, hospitals, nursing facilities, 
other health care providers, and fiscal intermediaries in evaluating 
individual's need for post-hospital extended care services, home health 
services, and long-term care services of health-related or supportive 
nature, and further provided for creation of advisory panel to assist 
Secretary and for a report to Congress not later than Jan. 1, 1989.


        Prior and Concurrent Authorization Demonstration Project

    Section 9305(k) of Pub. L. 99-509 directed Secretary of Health and 
Human Services to conduct a demonstration program concerning prior and 
concurrent authorization for post-hospital extended care services and 
home health services furnished under part A or part B of this 
subchapter, which was to include at least four projects and was to be 
initiated by not later than Jan. 1, 1987, under which the Secretary was 
to monitor the acceptance of individuals entitled to benefits under this 
subchapter by providers to ensure that the placement of such individuals 
was not delayed until the results of prior and concurrent review were 
known, and further directed Secretary to evaluate the demonstration 
program and report to Congress on such evaluation no later than Feb. 1, 
1989.


    Considerations in Establishing Limits on Payment for Home Health 
                                Services

    Section 9315(b) of Pub. L. 99-509 provided that: ``In establishing 
limitations under section 1861(v)(1)(L) of the Social Security Act 
[subsec. (v)(1)(L) of this section] on payment for home health services 
for cost reporting periods beginning on or after July 1, 1986, the 
Secretary of Health and Human Services shall--
        ``(1) base such limitations on the most recent data available, 
    which data may be for cost reporting periods beginning no earlier 
    than October 1, 1983; and
        ``(2) take into account the changes in costs of home health 
    agencies for billing and verification procedures that result from 
    the Secretary's changing the requirements for such procedures, to 
    the extent the changes in costs are not reflected in such data.
Paragraph (2) shall apply to changes in requirements effected before, 
on, or after July 1, 1986.''


  Comptroller General Study and Report on Cost Limits for Home Health 
                                Services

    Section 9315(c) of Pub. L. 99-509 directed Comptroller General to 
study and report to Congress, not later than Feb. 1, 1988, on 
appropriateness and impact on medicare beneficiaries of applying the per 
visit cost limits for home health services under subsec. (v)(1)(L) of 
this section on a discipline-specific basis, rather than on an aggregate 
basis, for all home health services furnished by an agency, and 
appropriateness of the percentage limits so established.


    Reduction in Payment To Avoid Duplicate Payment for Services of 
                          Physician Assistants

    Section 9338(d) of Pub. L. 99-509 directed Secretary of Health and 
Human Services to reduce the amount of payments otherwise made to 
hospitals and skilled nursing facilities under this subchapter to 
eliminate estimated duplicate payments for historical or current costs 
attributable to services described in section 1395x(s)(2)(K) of this 
title, prior to repeal by Pub. L. 101-508, title IV, Sec. 4002(f), Nov. 
5, 1990, 104 Stat. 1388-36, effective as if included in the enactment of 
Pub. L. 99-509.


          Study and Report on Payments for Physician Assistants

    Section 9338(e) of Pub. L. 99-509 directed Secretary to report to 
Congress, by Apr. 1, 1988, concerning adjustments to amount of payment 
made, under part B for services described in subsec. (s)(2)(K) of this 
section, to ensure that amount of such payments reflects approximate 
cost of furnishing the services, taking into account compensation costs 
and overhead and supervision costs attributable to physician assistants.


  Cost Limits for Routine Services for Urban and Rural Hospital-Based 
Skilled Nursing Facilities; Cost Reporting Periods Beginning On or After 
               October 1, 1982, and Prior to July 1, 1984

    Section 2319(d) of Pub. L. 98-369 provided that: ``Notwithstanding 
limits on the cost of skilled nursing facilities which may have been 
issued under section 1861(v) of the Social Security Act [subsec. (v) of 
this section] prior to the date of the enactment of this Act [July 18, 
1984], in the case of cost reporting periods beginning on or after 
October 1, 1982, and prior to July 1, 1984, the cost limits for routine 
services for urban and rural hospital-based skilled nursing facilities 
shall be 112 percent of the mean of the respective routine costs for 
urban and rural hospital-based skilled nursing facilities.''


    Study and Report Relating to Requirements That Core Services Be 
                     Furnished Directly by Hospices

    Section 2343(d) of Pub. L. 98-369 directed Secretary of Health and 
Human Services to conduct a study of necessity and appropriateness of 
requirements that certain ``core'' services be furnished directly by a 
hospice, as required under subsec. (dd)(2)(A)(ii)(I) of this section and 
report results of such study to Congress with the report required under 
section 122(i)(1) [122(j)(1)] of the Tax Equity and Fiscal 
Responsibility Act of 1982 (Pub. L. 97-248), set out as a note under 
section 1395f of this title.


  Report on Effect of 1982 Amendment on Hospital-Based Skilled Nursing 
                               Facilities

    Section 605(b) of Pub. L. 98-21 directed Secretary of Health and 
Human Services, prior to Dec. 31, 1983, to complete a study and report 
to Congress with respect to (1) effect which implementation of section 
102 of the Tax Equity and Fiscal Responsibility Act of 1982, amending 
this section, would have on hospital-based skilled nursing facilities, 
given the differences (if any) in patient populations served by such 
facilities and by community-based skilled nursing facilities and (2) 
impact on skilled nursing facilities of hospital prospective payment 
systems, and recommendations concerning payment of skilled nursing 
facilities.
    Section 2319(e) of Pub. L. 98-369 directed Secretary of Health and 
Human Services to submit to Congress, prior to Dec. 1, 1984, the report 
required under section 605(b) of the Social Security Amendments of 1983 
(Pub. L. 87-21), set out above.


                   Elimination of Private Room Subsidy

    Section 111 of Pub. L. 97-248 provided that:
    ``(a) The Secretary of Health and Human Services shall, pursuant to 
section 1861(v)(2) of the Social Security Act [subsec. (v)(2) of this 
section], not allow as a reasonable cost the estimated amount by which 
the costs incurred by a hospital or skilled nursing facility for 
nonmedically necessary private accommodations for medicare beneficiaries 
exceeds the costs which would have been incurred by such hospital or 
facility for semiprivate accommodations.
    ``(b) The Secretary of Health and Human Services shall first issue 
such final regulations (whether on an interim or other basis) as may be 
necessary to implement subsection (a) by October 1, 1982. 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.''


            Regulations Regarding Access to Books and Records

    Section 952(b) of Pub. L. 96-499, as added by Pub. L. 97-248, title 
I, Sec. 127(2), Sept. 3, 1982, 96 Stat. 366, provided that: ``Unless the 
Secretary of Health and Human Services first publishes final regulations 
prescribing the criteria and procedures described in the last sentence 
of section 1861(v)(1)(I) of the Social Security Act [subsec. (v)(1)(I) 
of this section] by January 1, 1983, after providing a period of not 
less than 60 days for public comment on proposed regulations, the 
amendment made by subsection (a) [amending this section] shall only 
apply to books, documents, and records relating to services furnished 
(pursuant to contract or subcontract) on or after the date on which 
final regulations of the Secretary are first published.''


   Compliance With the Life Safety Code or State Fire and Safety Code

    Section 915(b) of Pub. L. 96-499 provided that: ``Any institution 
(or part of an institution) which complied with the requirements of 
section 1861(j)(13) of the Social Security Act [subsec. (j)(13) of this 
section] on the day before the date of the enactment of this Act [Dec. 
5, 1980] shall, so long as such compliance is maintained (either by 
meeting the applicable provisions of the Life Safety Code (21st edition, 
1967, or 23d edition, 1973), with or without waivers of specific 
provisions, or by meeting the applicable provisions of a fire and safety 
code imposed by State law as provided for in such section 1861(j)(13)), 
be considered (for purposes of titles XVIII or XIX of such Act [this 
subchapter or subchapter XIX of this chapter]) to be in compliance with 
the requirements of such section 1861(j)(13), as it is amended by 
subsection (a) of this section.''
    Section 106(c) of Pub. L. 94-182 provided that: ``Any institution 
(or part of an institution) which complied with the requirements of 
section 1861(j)(13) of the Social Security Act [subsec. (j)(13) of this 
section] on the day preceding the first day referred to in subsection 
(b) [enacting provisions set out as a note under this section] shall, so 
long as such compliance is maintained (either by meeting the applicable 
provisions of the Life Safety Code (21st edition, 1967), with or without 
waivers of specific provisions, or by meeting the applicable provisions 
of a fire and safety code imposed by State law as provided for in such 
section 1861(j)(13)), be considered (for purposes of titles XVIII and 
XIX of such Act) [subchapters XVIII and XIX of this chapter] to be in 
compliance with the requirements of such section 1861(j)(13), as it is 
amended by subsection (a) of this section.''


 Private, Nonprofit Health Care Clinics Qualifying, as of July 1, 1977, 
                         as Rural Health Clinics

    Section 1(e) of Pub. L. 95-210 provided that: ``Any private, 
nonprofit health care clinic that--
        ``(1) on July 1, 1977, was operating and located in an area 
    which on that date (A) was not an urbanized area (as defined by the 
    Bureau of the Census) and (B) had a supply of physicians 
    insufficient to meet the needs of the area (as determined by the 
    Secretary), and
        ``(2) meets the definition of a rural health clinic under 
    section 1861(aa)(2) [subsec. (aa)(2) of this section] or section 
    1905(l) of the Social Security Act [section 1396d(l) of this title], 
    except for clause (i) of section 1861(aa)(2) [subsec. (aa)(2) of 
    this section],
shall be considered, for the purposes of title XVIII or XIX, 
respectively, of the Social Security Act [this subchapter or subchapter 
XIX of this chapter], as satisfying the definition of a rural health 
clinic under such section.''


Promulgation of Regulations Defining Costs Chargeable to Personal Funds 
       of Patients in Skilled Nursing Facilities; Date of Issuance

    Section 21(b) of Pub. L. 95-142 provided that: ``The Secretary of 
Health, Education, and Welfare [now Health and Human Services] shall, by 
regulation, define those costs which may be charged to the personal 
funds of patients in skilled nursing facilities who are individuals 
receiving benefits under the provisions of title XVIII [this 
subchapter], or under a State plan approved under the provisions of 
title XIX [subchapter XIX of this chapter], of the Social Security Act, 
and those costs which are to be included in the reasonable cost or 
reasonable charge for extended care services as determined under the 
provisions of title XVIII, or for skilled nursing and intermediate care 
facility services as determined under the provisions of title XIX, of 
such Act.''
    [Section 21(c)(2) of Pub. L. 95-142 provided that: ``The Secretary 
of Health, Education, and Welfare shall issue the regulations required 
under subsection (b) [set out above] within ninety days after the date 
of enactment of this Act [Oct. 25, 1977].'']


  Home Health Services; Grants for Establishment, Operation, Staffing, 
Etc., of Public and Nonprofit Private Agencies and Entities; Procedures; 
                Payments; Authorization of Appropriations

    Pub. L. 94-63, title VI, Sec. 602, July 29, 1975, 89 Stat. 346, as 
amended by Pub. L. 94-460, title III, Sec. 302, Oct. 8, 1976, 90 Stat. 
1960; Pub. L. 95-83, title III, Sec. 310, Aug. 1, 1977, 91 Stat. 397, 
which provided for a program of home health services and of training of 
professional and paraprofessional personnel, was repealed by Pub. L. 95-
626, title II, Sec. 207(b), Nov. 10, 1978, 92 Stat. 3586, effective Oct. 
1, 1978.


 Payment for Service of Physicians Rendered in a Teaching Hospital for 
 Accounting Periods Beginning After June 30, 1975, and Prior to October 
            1, 1978; Studies, Reports, etc.; Effective Dates

    Pub. L. 93-233, Sec. 15(a)(1), (b)-(d), Dec. 31, 1973, 87 Stat. 965, 
as amended by Pub. L. 93-368, Sec. 7, Aug. 7, 1974, 88 Stat. 422; Pub. 
L. 94-368, Sec. 1, July 16, 1976, 90 Stat. 997; Pub. L. 95-292, Sec. 7, 
June 13, 1978, 92 Stat. 316, provided that for the cost accounting 
periods beginning after June 30, 1975, and prior to October 1, 1978, 
subsec. (b) of this section will be administered as if paragraph (7) of 
subsec. (b) read as follows: ``(7) a physician where the hospital has a 
teaching program approved as specified in paragraph (6), if (A) the 
hospital elects to receive any payment due under this title [this 
subchapter] for reasonable costs of such services, and (B) all 
physicians in such hospital agree not to bill charges for professional 
services rendered in such hospital to individuals covered under the 
insurance program established by this title [this subchapter]'', 
provided for studies with respect to methods of reimbursement for 
physicians' services under subchapters XVIII and XIX of this chapter in 
hospitals which have a teaching program and a determination as to how 
and to what extent such funds are utilized, and provided that a final 
report be submitted to the Secretary of Health, Education, and Welfare, 
the Committee on Finance of the Senate, and the Committee on Ways and 
Means of the House of Representatives not later than Mar. 1, 1976.


   Physical Therapy Services Requirements; Effective Date Postponement

    Section 17(a) of Pub. L. 93-233 provided that: ``In the 
administration of title XVIII of the Social Security Act [this 
subchapter], the amount payable thereunder with respect to physical 
therapy and other services referred to in section 1861(v)(5)(A) of such 
Act [subsec. (v)(5)(A) of this section] (as added by section 151(c) 
[251(c)] of the Social Security Amendments of 1972) shall be determined 
(for the period with respect to which the amendment made by such section 
151(c) [251(c)] would, except for the provisions of this section, be 
applicable) in like manner as if the `December 31, 1972', which appears 
in such subsection (d)(3) of such section 151 [251(d)(3), set out as 
Effective Date of 1972 Amendment note above], read `the month in which 
there are promulgated, by the Secretary of Health, Education, and 
Welfare [now Health and Human Services], final regulations implementing 
the provisions of section 1861(v)(5) of the Social Security Act [subsec. 
(v)(5) of this section]'.''


                  Payment for Durable Medical Equipment

    Section 245(a)-(c) of Pub. L. 92-603 provided that:
    ``(a) The Secretary is authorized to conduct reimbursement 
experiments designed to eliminate unreasonable expenses resulting from 
prolonged rentals of durable medical equipment described in section 
1861(s)(6) of the Social Security Act [subsec. (s)(6) of this section].
    ``(b) Such experiment may be conducted in one or more geographic 
areas, as the Secretary deems appropriate, and may, pursuant to 
agreements with suppliers, provide for reimbursement for such equipment 
on a lump-sum basis whenever it is determined (in accordance with 
guidelines established by the Secretary) that a lump-sum payment would 
be more economical than the anticipated period of rental payments. Such 
experiments may also provide for incentives to beneficiaries (including 
waiver of the 20 percent coinsurance amount applicable under section 
1833 of the Social Security Act [section 1395l of this title]) to 
purchase used equipment whenever the purchase price is at least 25 
percent less than the reasonable charge for new equipment.
    ``(c) The Secretary is authorized, at such time as he deems 
appropriate, to implement on a nationwide basis any such reimbursement 
procedures which he finds to be workable, desirable and economical and 
which are consistent with the purposes of this section.''

                  Section Referred to in Other Sections

    This section is referred to in sections 255, 295p, 297n, 300t-12, 
426-1, 1301, 1320a-1, 1320a-3, 1320a-7b, 1320c-3, 1320c-11, 1320d, 
1395a, 1395d, 1395f, 1395g, 1395h, 1395i-3, 1395i-4, 1395k, 1395l, 
1395m, 1395n, 1395r, 1395u, 1395w-3, 1395w-4, 1395w-22, 1395y, 1395z, 
1395aa, 1395bb, 1395cc, 1395dd, 1395ee, 1395mm, 1395nn, 1395pp, 1395rr, 
1395uu, 1395ww, 1395yy, 1395bbb, 1395eee, 1395fff, 1396a, 1396b, 1396d, 
1396g, 1396n, 1396r, 1396u-2, 11151 of this title; title 10 sections 
1077, 1079; title 25 sections 1621d, 1621k; title 26 sections 101, 213, 
415, 7702B.
