TITLE XVIII-HEALTH INSURANCE FOR THE AGED AND DISABLED Page1 Sec. 1801. Prohibition Against Any Federal Interference... 407 Sec. 1802. Free Choice by Patient Guaranteed. --- 407 Sec. 1803. Option to Individuals To Obtain Other Health Insurance Pro tection. 407 PART A-HOSPITal Insurance Benefits for the AGED AND DISABLED (c) Limitation on Psychiatric Hospital Services.. 408 (d) Limitation on Post-Hospital Home Health Services__. 408 409 (f) Terms Defined in Section 1861. 409 Sec. 1813. Deductibles and Coinsurance_ (a) Reduction for Inpatient Hospital Deductible and Co- (b) Amount of Inpatient Hospital Deductible... Sec. 1814. Conditions of and Limitations on Payment for Services- (e) Payment for Inpatient Hospital Services Prior to Notifi- 414 (f) Payment for Certain Inpatient Hospital Services Fur- 415 (g) Payment for Services of a Physician Rendered in a 416 (h) Payment for Posthospital Extended Care Services.. 416 417 Sec. 1815. Payment to Providers of Services- 418 Sec. 1816. Use of Public Agencies or Private Organizations To Facilitate Payment to Providers of Services.. 418 Sec. 1817. Federal Hospital Insurance Trust Fund. 420 Sec. 1818. Hospital Insurance Benefits for Uninsured Individuals Not 424 PART B-SUPPLEMENTARY MEDICAL INSURANCE BENEFITS FOR THE Sec. 1831. Establishment of Supplementary Medical Insurance Program Sec. 1835 Procedure for Payment of Claims of Providers of Services... Sec. 1837. Enrollment Periods.. "" ! ! 429 432 433 PART B-SUPPLEMENTARY MEDICAL INSURANCE BENEFITS Continued Sec. 1841. Federal Supplementary Medical Insurance Trust Fund..... Sec. 1844. Appropriations To Cover Government Contributions and PART C-MISCELLANEOUS PROVISIONS Sec. 1861. Definition of Services, Institutions, etc. (a) Spell of Illness... (b) Inpatient Hospital Services (c) Inpatient Psychiatric Hospital Services.. (d) Inpatient Tuberculosis Hospital Services. Hospital... Page 441 443 448 451 452 452 452 453 453 453 455 456 457 457 457 (1) Agreements for Transfer Between Skilled Nursing Medical and Other Health Services- Provider of Services. Reasonable Cost.... (w) Arrangements for Certain Services_ (x) State and United States... (y) Post-Hospital Extended Care in Christian Science 460 461 462 463 463 464 465 465 466 468 468 468 472 473 473 474 Sec. 1866. Agreements With Providers of Services Sec. 1867. Health Insurance Benefits Advisory Council.. Sec. 1868. [Repealed.] Sec. 1862. Exclusions From Coverage__ Sec. 1863. Consultation With State Agencies and Other Organizations To Sec. 1865. Effect of Accreditation_... 475 478 478 480 481 485 Sec. 1873. Designation of Organization or Publication by Name_ Sec. 1869. Determinations; Appeals. Sec. 1870. Overpayments on Behalf of Individuals and Settlement of Sec. 1871. Regulations... Sec. 1872. Application of Certain Provisions of Title II.. 486 Claims for Benefits on Behalf of Deceased Individuals... 487 490 490 491 491 Sec. 1879. Lim tation on Liability of Beneficiary Where Medicare Claims 504 506 Prohibition Against Any Federal Interference Section 1801. Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person. Free Choice by Patient Guaranteed Sec. 1802. Any individual entitled to insurance benefits under this title may obtain health services from any institution, agency, or person qualified to participate under this title if such institution, agency, or person undertakes to provide him such services. Option to Individuals To Obtain Other Health Insurance Protection Sec. 1803. Nothing contained in this title shall be construed to preclude any State from providing, or any individual from purchasing or otherwise securing, protection against the cost of any health services. Part A-Hospital Insurance Benefits for the Aged and Disabled Description of Program Sec. 1811. The insurance program for which entitlement is established by section 226 provides basic protection against the costs of hospital and related post-hospital services in accordance with this part for (1) individuals who are age 65 or over and are entitled to retirement benefits under title II of this Act or under the railroad retirement system and (2) individuals under age 65 who have been entitled for not less than 24 consecutive months to benefits under title II of this Act or under the railroad retirement system on the basis of a disability. Scope of Benefits Sec. 1812. (a) The benefits provided to an individual by the insurance program under this part shall consist of entitlement to have payment made on his behalf or, in the case of payments referred to in section 1814 (d) (2) to him (subject to the provisions of this part) for (1) inpatient hospital services for up to 150 days during any spell of illness minus one day for each day of inpatient hospitai services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies in accordance with regulations of the Secretary that he does not desire to have such payment made); (2) post-hospital extended care services for up to 100 days during any spell of illness; and (3) post-hospital home health services for up to 100 visits (during the one-year period described in section 1861 (n)) after the beginning of one spell of illness and before the beginning of the next. (b) Payment under this part for services furnished an individual during a spell of illness may not (subject to subsection (c)) be made for (1) inpatient hospital services furnished to him during such spell after such services have been furnished to him for 150 days during such spell minus 1 day for each day of inpatient hospital services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies in accordance with regulations of the Secretary that he does not desire to have such payment made); (2) post-hospital extended care services furnished to him during such spell after such services have been furnished to him for 100 days during such spell; or (3) inpatient psychiatric hospital services furnished to him after such services have been furnished to him for a total of 190 days during his lifetime. (c) If an individual is an inpatient of a psychiatric hospital on the first day of the first month for which he is entitled to benefits under this part, the days on which he was an inpatient of such a hospital in the 150-day period immediately before such first day shall be included in determining the number of days limit under subsection (b)(1) insofar as such limit applies to (1) inpatient psychiatric hospital services, or (2) inpatient hospital services for an individual who is an inpatient primarily for the diagnosis or treatment of mental illness (but shall not be included in determining such number of days limit insofar as it applies to other inpatient hospital services or in determining the 190-day limit under subsection (b) (3)). (d) Payment under this part may be made for post-hospital home health services furnished an individual only during the one-year period described in section 1861 (n) following his most recent hospital discharge which meets the requirements of such section, and only for the first 100 visits in such period. The number of visits to be charged for purposes of the limitation in the preceding sentence, in connection with items or services described in section 1861 (m), shall be determined in accordance with regulations. (e) For purposes of subsections (b), (c), and (d), inpatient hospital services, inpatient psychiatric hospital services, post-hospital extended care services, and post-hospital home health services shall be taken into account only if payment is or would be, except for this section or the failure to comply with the request and certification requirements of or under section 1814 (a), made with respect to such services under this part. (f) For definition of "spell of illness", and for definitions of other terms used in this part, see section 1861. Deductibles and Coinsurance Sec. 1813. (a) (1) The amount payable for inpatient hospital services furnished an individual during any spell of illness shall be reduced by a deduction equal to the inpatient hospital deductible or, if less, the charges imposed with respect to such individual for such services, except that, if the customary charges for such services are greater than the charges so imposed, such customary charges shall be considered to be the charges so imposed. Such amount shall be further reduced by a coinsurance amount equal to (A) one-fourth of the inpatient hospital deductible for each day (before the 91st day) on which such individual is furnished such services during such spell of illness after such services have been furnished to him for 60 days during such spell; and (B) one-half of the inpatient hospital deductible for each day (before the day following the last day for which such individual is entitled under section 1812 (a) (1) to have payment made on his behalf for inpatient hospital services during such spell of illness) on which such individual is furnished such services during such spell of illness after such services have been furnished to him for 90 days during such spell; except that the reduction under this sentence for any day shall not exceed the charges imposed for that day with respect to such individual for such services (and for this purpose, if the customary charges for such services are greater than the charges so imposed, such customary charges shall be considered to be the charges so imposed). (2) The amount payable to any provider of services under this part for services furnished an individual during any spell of illness shall be further reduced by a deduction equal to the cost of the first three pints of whole blood (or equivalent quantities of packed red blood cells, as defined under regulations) furnished to him as part of such services during such spell of illness. (3) The amount payable for post-hospital extended care services furnished an individual during any spell of illness shall be reduced by 71-402 O 77 - 27 |