would otherwise be entitled to reimbursement or payment on the basis of reasonable cost, for services provided

§ 1395c. Description of program.

(1) under this subchapter,

(2) under a State plan approved under subchapter XIX of this chapter, or

(3) under a plan developed under subchapter V of this chapter,

and which are selected by the Secretary in accordance with regulations established by the Secretary, would be reimbursed or paid in any manner mutually agreed upon by the Secretary and the physician, organization, or institution. The method of payment (in the case of physicians) or reimbursement (in the case of an organization or institution) which may be applied in such experiments shall be such as the Secretary may select and may be based on charges or costs adjusted by incentive factors and may include specific incentive payments or reductions of payments for the performance of specific actions but in any case shall be such as he determines may, through experiment, be demonstrated to have the effect of increasing the efficiency and economy of health services through the creation of additional incentives to these ends without adversely affecting the quality of such services.

(b) Waiver of certain payment or reimbursement requirements; advice and recommendations of specialists preceding experimentation.

In the case of any experiment under subsection (a) of this section, the Secretary may waive compliance with the requirements of this subchapter and subchapters V and XIX of this chapter insofar as such requirements relate to reimbursement or payment on the basis of reasonable cost, or (in the case of physicians) on the basis of reasonable charge; and costs incurred in such experiment in excess of the costs which would otherwise be reimbursed or paid under such subchapters may be reimbursed or paid to the extent that such waiver applies to them (with such excess being borne by the Secretary). No experiment shall be engaged in or developed under subsection (a) of this section until the Secretary obtains the advice and recommendations of specialists who are competent to evaluate the proposed experiment as to the soundness of its objectives, the possibilities of securing productive results, the adequacy of resources to conduct the proposed experiment, and its relationship to other similar experiments already completed or in process. (Pub. L. 90-248, title IV, § 402(a), (b), Jan. 2, 1968, 81 Stat. 930, 931.) CODIFICATION

Section is comprised of subsecs. (a) and (b) of section 402 of Pub. L. 90-248. Subsec. (c) of such section 402 amended section 1395ll(b) of this title.

Section was enacted as a part of the Social Security Amendments of 1967 and not as a part of the Social Security Act which comprises this chapter.

SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in section 1395ll of this title. PART A.-HOSPITAL INSURANCE BENEFITS FOR THE AGED PART REFERRED TO IN OTHER SECTIONS

This part is referred to in sections 402, 417, 426, 426a, 429, 907, 13951, 1395p, 1395x, 1395y, 1395aa, 1395ll of this title; title 26 section 6051.

The insurance program for which entitlement is established by section 426 of this title provides basic protection against the costs of hospital and related post-hospital services in accordance with this part for individuals who are age 65 or over and are entitled to retirement benefits under subchapter II of this chapter or under the railroad retirement system. (Aug. 14, 1935, ch. 531, title XVIII, § 1811, as added July 30, 1965, Pub. L. 89-97, title I, § 102(a), 79 Stat. 291.)

ADVISORY COUNCIL TO STUDY COVERAGE OF THE DISABLED UNDER SUBCHAPTER XVIII

Section 140 of Pub. L. 90-248, title I, Jan. 2, 1968, 81 Stat. 854, provided that:

"(a) The Secretary of Health, Education, and Welfare shall appoint an Advisory Council to study the need for coverage of the disabled under the health insurance program of title XVIII of the Social Security Act [this subchapter].

"(b) The Council shall be appointed by the Secretary during 1968 without regard to the provisions of title 5, United States Code [Title 5, Government Organization and Employees], governing appointments in the competitive service and shall consist of 12 persons who shall, to the extent possible, represent organizations of employer and employees in equal numbers, and represent self-employed persons and the public.

"(c) The Council is authorized to engage such technical assistance, including actuarial services, as may be required to carry out its functions, and the Secretary shall, in addition, make availble to such Council such secretrial, clerical, and other assistance and such actuarial and other pertinent data prepared by the Department of Health, Education, and Welfare as it may require to carry out such functions.

"(d) Members of the Council, while serving on the business of the Council (inclusive of travel time), shall receive compensation at rates fixed by the Secretary, but not exceeding $100 per day and, while so serving away from their homes or regular places fo business, they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703 of title 5, United States Code [section 5703 of Title 5, Government Organization and Employees], for persons in the Government employed intermittently.

"(e) The Council shall make findings on the unmet need of the disabled for health insurance, on the costs involved in providing the disabled with insurance protection to cover the cost of hospital and medical services, and on the ways of financing this insurance. The Council shall submit a report of its findings to the Secretary not later than January 1, 1969, together with recommendations on how such protection should be financed and, if such financing is to be accomplished through the trust funds established under title XVIII of the Social Securtly Act [this subchapter], on the extent to which each of such trust funds should bear the cost of such financing. Such report shall thereupon be transmitted to the Congress and to the Boards of Trustees created by sections 1817(b) and 1841(b) of the Social Security Act [sections 13951 and 1395t of this title]. After the date of transmittal to the Congress of the report, the Council shall cease to exist."

REIMBURSEMENT OF CHARGES UNDER PART A FOR SERVICES TO PATIENTS ADMITTED PRIOR TO 1968 TO CERTAIN

HOSPITALS

Section 142 of Pub. L. 90-248, title I, Jan. 2, 1968, 81 Stat. 855, provided that:

"(a) Notwithstanding any provision of title XVIII of the Social Security Act [this subchapter] an individual who is entitled to hospital insurance benefits under section 226 of such Act [section 426 of this title] may, subject to subsections (b) and (c), receive, on the basis of an itemized bill, reimbursement for charges to him for inpatient hospital services (as defined in section 1861 of such Act [section 1395x of this title], but without regard to subsection (e) of such section) furnished by, or under

arrangements (as defined in section 1861 (w) of such Act [section 1395x(w) of this title] with, a hospital if—

"(1) the hospital did not have an agreement in effect under section 1866 of such Act [section 1395cc of this title] but would have been eligible for payment under part A of title XVIII of such Act [this part] with respect to such services if at the time such services were furnished the hospital had such an agreement in effect;

"(2) the hosptial (A) meets the requirements of paragraphs (5) and (7) of section 1861 (e) of such Act [section 1395x(e) of this title], (B) is not primarily engaged in providing the services described in section 1861 (j) (1) (A) of such Act [section 1395x(j)(1)(A) of this title], and (C is primarily engaged in providing, by or under the supervision of individuals referred to in paragraph (1) of section 1861(r) of such Act [section 1395x (r) of this title], to inpatients (1) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (ii) rehabilitation services for the rehabilitation of injured, disabled, or sick persons;

"(3) the hospital did not meet the requirements that must be met to permit payment to the hosptial under part A of title XVIII of such Act [this part]; and

"(4) an application is filed (submitted in such form and manner and by such person, and containing and supported by such information, as the Secretary shall by regulations prescribe) for reimbursement before January 1, 1969.

"(b) Payments under this section may not be made for inpatient hospital services (as described in subsection (a)) furnished to an individual—

"(1) prior to July 1, 1966,

"(2) after December 31, 1967, unless furnished with respect to an admission to the hospital prior to January 1, 1968, and

"(3) for more than

"(A) 90 days in any spell of illness, but only if (1) prior to January 1, 1969, the hospital furnishing such services entered into an agreement under section 1866 of the Social Security Act [section 1395cc of this title] and (11) the hospital's plan for utilization review, as provided for in section 1861(k) of such Act [section 1395x(k) of this title], has, in accordance with section 1814 of such Act [section 1395f of this title], been applied to the services furnished such individual, or

"(B) 20 days in any spell of illness, if the hospital did not meet the conditions of clauses (1) and (11) of subparagraph (A).

"(c) (1) The amounts payable in accordance with subsection (a) with respect to inpatient hospital services shall, subject to paragraph (2) of this subsection, be paid from the Federal Hospital Insurance Trust Fund in amounts equal to 60 percent of the hospital's reasonable charges for routine services furnished in the accommodations occupied by the individual or in semi-private accommodations (as defined in section 1861(v) (4) of the Social Security Act [section 1395x (v) (4) of this title]) whichever is less, plus 80 percent of the hosptial's reasonable charges for ancillary services. If separate charges for routine and ancillary services are not made by the hospital, reimbursement may be based on two-thirds of the hospital's reasonable charges for the services received but not to exceed the charges which would have been made if the patient had occupied semi-private accommodations (as so defined). For purposes of the preceding provisions of this paragraph, the term 'routine services' shall mean the regular room, dietary, and nursing services, minor medical and surgical supplies and the use of equipment and facilities for which a separate charge is not customarily made; the term 'ancillary services' shall mean those special services' for which charges are customarily made in addition to routine services.

"(2) Before applying paragraph (1), payments made under this section shall be reduced to the extent provided for under section 1813 of the Social Security Act [section 1395e of this title] in the case of benefits payable to providers of services under part A of title XVIII of such Act [this part].

"(d) For the purposes of this section"(1) the 90-day period, referred to in subsection (b) (3) (A), shall be reduced by the number of days of inpatient hospital services furnished to such individual during the spell of illness, referred to therein, and with respect to which he was entitled to have payment made under part A of title XVIII of the Social Security Act [this part];

"(2) the 20-day period, referred to in subsection (b) (3) (B) shall be reduced by the number of days in excess of 70 days of inpatient hospital services furnished during the spell of illness, referred to therein, and with respect to which such individual was entitled to have payment made under such part A [this part];

"(3) the term 'spell of illness' shall have the meaning assigned to it by subsection (a) of section 1861 of such Act [section 1395x (a) of this title] except that the term 'inpatient hospital services' as it appears in such subsection shall have the meaning assigned to it by subsection (a) of this section."

§ 1395d. Scope of benefits.

(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 1395f (d) (2) of this title 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 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 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 1395x (n) of this title) 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) of this section) be made for

(1) inpatient 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) of this section 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) of this section).

(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 1395x (n) of this title 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 1395x(m) of this title, shall be determined in accordance with regulations.

(e) For purposes of subsections (b), (c), and (d) of this section, 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 1395f (a) of this title, made with respect to such services under this part.

(f) For definitions of "spell of illness", and for definitions of other terms used in this part, see section 1395x of this title. (Aug. 14, 1935, ch. 531, title XVIII, § 1812, as added July 30, 1965, Pub. L. 89-97, title I, § 102(a), 79 Stat. 291, and amended Jan. 2, 1968, Pub. L. 90-248, title I, §§ 129 (c) (2), 137(a), 138(a), 143(b), 146(a), 81 Stat. 847, 853, 854, 857, 859.)

AMENDMENTS

1968 Subsec. (a). Pub. L. 90-248, § 143 (b), inserted "or, in the case of payments referred to in section 1395f (d) (2) of this title to him" after "on his behalf" in text preceding par. (1).

Subsec. (a)(1). Pub. L. 90-248, § 137(a)(1), increased the maximum duration of benefits from 90 to 150 days 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 that he does not desire to have such payment made).

Subsec. (a) (4). Pub. L. 90-248, 129 (c) (2), deleted former par. (4) which provided for payment for outpatient hospital diagnostic services.

Subsec. (b) (1). Pub. L. 90–248, § 137(a) (2), changed the limitation on payments from 90 to 150 days 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 that he does not desire to have such payment made).

Subsec. (c). Pub. L. 90-248, § 138(a), increased the limit from 90 to 150 days so that if an individual was an inpatient of a psychiatric or tuberculosis hospital on the first day of the first month for which he is entitled to benefits, the days he was an inpatient in the 150-day period immediately before such first day are included in determining the limit under subsec. (b)(1) insofar as such limit applies to (1) inpatient psychiatric hospital services and inpatient tuberculosis hospital services, or (2) inpatient hospital services for an individual who is an inpatient primarily for the diagnosis or treatment of mental illness or tuberculosis (but are not included in

determining such limit as it applies to other inpatient hospital services or in determining the 190-day limit under subsec. (b)(3)).

Pub. L. 90-248, § 146(a), provided that the limitation of allowable days of inpatient hospital services will not apply to services provided to an inpatient of a tuberculosis hospital.

EFFECTIVE DATE OF 1968 AMENDMENT

Section 129 (d) of Pub. L. 90-248 provided that: "The amendments made by this section [to subsec. (a) (4) of this section and sections 426 (b) (1), 1395e (a) (2)-(4), (b) (1), (2), 1395f (a), (d), 1395k(a) (2) (B), 13951(b), (d), 1395n (a)-(c), 1395x (e), (p), (s) (2), (y) (3), 1395cc (a) (2) of this title, and section 228s-2(a) of Title 45] shall apply with respect to services furnished after March 31, 1968, except that subsection (c) (5) of such section [amending section 1395f (a) of this title] shall become effective with respect to services furnished after the date of enactment of this Act [Jan. 2, 1968]."

Section 137 (c) of Pub. L. 90-248 provided that: "The amendments made by subsections (a) and (b) [to subsecs. (a) (1) and (b) (1) of this section and section 1395e (a) (1) of this title] shall apply with respect to services furnished after December 31, 1967."

Section 138 (b) of Pub. L. 90-248 provided that: "The amendments made by subsection (a) [to subsec. (c) of this section] shall apply with respect to payment for services furnished after December 31, 1967."

Section 143 (d) of Pub. L. 90-248 provided that: "The provisions made by subsection (a) of this section (amending section 1395x(e) of this title] shall become effective as of July 1, 1966, and the provisions made by subsections (b) and (c) of this section [amending subsec. (a) of this section and section 1395f (d) of this title] shall apply to services furnished with respect to admissions occurring after December 31, 1967, and to outpatient hospital diagnostic services furnished after December 31, 1967, and before April 1, 1968."

Section 146(b) of Pub. L. 90-248 provided that: "The amendment made by subsection (a) [to subsec. (c) of this section] shall apply with respect to payment for services furnished after December 31, 1967."

SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in section 1395f of this title. § 1395e. Deductibles and coinsurance.

(a) Inpatient hospital services; outpatient hospital diagnostic services; blood; post-hospital extended care services.

(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 1395d(a)(1) of this title 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 a coinsurance amount equal to one-eighth of the inpatient hospital deductible for each day (before the 101st day) on which he is furnished such services after such services have been furnished to him for 20 days during such spell.

(b) Inpatient hospital deductible.

(1) The inpatient hospital deductible which shall be applicable for the purposes of subsection (a) of this section shall be $40 in the case of any spell of illness beginning before 1969.

(2) The Secretary shall, between July 1 and October 1 of 1968, and of each year thereafter, determine and promulgate the inpatient hospital deductible which shall be applicable for the purposes of subsection (a) of this section in the case of any spell of illness beginning during the succeeding calendar year. Such inpatient hospital deductible shall be equal to $40 multiplied by the ratio of (A) the current average per diem rate for inpatient hospital services for the calendar year preceding the promulgation, to (B) the current average per diem rate for such services for 1966. Any amount determined under the preceding sentence which is not a multiple of $4 shall be rounded to the nearest multiple of $4 (or, if it is midway between two multiples of $4, to the next higher multiple of $4). The current average per diem rate for any year shall be determined by the Secretary on the basis of the best information available to him (at the time the determination is made) as to the amounts paid under this part on account of inpatient hospital services furnished during such year, by hospitals which have agreements in effect under section 1395cc of this title, to individuals who are entitled to hospital insurance benefits under section 426 of this title, plus the amount which would have been so paid but for subsection (a)(1) of this section. (Aug. 14, 1935, ch. 531, title XVIII, § 1813, as added July 30, 1965, Pub. L. 89-97, title I, § 102(a), 79 Stat. 292, and amended Jan. 2, 1968, Pub. L. 90-248, title I, §§ 129 (c) (3), (4), 135 (a), 137(b), 81 Stat. 847, 848, 852, 854.)

AMENDMENTS

1968 Subsec. (a)(1). Pub. L. 90-248, § 137(b), designated existing provisions as subpar. (A), added subpar. (B) and the exception provision that the reduction for any day shall not exceed the charges for that day.

Subsec. (a) (2). Pub. L. 90-248, § 135 (a), made the three pint deductible applicable also to equivalent quantities of packed red blood cells, as defined by the Secretary under regulations.

Subsec. (a) (2)-(4). Pub. L. 90-248, § 129 (c) (3), deleted former par. (2) which provided for the reduction of the amount payable for outpatient hospital diagnostic services furnished an individual during a diagnostic study, and redesignated former pars. (3) and (4) as (2) and (3), respectively.

Subsec. (b) (1), (2). Pub. L. 90-248, § 129 (c) (4) (A), (B), eliminated diagnostic studies from the application of the inpatient hospital deductible.

EFFECTIVE DATE OF 1968 AMENDMENT Amendment of subsecs. (a) (2)—(4), (b) (1), (2) of this section by section 129 (c) (3), (4) (A), (B) of Pub. L. 90-248 applicable with respect to services furnished after March 31, 1968, see section 129 (d) of Pub. L. 90-248, set out as a note under section 1395d of this title.

Section 135(d) of Pub. L. 90-248 provided that: "The amendments made by this section [to subsec. (a) (2) of this section and sections 1395(1)(b) and 1395cc (a) (2) of this title] shall apply with respect to payment for blood (or packed red blood cells) furnished an individual after December 31, 1967."

Amendment of subsec. (a) (1) of this section by section 137(b) of Pub. L. 90-248, applicable with respect to services furnished after December 31, 1967, see section 137 (c) of Pub. L. 90-248, set out as a note under section 1395d of this title.

SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in sections 1395f, 13951, 1395x, 1395cc of this title.

§ 1395f. Conditions of and limitations on payment for services.

(a) Requirement of requests and certifications.

Except as provided in subsection (d) of this section, payment for services furnished an individual may be made only to providers of services which are eligible therefor under section 1395cc of this title and only if

(1) written request, signed by such individual except in cases in which the Secretary finds it impracticable for the individual to do so, is filed for such payment in such form, in such manner, within such time, and by such person or persons as the Secretary may by regulation prescribe;

(2) a physician certifies (and recertifies, where such services are furnished over a period of time, in such cases, with such frequency, and accompanied by such supporting material, appropriate to the case involved, as may be provided by regulations, except that the first of such recertifications shall be required in each case of inpatient hospital services not later than the 20th day of such period) that

(A) in the case of inpatient psychiatric hospital services, such services are or were required to be given on an inpatient basis by or under the supervision of a physician, for the psychiatric treatment of an individual; and (1) such treatment can or could reasonably be expected to improve the condition for which such treatment is or was necessary or (ii) inpatient diagnostic study is or was medically required and such services are or were necessary for such purposes;

(B) in the case of inpatient tuberculosis hospital services, such services are or were required to be given on an inpatient basis, by or under

the supervision of a physician, for the treatment of an individual for tuberculosis; and such treatment can or could reasonably be expected to (i) improve the condition for which such treatment is or was necesary or (ii) render the condition noncommunicable;

(C) in the case of post-hospital extended care services, such services are or were required to be given on an inpatient basis because the individual needs or needed skilled nursing care on a continuing basis for any of the conditions with respect to which he was receiving inpatient hospital services (or services which would constitute inpatient hospital services if the institution met the requirements of paragraphs (6) and (8) of section 1395x(e) of this title) prior to transfer to the extended care facility or for a condition requiring such extended care services which arose after such transfer and while he was still in the facility for treatment of the condition or conditions for which he was receiving such inpatient hospital services; or

(D) in the case of post-hospital home health services, such services are or were required because the individual is or was confined to his home (except when receiving items and services referred to in section 1395x (m) (7) of this title) and needed skilled nursing care on an intermittent basis, or physical or speech therapy, for any of the conditions with respect to which he was receiving inpatient hospital services (or services which would constitute inpatient hospital services if the institution met the requirements of paragraphs (6) and (8) of section 1395x (e) of this title) or post-hospital extended care services; a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician; and such services are or were furnished while the individual was under the care of a physician; (3) with respect to inpatient hospital services (other than inpatient psychiatric hospital services and inpatient tuberculosis hospital services) which are furnished over a period of time, a physician certifies that such services are required to be given on an inpatient basis for such individual's medical treatment, or that inpatient diognostic study is medically required and such services are necessary for such purpose, except that (A) such certification shall be furnished only in such cases, with such frequency, and accompanied by such supporting material, appropriate to the cases involved, as may be provided by regulations, and (B) the first such certification required in accordance with clause (A) shall be furnished no later than the 20th day of such period;

(4) in the case of inpatient psychiatric hospital services, the services are those which the records of the hospital indicate were furnished to the individual during periods when he was receiving (A) intensive treatment services, (B) admission and related services necessary for a diagnostic study, or (C) equivalent services;

(5) in the case of inpatient tuberculosis hospital services, the services are those which the records of the hospital indicate were furnished to the

individual during periods when he was receiving treatment which could reasonably be expected to (A) improve his condition or (B) render it noncommunicable;

(6) with respect to inpatient hospital services furnished such individual after the 20th day of a continuous period of such services and with respect to post-hospital extended care services furnished after such day of a continuous period of such services as may be prescribed in or pursuant to regulations, there was not in effect, at the time of admission of such individual to the hospital or extended care facility, as the case may be, a decision under section 1395cc (d) of this title (based on a finding that utilization review of longstay cases is not being made in such hospital or facility); and

(7) with respect to inpatient hospital services or post-hospital extended care services furnished such individual during a continuous period, a finding has not been made (by the physician members of the committee or group, as described in section 1395x(k) (4) of this title) pursuant to the system of utilization review that further inpatient hospital services or further post-hospital extended care services, as the case may be, are not medically necessary; except that, if such a finding has been made, payment may be made for such services furnished before the 4th day after the day on which the hospital or extended care facility, as the case may be, received notice of such finding. To the extent provided by regulations, the certification and recertification requirements of paragraph (2) shall be deemed satisfied where, at a later date, a physician makes certification of the kind provided in subparagraph (A), (B), (C), or (D) of paragraph (2) (whichever would have applied), but only where such certification is accompanied by such medical and other evidence as may be required by such regulations.

(b) Reasonable cost of services.

The amount paid to any provider of services with respect to services for which payment may be made under this part shall, subject to the provisions of section 1395e of this title, be the reasonable cost of such services, as determined under section 1395x(v) of this title.

(c) No payments to Federal providers of services.

No payment may be made under this part (except under subsection (d) of this section) to any Federal provider of services, except a provider of services which the Secretary determines is providing services to the public generally as a community institution or agency; and no such payment may be made to any provider of services for any item or service which such provider is obligated by a law of, or a contract with, the United States to render at public expense.

(d) Payments for emergency hospital services.

(1) Payments shall also be made to any hospital for inpatient hospital services furnished in a calendar year, by the hospital or under arrangements (as defined in section 1395x(w) of this title) with it, to an individual entitled to hospital insurance benefits under section 426 of this title even though such