TITLE XI-GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION 1 Sec. 1101. Sec. 1103. Sec. 1104. Sec. 1105. Sec. 1106. Sec. 1108. Sec. 1109. Sec. 1110. Sec. 1113. Sec. 1114. Sec. 1116. TABLE OF CONTENTS OF TITLE 2 Part A-General Provisions Definitions Rules and regulations Reservation of power Short title Disclosure of information in possession of agency Additional grants to Puerto Rico, the Virgin Islands, Guam, Cooperative research or demonstration projects Assistance for United States citizens returned from foreign Appointment of Advisory Council and other advisory groups Administrative and judicial review of certain administrative de- Page 533 536 536 537 537 537 539 540 543 543 545 545 545 546 548 550 Title XI of the Social Security Act is administered by the Department of Health and Human Services and by the Department of Labor. Title XI appears in the United States Code as §§1301-1320d-8, subchapter XI, chapter 7, Title 42. Regulations of the Secretary of Health and Human Services relating to Title XI are contained in chapter III, Title 20, in chapters I, II, and IV, Title 42, and in subtitle A and chapters I, III, and XIII, Title 45, Code of Federal Regulations. Regulations of the Secretary of Labor relating to Title XI are contained in chapter V, Title 20, and subtitle A, Title 29, Code of Federal Regulations. P.L. 104-191, §262(b)(2), struck out "TITLE XI-GENERAL PROVISIONS AND PEER REVIEW" and substituted "TITLE XI-GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION", effective August 21, 1996. See Vol. II, P.L. 88–164, §124(b)(4), with respect to the membership of the State Planning Councils. See Vol. II, P.L. 88-352, §601, for prohibition against discrimination in federally assisted programs. See Vol. II, P.L. 100-204, §724(d), with respect to furnishing information to the United States Commission on Improving the Effectiveness of the United Nations; and §725(b), with respect to the detailing of Government personnel. See Vol. II, P.L. 100-235, §§5-8, with respect to responsibilities of each Federal agency for computer systems security and privacy. See Vol. II, P.L. 101-508, §5120, with respect to vocational rehabilitation demonstration projects. See Vol. II, P.L. 103-432, §232, with respect to measurement and reporting of welfare receipt. 2 This table of contents does not appear in the law. Sec. 1117. Sec. 1118. Sec. 1119. Sec. 1120. Sec. 1122. Sec. 1124. Sec. 1125. Sec. 1127. Sec. 1128. Sec. 1128A. Sec. 1128C. Sec. 1128E. Sec. 1132. Sec. 1134. Sec. 1137. Sec. 1138. Sec. 1139. Sec. 1141. Sec. 1147. Appointment of the Administrator and Chief Actuary of the Federal participation in payments for repairs to home owned by Approval of certain projects Uniform reporting systems for health services facilities and or ganizations. Limitation on Federal participation for capital expenditures Reviews of child and family services programs, and of foster Disclosure of ownership and related information Issuance of subpenas by Comptroller General Disclosure by institutions, organizations, and agencies of own- Adjustments in SSI benefits on account of retroactive benefits Exclusion of certain individuals and entities from participation Criminal penalties for acts involving Federal health care pro- Fraud and abuse control program Guidance regarding application of health care fraud and abuse Health care fraud and abuse data collection program Civil monetary penalties and assessments for titles II and XVI Effect of failure to carry out State plan Notification of social security claimant with respect to deferred vested benefits. Period within which certain claims must be filed Nonprofit hospital philanthropy Development of model prospective rate methodology Repealed.] Income and eligibility verification system Hospital protocols for organ procurement and standards for organ procurement agencies. National Commission on Children Prohibition of misuse of symbols, emblems, or names in ref- Blood donor locator service .... Research on outcomes of health care services and procedures Protection of social security and medicare trust funds Public disclosure of certain information on hospital financial in- Recovery of SSI overpayments from Social Security benefits...... Page 551 552 552 553 553 554 558 558 559 561 562 563 563 564 573 582 586 587 590 593 597 600 600 601 601 602 603 604 604 608 611 615 617 619 623 624 624 625 625 Sec. 1153. Part B-Peer Review of the Utilization and Quality of Health Care Services Sec. 1151. Sec. 1154. Sec. 1157. Sec. 1159. Sec. 1160. [Sec. 1164. Sec. 1171. Sec. 1175. Sec. 1177. Sec. 1178. Purpose Definition of utilization and quality control peer review organi zation. Contracts with utilization and quality control peer review orga- Functions of peer review organizations Obligations of health care practitioners and providers of health Application of this part to certain State programs receiving Authorization for use of certain funds to administer the provi- Prohibition against disclosure of information Annual reports Exemptions for religious nonmedical health care institutions lands, and the Trust Territory of the Pacific Islands to be in- Part C-Administrative Simplification Definitions General Requirements for Adoption of Standards Requirements General penalty for failure to comply with requirements and Wrongful disclosure of individually identifiable health informa- Effect on State law Processing payment transactions by financial institutions Part A-General Provisions Page 'P.L. 105-33, §4901(b)(1)(A), struck out "and XIX" and substituted "XIX and XXI”. 626 626 626 630 638 638 640 641 642 642 644 644 644 645 645 647 648 650 650 652 653 653 654 DEFINITIONS SEC. 1101. [42 U.S.C. 1301] (a) When used in this Act (1) The term "State", except where otherwise provided, includes the District of Columbia and the Commonwealth of Puerto Rico, and when used in titles IV, V, VII, XI, XIX, and XXI3 includes the Virgin Islands and Guam. Such term when used in titles III, IX, and XII also includes the Virgin Islands. Such term when used in title V and in part B of this title also includes American Samoa, the Northern Mariana Islands, and the Trust Territory of the Pacific Islands. Such term when used in titles XIX and XXI also includes the Northern Mariana Islandsand American Samoa. In the case of Puerto Rico, the Virgin Islands, and Guam, titles I, X, and XIV, and title XVI (as in effect without regard to the amendment made by section 301 of the Social Security Amendments of 19725) shall continue to apply, and the term "State" when used in such titles (but not in title XVI as in effect pursuant to such amendment after December 31, 1973) includes Puerto Rico, the Virgin Islands, and Guam. Such term when used in title XX also includes the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. Such term when used in title IV also includes American Samoa. (2) The term "United States" when used in a geographical sense means, except where otherwise provided, the States. (3) The term "person" means an individual, a trust or estate, a partnership, or a corporation. (4) The term "corporation" includes associations, joint-stock companies, and insurance companies. (5) The term “shareholder” includes a member in an association, joint-stock company, or insurance company. (6) The term "Secretary", except when the context otherwise requires, means the Secretary of Health and Human Services. (7) The terms "physician" and "medical care" and "hospitalization" include osteopathic practitioners or the services of osteopathic practitioners and hospitals within the scope of their practice as defined by State law. (8)(A)_ The "Federal percentage" for any State (other than Puerto Rico, the Virgin Islands, and Guam) shall be 100 per centum less the State percentage; and the State percentage shall be that percentage which bears the same ratio to 50 per centum as the square of the per capita income of such State bears to the square of the per capita income of the United States; except that the Federal percentage shall in no case be less than 50 per centum or more than 65 per centum. (B) The Federal percentage for each State (other than Puerto Rico, the Virgin Islands, and Guam) shall be promulgated by the Secretary between October 1 and November 30 of each year, on the basis of the average per capita income of each State and of the United States for the three most recent calendar years for which satisfactory data are available from the Department of Commerce. Such promulgation shall be conclusive for each of the four quarters in the period beginning October 1 next succeeding such promulgation: Provided, That the Secretary shall promulgate such percentages as soon as possible after the enactment of the Social Security Amendments of 1958, which promulgation shall be conclusive for each of the eleven quarters in the period beginning October 1, 1958, and ending with the close of June 30, 1961. (C) The term "United States" means (but only for purposes of subparagraphs (A) and (B) of this paragraph) the fifty States and the District of Columbia. (D) Promulgations made before satisfactory data are available from the Department of Commerce for a full year on the per capita income of Alaska shall prescribe a Federal percentage for Alaska of 50 per centum and, for purposes of such promulgations, Alaska shall not be included as part of the "United SP.L. 92-603, §301, added Title XVI, Supplemental Security Income for the Aged, Blind, and Disabled. August 28, 1958 (P.L. 85-840; 72 Stat. 1013]. States". Promulgations made thereafter but before per capita income data for Alaska for a full three-year period are available from the Department of Commerce shall be based on satisfactory data available therefrom for Alaska for such one full year or, when such data are available for a two-year period, for such two years. (9) The term "shared health facility" means any arrangement whereby (A) two or more health care practitioners practice their professions at a common physical location; (B) such practitioners share (i) common waiting areas, examining rooms, treatment rooms, or other space, (ii) the services of supporting staff, or (iii) equipment; (C) such practitioners have a person (who may himself be a practitioner) (i) who is in charge of, controls, manages, or supervises substantial aspects of the arrangement or operation for the delivery of health or medical services at such common physical location, other than the direct furnishing of professional health care services by the practitioners to their patients; or (ii) who makes available to such practitioners the services of supporting staff who are not employees of such practitioners; and who is compensated in whole or in part, for the use of such common physical location or support services pertaining thereto, on a basis related to amounts charged or collected for the services rendered or ordered at such location or on any basis clearly unrelated to the value of the services provided by the person; and (D) at least one of such practitioners received payments on a fee-for-service basis under titles XVIII and XIX in an amount exceeding $5,000 for any one month during the preceding 12 months or in an aggregate amount exceeding $40,000 during the preceding 12 months; except that such term does not include a provider of services (as defined in section 1861(u) of this Act), a health maintenance organization (as defined in section 1301(a) of the Public Health Service Act 7), a hospital cooperative shared services organization meeting the requirements of section 501(e) of the Internal Revenue Code of 19548, or any public entity. (10) The term "Administration" means the Social Security Administration, except where the context requires otherwise. (b) The terms "includes" and "including" when used in a definition contained in this Act shall not be deemed to exclude other things otherwise within the meaning of the term defined. (c) Whenever under this Act or any Act of Congress, or under the law of any State, an employer is required or permitted to deduct any amount from the remuneration of an employee and to pay the amount deducted to the United States, a State, or any political subdivision thereof, then for the purposes of this Act the amount so 7See Vol. II, P.L. 78-410. See Vol. II, P.L. 83-591. P.L. 99-514, §2, provides, except when inappropriate, that any reference to the Internal Revenue Code of 1954 shall include a reference to the Internal Revenue Code of 1986. |