(other than services to which such sentence applies through the operation of section 1861(g)); (D)(i) rural health clinic services and (ii) Federally qualified health center services; (E) comprehensive outpatient rehabilitation facility services; (F) facility services furnished in connection with surgical procedures specified by the Secretary (i) pursuant to section 1833(1)(1)(A) and performed in an ambulatory surgical center (which meets health, safety, and other standards specified by the Secretary in regulations) if the center has an agreement in effect with the Secretary by which the center agrees to accept the standard overhead amount determined under section 1833(i)(2)(A) as full payment for such services (including intraocular lens in cases described in section 1833(i)(2)(A)(iii)) and to accept an assignment described in section 1842(b)(3)(B)(ii) with respect to payment for all such services (including intraocular lens in cases described in section 1833(i)(2)(A)(iii)) furnished by the center to individuals enrolled under this part, or (ii) pursuant to section 1833(i)(1)(B) and performed by a physician, described in paragraph (1), (2), or (3) of section 1861(r), in his office, if the Secretary has determined that (I) a quality control and peer review organization (having a contract with the Secretary (II) the particular physician involved has agreed to make available to such organization such records as the Secretary determines to be necessary to carry out the review, and (III) the physician is authorized to perform the procedure in a hospital located in the area in which the office is located, and if the physician agrees to accept the standard overhead amount determined under section 1833(i)(2)(B) as full payment for such services and to accept payment on an assignment-related basis with respect to payment for all services (including all preand post-operative services) described in paragraphs (1) and (2)(A) of section 1861(s) and furnished in connection with such surgical procedure to individuals enrolled under this part; (G) covered items (described in section 1834(a)(13)) furnished by a provider of services or by others under arrangements with them made by a provider of services; (H) outpatient critical access 94 hospital services (as defined in section 1861(mm)(3)); (I) prosthetic devices and orthotics and prosthetics (described in section 1834(h)(4)) furnished by a provider of services or by others under arrangements with them made by a provider of services; and (J) partial hospitalization services provided by a community mental health center (as described in section 1861(ff)(2)(B)). (b) For definitions of "spell of illness", "medical and other health services", and other terms used in this part, see section 1861. PAYMENT OF BENEFITS SEC. 1833. [42 U.S.C. 13951] (a) Except as provided in section 1876, and subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are payable under this part, amounts equal to 96 (1) in the case of services described in section 1832(a)(1)-80 percent of the reasonable charges for the services; except that (A) an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis (and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services) 95 may elect to be paid 80 percent of the reasonable cost of services for which payment may be made under this part on behalf of individuals enrolled in such organization in lieu of 80 percent of the reasonable charges for such services if the organization undertakes to charge such individuals no more than 20 percent of such reasonable cost plus any amounts payable by them as a result of subsection (b), 9% (B) with respect to items and services described in section 1861(s) (10)(A), the amounts paid shall be 100 percent of the reasonable charges for such items and services, (C) with respect to expenses incurred for those physicians' services for which payment may be made under this part that are described in section 1862(a)(4), the prosthetic devices and orthotics and prosthetics (as defined in section 1834(h)(4)), the amounts paid shall be the amounts described in section 1834(h)(1), the amounts paid shall be subject to such limitations as may be prescribed by regulations, (D) with respect to clinical diagnostic laboratory tests for which payment is made under this part (i) on the basis of a fee schedule under subsection (h)(1) or section 1834(d)(1)97, the amount paid shall be equal to 80 percent (or 100 percent, in the case of such tests P.L. 105-33, §4201(c)(1), struck out "rural primary care" and substituted "critical access", applicable to services furnished on or after October 1, 1997. 95 P.L. 105-33, §4002(j)(1)(A), added "(and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services)," applicable to new contracts entered into after August 5, 1997 and, with respect to contracts in effect, shall apply to payment for services furnished after December 31, 1998. See Vol. II, P.L. 100–360, §222, with respect to the adjustment of contracts with prepaid health plans. See Vol. II, P.L. 103-66, §13531, with respect to ambulatory surgical center services. P.L. 105-33, §4104(c)(1), added "or section 1834(d)(1)", applicable to items and services furnished on or after January 1, 1998. for which payment is made on an assignment-related basis) of the lesser of the amount determined under such fee schedule, the limitation amount for that test determined under subsection (h)(4)(B), or the amount of the charges billed for the tests, or (ii) on the basis of a negotiated rate established under subsection (h)(6), the amount paid shall be equal to 100 percent of such negotiated rate, (E) with respect to services furnished to individuals who have been determined to have end stage renal disease, the amounts paid shall be determined subject to the provisions of section 1881, (F) with respect to clinical social worker services under section 1861(s)(2)(N), the amounts paid shall be 80 percent of the lesser of (i) the actual charge for the services or (ii) 75 percent of the amount determined for payment of a psychologist under clause (L), [(G) Stricken. 981 (H) with respect to services of a certified registered nurse anesthetist anesthetist under section 1861(s)(11), the amounts paid shall be 80 percent of the least of the actual charge, the prevailing charge that would be recognized (or, for services furnished on or after January 1, 1992, the fee schedule amount provided under section 1848) if the services had been performed by an anesthesiologist, or the fee schedule for such services established by the Secretary in accordance with subsection (1), (I) with respect to covered items (described in section 1834(a)(13)), the amounts paid shall be the amounts described in section 1834(a)(1), and (J) with respect to expenses incurred for radiologist services (as defined in section 1834(b)(6)), subject to section 1848, the amounts paid shall be 80 percent of the lesser of the actual charge for the services or the amount provided under the fee schedule established under section 1834(b), (K) with respect to certified nurse-midwife services under section 1861(s)(2)(L), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or the amount determined by a fee schedule established by the Secretary for the purposes of this subparagraph (but in no event shall such fee schedule exceed 65 percent of the prevailing charge that would be allowed for the same service performed by a physician, or, for services furnished on or after January 1, 1992, 65 percent of the fee schedule amount provided under section 1848 for the same service performed by a physician), (L) with respect to qualified psychologist services under section 1861(s)(2)(M), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or the amount determined by a fee schedule established by the Secretary for the purposes of this subparagraph, (M) with respect to prosthetic devices and orthotics and (N) with respect to expenses incurred for physicians' services (as defined in section 1848(j)(3)), the amounts paid shall be 80 percent of the payment basis determined under section 1848(a)(1), (O) with respect to services described in section 1861(s)(2)(K) 99 (relating to services furnished by physicians assistants, nurse practitioners, or clinical nurse specialists 100), the amounts paid shall be 98 P.L. 103-432, §156(a)(2)(B)(ii); 108 Stat. 4440. PL. 105-33, §4512(b)(1)(A), struck out "section 1861(s)(2)(K)(ii)" and substituted "1861(s)(2)(K)”. 100 P.L. 105-33, §4512(b)(1)(B), struck out "nurse practitioner or clinical nurse specialist services" and substituted "services furnished by physicians assistants, nurse practitioners, or clinical equal to 80 percent of (i) the lesser of the actual charge or 85 (2) in the case of services described in section 1832(a)(2) (except those services described in subparagraphs (C), 106 (D), (E), (F), (G), (H), and (I) of such section and unless otherwise specified in section 1881) (A) with respect to home health services (other than a covered osteoporosis drug) (as defined in section 1861(kk)), the amount determined under the prospective payment system under section 1895; 107 (B) with respect to other items and services (except those described in subparagraph (C), (D), or (E) of this paragraph and except as may be provided in section 1886 or section 1888(e)(9) 108)— nurse specialists", applicable with respect to services furnished and supplies provided on and after January 1, 1998. 101 P.L. 105-33, §4511(b)(1), amended subparagraph (O) in its entirety, applicable with respect to services furnished and supplies provided on and after January 1, 1998. For subparagraph (0) as it formerly read, see Vol. II, Superseded Provisions, P.L. 105–33. 102 P.L. 105-33, §4315(b)(A), struck out "and (P)" and substituted "(P)". 103 P.L. 105-33, §4315(b)(B), struck out the semicolon and substituted “, and (Q)* with respect to items or services for which fee schedules are established pursuant to section 1842(s), the amounts paid shall be 80 percent of the lesser of the actual charge or the fee schedule established in such section;", applicable to particular services as of the date specified by the Secretary of Health and Human Services. *P.L. 105-33, §4531(b)(1)(A), struck out “and (Q)" and substituted “(Q)". 104 P.L. 105-33, §4531(b)(1)(B), struck out the semicolon and added ", and (R)* with respect to ambulance service, the amounts paid shall be 80 percent of the lesser of the actual charge for the services or the amount determined by a fee schedule established by the Secretary under section 1834(1);", applicable to services furnished on or after January 1, 2000. *P.L. 105-33, §4556(b)(1), struck out “and (R)” and substituted “(R)". 105 P.L. 105-33, §4556(b)(2), struck out the semicolon and substituted ", and (S) with respect to drugs and biologicals not paid on a cost or prospective payment basis as otherwise provided in this part (other than items and services described in subparagraph (B)), the amounts paid shall be 80 percent of the lesser of the actual charge or the payment amount established in section 1842(0);", applicable to drugs and biologicals furnished on or after January 1, 1998. 106 P.L. 105-33, §4541(a)(1), added "(C)". 107 P.L. 105-33, $4603(c)(2)(A)(i), amended subparagraph (A) in its entirety, applicable to cost reporting periods beginning on or after October 1, 1999. For subparagraph (A) as it formerly read, see Vol. II, Superseded Provisions, P.L. 105-33. *P.L. 105-277, §5101(c)(2), revised the effective date provided for in P.L. 105-33, §4603(d) to read "portions of cost reporting periods occurring on or after October 1, 2000". 108 P.L. 105-33, §4432(b)(5)(C), added "or section 1888(e)(9)", applicable to items and services furnished on or after July 1, 1998. (i) furnished before January 1, 1999, 109 the lesser of (I) the reasonable cost of such services, as determined under section 1861(v), or (II) the customary charges with respect to such services, less the amount a provider may charge as described in clause (ii) of section 1866(a)(2)(A), but in no case may the payment for such other services exceed 80 percent of such reasonable cost, or (ii) if such services are furnished before January 1, 1999, 110 by a public provider of services, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this clause), free of charge or at nominal charges to the public, 80 percent of the amount determined in accordance with section 1814(b)(2), or 111 (iii) if such services are furnished on or after January 1, 1999, the amount determined under subsection (t), or 112 (iv) 113 if (and for so long as) the conditions described in section 1814(b)(3) are met, the amounts determined under the reimbursement system described in such section; (C) with respect to services described in the second sentence of section 1861(p), 80 percent of the reasonable charges for such services; (D) with respect to clinical diagnostic laboratory tests for which payment is made under this part (i) on the basis of a fee schedule determined under subsection (h)(1) or section 1834(d)(1) 114, the amount paid shall be equal to 80 percent (or 100 percent, in the case of such tests for which payment is made on an assignment-related basis or to a provider having an agreement under section 1866 of the lesser of the amount determined under such fee schedule, the limitation amount for that test determined under subsection (h)(4)(B), or the amount of the charges billed for the tests, or (ii) on the basis of a negotiated rate established under subsection (h)(6), the amount paid shall be equal to 100 percent of such negotiated rate for such tests; (E) with respect to- (i) outpatient hospital radiology services (including diagnostic and therapeutic radiology, nuclear medicine and CAT scan procedures, magnetic resonance imaging, and ultrasound and other imaging services, but excluding screening mammography), and (ii) effective for procedures performed on or after October 1, 1989, diagnostic procedures (as defined by the 109 P.L. 105-33, §4523(d)(3)(A), added “furnished before January 1, 1999,", effective August 5, 1997. 110 P.L. 105-33, §4523(d)(3)(B), added "before January 1, 1999,", effective August 5, 1997. 111 See Vol. II, P.L. 98-369, §2308(b)(1), with respect to rules applicable to the nominality test. 112 P.L. 105-33, §4523(d)(3)(D), added clause (iii), effective August 5, 1997. 113 P.L. 105-33, §4523(d)(3)C), redesignated the former clause (iii) as clause (iv). 114 P.L. 105-33, §4104(c)(1), added "or section 1834(d)(1)", applicable to items and services furnished on or after January 1, 1998. |