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Public Law 89-94 AN ACT July 27, 1965 To authorize the Secretary of the Interior to contract with the Middle Rio Grande ___[S^_J462] Conservancy District of New Mexico for the payment of operation and maintenance charges on certain Pueblo Indian lands.

Be it enacted by the Senate and House of Representatives of the Middle Rio United States of America in Congress assembled, That the provisions ^^^^^^ ConservGrande ^^^^^^ of the Act of August 27, 1935 (49 Stat. 887), as amended by section 5 ancy District, of the Act of June 20, 1938 (52 Stat. 779), by the Act of April 24, N. Max. 1946 (60 Stat. 121), and by the Act of May 29, 1956 (70 Stat. 221), trac'r '°"" authorizing the Secretary of the Interior to provide by agreement with the Middle Kio Grande Conservancy District, a subdivision of the State of New Mexico, for the payment of operation and maintenance charges on newly reclaimed Pueblo Indian lands and lands purchased by the United States by virtue of the Act of June 7, 1924 (43 Stat. 636), as amended, for certain Pueblo Indians, are hereby extended for an additional period of ten years to 1975. Approved July 27, 1965. Public Law 89-95 AN ACT To provide for safety regulation of common carriers by piix'liiie under the jurisdiction of the Interstate Commerce Commission, and for other purposes.

j^ly 27, 1965 [H. R. 5041]

lie it enacted by the Senate- and House of Representatives of the United States of America in Congress assembled, That the definition i-cc. of "carrier' contained in section 831 of title 18 of the United States ^ilTn^lT °' Code, as amended, is hereby amended to read as follows: 74 Stat. sos. "L^nless otherwise indicated, 'carrier' means any person engaged in the transportation of passengers or property by land, as a common, contract, or private carrier, or freight forwarder as those terms are used in the Interstate Commerce Act, as amended, and officers, agents, and employees of such carriers." Approved July 27, 1965. Public Law 89-96 JOINT RESOLUTION Making continuing appropriations for the fiscal year 1866, and for other purposes,

j ^ ^ 3,,,,, 3 [H. J. Res. 591]

Resolved by the SenMe and House of Representatives of the United States of Arrberica in Congress assembled, That clause (c) of section continuing ap102 of the joint resolution of June 30, 1965 (Public Law 89-58), is ''XeTpTiMs!'^* hereby amended by striking out "July 31, 1965" and inserting in lieu thereof "August 31, 1965". Approved July 30, 1965.

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[79 STAT.

Public Law 89-97 .
 * H/R°66?f]

Am^ndments'^f*^ 1965.

^ AN ACT To provide a hospital insurance program for the aged under the Social Security Act with a supplementary medical benefits program and an expanded program of medical assistance, to increase benefits under the Old-Age, Survivors, and Disability Insurance System, to improve the Federal-State public assistance programs, and for other purposes.

Be it enacted by the Senate and House of Representatives of the ?7m^e<^ States of America in Congress assembled, That this Act, with the following table of contents, may be cited as the "Social Security Amendments of 1965". TABLE OF CONTENTS TITLE I—HEALTH INSTJBANCE FOB THE AGED AND MEDICAL ASSISTANCE

SEC. 100. Short title. P A E T I—HEALTH INSURANCE BENEFITS FOR THE AGED

SEC. 101. Entitlement to hospital insurance benefits. SEC. 102. Hospital insurance benefits and supplementary medical insurance benefits. TITLE XVIII—HEALTH INSURANCE FOR THE AGED

SEC. 1801. Prohibition against any Federal interference. SEC. 1802. Free choice by patient guaranteed. SEC. 1803. Option to individuals to obtain other health insurance protection. PART A — H O S P I T A L INSURANCE BENEFITS FOB THE AGED

SEC. SEC. SEC. SEC.

1811. Description of program. 1812. Scope of benefits. 1813. Deductibles and coinsurance. 1814. Conditions of and limitations on payment for services. (a) Requirement of requests and certifications. (b) Reasonable cost of services. (c) No payments to Federal providers of services. (d) Payments for emergency hospital services. (e) Payment for inpatient hospital services prior to notification of noneligibility. (f) Payment for certain emergency hospital services furnished outside the United States. SEC. 1815. Payment to providers of services SEC. 1816. Use of public agencies or private organizations to facilitate payment to providers of services. SEC. 1817. Federal hospital insurance trust fund. PART B — S U P P L E M E N T A BY MEDICAL INSURANCE BENEFITS FOB THE AGED

SEC. 1831. Establishment of supplementary medical insurance program for the aged. SEC. 1832. Scope of benefits. SEC. 1833. Payment of benefits. SEC. 1834. Limitation on home health services. SEC. 1835. Procedure for payment of claims of providers of services. SEC. 1836. Eligible individuals. SEC. 1837. Enrollment periods. SEC. 1838. Coverage period. SEC. 1839. Amounts of premiums. SEC. 1840. Payment of premiums. SEC. 1841. Federal supplementary medical insurance trust fund. SEC. 1842. Use of carriers for administration of benefits. SEC. 1843. State agreements for coverage of eligible individuals who are receiving money payments under public assistance programs. SEC. 1844. Appropriations to cover Government contributions and contingency reserve.

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TABLE OF CONTENTS—Continued TITLE XVIII—HEALTH INSURANCE FOR THE AGED—Continued PART C — M I S C E L L A N E O U S PROVISIONS

j

SEC. 1861. Definitions of services, institutions, etc. (a) Spell of illness. (b) Inpatient hospital services. I (c) Inpatient psychiatric hospital services. (d) Inpatient tuberculosis hospital services. (e) Hospital. (f) Psychiatric hospital. (g) Tuberculosis hospital, (h) Extended care services. (i) Post-hospital extended care services, (j) Extended care facility, (k) Utilization review. (1) Agreements for transfer between extended care facilities and hospitals, (m) Home health services, (n) Post-hospital home health services, (o) Home health agency, (p) Outpatient hospital diagnostic services, (q) Physicians' services, (r) Physician. (s) Medical and other health services, (t) Drugs and biologicals. (u) Provider of services, (v) Reasonable cost, (w) Arrangements for certain services, (x) State and United States. (y) Post-hospital extended care in CJhristian Science extended care facilities. SEC. 1862. Exclusions from coverage. SEC 1863. Consultation with State agencies and other organizations to develop conditions of participation for providers of services. SEC 1864. Use of State agencies to determine compliance by providers of services with conditions of participation. SEC 1865. Effect of accreditation. SEC 1866. Agreements with providers of services. SEC 1867. Health insurance benefits advisory council. SEC 1868. National medical review committee. SEC 1869. Determinations; appeals. SEC 1870. Overpayments on behalf of individuals. SEC 1871. Regulations. SEC. 1872. Application of certain provisions of title II. SEC 1873. Designation of organization or publication by name. SEC 1874. Administration. SEC 1875. Studies and recommendations. SEC. 103. Transitional provision on eligibility of presently uninsured individuals for hospital insurance benefits. SEC. 104. Suspension in case of aliens; persons convicted of subversive activities. SEC 105. Railroad retirement amendments. SEC 106. Medical expense deduction. SEC 107. Receipts for employees must show taxes separately. SEC 108. Technical and administrative amendments relating to trust funds. SEC 109. Advisory council on social security. SEC 110. Meaning of term "Secretary". SEC 111. Role of the Railroad Retirement Board in the administration of hospital insurance for the aged.

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[79

STAT.

TABLE OF CONTENTS—Continued TITLE XVIII—HEALTH INSURANCE FOR THE AGED—Continued PART 2—GRANTS' TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

SEC. 121. Establishment of programs. TiTi-E XIX—GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

SEC. 1901. Appropriation. SEC. 1902. State plans for medical assistance. SEC. 1903. Payment to States. SEC. 1904. Operation of State plans. SEC. 1905. Definitions. SEC. 122. Payment by States of premiums for supplementary medical insurance. TITLE II—OTHES AMENDMENTS RELATING TO HEALTH CARE PART 1 — M A T E R N A L AND CHILD HEALTH AND CRIPPLED CHILDREN'S SERVICES

SEC. SEC. SEC. SEC SEC. SEC SEC SEC.

201. Increase in maternal and child health services. 202. Increase in crippled children'services. 203. Training of professional personnel for the care of crippled children. 204. Payment for inpatient hospital services. 205. Special project grants for health of school and preschool children. 206. Evaluation and report. 207. Increase in child welfare services. 208. Day care services. PART 2—IMPLEMENTATION OF MENTAL RETARDATION PLANNING

SEC. 211. Authorization of appropriations. PART 3 — P U B L I C ASSISTANCE AMENDMENTS RELATING TO HEALTH CARE

SEC. 22L Removal of limitations on Federal participation in assistance to individuals with tuberculosis or mental disease. SEC. 222. Amendment to definition of medical assistance for the aged. PART 4—MISCELLANEOUS AMENDMENTS RELATING TO HEALTH CARE

SEC 231. Health study of resources relating to children's emotional illness. TITLE III—SOCIAL SECURITY AMENDMENTS

SEC. SEC. SEC SEC. SEC. SEC. SEC SEC SEC SEC SEC SEC SEC SEC SEC

300. Short title. 301. Increase in old-age, survivors, and disability insurance benefits. 302. Computation and recomputation of benefits. 303. Disability insurance benefits. 304. Payment of disability insurance benefits after entitlement to other monthly insurance benefits. 305. Disability insurance trust fund. 306. Payment of child's insurance benefits after attainment of age 18 in case of child attending school. 307. Reduced benefits for widows at age 60. 308. Wife's and widow's benefits for divorced women. 309. Transitional insured status. 310. Increase in amount an individual is permitted to earn without suffering full deductions from benefits. 311. Coverage for doctors of medicine. 312. Gross income of farmers. 313. Coverage of tips. 314. Inclusion of Alaska among States permitted to divide their retirement systems.

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PUBLIC LAW 89-97-JULY 30, 1965 TABLE OF CONTENTS—Continued TITLE III—SOCIAL SECURITY AMENDMENTS—Continued

SEC. 315. Additional period for electing coverage under divided retirement system. SEC. 316. Employees of nonprofit organizations. SEC. 317. Coverage of temporary employees of the District of Columbia. SEC. 318. Coverage for certain additional hospital employees in California. SEC. 319. Tax exemption for religious groups opposed to insurance. SEC. 320. Increase of earnings counted for benefit and tax purposes. SEC. 321. Changes in tax schedules. SEC. 322. Reimbursement of trust funds for cost of noncontributory military service credits. SEC. 323. Adoption of child by retired worker. SEC. 324. Extension of period for filing proof of support and applications for lump-sum death payment. SEC. 325. Treatment of certain royalties for retirement test purposes. SEC. 326. Amendments preserving relationship between railroad retirement and old-age, survivors, and disability insurance systems. SEC. 327. Technical amendment relating to meetings of board of trustees of the old-age, survivors, and disability insurance trust funds. SEC. 328. Applications for benefits. SEC. 329. Underpayments. SEC. 330. Payments to two or more individuals of the same family. SEC. 331. Validating certificates filed by ministers. SEC. 332. Determination of attorneys' fees in court proceedings under title II. SEC. 333. Continuation of widow's and widower's insurance benefits after remarriage. SEC. 334. Changes in definitions of wife, widow, husband, and widower. SEC. 335. Reduction of benefits on receipt of workmen's compensation. SEC. 336. Payment of costs of rehabilitation services from the trust funds. SEC. 337. Teachers in the State of Maine. SEC 338. Modification of agreement with North Dakota and Iowa with respect to certain students. SEC. 339. Qualification of children not qualified under State law. SEC. 340. Disclosure, under certain circumstances, to courts and interested welfare agencies of whereabouts of individuals. SEC. 341. Additional period for filing of ministers certificates. SEC 342. Rectifying error in interpreting law with respect to certain school employees in Alaska. SEC 343. Continuation of child's insurance benefits after adoption by brother or sister. SEC. 344. Disability insurance benefits for the blind; special provisions. TITLE IV—PUBLIC ASSISTANCE AMENDMENTS

SEC. 401. Increased Federal payments under public assistance titles of the Social Security Act. SEC 402. Protective payments. SEC 403. Disregarding certain earnings in determining need under assistance programs for the aged, blind, and disabled. SEC 404. Administrative and judicial review of public assistance determinations. SEC 405. Maintenance of State public assistance expenditures. SEC 406. Disregarding OASDI benefit increase, and child's insurance benefit payments beyond age 18, to the extent attributable to retroactive effective date. SEC 407. Extension of grace period for disregarding certain income for States where legislature has not met in regular session. SEC 408. Technical amendments relating to public assistance programs. SEC 409. Eligibility of children over age 18 attending school. SEC 410. Disregarding certain earnings in determining need of certain dependent children. SEC 411. Federal share of public assistance expenditures.

289

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[79 STAT.

TITLE I—HEALTH INSURANCE FOR THE AGED AND MEDICAL ASSISTANCE SHORT TITLE

Health insurAged Act. a n c e for the

gj,(,. iQO. This title may be cited as the "Health Insurance for A J A j.« the Aged Act". AT,

PART 1—HEALTH INSURANCE BENEFITS FOR THE AGED ENTITLEMENT TO HOSPITAL INSURANCE BENEFITS

11 f.?'- 1362.

42 USC 401-425.

SEC. 101. Title II of the Social Security Act is amended by adding at the end thereof the following new section: a. ENTITLEMENT TO HOSPITAL INSURANCE BENEFITS

42 USC 40 2. Post, p. 291.

Post. pp. 335, 340.

"SEC. 226. (a) Every individual who— " (1) has attained the age of 65, and "(2) is entitled to monthly insurance benefits under section 202 or is a qualified railroad retirement beneficiary, shall be entitled to hospital insurance benefits under part A of title X VIII for each month for which he meets the condition specified in paragraph (2), beginning with the first month after June 1966 for which he meets the conditions specified in paragraphs (1) and (2). " (b) For purposes of subsection (a) — "(1) entitlement of an individual to hospital insurance benefits for a month shall consist of entitlement to have payment made under, and subject to the limitations in, part A of title X VIII on his behalf for inpatient hospital services, post-hospital extended care services, post-hospital home health services, and outpatient hospital diagnostic services (as such terms are defined in part C of title X VIII) furnished him in the United States (or outside the United States in the case of inpatient hospital services furnished under the conditions described in section 1814(f)) during such month; except that (A) no such payment may be made for post-hospital extended care services furnished before January 1967, and (B) no such payment may be made for posthospital extended care services or post-hospital home health services unless the discharge from the hospital required to qualify such services for payment under part A of title X VIII occurred after June 30, 1966, or on or after the first day of the month in which he attains age 65, whichever is later; and "(2) an individual shall be deemed entitled to monthly insurance benefits under section 202, or to be a qualified railroad retirement beneficiary, for the month in which he died if he would have been entitled to such benefits, or would have been a qualified railroad retirement beneficiary, for such month had he died in the next month. "(c) For purposes of this section, the term 'qualified railroad retirement beneficiary' means an individual whose name has been certified to the Secretary by the Railroad Retirement Board under section 21 of the Railroad Retirement Act of 1937. A n individual shall cease to be a qualified railroad retirement beneficiary at the close of the month preceding the month which is certified by the

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Kailroad Retirement Board as the month in which he ceased to meet the requirements of section 21 of the Railroad Retirement Act of 1937. ^ 34^°^'' pp- " ^ ' " (d) For entitlement to hospital insurance benefits in the case of certain uninsured individuals, see section 103 of the Social Security Amendments of 1965." HOSPITAL INSURANCE BENEFITS AND SUPPLEMENTARY MEDICAL INSURANCE BENEFITS

SEC. 102. (a) The Social Security Act is amended by adding after title X VII the following new title:

42 USC i sos.

"TITLE XVIII—HEALTH INSURANCE FOR THE AGED " P R O H I B I T I O N AGAINST ANY FEDERAL INTERFERENCE

"SEC. 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. u 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. " O P T I O N TO INDIVIDUAIiS TO OBTAIN OTHER HEALTH INSURANCE PROTECTION

" S E C 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. " P A R T A—HOSPITAL INSURANCE BENEFITS FOR THE AGED "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 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. " S C O P E o r 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 (subject to the provisions of this part) for— "(1) inpatient hospital services for up to 90 days during any spell of ilmess;

^"'*' P- 290. 42 USC 401-425.

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Post, p. 320.

Post,

p. 3 1 3.

[79 STAT.

"(2) post-hospital extended care services for up to 100 days during any spell of illness; "(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; and " (4) outpatient hospital diagnostic services, "^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 90 days during such spell; "(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 or a tuberculosis 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 90-day period immediately before such first day shall be included in determining the 90-day limit under subsection (b)(1) (but not 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 oneyear 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. IIDEDUCTIBLES A N D C O INSURANCE

Inpatient hos. pitai services.

"SEC. 1813. (a)(1) The amount payable for inpatient hospital services fumished 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 one-fourth of the

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PUBLIC LAW 89-97-JULY 30, 1965

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. "(2) The amount payable for outpatient hospital diagnostic services furnished an individual during a diagnostic study shall be reduced by a deduction equal to the sum of (A) one-half of the inpatient hospital deductible which is applicable to spells of illness beginning in the same calendar year as such diagnostic study and (B) 20 per centum of the remainder of such amount. For purposes of the preceding sentence, a diagnostic study for any individual consists of the outpatient hospital diagnostic services provided by (or under arrangements made by) the same hospital during the 20-day period beginning on the first day (not included in a previous diagnostic study) on which he is entitled to hospital insurance benefits under section 226 and on which outpatient hospital diagnostic services are furnished him. "(3) 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 an amount equal to the cost of the first three pints of whole blood furnished to him as part of such services during such spell of illness. "(4) 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)(1) The inpatient hospital deductible which shall be applicable for the purposes of subsection (a) shall be $40 in the case of any spell of illness or diagnostic study 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) in the case of any spell of illness or diagnostic study 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 1866, to individuals who are entitled to hospital insurance benefits under section 226, plus the amount which would have been so paid but for subsection (a)(1) of this section.

293

Outpatient hospuai diagnost services.

Ante, p. 290.

Inpatient hospital

deduc'tibie.

Post, p. 327.

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"CONDITIONS OF AND L I M I T A T I O N S ON P A Y M E N T FOR SERVICES

"Requirement of Requests and Certifications

Post, p. 327.

Post. p. 314.

"SEC. 1814. (a) Except as provided in subsection (d), payment for services furnished an individual may be made only to providers Qf services which are eligible therefor under section 1866 and only "(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 hospital services (other than inpatient psychiatric hospital services and inpatient tuberculosis hospital services), such services are or were required to be given on an inpatient basis for such individual's medical treatment, or that inpatient diagnostic study is or was medically required and such services are or were necessary for such purpose; " (B) 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 (i) 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; " (C) 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 necessary or (ii) render the condition noncommunicable; " (D) 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 1861(e)) 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;

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" (E) 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 1861(m)(7)) 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 1861(e)) 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; or " (F) in the case of outpatient hospital diagnostic services, such services are or were required for diagnostic study; "(3) 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; "(4) 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; "(5) 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 1866(d) (based on a finding that utilization review of long-stay cases is not being made in such hospital or facility); and "(6) with respect to inpatient hospital services or posthospital 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 1861 (k)(4)) 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), (D), (E), or (F) of paragraph (2)

295

^°«''P- 319.

Post, p. in.

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(whichever would have applied), but only where such certification is accompanied by such medical and other evidence as may be required by such regulations. "Eeasonable Cost of Services

Ante, p. 292. Post,

p. 322.

"(b) 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 1813, be the reasonable cost of such services, as determined under section 1861(v). "No Payments to Federal Providers of Services "(c) No payment may be made under this part (except under subsection (d)) 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. "Payments for Emergency Hospital Services

Ante, p. 290.

Post,

p. 327.

" (d) Payments shall also be made to any hospital for inpatient hospital services or outpatient hospital diagnostic services furnished, by the hospital or under arrangements (as defined in section 1861(w)) with it, to an individual entitled to hospital insurance benefits under section 226 even though such hospital does not have an agreement in effect under this title if (A) such services were emergency services and (B) the Secretary would be required to make such payment if the hospital had such an agreement in effect and otherwise met the conditions of payment hereunder. Such payments shall be made only in the amounts provided under subsection (b) and then only if such hospital agrees to complv, with respect to the emergency services provided, with the provisions of section 1866(a). "Payment for Inpatient Hospital Services Prior to Notification of Noneligibility

Ante.p. 291.

"(e) Notwithstanding that an individual is not entitled to have payment made under this part for inpatient hospital services furnished by any hospital, payment shall be made to such hospital (unless it elects not to receive such payment or, if payment has already been made by or on behalf of such individual, fails to refund such payment within the time specified by the Secretary) for such services which are furnished to the individual prior to notification to such hospital from the Secretary of his lack of entitlement, if such payments are precluded ouly by reason of section 1812 and if such hospital complies with the requirements of and regulations under this title with respect to such payments, has acted in good faith and without knowledge of such lack of entitlement, and has acted reasonably in assuming entitlement existed. Payment under the preceding sentence may not be made for services furnished an individual pursuant to any admission after the 6th elapsed day (not including as an elapsed day Saturday, Sunday, or a legal holiday) after the day on which such admission occurred.

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"Payment for Certain Emergency Hospital Services Furnished Outside the United States "(f) The authority contained in subsection (d) shall be applicable to emergency inpatient hospital services furnished an individual by a hospital located outside the United States if— "(1) such individual was physically present in a place within the United States at the time the emergency which necessitated such inpatient hospital services occurred; and "(2) such hospital was closer to, or substantially more accessible from, such place than the nearest hospital within the United States which was adequately equipped to deal with, and was available for the treatment of, such individual's illness or injury. ((PAYMENT TO PROVTOERS OF SERVICES

"SEC. 1815. The Secretary shall periodically determine the amount which should be paid under this part to each provider of services with respect to the services furnished by it, and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) and prior to audit or settlement by the General Accounting Office, from the Federal Hospital Insurance Trust Fund, the amounts so determined, with necessary ^°^^' P- 299. adjustments on account of previously made overpayments or underpayments; except that no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period. " U S E OF P U B L I C AGENCIES OR PRIVATE ORGANIZATIONS TO FACILITATE PAYMENT TO PROVIDERS OF SERVICES

"SEC. 1816. (a) If any group or association of providers of services wishes to have payments under this part to such providers made through a national. State, or other public or private agency or organization and nominates such agency or organization for this purpose, the Secretary is authorized to enter into an agreement with such agency or organization providing for the determination by such agency or organization (subject to such review by the Secretary as may be provided for by the agreement) of the amount of the payments required pursuant to this part to be made to such providers, and for the making of such payments by such agency or organization to such providers. Such agreement may also include provision for the agency or organization to do all or any part of the following: (1) to provide consultative services to institutions or agencies to enable them to establish and maintain fiscal records necessary for purposes of this part and otherwise to qualify as hospitals, extended care facilities, or home health agencies, and (2) with respect to the providers of services which are to receive payments through it (A) to serve as a center for, and communicate to providers, any information or instructions furnished to it by the Secretary, and serve as a channel of communication from providers to the Secretary; (B) to make such audits of the records of providers as may be necessary to insure that proper payments are made under this part; and (C) to perform such other functions as are necessary to carry out this subsection. 49-850 0-66—22

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[79 STAT.

" (b) The Secretary shall not enter into an agreement with any agency or organization under this section unless (1) he finds (A) that to do so is consistent with the effective and efficient administration of this part, and (B) that such agency or organization is willing and able to assist the providers to which payments are made through it under this part in the application of safeguards against unnecessarv utilization of services furnished by them to individuals entitled to hospital insurance benefits under section 226, and the agreement provides for such assistance, and (2) such agency or organization agrees to furnish to the Secretary such of the information acquired by it in carrying out its agreement under this section as the Secretary may find necessary in performing his functions under this part. (c) An agreement with any agency or organization under this section may contain such terms and conditions as the Secretary finds necessary or appropriate, may provide for advances of funds to the agency or organization for the making of payments by it under subsection (a), and shall provide for payment of so much of the cost of administration of the agency or organization as is determined by the Secretary to be necessary and proper for carrying out the functions covered by the agreement. " (d) If the nomination of an agency or organization as provided in this section is made by a group or association of providers of services, it shall not be binding on members of the group or association which notify the Secretary of their election to that effect. Any provider may, upon such notice as may be specified in the agreement under this section with an agency or organization, withdraw its nomination to receive payments through such agency or organization. Any provider which has withdrawn its nominatioUj and any provider which has not made a nomination, may elect to receive payments from any agency or organization which has entered into an agreement with the Secretary under this section if the Secretary and such agency or organization agree to it. "(e) An agreement with the Secretary under this section may be terminated— "(1) by the agency or organization which entered into such agreement at such time and upon such notice to the Secretary, to the public, and to the providers as may be provided in regulations, or "(2) by the Secretary at such time and upon such notice to the agency or organization, to the providers which have nominated it for purposes of this section, and to the public, as may be provided in regulations, but only if he finds, after reasonable notice and opportunity for hearing to the agency or organization, that (A) the agency or organization has failed substantially to carry out the agreement, or (B) the continuation of some or all of the functions provided for in the agreement with the agency or organization is disadvantageous or is inconsistent with the efficient administration of this part. " (f) An agreement with an agency or organization under this section may require any of its officers or employees certifying payments or disbursing funds pursuant to the agreement, or otherwise participating in carrying out the agreement, to give surety bond to the United States in such amount as the Secretary may deem appropriate.

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299

" (g)(1) ^ o individual designated pursuant to an agreement under this section as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him under this section. " (2) No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payment by him under this section if it was based upon a voucher signed by a certifying officer designated as provided in paragraph (1) of this subsection, "(3) No such agency or organization shall be liable to the United States for any payments referred to in paragraph (1) or (2), "FEDERAL HOSPITAL INSURANCE TRUST FUND

"SEC. 1817. (a) There is hereby created on the books of the Treasury of the United States a trust fund to be known as the 'Federal Hospital Insurance Trust Fund' (hereinafter in this section referred to as the 'Trust F u n d '). The Trust Fund shall consist of such amounts as may be deposited in, or appropriated to, such fund as provided in this part. There are hereby appropriated to the Trust F u n d for the fiscal year ending June 30, 1966, and for each fiscal year thereafter, out of any moneys in the Treasury not otherwise appropriated, amounts equivalent to 100 per centum of— "(1) the taxes imposed by sections 3101(b) and 3111(b) of the Internal Revenue Code of 1954 with respect to wages reported ^°®*' PP* ^^^' ^^^• to the Secretary of the Treasury or his delegate pursuant to subtitle F of such Code after December 31, 1965, as determined by J^^^^ ^''°^ "^ the Secretary of the Treasury by applying the applicable rates of tax under such sections to such wages, which wages shall be certified by the Secretary of Health, Education, and Welfare on the basis 01 records of wages established and maintained by the Secretary of Health, Education, and Welfare in accordance with such reports; and "(2) the taxes imposed by section 1401(b) of the Internal Revenue Code of 1954 with respect to self-employment income ^°®/' P* ^^'^^ reported to the Secretary of the Treasury or his delegate on tax returns under subtitle F of such Code, as determined by the Secretary of the Treasury by applying the applicable rate of tax under such section to such self-employment income, which self-employment income shall be certified by the Secretary of Health, Education, and Welfare on the basis of records of selfemployment established and maintained by the Secretary of Health, Education, and Welfare in accordance with such returns. The amounts appropriated by the preceding sentence shall be transferred from time to time from the general fund in the Treasury to the Trust Fund, such amounts to be determined on the basis of estimates by the Secretary of the Treasury of the taxes, specified in the preceding sentence, paid to or deposited into the Treasury; and proper adjustments shall be made in amounts subsequently transferred to the extent prior estimates were in excess of or were less than the taxes specified in such sent-ence. " (b) With respect to the Trust Fund, there is hereby created a Tm°stets^ body to be known as the Board of Trustees of the Trust Fund (hereinafter in this section referred to as the 'Board of Trustees') composed of the Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health, Education, and Welfare, all ex officio. The Secretary of the Treasury shall be the Managing Trustee of the Board of Trustees (hereinafter in this section referred to as the

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[79 STAT.

'Managing Trustee'). The Commissioner of Social Security shall gresT'*'''° ^°"" serve as the Secretary of the Board of Trustees. The Board of Trustees shall meet not less frequently than once each calendar year. I t shall be the duty of the Board of Trustees to— " (1) Hold the Trust F u n d; "(2) Report to the Congress not later than the first day of March of each year on the operation and status of the Trust Fund during the preceding fiscal year and on its expected operation and status during the current fiscal year and the next 2 fiscal years; "(3) Report immediately to the Congress whenever the Board is of the opinion that the amount of the Trust Fund is unduly small; and "(4) Review the general policies followed in managing the Trust Fund, and recommend changes in such policies, including necessary changes in the provisions of law which govern the way in which the Trust Fund is to be managed. The report provided for in paragraph (2) shall include a statement of the assets of, and the disbursements made from, the Trust Fund during the preceding fiscal year, an estimate of the expected income to, and disbursements to be made from, the Trust Fund during the current fiscal year and each of the next 2 fiscal years, and a statement of the actuarial status of the Trust Fund. Such report shall be printed as a House document of the session of the Congress to which the report is made. Fund"oniTs°^ "(c) It shall be the duty of the Managing Trustee to invest such portion of the Trust Fund as is not, in his judgment, required to meet current withdrawals. Such investments may be made only in interest-bearing obligations of the United States or in obligations guaranteed as to both principal and interest by the United States. For such purpose such obligations may be acquired (1) on original issue at the issue price, or (2) by purchase of outstanding obligations at the market price. The purposes for which obligations of the 31 USC 77^4.' United States may be issued under the Second Liberty Bond Act, as amended, are hereby extended to authorize the issuance at par of public-debt obligations for purchase by the Trust Fund. Such obligations issued for purchase by the Trust F u n d shall have maturities fixed with due regard for the needs of the Trust Fund and shall bear interest at a rate equal to the average market yield (computed by the Managing Trustee on the basis of market quotations as of the end of the calendar month next preceding the date of such issue) on all marketable interest-bearing obligations of the United States then forming a part of the public debt which are not due or callable until after the expiration of 4 years from the end of such calendar month; except that where such average market yield is not a multiple of oneeighth of 1 per centum, the rate of interest on such obligations shall be the multiple of one-eighth of 1 per centum nearest such market yield. The Managing Trustee may purchase other interest-bearing obligations of the United States or obligations guaranteed as to both principal and interest by the United States, on original issue or at the market price, only where he determines that the purchase of such other obligations is in the public interest. " (d) Any obligations acquired by the Trust F u n d (except publicdebt obligations issued exclusively to the Trust Fund) may be sold by the Managing Trustee at the market price, and such public-debt obligations may be redeemed at par plus accrued interest.

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301

"(e) The interest on, and the proceeds from the sale or redemption of, any obligations held in the Trust Fund shall be credited to and form a part of the Trust Fund. " (f)(1) The Managing Trustee is directed to pay from time to time from the Trust Fund into the Treasury the amount estimated by him as taxes imposed under section 3101(b) which are subject to ^°®'' P- •^^^• refund under section 6413(c) of the Internal Revenue Code of 1954 ^°«'' P- ^^3. with respect to wages paid after December 31, 1965. Such taxes shall be determined on the basis of the records of wages established and maintained by the Secretary of Health, Education, and Welfare in accordance with the wages reported to the Secretary of the Treasury or his delegate pursuant to subtitle F of the Internal Revenue Code ^6 USC eoo i et of 1954, and the Secretary of Health, Education, and Welfare shall ^^'^' furnish the Managing Trustee such information as may be required by the Managing Trustee for such purpose. The payments by the Managing Trustee shall be covered into the Treasury as repayments to the account for refunding internal revenue collections. "(2) Repayments made under paragraph (1) shall not be available for expenditures but shall be carried to the surplus fund of the Treasury. If it subsequently appears that the estimates under such paragraph in any particular period were too hi^h or too low, appropriate adjustments shall be made by the Managing Trustee in future payments. " (g) There shall be transferred periodically (but not less often than once each fiscal year) to the Trust Fund from the Federal Old-Age and Survivors Insurance Trust F u n d and from the Federal Disability Insurance Trust Fund amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments (other than amounts so certified to the Railroad Retirement Board) pursuant to section 1870(b) of this Act. There shall be transferred periodi- Post, p. 331. cally (but not less often than once each fiscal year) to the Trust Fund from the Railroad Retirement Account amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments to the Railroad Retirement Board pursuant to section 1870(b) of this Act. " (h) The Managing Trustee shall also pay from time to time from the Trust F u n d such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to make the payments provided for by this part, and the payments with respect to administrative expenses in accordance with section 201(g)(1). ^°^^' P« -'38. " P A R T B—SUPPLEMENTARY MEDICAL INSURANCE BENEFITS FOR THE AGED "ESTABLISHMENT OF SUPPLEMENTARY MEDICAL INSURANCE PROGRAM FOR THE AGED

"SEC. 1831. There is hereby established a voluntary insurance program to provide medical insurance benefits in accordance with the provisions of this part for individuals 65 years of age or over who elect to enroll under such program, to be financed from premium payments by enrollees together with contributions from funds appropriated by the Federal Government.

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[79 STAT.

"SCOPE OF B E N E F I T S

Post, p. 313.

"SEC. 1832. (a) The benefits provided to an individual by the insurance program established by this part shall consist of— "(1) entitlement to have payment made to him or on his behalf (subject to the provisions of this part) for medical and other health services, except those described in paragraph (2) (B);and "(2) entitlement to have payment made on his behalf (subject to the provisions of this part) for— " (A) home health services for up to 100 visits during a calendar year; and " (B) medical and other health services (other than physicians' services unless furnished by a resident or intern of a hospital) furnished by a provider of services or by others under arrangements with them made by a provider of services. "(b) For definitions of 'spell of illness', 'medical and other health services', and other terms used in this part, see section 1861. il

PAYMENT OF BENEFITS

"SEC. 1833. (a) Subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Post, p. 308. 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— "(1) in the case of services described in section 1832(a)(1)— 80 percent of the reasonable charges for the services; except that an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis 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); and "(2) in the case of services described in section 1832(a)(2)— 80 percent of the reasonable cost of the services (as determined Post, p. 322. yjjder section 1861(v)). Deductible pro"(j^) Before applying subsection (a) with respect to expenses ^*°"" incurred by an individual during any calendar year, the total amount of the expenses incurred by such individual during such year (which would, except for this subsection, constitute incurred expenses from which benefits payable under subsection (a) are determinable) shall be reduced by a deductible of $50; except that (1) the amount of the deductible for such calendar year as so determined shall first be reduced by the amount of any expenses incurred by such individual in the last three months of the preceding calendar year (or regarded under clause (2) as incurred in such preceding year with respect to services furnished in such last three months) and applied toward such individual's deductible under this section for such preceding year, and (2) the Ante, p. 29 2. amount of any deduction imposed under section 1813(a)(2)(A) with

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respect to outpatient hospital diagnostic services furnished in any calendar year shall be regarded as an incurred expense under this part for such year. "(c) Notwithstanding any other provision of this part, with respect to expenses incurred in any calendar year in connection with the treatment of mental, psychoneurotic, and personality disorders of an individual who is not an inpatient of a hospital at the time such expenses are incurred, there shall be considered as incurred expenses for purposes of subsections (a) and (b) only whichever of the following amounts is the smaller: "(1) $312.50, or " (2) 621/^ percent of such expenses. " (d) No payment may be made under this part with respect to any services furnished an individual to the extent that such individual is entitled (or would be entitled except for section 1813 other than subsection (a)(2)(A) thereof) to have payment made with respect to such services under part A. "(e) No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

303

Mental d i s orders.

^"**' P- '^9 2.

a L I M I T A T I O N ON H O M E H E A L T H SERVICES

"SEC. 1834. (a) Payment under this part may be made for home health services furnished an individual during any calendar year only for 100 visits during such year. The number of visits to be charged for purposes of the limitation in the preceding sentence, in connection with items and services described in section 1861(m), shall be determined in accordance with regulations. " (b) For purposes of subsection (a), home health services shall be taken into account only if payment under this part is or would be, except for this section or the failure to comply with the request and certification requirements of or under section 1835(a), made with respect to such services.

^°^^' P- 3^9.

" P R O C E D U R E FOR P A Y M E N T OF CLAIMS OF PROVIDERS OF SERVICES

"SEC. 1835. (a) Payment for services described in section 1832(a) (2) furnished an individual may be made only to providers of services which are eligible therefor under section 1866(a), and only if— "(1) written request, signed b ^ 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 regulations prescribe; and "(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) that— " (A) in the case of home health services (i) 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 1861(m)(7)) and needed skilled nursing care on an intermittent basis, or physical or speech therapy,

Post,

p. 327.

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[79 STAT.

(ii) a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician; and " (B) in the case of medical and other health services, such services are or were medically required. To the extent provided by regulations, the certification and recertification requirements of paragraph (2) shall be deemed satisfied where, at a later date, a phvsician makes a certification of the kind provided in subparagraph (A) or (B) 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) No payment may be made under this part to any Federal provider of services or other Federal agency, 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 or other person for any item or service which such provider or person is obligated by a law of, or a contract with, the United States to render at pufclic expense. "ELIGIBLE INDIVIDUALS

"SEC. 1836. Every individual who— " (1) has attained the age of 65, and "(2)(A) is a resident of the United States, and is either (i) a citizen or (ii) an alien lawfully admitted for permanent residence who has resided in the United States continuously during the 5 years immediately preceding the month in which he applies for enrollment under this part, or (B) is entitled to hospital insurance benefits under part A, is eligible to enroll in the insurance program established by this part. "ENROLLMENT PERIODS

"SEC. 1837. (a) An individual may enroll in the insurance program established by this part only in such manner and form as may be prescribed by regulations, and only during an enrollment period prescribed in or under this section. " (b)(1) No individual may enroll for the first time under this part more than 3 years after the close of the first enrollment period during which he could have enrolled under this part. " (2) An individual whose enrollment under this part has terminated may not enroll for the second time under this part unless he does so in a general enrollment period (as provided in subsection (e)) which begins within 3 years after the effective date of such termination. No individual may enroll under this part more than twice. "(c) I n the case of individuals who first satisfy paragraphs (1) and (2) of section 1836 before January 1, 1966, the initial general enrollment period shall begin on the first day of the second month which begins after the date of enactment of this title and shall end on March 31, 1966. For purposes of this subsection and subsection (d), an individual who satisfies paragraph (2) of section 1836 solely by reason of subparagraph (B) thereof shall be treated as satisfying such paragraph (2) on the first day on which he is (or on filing application would be) entitled to hospital insurance benefits under part A. " (d) In the case of an individual who first satisfies paragraphs (1) and (2) of section 1836 on or after January 1, 1966, his initial enroll-

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ment period shall begin on the first day of the third month before the month in which he first satisfies such paragraphs and shall end seven months later. "(e) There shall be a general enrollment period, after the period described in subsection (c), during the period beginning on October 1 and ending on December 31 of each odd-numbered year beginning with 1967. "COVERAGE PERIOD

"SEC. 1838. (a) The period during which an individual is entitled to benefits under the insurance program established hj this part (hereinafter referred to as his 'coverage period') shall begin on whichever of the following is the latest: "(1) July 1, 1966; or "(2)(A) in the case of an individual who enrolls pursuant to subsection (d) of section 1837 before the month in which he first satisfies paragraphs (1) and (2) of section 1836, the first day of such month, or " (B) in the case of an individual who enrolls pursuant to such subsection (d) in the month in which he first satisfies such paragraphs, the first day of the month following the month in which he so enrolls, or " (C) in the case of an individual who enrolls pursuant to such subsection (d) in the month following the month in which he first satisfies such paragraphs, the first day of the second month following the month in which he so enrolls, or " (D) in the case of an individual who enrolls pursuant to such subsection (d) more than one month following the month in which he satisfies such paragraphs, the first day of the third month following the month in which he so enrolls, or " (E) in the case of an individual who enrolls pursuant to subsection (e) of section 1837, the July 1 following the month in which he so enrolls. " (b) An individual's coverage period shall continue until his enrollment has been terminated— "(1) by the filing of notice, during a general enrollment period described in section 1837(e), that the individual no longer wishes to participate in the insurance program estsiblished by this part, or "(2) for nonpayment of premiums. The termination of a coverage period under paragraph (1) shall take effect at the close of December 31 of the year in which the notice is filed. The termination of a coverage period under paragraph (2) shall take effect on a date determined under regulations, which may be determined so as to provide a grace period (not in excess of 90 days) in which overdue premiums may be paid and coverage continued. "(c) No payments may be made under this part with respect to the expenses of an individual unless such expenses were incurred by such individual during a period which, with respect to him, is a coverage period. "AMOUNTS OF PREMIUMS

"SEC. 1839. (a) The monthly premium of each individual enrolled under this part for each month before 1968 shall be $3. "(b)(1) The monthly premium of each individual enrolled under this part for each month after 1967 shall be the amount determined under paragraph (2).

305

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p. 308.

[79 STAT.

"(2) The Secretary shall, between July 1 and October 1 of 1967 and of each odd-numbered year thereafter, determine and promulgate the dollar amount which shall be applicable for premiums for months occurring in either of the two succeeding calendar years. Such dollar amount snail be such amount as the Secretary estimates to be necessary so that the aggregate premiums for such two succeeding calendar years will equal one-half of the total of the benefits and admmistrative costs which he estimates will be payable from the Federal Supplementary Medical Insurance Trust Fund for such two succeeding calendar years. I n estimating aggregate benefits payable for any period, the Secretary shall include an appropriate amount for a contingency margin. " (c) In the case of an individual whose coverage period began pursuant to an enrollment after his initial enrollment period (determined pursuant to subsection (c) or (d) of section 1837), the monthly premium determined under subsection (b) shall be increased by 10 percent of the monthly premium so determined for each full 12 months m which he could have been but was not enrolled. For purposes of the preceding sentence, there shall be taken into account (1) the months which elapsed between the close of his initial enrollment period and the close of the enrollment period in which he enrolled, plus (in the case of an individual who enrolls for a second time)(2) the months which elapsed between the date of the termination of his first coverage period and the close of the enrollment period in which he enrolled for the second time. " (d) If any monthly premium determined under the foregoing provisions of this section is not a multiple of 10 cents, such premium shall be rounded to the nearest multiple of 10 cents. ('T

P A Y M E N T OF P R E M I U M S

"SEC. 1840. (a)(1) I n the case of an individual who is entitled to 42 u*sc 40^2 ^* monthly benefits under section 202, his monthly premiums under this part shall (except as provided in subsection (d)) be collected by deducting the amount thereof from the amount of such monthly benefits. Such deduction shall be made in such manner and at such times as the Secretary shall by regulation prescribe. " (2) The Secretary of the Treasury shall, from time to time, trans70 Stat. 819. fer from the Federal Old-Age and Survivors Insurance Trust Fund ^^ "^ ' or the Federal Disability Insurance Trust F u n d to the Federal SupPost. p. 308. plementary Medical Insurance Trust F u n d the aggregate amount deducted under paragraph (1) for the period to which such transfer relates from benefits under section 202 which are payable from such Trust Fund. Such transfer shall be made on the basis of a certification by the Secretary of Health, Education, and Welfare and shall be appropriately adjusted to the extent that prior transfers were too great or too small. miltAcrl^u"'*' " ( ^) (1) I ^ ^^^ ^^'^^ ^f ^^ individual who is entitled to receive for ^n"s. " ^"""^" g month an annuity or pension under the Railroad Retirement Act of " ^ P°^*' pp- 335. 1937, his monthly premiums under this part shall (except as provided in subsection (d)) be collected by deducting the amount thereof from such annuity or pension. Such deduction shall be made in such manner and at such times as the Secretary shall by regulations prescribe. Such regulations shall be prescribed only after consultation with the Railroad Retirement Board. "(2) The Secretary of the Treasury shall, from time to time, trans45 USC 228o.
 * QJ. ffQjn the Railroad Retirement Account to the Federal Supplementary Medical Insurance Trust Fund the aggregate amount

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24 Richter (Dr. Jean Paul) Italian Art in the National Gallery. 4to. Illustrated. Cloth gilt, £2 2s. half-morocco, uncut, £2 12s. 6d. —— See also Riddell (Mrs. J. H.) See  Robertson (Anne J.) Myself and my Relatives. New Edition, crown 8vo, 5s. Robin Hood; Merry Adventures of. Written and illustrated by HOWARD PYLE. Imperial 8vo, 15s. Robinson (Phil.) In my Indian Garden. New Edition, 16mo, limp cloth, 2s. —— ''Noah's Ark. Unnatural History''. Sm. post 8vo, 12s. 6d. —— Sinners and Saints: a Tour across the United States of America, and Round them. Crown 8vo, 10s. 6d. —— Under the Punkah. New Ed., cr. 8vo, limp cloth, 2s. Rockstro (W. S.) History of Music. New Edition. 8vo, 14s. Roland, The Story of. Crown 8vo, illustrated, 6s. Rolfe (Eustace Neville) Pompeii, Popular and Practical. Cr. 8vo, 7s. 6d. Rome and the Environs. With plans, 3s. Rose (J.) Complete Practical Machinist. New Ed., 12mo, 12s. 6d. —— Key to Engines and Engine-running. Crown 8vo, 8s. 6d. —— Mechanical Drawing. Illustrated, small 4to, 16s. —— Modern Steam Engines. Illustrated. 31s. 6d. —— ''Steam Boilers. Boiler Construction and Examination''. Illust., 8vo, I2s. 6d. Rose Library. Each volume, 1s. Many are illustrated— Little Women. By LOUISA M. ALCOTT. Little Women Wedded. Forming a Sequel to "Little Women." Little Women and Little Women Wedded. I vol., cloth gilt, 3s. 6d. Little Men. By L. M. ALCOTT. Double vol., 2s. cloth gilt, 3s. 6d. An Old-Fashioned Girl. By LOUISA M. ALCOTT. 2s.; cloth, 3s. 6d. Work. A Story of Experience. By L. M. ALCOTT. 3s. 6d.; 2 vols., 1s. each. Stowe (Mrs. H. B.) Tlie Pearl of Orr's Island. —— The Minister's Wooing. ——We and our Neig-hbours. 2s.; cloth gilt, 6s. —— My Wife and I. 2s. Hans Brinker; or, the Silver Skates. By Mrs. DODGE. Also 5s. My Study Windows. By J. R. LOWELL. The Guardian Angel. By OLIVER WENDELL HOLMES. My Summer in a Garden. By C. D. WARNER. Dred. By Mrs. BEECHER STOWE. 2s.; cloth gilt, 3s. 6d. City Ballads. New Ed. 16mo. By WILL CARLETON.


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deducted under paragraph (1) for the period to which such transfer relates. Such transfers shall be made on the basis of a certification by the Kailroad Eetirement Board and shall be appropriately adjusted to the extent that prior transfers were too great or too small. "(c) I n the case of an individual who is entitled both to monthly benefits under section 202 and to an annuity or pension under the Railroad Retirement Act of 1937 at the time he enrolls under this part, subsection (a) shall apply so long as he continues to be entitled both to such benefits and such annuity or pension. In the case of an individual who becomes entitled both to such benefits and such an annuity or pension after he enrolls under this part, subsection (a) shall apply if the first month for which he was entitled to such benefits was the same as or earlier than the first month for which he was entitled to such annuity or pension, and otherwise subsection (b) shall

307

^2 USC 402. 34^°4QO^''' ^^^'

" (d) If an individual to whom subsection (a) or (b) applies estimates that the amount which will be available for deduction under such subsection for any premium payment period will be less than the amount of the monthly premiums for such period, he may (under regulations) pay to the Secretary such portion of the monthly pre miums for such period as he desires. " (e)(1) I n the case of an individual receiving an annuity under the R^lfiJnenrAcT Civil Service Retirement Act, or other Act administered by the Civil annuitants. Service Commission providing retirement or survivorship protection, l^i^sc^l^i' to whom neither subsection (a) nor subsection (b) applies, his monthly note. premiums under this part (and the monthly premiums of the spouse of such individual under this part if neither subsection (a) nor subsection (b) applies to such spouse and if such individual agrees) shall, upon notice from the Secretary of Health, Education, and Welfare to the Civil Service Commission, be collected by deducting the amount thereof from each installment of such annuity. Such deduction shall be made in such manner and at such times as the Civil Service Commission may determine. The Civil Service Commission shall furnish such information as the Secretary of Health, Education, and Welfare may reasonably request in order to carry out his functions under this part with respect to individuals to whom this subsection applies. "(2) The Secretary of the Treasury shall, from time to time, but not less often than quarterly, transfer from the Civil Service Retirement and Disability Fund, or the account (if any) applicable in the case of such other Act administered by the Civil Service Commission, to the Federal Supplementary Medical Insurance Trust F u n d the aggregate amount deducted under paragraph (1) for the period to which such transfer relates. Such transfer shall be made on the basis of a certification by the Civil Service Commission and shall be appropriately adjusted to the extent that prior transfers were too great or too small. " (f) I n the case of an individual who participates in the insurance program established by this part but with respect to whom none of the preceding provisions of this section applies, or with respect to whom subsection (d) applies, the premiums shall be paid to the Secretary at such times, and m such manner, as the Secretary shall by regulations prescribe. " (g) Amounts paid to the Secretary under subsection (d) or (f) shall be deposited m the Treasury to the credit of the Federal Supplementary Medical Insurance Trust Fund.

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[79 STAT.

" (h) I n the case of an individual who participates in the insurance program established hj this part, premiums shall be payable for the period commencing with the first month of his coverage period and ending with the month in which he dies or, if earlier, in which his coverage under such program terminates. "rEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUND

Board of Trustees.

Reports to Congress,

Investment of Fund monies.

40 Stat. 288. 31 USC 774.

"SEC. 1841. (a) There is hereby created on the books of the Treasury of the United States a trust fund to be known as the 'Federal Supplementary Medical Insurance Trust F u n d ' (hereinafter in this section referred to as the 'Trust F u n d '). The Trust F u n d shall consist of such amounts as may be deposited in, or appropriated to, such fund as provided in this part. " (b) With respect to the Trust Fund, there is hereby created a body to be known as the Board of Trustees of the Trust F u n d (hereinafter in this section referred to as the 'Board of Trustees') composed of the Secretary of the Treasury the Secretary of Labor, and the Secretary of Health, Education, ana Welfare, all ex officio. The Secretary of the Treasury shall be the Managing Trustee of the Board of Trustees (hereinafter in this section referred to as the 'Managing Trustee'). The Commissioner of Social Security shall serve as the Secretary of the Board of Trustees. The Board of Trustees shall meet not less frequently than once each calendar year. I t shall be the duty of the Board of Trustees to— " (1) Hold the Trust F u n d; "(2) Report to the Congress not later than the first day of March of each year on the operation and status of the Trust Fund during the preceding fiscal year and on its expected operation and status during the current fiscal year and the next 2 fiscal years; "(3) Report immediately to the Congress whenever the Board is of the opinion that the amount of the Trust Fund is unduly small; and "(4) Review the general policies followed in managing the Trust Fund, and recommend changes in such policies, including necessary changes in the provisions of law which govern the way in which the Trust F u n d is to be managed. The report provided for in paragraph (2) shall include a statement of the assets of, and the disbursements made from, the Trust Fund during the preceding fiscal year, an estimate of the expected income to, and disbursements to be made from, the Trust Fund during the current fiscal year and each of the next 2 fiscal years, and a statement of the actuarial status of the Trust Fund. Such report shall be printed as a House document of the session of the Congress to which the report is made. "(c) I t shall be the duty of the Managing Trustee to invest such portion of the Trust Fund as is not, in his judgment, required to meet current withdrawals. Such investments may be made only in interest-bearing obligations of the United States or in obligations guaranteed as to both principal and interest by the United States. For such purpose such obligations may be acquired (1) on original issue at the issue price, or (2) by purchase of outstanding obligations at the market price. The purposes for which obligations of the United States may be issued under the Second Liberty Bond Act, as amended, are hereby extended to authorize the issuance at par of public-debt obligations for purchase by the Trust Fund. Such obligations issued for purchase by the Trust F u n d shall have matu-

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PUBLIC LAW 89-97-JULY 30, 1965

rities fixed with due regard for the needs of the Trust Fund and shall bear interest at a rate equal to the average market yield (computed by the Managing Trustee on the basis of market quotations as of the end of the calendar month next preceding the date of such issue) on all marketable interest-bearing obligations of the United States then forming a part of the public debt which are not due or callable until after the expiration of 4 years from the end of such calendar month; except that where such average market yield is not a multiple of one-eighth of 1 per centum, the rate of interest on such obligations shall be the multiple of one-eighth of 1 per centum nearest such market yield. The Managing Trustee may purchase other interest-bearing obligations of the United States or obligations guaranteed as to both principal and interest by the United States, on original issue or at the market price, only where he determines that the purchase of such other obligations is in the public interest. " (d) Any obligations acquired by the Trust Fund (except publicdebt obligations issued exclusively to the Trust Fund) may be sold by the Managing Trustee at the market price, and such public-debt obligations may be redeemed at par plus accrued interest. "(e) The interest on, and the proceeds from the sale or redemption of, any obligations held in the Trust Fund shall be credited to and form a part of the Trust Fund. " (f) There shall be transferred periodically (but not less often than once each fiscal year) to the Trust Fund from the Federal Old-Age and Survivors Insurance Trust Fund and from the Federal Disability Insurance Trust F u n d amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments (other than amounts so certified to the Railroad Retirement Board) pursuant to section 1870(b) of this Act. There shall be transferred periodically (but not less often than once each fiscal year) to the Trust Fund from the Railroad Retirement Account amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments to the Railroad Retirement Board pursuant to section 1870(b) of this Act. " (g) The Managing Trustee shall pay from time to time from the Trust Fund such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to make the payments provided for by this part, and the payments with respect to administrative expenses in accordance with section 201(g)(1). " (h) The Managing Trustee shall pay from time to time from the Trust F u n d such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to pay the costs incurred by the Civil Service Commission in making deductions pursuant to section 1840(e). During each fiscal year, or after the close of such fiscal year, the Civil Service Commission shall certify to the Secretary the amount of the costs it incurred in making such deductions, and such certified amount shall be the basis for the amount of such costs certified by the Secretary to the Managing Trustee. "USE OF CARRIERS FOR ADMINISTRATION OF BENEFITS

"SEC, 1842. (a) I n order to provide for the administration of the benefits under this part with maximum efficiency and convenience for individuals entitled to benefits under this part and for providers of services and other persons furnishing services to such individuals, and with a view to furthering coordination of the administration of the

309

^°®'' P- •'3^-

Post,

p. 338.

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 310

Ante, p. 297.

Post. p. 318.

Contracts with carriers. 41 USC 5.

Post, p. 322.

PUBLIC LAW 89-97-JULY 30, 1965

[79 STAT.

benefits under part A and under this part, the Secretary is authorized to enter into contracts with carriers, including carriers with which agreements under section 1816 are in effect, which will perform some or all of the following functions (or, to the extent provided in such contracts, will secure performance thereof by other organizations); and, with respect to any of the following functions which involve payments for physicians' services, the Secretary shall to the extent possible enter into such contracts: " (1)(A) make determinations of the rates and amounts of payments required pursuant to this part to be made to providers of services and other persons on a reasonable cost or reasonable charge basis (as may oe applicable); " (B) receive, disburse, and account for funds in making such payments; and " (C) make such audits of the records of providers of services as may be necessary to assure that proper payments are made under this part; "(2)(A) determine compliance with the requirements of section 1861(k) as to utilization review; and " (B) assist providers of services and other persons who furnish services for which payment may be made under this part in the development of procedures relating to utilization practices, make studies of the effectiveness of such procedures and methods for their improvement, assist in the application of safeguards against unnecessary utilization of services furnished by providers of services and other persons to individuals entitled to benefits under this part, and provide procedures for and assist in arranging, where necessary, the establishment of groups outside hospitals (meeting the requirements of section 1861(k)(2)) to make reviews of utilization; "(3) serve as a channel of communication of information relating to the administration of this part; and " (4) otherwise assist, in such manner as the contract may provide, in discharging administrative duties necessary to carry out the purposes of this part. " (b)(1) Contracts with carriers under subsection (a) may be entered into without regard to section 3709 of the Revised Statutes or any other provision of law requiring competitive bidding. "(2) No such contract shall be entered into with any carrier unless the Secretary finds that such carrier will perform its obligations under the contract efficiently and effectively and will meet such requirements as to financial responsibility, legal authority, and other matters as he finds pertinent. "(3) Each such contract shall provide that the carrier— " (A) will take such action as may be necessary to assure that, where payment under this part for a service is on a cost basis, the cost is reasonable cost (as''determined under section 1861(v)); " (B) will take such action as may be necessary to assure that, where payment under this part for a service is on a charge basis, (i) such charge will be reasonable and not higher than the charge applicable, for a comparable service and under comparable circumstances, to the policyholders and subscribers of the carrier, and (ii) such payment will be made on the basis of a receipted bill, or on the basis of an assignment under the terms of which the reasonable charge is the full charge for the service; " (C) will establish and maintain procedures pursuant to which an individual enrolled under this part will be granted an oppor-

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tunity for a fair hearing by the carrier when requests for payment under this part with respect to services furnished him are denied or are not acted upon with reasonable promptness or when the amount of such payment is in controversy; " (D) will furnish to the Secretary such timely information and reports as he may find necessary in performing his functions under this part; and " (E) will maintain such records and afford such access thereto as the Secretary finds necessary to assure the correctness and verification of the information and reports under subparagraph (D) and otherwise to carry out the purposes of this part; and shall contain such other terms and conditions not inconsistent with this section as the Secretary may find necessary or appropriate. I n determining the reasonable charge for services for purposes of this paragraph, there shall be taken into consideration the customary charges for similar services generally made by the physician or other person furnishing such services, as well as the prevailing charges in the locality for similar services. "(4) Each contract under this section shall be for a term of at least one year, and may be made automatically renewable from term to term in the absence oi notice by either party of intention to terminate at the end of the current term; except that the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the carrier involved as he may provide in regulations) if he finds that the carrier has failed substantially to carry out the contract or is carrying out the contract in a manner inconsistent with the efficient and effective administration of the insurance program established by this part. "(c) Any contract entered into with a carrier under this section shall provide for advances of funds to the carrier for the making of payments by it under this part, and shall provide for payment of the cost of administration of the carrier, as determined by the Secretary to be necessary and proper for carrying out the functions covered by the contract. " (d) Any contract with a carrier under this section may require such carrier or any of its officers or employees certifying payments or disbursing funds pursuant to the contract, or otherwise participating in carrying out the contract, to give surety bond to the United States in such amount as the Secretary may deem appropriate. " (e)(1) No individual designated pursuant to a contract under this section as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him under this section. "(2) No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payment by him under this section if it was based upon a voucher signed by a certifying officer designated as provided in paragraph (1) of this subsection. "(3) No such carrier shall be liable to the United States for any payments referred to in paragraph (1) or (2). "(f) For purposes of this part, the term 'carrier' means— "(1) with respect to providers of services and other persons, a voluntary association, corporation, partnership, or other nongovernmental organization which is lawfully engaged in providing, paying for, or reimbursing the cost of, health services under group insurance policies or contracts, medical or hospital service agreements, membership or subscription contracts, or similar

311

"Carrier."

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Ante, p. 29 7.

PUBLIC LAW 89-97-JULY 30, 1965

[79 STAT.

group arrangements, in consideration of premiums or other periodic charges payable to the carrier, including a health benefits plan duly sponsored or underwritten by an employee organization; and "(2) with respect to providers of services only, any agency or organization (not described in paragraph (1)) with which an agreement is in effect under section 1816. ((STATE

AGREEMENTS FOR COVERAGE OF ELIGIBLE INDIVIDUALS WHO ARE RECEIVING MONEY PAYMENTS UNDER PUBLIC ASSISTANCE PROGRAMS

"SEC. 1843. (a) The Secretary shall, at the request of a State made before January 1, 1968, enter into an agreement with such State pursuant to which all eligible individuals in either of the coverage groups described in subsection (b) (as specified in the agreement) will be enrolled under the program established by this part. " (b) An agreement entered into with any State pursuant to subsection (a) may be applicable to either o i the following coverage groups: "(1) individuals receiving money payments under the plan of such State approved under title I or title X VI; or "(2) individuals receiving money payments under all of the plans of such State approved under titles I, IV, X, X IV, and 42 USC 30 1, 60 1, 42 USC 401.

340° 400^^* ^^^' Ante, p. 304.

XVI •

except that there shall be excluded from any coverage group any individual who is entitled to monthly insurance benefits under title II or who is entitled to receive an annuity or pension under the Railroad I^tirement Act of 1937. "(c) For purposes of this section, an individual shall be treated as an eligible individual only if he is an eligible individual (within ^j^g meaning of section 1836) on the date an agreement covering him is entered into under subsection (a) or he becomes an eligible individual (within the meaning of such section) at any time after such date and before January 1, 1968; and he shall be treated as receiving money payments described in subsection (b) if he receives such payments for the month in which the agreement is entered into or any month thereafter before January 1968. " (d) I n the case of any individual enrolled pursuant to this section— "(1) the monthly premium to be paid by the State shall be determined under section 1839 (without any increase under subsection (c) thereof); "(2) his coverage period shall begin on whichever of the following is the latest; " (A) July 1, 1966; " (B) the first day of the third month following the month firs " in which the State agreement is entered into; " (C) the first day of the first month in which he is both an eligible individual and a member^f a coverage group specified in the agreement under this section; or " (D) such date (not later than January 1, 1968) as may be specified in the agreement; and " (3) his coverage period attributable to the agreement with the State under this section shall end on the last day of whichever of the following first occurs: " (A) the month in which he is determined by the State agency to have become ineligible for money payments of a kind specified in the agreement, or

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313

" (B) the month preceding the first month for which he becomes entitled to monthly benefits under title II or to an annuity or pension under the Railroad Retirement Act of

42 USC 401.

]^937_

Post, pp. 335,

"(e) Any individual whose coverage period attributable to the State agreement is terminated pursuant to subsection (d)(3) shall be deemed for purposes of this part (including the continuation of his coverage period under this part) to have enrolled under section 1837 in the mitial general enrollment period provided by section ^"^^' P- ^°'*1837(c). "(f) With respect to eligible individuals receiving money payments under the plan of a State approved under title I, IV, X, X IV, or X VI, if the agreement entered into under this section so provides, ^^^ ^^oi ^usi the term ' c a r r i e r ' a s defined in section 1842(f) also includes the State iss'i. agency, specified in such agreement, which administers or supervises the administration of the plan of such State approved under title I, X VI, or X IX. The agreement shall also contain such provisions as will facilitate the financial transactions of the State and the carrier with respect to deductions, coinsurance, and otherwise, and as will lead to economy and efficiency of operation, with respect to individuals receiving money payments under plans of the State approved under titles I, IV, X, X IV, and X VI. "APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS AND CONTINGENCY RESERVE

"SEC. 1844. (a) There are authorized to be appropriated from time to time, out of any moneys in the Treasury not otherwise appropriated, to the Federal Supplementary Medical Insurance Trust Fund, a Government contribution equal to the aggregate premiums payable under this part. "(b) I n order to assure prompt payment of benefits provided under this part and the administrative expenses thereunder during the early months of the program established by this part, and to provide a contingency reserve, there is also authorized to be appropriated, out of any moneys in the Treasury not otherwise appropriated, to remain available through the calendar year 1967 for repayable advances (without interest) to the Trust Fund, an amount equal to $18 multiplied by the number of individuals (as estimated by the Secretary) who could be covered in July 1966 by the insurance program established by this part if they had theretofore enrolled under this part. " P A R T C—MISCELLANEOUS PROVISIONS "DEFINITIONS OF SERVICES, INSTITUTIONS, ETC.

"SEC. 1861. For purposes of this title— "Spell of Illness " (a) 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 or extended care services, and (B) which occurs in a month for which he is entitled to benefits under part A, and 49-850 0-66—23

Ante. p. 291.

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[79 STAT.

"(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 nor an inpatient of an extended care facility. "Inpatient Hospital Services " (b) 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; and "(5) the services of a private-duty nurse or other private-duty attendant. Paragraph (4) shall not apply to services provided in the hospital by 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. "Inpatient Psychiatric Hospital Services "(c) The term 'inpatient psychiatric hospital services' means inpatient hospital services furnished to an inpatient of a psychiatric hospital. "Inpatient Tuberculosis Hospital Services " (d) The term 'inpatient tuberculosis hospital services' means inpatient hospital services fumisheid to an inpatient of a tuberculosis hospital. "Hospital Ante, p. 296.

"(e) The term 'hospital' (except for purposes of section 1814^d), subsection (a)(2) of this section, paragraph (7) of this subsection, and subsections (i) and (n) 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;

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