§ 1395m. Special payment rules for particular items and services

(ii) assign drugs to such categories, in accordance with such clauses;

(iii) assign appropriate Healthcare Common Procedure Coding System (HCPCS) codes to each payment category; and

(iv) establish a single payment amount for each such payment category, in accordance with subparagraph (D), for each infusion drug administration calendar day in the individual’s home for drugs assigned to such category.

(C) Payment categories

(i) Payment category 1 The Secretary shall create a payment category 1 and assign to such category drugs which are covered under the Local Coverage Determination on External Infusion Pumps (LCD number L33794) and billed with the following HCPCS codes (as identified as of January 1, 2018, and as subsequently modified by the Secretary): J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1570, J2175, J2260, J2270, J2274, J2278, J3010, or J3285.

(ii) Payment category 2 The Secretary shall create a payment category 2 and assign to such category drugs which are covered under such local coverage determination and billed with the following HCPCS codes (as identified as of January 1, 2018, and as subsequently modified by the Secretary): J1555 JB, J1559 JB, J1561 JB, J1562 JB, J1569 JB, or J1575 JB.

(iii) Payment category 3 The Secretary shall create a payment category 3 and assign to such category drugs which are covered under such local coverage determination and billed with the following HCPCS codes (as identified as of January 1, 2018, and as subsequently modified by the Secretary): J9000, J9039, J9040, J9065, J9100, J9190, J9200, J9360, or J9370.

(iv) Infusion drugs not otherwise included With respect to drugs that are not included in payment category 1, 2, or 3 under clause (i), (ii), or (iii), respectively, the Secretary shall assign to the most appropriate of such categories, as determined by the Secretary, drugs which are—

(I) covered under such local coverage determination and billed under HCPCS codes J7799 or J7999 (as identified as of July 1, 2017, and as subsequently modified by the Secretary); or

(II) billed under any code that is implemented after February 9, 2018, and included in such local coverage determination or included in subregulatory guidance as a home infusion drug described in subparagraph (A)(i).

(D) Payment amounts

(i) In general Under the payment methodology, the Secretary shall pay eligible home infusion suppliers, with respect to items and services described in subparagraph (A)(i) furnished during the period described in subparagraph (A)(ii) by such supplier to an individual, at amounts equal to the amounts determined under the physician fee schedule established under section 1395w–4 of this title for services furnished during the year for codes and units of such codes described in clauses (ii), (iii), and (iv) with respect to drugs included in the payment category under subparagraph (C) specified in the respective clause, determined without application of the geographic adjustment under subsection (e) of such section.

(ii) Payment amount for category 1 For purposes of clause (i), the codes and units described in this clause, with respect to drugs included in payment category 1 described in subparagraph (C)(i), are one unit of HCPCS code 96365 plus three units of HCPCS code 96366 (as identified as of January 1, 2018, and as subsequently modified by the Secretary).

(iii) Payment amount for category 2 For purposes of clause (i), the codes and units described in this clause, with respect to drugs included in payment category 2 described in subparagraph (C)(i), are one unit of HCPCS code 96369 plus three units of HCPCS code 96370 (as identified as of January 1, 2018, and as subsequently modified by the Secretary).

(iv) Payment amount for category 3 For purposes of clause (i), the codes and units described in this clause, with respect to drugs included in payment category 3 described in subparagraph (C)(i), are one unit of HCPCS code 96413 plus three units of HCPCS code 96415 (as identified as of January 1, 2018, and as subsequently modified by the Secretary).

(E) Clarifications

(i) Infusion drug administration day For purposes of this subsection, with respect to the furnishing of transitional home infusion drugs or home infusion drugs to an individual by an eligible home infusion supplier or a qualified home infusion therapy supplier, a reference to payment to such supplier for an infusion drug administration calendar day in the individual’s home shall refer to payment only for the date on which professional services (as described in section 1395x(iii)(2)(A) of this title) were furnished to administer such drugs to such individual. For purposes of the previous sentence, an infusion drug administration calendar day shall include all such drugs administered to such individual on such day.

(ii) Treatment of multiple drugs administered on same infusion drug administration day In the case that an eligible home infusion supplier, with respect to an infusion drug administration calendar day in an individual’s home, furnishes to such individual transitional home infusion drugs which are not all assigned to the same payment category under subparagraph (C), payment to such supplier for such infusion drug administration calendar day in the individual’s home shall be a single payment equal to the amount of payment under this paragraph for the drug, among all such drugs so furnished to such individual during such calendar day, for which the highest payment would be made under this paragraph.

(F) Eligible home infusion suppliers In this paragraph, the term “eligible home infusion supplier” means a supplier that is enrolled under this part as a pharmacy that provides external infusion pumps and external infusion pump supplies and that maintains all pharmacy licensure requirements in the State in which the applicable infusion drugs are administered.

(G) Implementation Notwithstanding any other provision of law, the Secretary may implement this paragraph by program instruction or otherwise.

(v) Payment for outpatient physical therapy services and outpatient occupational therapy services furnished by a therapy assistant

(1) In general In the case of an outpatient physical therapy service or outpatient occupational therapy service furnished on or after January 1, 2022, for which payment is made under section 1395w–4 of this title or subsection (k), that is furnished in whole or in part by a therapy assistant (as defined by the Secretary), the amount of payment for such service shall be an amount equal to 85 percent of the amount of payment otherwise applicable for the service under this part. Nothing in the preceding sentence shall be construed to change applicable requirements with respect to such services.

(2) Use of modifier

(A) Establishment Not later than January 1, 2019, the Secretary shall establish a modifier to indicate (in a form and manner specified by the Secretary), in the case of an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a therapy assistant (as so defined), that the service was furnished by a therapy assistant.

(B) Required use Each request for payment, or bill submitted, for an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a therapy assistant (as so defined) on or after January 1, 2020, shall include the modifier established under subparagraph (A) for each such service.

(3) Implementation The Secretary shall implement this subsection through notice and comment rulemaking.

(w) Opioid use disorder treatment services

(1) In general The Secretary shall pay to an opioid treatment program (as defined in paragraph (2) of section 1395x(jjj) of this title) an amount that is equal to 100 percent of a bundled payment under this part for opioid use disorder treatment services (as defined in paragraph (1) of such section) that are furnished by such program to an individual during an episode of care (as defined by the Secretary) beginning on or after January 1, 2020. The Secretary shall ensure, as determined appropriate by the Secretary, that no duplicative payments are made under this part or part D for items and services furnished by an opioid treatment program.

(2) Considerations The Secretary may implement this subsection through one or more bundles based on the type of medication provided (such as buprenorphine, methadone, naltrexone, or a new innovative drug), the frequency of services, the scope of services furnished, characteristics of the individuals furnished such services, or other factors as the Secretary determine 88 So in original. Probably should be “determines”. appropriate. In developing such bundles, the Secretary may consider payment rates paid to opioid treatment programs for comparable services under State plans under subchapter XIX or under the TRICARE program under chapter 55 of title 10.

(3) Annual updates The Secretary shall provide an update each year to the bundled payment amounts under this subsection.

(x) Payment rules relating to rural emergency hospitals

(1) Payment for rural emergency hospital services In the case of rural emergency hospital services (as defined in section 1395x(kkk)(1) of this title), furnished by a rural emergency hospital (as defined in section 1395x(kkk)(2) of this title) on or after January 1, 2023, the amount of payment for such services shall be equal to the amount of payment that would otherwise apply under section 1395l(t) of this title for covered OPD services (as defined in section 1395l(t)(1)(B) of this title (other than clause (ii) of such section)), increased by 5 percent to reflect the higher costs incurred by such hospitals, and shall include the application of any copayment amount determined under section 1395l(t)(8) of this title as if such increase had not occurred.

(2) Additional facility payment

(A) In general The Secretary shall make monthly payments to a rural emergency hospital in an amount that is equal to ^1⁄12 of the annual additional facility payment specified in subparagraph (B).

(B) Annual additional facility payment amount The annual additional facility payment amount specified in this subparagraph is—

(i) for 2023, a Medicare subsidy amount determined under subparagraph (C); and

(ii) for 2024 and each subsequent year, the amount determined under this subparagraph for the preceding year, increased by the hospital market basket percentage increase.

(C) Determination of medicare subsidy amount For purposes of subparagraph (B)(i), the Medicare subsidy amount determined under this subparagraph is an amount equal to—

(i) the excess (if any) of—

(I) the total amount that the Secretary determines was paid under this subchapter to all critical access hospitals in 2019; over

(II) the estimated total amount that the Secretary determines would have been paid under this subchapter to such hospitals in 2019 if payment were made for inpatient hospital, outpatient hospital, and skilled nursing facility services under the applicable prospective payment systems for such services during such year; divided by

(ii) the total number of such hospitals in 2019.

(D) Reporting on use of the additional facility payment A rural emergency hospital receiving the additional facility payment under this paragraph shall maintain detailed information as specified by the Secretary as to how the facility has used the additional facility payments. Such information shall be made available to the Secretary upon request.

(3) Payment for ambulance services For provisions relating to payment for ambulance services furnished by an entity owned and operated by a rural emergency hospital, see subsection (l).

(4) Payment for post-hospital extended care services For provisions relating to payment for post-hospital extended care services furnished by a rural emergency hospital that has a unit that is a distinct part licensed as a skilled nursing facility, see section 1395yy(e) of this title.

(5) Source of payments

(A) In general Except as provided in subparagraph (B), payments under this subsection shall be made from the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title.

(B) Additional facility payment and post-hospital extended care services Payments under paragraph (2) shall be made from the Federal Hospital Insurance Trust Fund under section 1395i of this title.

(y) Payment for certain services furnished by rural health clinics

(1) Attending physician services for hospice patients In the case of services described in section 1395d(d)(2)(A)(ii) of this title furnished on or after January 1, 2022, by an attending physician (as defined in section 1395x(dd)(3)(B) of this title, other than a physician or practitioner who is employed by a hospice program) who is employed by or working under contract with a rural health clinic, a rural health clinic shall be paid for such services under the methodology for all-inclusive rates (established by the Secretary) under section 1395l(a)(3) of this title, subject to the limits described in section 1395l(f) of this title.

(2) Mental health visits furnished via telecommunications technology In the case of mental health visits furnished via interactive, real-time, audio and video telecommunications technology or audio-only interactions, the in-person mental health visit requirements established under section 405.2463(b)(3) of title 42 of the Code of Federal Regulations (or a successor regulation) shall not apply prior to January 31, 2026.

(3) Special payment rule for intensive outpatient services

(A) In general In the case of intensive outpatient services furnished by a rural health clinic, the payment amount for such services shall be equal to the amount that would have been paid under this subchapter for such services had such services been covered OPD services furnished by a hospital.

(B) Exclusion Costs associated with intensive outpatient services shall not be used to determine the amount of payment for rural health clinic services under the methodology for all-inclusive rates (established by the Secretary) under section 1395l(a)(3) of this title.

(z) Payment for lymphedema compression treatment items

(1) In general The Secretary shall determine an appropriate payment basis for lymphedema compression treatment items (as defined in section 1395x(mmm) of this title). In making such a determination, the Secretary may take into account payment rates for such items under State plans (or waivers of such plans) under subchapter XIX, the Veterans Health Administration, and group health plans and health insurance coverage (as such terms are defined in section 300gg–91 of this title), and such other information as the Secretary determines appropriate.

(2) Frequency limitation No payment may be made under this part for lymphedema compression treatment items furnished other than at such frequency as the Secretary may establish.

(3) Application of competitive acquisition In the case of lymphedema compression treatment items that are included in a competitive acquisition program in a competitive acquisition area under section 1395w–3(a) of this title—

(A) the payment basis under this subsection for such items furnished in such area shall be the payment basis determined under such competitive acquisition program; and

(B) the Secretary may use information on the payment determined under such competitive acquisition programs to adjust the payment amount otherwise determined under this subsection for an area that is not a competitive acquisition area under section 1395w–3 of this title, and in the case of such adjustment, paragraphs (8) and (9) of section 1395u(b) of this title shall not be applied.

(Aug. 14, 1935, ch. 531, title XVIII, § 1834, as added and amended Pub. L. 100–203, title IV, §§ 4049(a)(2), 4062(b), Dec. 22, 1987, 101 Stat. 1330–91, 1330–100; Pub. L. 100–360, title II, §§ 202(b)(4), 203(c)(1)(F), 204(b), title IV, § 411(a)(3)(A), (B)(ii), (C)(ii), (f)(8)(A), (B)(ii), (D), (g)(1)(A), (B), July 1, 1988, 102 Stat. 704, 722, 726, 768, 779, 781; Pub. L. 100–485, title VI, § 608(d)(21)(C), (22)(A), Oct. 13, 1988, 102 Stat. 2420; Pub. L. 101–234, title II, § 201(a), title III, § 301(b)(1), (c)(1), Dec. 13, 1989, 103 Stat. 1981, 1985; Pub. L. 101–239, title VI, §§ 6102(f)(1), 6105(a), 6112(a), (c), (d)(1), (e)(2), 6116(b)(2), 6140, Dec. 19, 1989, 103 Stat. 2188, 2210, 2214–2216, 2220, 2224; Pub. L. 101–508, title IV, §§ 4102(a), (d), (f), 4104(a), 4152(a)(1), (b), (c)(1)–(4)(B)(i), (e), (f)(1), (g)(1), 4153(a)(1), (2)(D), 4163(b), Nov. 5, 1990, 104 Stat. 1388–55, 1388–57, 1388–59, 1388–74, 1388–77 to 1388–81, 1388–83, 1388–97; Pub. L. 103–66, title XIII, §§ 13542(a), 13543(a), (b), 13544(a)(1), (2), (b)(1), 13545(a), 13546, Aug. 10, 1993, 107 Stat. 587, 589, 590; Pub. L. 103–432, title I, §§ 102(e), 126(b)(1), (2), (4), (5), (g)(1), (10)(B), 131(a), 132(a), (b), 133(a)(1), 134(a)(1), 135(a)(1), (b)(1), (3), (d)(1), (e)(2)–(5), 145(a), 156(a)(2)(C), Oct. 31, 1994, 108 Stat. 4403, 4414–4416, 4419, 4421–4424, 4427, 4440; Pub. L. 105–33, title IV, §§ 4101(a), (c), 4104(b)(1), 4105(b)(2), 4201(c)(5), 4312(a), (c), 4316(b), 4531(b)(2), 4541(a)(2), 4551(a), (c)(1), 4552(a), (b), Aug. 5, 1997, 111 Stat. 360, 363, 367, 374, 386, 387, 392, 451, 455, 457–459; Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(e)(2), title III, § 321(k)(3), title IV, § 403(d)(1)], Nov. 29, 1999, 113 Stat. 1536, 1501A–340, 1501A–366, 1501A–371; Pub. L. 106–554, § 1(a)(6) [title I, §§ 103(b), 104(b), title II, §§ 201(a), 202(a), 204(a), 205(a), 221(a), 223(b), title IV, §§ 423(a)(1), (b)(1), 425(a), 426(a), 427(a), 428(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–468, 2763A–469, 2763A–481, 2763A–482, 2763A–486, 2763A–487, 2763A–518 to 2763A–520, 2763A–522; Pub. L. 108–173, title III, § 302(a), (c)(1)(A), (2), (3), (d)(1), (2), title IV, §§ 405(a)(1), (b)(1), (d)(1), 414(a)–(c)(1), (d), 415(a), title VI, § 627(b)(1), title VII, § 736(b)(4), (5), Dec. 8, 2003, 117 Stat. 2223, 2230–2232, 2266, 2267, 2278–2281, 2321, 2356; Pub. L. 109–171, title V, §§ 5101(a)(1), (b)(1), 5113(b), Feb. 8, 2006, 120 Stat. 37, 38, 44; Pub. L. 110–275, title I, §§ 125(b)(5), 135(a)(1), 144(b)(1), 146(a), (b)(2)(A), 148(a), 149(a), 154(a)(2)(A), (3), (4), (b)(1)(A), (d)(2), July 15, 2008, 122 Stat. 2519, 2532, 2547–2549, 2563, 2564, 2567; Pub. L. 111–72, § 1(a), Oct. 13, 2009, 123 Stat. 2059; Pub. L. 111–148, title III, §§ 3105(a), (c), 3109(a), 3128(a), 3136(a), (b), 3401(j), (m), (n), title IV, § 4105(a), title V, §§ 5501(a)(2), (b)(2), 5502(b), title VI, §§ 6402(g)(1), 6405(a), 6407(b), 6410(b), title X, §§ 10311(a), (c), 10501(i)(1), (3)(A), Mar. 23, 2010, 124 Stat. 417, 418, 426, 437, 438, 486, 487, 558, 653, 654, 759, 768, 770, 773, 942, 943, 997; Pub. L. 111–309, title I, § 106(a), (c), Dec. 15, 2010, 124 Stat. 3287; Pub. L. 112–78, title III, § 306(a), (c), Dec. 23, 2011, 125 Stat. 1285; Pub. L. 112–96, title III, § 3007(a), (c), Feb. 22, 2012, 126 Stat. 190; Pub. L. 112–240, title VI, §§ 604(a), (c), 633(b), 636, 637, Jan. 2, 2013, 126 Stat. 2347, 2348, 2355–2357; Pub. L. 113–67, div. B, title I, § 1104, Dec. 26, 2013, 127 Stat. 1196; Pub. L. 113–93, title I, § 104, title II, § 218(a)(1), (b)(1), Apr. 1, 2014, 128 Stat. 1042, 1063, 1065; Pub. L. 113–295, div. B, title II, § 203, Dec. 19, 2014, 128 Stat. 4065; Pub. L. 114–10, title II, § 203, title V, §§ 504(a), 515(b), Apr. 16, 2015, 129 Stat. 144, 165, 174; Pub. L. 114–27, title VIII, § 808(b), June 29, 2015, 129 Stat. 418; Pub. L. 114–40, § 3, July 30, 2015, 129 Stat. 441; Pub. L. 114–113, div. O, title V, § 504(a), Dec. 18, 2015, 129 Stat. 3021; Pub. L. 114–255, div. A, title IV, § 4011, title V, § 5012(b), div. C, title XVI, § 16008(a), (b)(1), Dec. 13, 2016, 130 Stat. 1186, 1199, 1329; Pub. L. 115–123, div. E, title II, § 50203, title III, §§ 50302(b), 50325, title IV, §§ 50401(a), 50402, 50411, title XII, §§ 53107, 53108, Feb. 9, 2018, 132 Stat. 178, 191, 205, 214, 217, 220, 303; Pub. L. 115–271, title II, §§ 2001(a), 2005(c)(2), title VI, § 6083(a), Oct. 24, 2018, 132 Stat. 3924, 3929, 3994; Pub. L. 116–136, div. A, title III, § 3704, Mar. 27, 2020, 134 Stat. 416; Pub. L. 116–260, div. CC, title I, §§ 121(a), (b)(1), 122(c), 123(a), 125(a)(2)(B), (c), 132, Dec. 27, 2020, 134 Stat. 2955, 2956, 2964, 2966, 2976; Pub. L. 117–103, div. P, title III, §§ 301–305, 311, Mar. 15, 2022, 136 Stat. 804–806, 808; Pub. L. 117–215, title I, § 103(b)(4)(B), Dec. 2, 2022, 136 Stat. 2263; Pub. L. 117–328, div. FF, title I, § 1262(b)(6), title IV, §§ 4103, 4113(a)–(e), 4124(c), 4133(a)(2)(B), (b), 4134(c), 4136(a), Dec. 29, 2022, 136 Stat. 5682, 5896, 5898, 5899, 5909, 5919–5921, 5924; Pub. L. 118–158, div. C, title II, §§ 3203, 3207(a)–(e), Dec. 21, 2024, 138 Stat. 1765, 1766; Pub. L. 119–4, div. B, title II, §§ 2203, 2207(a)–(e), Mar. 15, 2025, 139 Stat. 43, 44; Pub. L. 119–26, § 4(2)(B)(vi), July 16, 2025, 139 Stat. 417; Pub. L. 119–37, div. F, title II, §§ 6206, 6208(a)–(e), Nov. 12, 2025, 139 Stat. 632, 633.)

Editorial Notes

References in Text

Section 302(c)(1)(B) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to in subsec. (a)(14)(H)(i), is section 302(c)(1)(B) of Pub. L. 108–173, which is set out as a note under this section.

Section 4531(a) of the Balanced Budget Act of 1997, referred to in subsec. (l)(3)(A), is section 4531(a) of Pub. L. 105–33, which amended sections 1395u and 1395x of this title.

Section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015, referred to in subsec. (l)(16)(A), is section 515(a) of Pub. L. 114–10, title V, Apr. 16, 2015, 129 Stat. 174, which relates to the initial expansion of prior authorization model for repetitive scheduled non-emergent ambulance transports and is not classified to the Code.

Codification

Amendment of subsec. (a)(4) by Pub. L. 101–508, § 4152(c)(4)(B)(i), did not become effective pursuant to Pub. L. 101–508, § 4152(c)(4)(B)(ii), because of action of Secretary in developing specific criteria for the treatment of wheelchairs as customized items for purposes of subsec. (a)(4). See Effective Date of 1990 Amendment note below.

Prior Provisions

A prior section 1395m, act Aug. 14, 1935, ch. 531, title XVIII, § 1834, as added July 30, 1965, Pub. L. 89–97, title I, § 102(a), 79 Stat. 303, prescribed limitations on payments for home health services, prior to repeal by Pub. L. 96–499, title IX, § 930(i), Dec. 5, 1980, 94 Stat. 2631, effective with respect to services furnished on or after July 1, 1981.

Amendments

2025—Subsec. (l)(12)(A). Pub. L. 119–37, § 6206(1), substituted “January 31, 2026” for “October 1, 2025”.

Pub. L. 119–4, § 2203(1), substituted “October 1, 2025” for “April 1, 2025”.

Subsec. (l)(13)(A). Pub. L. 119–37, § 6206(2), substituted “January 31, 2026” for “October 1, 2025” wherever appearing.

Pub. L. 119–4, § 2203(2), substituted “October 1, 2025” for “April 1, 2025” wherever appearing.

Subsec. (m)(2)(B)(iii). Pub. L. 119–37, § 6208(a)(1), substituted “ending January 30, 2026” for “ending September 30, 2025”.

Pub. L. 119–4, § 2207(a)(1), substituted “ending September 30, 2025” for “ending March 31, 2025”.

Subsec. (m)(4)(C)(iii). Pub. L. 119–37, § 6208(a)(2), substituted “ending on January 30, 2026” for “ending on September 30, 2025”.

Pub. L. 119–4, § 2207(a)(2), substituted “ending on September 30, 2025” for “ending on March 31, 2025”.

Subsec. (m)(4)(E). Pub. L. 119–37, § 6208(b), substituted “ending on January 30, 2026” for “ending on September 30, 2025”.

Pub. L. 119–4, § 2207(b), substituted “ending on September 30, 2025” for “ending on March 31, 2025”.

Subsec. (m)(7)(B)(i). Pub. L. 119–37, § 6208(d)(1), substituted “on or after January 31, 2026” for “on or after October 1, 2025” in introductory provisions.

Pub. L. 119–4, § 2207(d)(1), substituted “on or after October 1, 2025,” for “on or after April 1, 2025” in introductory provisions.

Subsec. (m)(8)(A). Pub. L. 119–37, § 6208(c), substituted “ending on January 30, 2026” for “ending on September 30, 2025” in introductory provisions.

Pub. L. 119–4, § 2207(c), substituted “ending on September 30, 2025” for “ending on March 31, 2025” in introductory provisions.

Subsec. (m)(9). Pub. L. 119–37, § 6208(e), substituted “ending on January 30, 2026” for “ending on September 30, 2025”.

Pub. L. 119–4, § 2207(e), substituted “ending on September 30, 2025” for “ending on March 31, 2025”.

Subsec. (o)(3)(C)(ii). Pub. L. 119–26, § 4(2)(B)(vi), amended Pub. L. 117–328, § 1262(b)(6). See 2022 Amendment note below.

Subsec. (o)(4)(B). Pub. L. 119–37, § 6208(d)(3), substituted “January 31, 2026” for “October 1, 2025”.

Pub. L. 119–4, § 2207(d)(3), substituted “October 1, 2025” for “April 1, 2025”.

Subsec. (y)(2). Pub. L. 119–37, § 6208(d)(2), substituted “January 31, 2026” for “October 1, 2025”.

Pub. L. 119–4, § 2207(d)(2), substituted “October 1, 2025” for “April 1, 2025”.

2024—Subsec. (l)(12)(A). Pub. L. 118–158, § 3203(1), substituted “April 1, 2025” for “January 1, 2025”.

Subsec. (l)(13)(A). Pub. L. 118–158, § 3203(2), substituted “April 1, 2025” for “January 1, 2025” wherever appearing.

Subsec. (m)(2)(B)(iii). Pub. L. 118–158, § 3207(a)(1), substituted “ending March 31, 2025” for “ending December 31, 2024”.

Subsec. (m)(4)(C)(iii). Pub. L. 118–158, § 3207(a)(2), substituted “ending on March 31, 2025” for “ending on December 31, 2024”.

Subsec. (m)(4)(E). Pub. L. 118–158, § 3207(b), substituted “ending on March 31, 2025” for “ending on December 31, 2024”.

Subsec. (m)(7)(B)(i). Pub. L. 118–158, § 3207(d)(1), substituted “on or after April 1, 2025” for “on or after January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)” in introductory provisions.

Subsec. (m)(8)(A). Pub. L. 118–158, § 3207(c), substituted “ending on March 31, 2025” for “ending on December 31, 2024”.

Subsec. (m)(9). Pub. L. 118–158, § 3207(e), substituted “ending on March 31, 2025” for “ending on December 31, 2024”.

Subsec. (o)(4)(B). Pub. L. 118–158, § 3207(d)(3), substituted “April 1, 2025.” for “January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title).”

Subsec. (y)(2). Pub. L. 118–158, § 3207(d)(2), substituted “April 1, 2025.” for “January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title).”

2022—Subsec. (a)(20)(D)(iv). Pub. L. 117–328, § 4133(b)(1), added cl. (iv).

Subsec. (j)(5)(E). Pub. L. 117–328, § 4134(c)(2), added subpar. (E), relating to items and services related to the administration of intravenous immune globulin furnished on or after January 1, 2024, after subpar. (D). Former subpar. (E), added by Pub. L. 117–328, § 4133(b)(2)(B), redesignated (F). See note below.

Pub. L. 117–328, § 4133(b)(2)(B), added subpar. (E), relating to lymphedema compression treatment items, after subpar. (D). Former subpar. (E) redesignated (F).

Subsec. (j)(5)(F). Pub. L. 117–328, § 4134(c)(1), redesignated subpar. (E), added by Pub. L. 117–328, § 4133(b)(2)(B), relating to lymphedema compression treatment items, as (F). Former subpar. (F), as previously redesignated by Pub. L. 117–328, § 4133(b)(2)(A), redesignated (G).

Pub. L. 117–328, § 4133(b)(2)(A), redesignated subpar. (E) as (F). Former subpar. (F) redesignated (G).

Subpar. (j)(5)(G). Pub. L. 117–328, § 4134(c)(1), redesignated subpar. (F), as previously redesignated by Pub. L. 117–328, § 4133(b)(2)(A), as (G).

Pub. L. 117–328, § 4133(b)(2)(A), redesignated subpar. (F) as (G).

Subsec. (l)(12)(A). Pub. L. 117–328, § 4103(1), substituted “January 1, 2025” for “January 1, 2023”.

Subsec. (l)(13)(A). Pub. L. 117–328, § 4103(2), substituted “January 1, 2025” for “January 1, 2023” wherever appearing.

Subsec. (l)(17)(F)(i). Pub. L. 117–103, § 311, substituted “Not later than the second June 15th following the date on which the Secretary transmits data for the first representative sample of providers and suppliers of ground ambulance services to the Medicare Payment Advisory Commission, and as determined necessary by such Commission thereafter,” for “Not later than March 15, 2023, and as determined necessary by the Medicare Payment Advisory Commission thereafter”.

Subsec. (m)(1). Pub. L. 117–103, §§ 302(1), 305(1), substituted “paragraphs (8) and (9)” for “paragraph (8)” and “(as defined in paragraph (4)(E))” for “(described in section 1395u(b)(18)(C) of this title)”.

Subsec. (m)(2)(B)(i). Pub. L. 117–103, § 301(b)(1), substituted “clauses (ii) and (iii)” for “clause (ii)” in introductory provisions.

Subsec. (m)(2)(B)(iii). Pub. L. 117–328, § 4113(a)(1), substituted “In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with” for “With” and “that are furnished during the period beginning on the first day after the end of such emergency period and ending December 31, 2024” for “that are furnished during the 151-day period beginning on the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title”.

Pub. L. 117–103, § 301(b)(2), added cl. (iii).

Subsec. (m)(4)(C)(i). Pub. L. 117–103, § 301(a)(1)(A), inserted “clause (iii) and” after “Except as provided in” in introductory provisions.

Subsec. (m)(4)(C)(iii). Pub. L. 117–328, § 4113(a)(2), substituted “In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with” for “With” and “that are furnished during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024” for “that are furnished during the 151-day period beginning on the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title”.

Pub. L. 117–103, § 301(a)(1)(B), added cl. (iii).

Subsec. (m)(4)(E). Pub. L. 117–328, § 4113(b), substituted “and, in the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, for the period beginning on the first day after the end of such emergency period and ending on December 31, 2024” for “and, for the 151-day period beginning on the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title”.

Pub. L. 117–103, § 302(2), inserted before period at end: “and, for the 151-day period beginning on the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title, shall include a qualified occupational therapist (as such term is used in section 1395x(g) of this title), a qualified physical therapist (as such term is used in section 1395x(p) of this title), a qualified speech-language pathologist (as defined in section 1395x(ll)(4)(A) of this title), and a qualified audiologist (as defined in section 1395x(ll)(4)(B) of this title)”.

Subsec. (m)(7)(A). Pub. L. 117–103, § 301(a)(2), inserted “or, for the period for which clause (iii) of paragraph (4)(C) applies, at any site described in such clause” before period at end.

Subsec. (m)(7)(B)(i). Pub. L. 117–328, § 4113(d)(1), which directed the substitution of “on or after January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)” for “on or after the day that is the 152nd day after the end of the period at the end of the emergency sentence described in section 1320b–5(g)(1)(B) of this title)” in introductory provisions, was executed by making the substitution for “on or after the day that is the 152nd day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)”, to reflect the probable intent of Congress.

Pub. L. 117–103, § 304(a), inserted “on or after the day that is the 152nd day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)” after “telehealth services furnished” in introductory provisions.

Subsec. (m)(8). Pub. L. 117–103, § 303(1), struck out “during emergency period” after “clinics” in heading.

Subsec. (m)(8)(A). Pub. L. 117–328, § 4113(c), substituted “in the case that such emergency period ends before December 31, 2024, during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024” for “during the 151-day period beginning on the first day after the end of such emergency period” in introductory provisions.

Pub. L. 117–103, § 303(2), inserted “and, during the 151-day period beginning on the first day after the end of such emergency period” after “section 1320b–5(g)(1)(B) of this title” in introductory provisions.

Subsec. (m)(8)(B)(i). Pub. L. 117–103, § 303(3), substituted “the periods for which subparagraph (A) applies” for “such emergency period”.

Subsec. (m)(9). Pub. L. 117–328, § 4113(e), substituted “In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, the Secretary shall continue to provide coverage and payment under this part for telehealth services identified in paragraph (4)(F)(i) as of March 15, 2022, that are furnished via an audio-only communications system during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024” for “The Secretary shall continue to provide coverage and payment under this part for telehealth services identified in paragraph (4)(F)(i) as of March 15, 2022, that are furnished via an audio-only telecommunications system during the 151-day period beginning on the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title”.

Pub. L. 117–103, § 305(2), added par. (9).

Subsec. (o)(3)(C)(ii). Pub. L. 117–328, § 1262(b)(6), as amended by Pub. L. 119–26, § 4(2)(B)(vi), substituted “first begins prescribing narcotic drugs in schedule III, IV, or V of section 812 of title 21 for the purpose of maintenance or detoxification treatment on or after January 1, 2021” for “first receives a waiver under section 823(h) of title 21 on or after January 1, 2019”.

Pub. L. 117–215 substituted “823(h)” for “823(g)”.

Subsec. (o)(4). Pub. L. 117–328, § 4113(d)(3)(A), struck out “to hospice patients” after “federally qualified health centers” in heading.

Pub. L. 117–103, § 304(c), substituted “certain” for “attending physician” in par. heading, designated existing provisions as subpar. (A) and inserted heading, and added subpar. (B).

Subsec. (o)(4)(B). Pub. L. 117–328, § 4113(d)(3)(B), substituted “prior to January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)” for “prior to the day that is the 152nd day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)”.

Subsec. (o)(5). Pub. L. 117–328, § 4124(c)(1), added par. (5).

Subsec. (s)(3). Pub. L. 117–328, § 4136(a)(1), amended par. (3) generally. Prior to amendment, text read as follows: “The separate payment amount established under this paragraph for an applicable disposable device for a year shall be equal to the amount of the payment that would be made under section 1395l(t) of this title (relating to payment for covered OPD services) for the year for the Level I Healthcare Common Procedure Coding System (HCPCS) code for which the description for a professional service includes the furnishing of such device.”

Subsec. (s)(4). Pub. L. 117–328, § 4136(a)(2), added par. (4).

Subsec. (y). Pub. L. 117–328, § 4124(c)(2)(A), which directed amendment of subsec. (y) by striking out “to hospice patients” in heading, could not be executed in view of the intervening amendment by Pub. L. 117–328, § 4113(d)(2)(A). See below.

Pub. L. 117–328, § 4113(d)(2)(A), struck out “to hospice patients” after “rural health clinics” in heading.

Pub. L. 117–103, § 304(b), substituted “certain” for “attending physician” in heading, designated existing provisions as par. (1) and inserted heading, and added par. (2).

Subsec. (y)(2). Pub. L. 117–328, § 4113(d)(2)(B), substituted “prior to January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)” for “prior to the day that is the 152nd day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title)”.

Subsec. (y)(3). Pub. L. 117–328, § 4124(c)(2)(B), added par. (3).

Subsec. (z). Pub. L. 117–328, § 4133(a)(2)(B), added subsec. (z).

2020—Subsec. (a)(9)(D). Pub. L. 116–260, § 121(b)(1), made technical correction to Pub. L. 105–33, § 4552(b). See 1997 Amendment note below.

Subsec. (a)(9)(D)(ii). Pub. L. 116–260, § 121(a), inserted at end “The requirement of the preceding sentence shall not apply beginning with the second calendar quarter beginning on or after December 27, 2020.”

Subsec. (d)(2)(C)(ii), (3)(C)(ii). Pub. L. 116–260, § 122(c)(1), substituted “Subject to section 1395l(a)(1)(Y) of this title, but notwithstanding” for “Notwithstanding” in introductory provisions.

Subsec. (d)(2)(D), (3)(D). Pub. L. 116–260, § 122(c)(2), substituted “Subject to section 1395l(a)(1)(Y) of this title, if during” for “If during”.

Subsec. (m)(1). Pub. L. 116–136, § 3704(1), substituted “Subject to paragraph (8), the Secretary” for “The Secretary”.

Subsec. (m)(2)(A). Pub. L. 116–136, § 3704(2), substituted “Subject to paragraph (8), the Secretary” for “The Secretary”.

Subsec. (m)(4)(A). Pub. L. 116–136, § 3704(3)(A), substituted “Subject to paragraph (8), the term” for “The term”.

Subsec. (m)(4)(C)(ii)(XI). Pub. L. 116–260, § 125(c), added subcl. (XI).

Subsec. (m)(4)(F)(i). Pub. L. 116–136, § 3704(3)(B), substituted “Subject to paragraph (8), the term” for “The term”.

Subsec. (m)(7). Pub. L. 116–260, § 123(a), substituted “disorder services and mental health services furnished through telehealth” for “disorder services furnished through telehealth” in heading, designated existing provisions as subpar. (A) and inserted heading, inserted “or, on or after the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title, subject to subparagraph (B), to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder, as determined by the Secretary,” after “as determined by the Secretary,”, and added subpar. (B).

Subsec. (m)(8). Pub. L. 116–136, § 3704(4), added par. (8).

Subsec. (o)(4). Pub. L. 116–260, § 132(1), added par. (4).

Subsec. (x). Pub. L. 116–260, § 125(a)(2)(B), added subsec. (x).

Subsec. (y). Pub. L. 116–260, § 132(2), added subsec. (y).

2018—Subsec. (a)(2)(A)(iv). Pub. L. 115–123, § 50411, struck out “and before October 1, 2018,” after “October 1, 2015,”.

Subsec. (h)(5). Pub. L. 115–123, § 50402, added par. (5).

Subsec. (l)(12)(A). Pub. L. 115–123, § 50203(a)(2), substituted “2023” for “2018”.

Subsec. (l)(13)(A). Pub. L. 115–123, § 50203(a)(1), substituted “2023” for “2018” wherever appearing.

Subsec. (l)(15). Pub. L. 115–123, § 53108, substituted “during the period beginning on October 1, 2013, and ending on September 30, 2018, and by 23 percent for such services furnished on or after October 1, 2018” for “on or after October 1, 2013”.

Subsec. (l)(17). Pub. L. 115–123, § 50203(b), added par. (17).

Subsec. (m)(2)(B). Pub. L. 115–123, § 50302(b)(2), redesignated existing provisions as cl. (i), inserted heading, substituted “Subject to clause (ii), with respect to” for “With respect to”, redesignated former cls. (i) and (ii) as subcls. (I) and (II), respectively, of cl. (i), substituted “subclause (I) or this subclause” for “clause (i) or this clause” in subcl. (II), and added cl. (ii).

Subsec. (m)(2)(B)(i). Pub. L. 115–271, § 2001(a)(1)(A), substituted “clause (ii) and paragraph (6)(C)” for “clause (ii)” in introductory provisions.

Subsec. (m)(2)(B)(ii). Pub. L. 115–271, § 2001(a)(1)(B), struck out “for home dialysis therapy” after “site” in heading.

Subsec. (m)(4)(C)(i). Pub. L. 115–271, § 2001(a)(2)(A), substituted “paragraphs (5), (6), and (7)” for “paragraph (6)” in introductory provisions.

Pub. L. 115–123, § 50325(1), substituted “Except as provided in paragraph (6), the term” for “The term” in introductory provisions.

Subsec. (m)(4)(C)(ii)(IX). Pub. L. 115–123, § 50302(b)(1)(A), added subcl. (IX).

Subsec. (m)(4)(C)(ii)(X). Pub. L. 115–271, § 2001(a)(2)(B), inserted “or telehealth services described in paragraph (7)” before period at end.

Pub. L. 115–123, § 50302(b)(1)(A), added subcl. (X).

Subsec. (m)(5). Pub. L. 115–123, § 50302(b)(1)(B), added par. (5).

Subsec. (m)(6). Pub. L. 115–123, § 50325(2), added par. (6).

Subsec. (m)(7). Pub. L. 115–271, § 2001(a)(3), added par. (7).

Subsec. (o)(3). Pub. L. 115–271, § 6083(a), added par. (3).

Subsec. (u)(7). Pub. L. 115–123, § 50401(a), added par. (7).

Subsec. (v). Pub. L. 115–123, § 53107, added subsec. (v).

Subsec. (w). Pub. L. 115–271, § 2005(c)(2), added subsec. (w).

2016—Subsec. (a)(1)(G). Pub. L. 114–255, § 16008(a), inserted at end “In the case of items and services furnished on or after January 1, 2019, in making any adjustments under clause (ii) or (iii) of subparagraph (F), under subsection (h)(1)(H)(ii), or under section 1395u(s)(3)(B) of this title, the Secretary shall—” and added cls. (i) and (ii).

Subsec. (h)(1)(H)(ii). Pub. L. 114–255, § 16008(b)(1), substituted “subject to subsection (a)(1)(G), the Secretary” for “the Secretary”.

Subsec. (t). Pub. L. 114–255, § 4011, added subsec. (t).

Subsec. (u). Pub. L. 114–255, § 5012(b), added subsec. (u).

2015—Subsec. (a)(2)(A)(iv). Pub. L. 114–40 added cl. (iv).

Subsec. (a)(11)(B)(ii). Pub. L. 114–10, § 504(a), struck out “the physician documenting that” after “written pursuant to” and substituted “documenting such physician, physician assistant, practitioner, or specialist has had a face-to-face encounter” for “has had a face-to-face encounter”.

Subsec. (l)(12)(A). Pub. L. 114–10, § 203(b), substituted “January 1, 2018” for “April 1, 2015”.

Subsec. (l)(13)(A). Pub. L. 114–10, § 203(a), substituted “January 1, 2018” for “April 1, 2015” wherever appearing.

Subsec. (l)(16). Pub. L. 114–10, § 515(b), added par. (16).

Subsec. (r). Pub. L. 114–27 added subsec. (r).

Subsec. (s). Pub. L. 114–113 added subsec. (s).

2014—Subsec. (a)(1)(I). Pub. L. 113–295 added subpar. (I).

Subsec. (l)(12)(A). Pub. L. 113–93, § 104(b), substituted “April 1, 2015” for “April 1, 2014”.

Subsec. (l)(13)(A). Pub. L. 113–93, § 104(a), substituted “April 1, 2015” for “April 1, 2014” wherever appearing.

Subsec. (p). Pub. L. 113–93, § 218(a)(1), added subsec. (p).

Subsec. (q). Pub. L. 113–93, § 218(b)(1), added subsec. (q).

2013—Subsec. (a)(1)(F). Pub. L. 112–240, § 636(a)(1), substituted “subparagraphs (G) and (H)” for “subparagraph (G)” in introductory provisions.

Subsec. (a)(1)(H). Pub. L. 112–240, § 636(a)(2), added subpar. (H).

Subsec. (a)(22). Pub. L. 112–240, § 636(b), added par. (22).

Subsec. (k)(7). Pub. L. 112–240, § 633(b), added par. (7).

Subsec. (l)(12)(A). Pub. L. 113–67, § 1104(b), substituted “April 1, 2014” for “January 1, 2014”.

Pub. L. 112–240, § 604(c), substituted “January 1, 2014” for “January 1, 2013”.

Subsec. (l)(13)(A). Pub. L. 113–67, § 1104(a), substituted “April 1, 2014” for “January 1, 2014” wherever appearing.

Pub. L. 112–240, § 604(a), substituted “January 1, 2014” for “January 1, 2013” wherever appearing.

Subsec. (l)(15). Pub. L. 112–240, § 637, added par. (15).

2012—Subsec. (l)(12)(A). Pub. L. 112–96, § 3007(c), substituted “January 1, 2013” for “March 1, 2012”.

Subsec. (l)(13)(A). Pub. L. 112–96, § 3007(a), substituted “January 1, 2013” for “March 1, 2012” wherever appearing.

2011—Subsec. (l)(12)(A). Pub. L. 112–78, § 306(c), substituted “March 1, 2012” for “January 1, 2012”.

Subsec. (l)(13)(A). Pub. L. 112–78, § 306(a), substituted “March 1, 2012” for “January 1, 2012” wherever appearing.

2010—Subsec. (a)(1)(F)(ii). Pub. L. 111–148, § 6410(b)(2)(A), inserted “(and, in the case of covered items furnished on or after January 1, 2016, subject to clause (iii), shall)” after “may”.

Subsec. (a)(1)(F)(iii). Pub. L. 111–148, § 6410(b)(1), (2)(B), (3), added cl. (iii).

Subsec. (a)(7)(A)(i)(II). Pub. L. 111–148, § 3136(a)(1)(A), inserted “subclause (III) and” after “Subject to”.

Subsec. (a)(7)(A)(i)(III). Pub. L. 111–148, § 3136(a)(1)(B), added subcl. (III).

Subsec. (a)(7)(A)(iii). Pub. L. 111–148, § 3136(a)(2)(B), inserted “complex, rehabilitative” after “case of a”.

Pub. L. 111–148, § 3136(a)(2)(A), inserted “complex, rehabilitative” after “option for” in heading.

Subsec. (a)(7)(C)(ii)(II). Pub. L. 111–148, § 3136(b), struck out “(A)(ii) or” after “subparagraph”.

Subsec. (a)(11)(B). Pub. L. 111–148, § 6407(b)(1), designated existing provisions as cl. (i) and inserted heading.

Pub. L. 111–148, § 6405(a), substituted “physician enrolled under section 1395cc(j) of this title or an eligible professional under section 1395w–4(k)(3)(B) of this title that is enrolled under section 1395cc(j) of this title” for “physician”.

Subsec. (a)(11)(B)(ii). Pub. L. 111–148, § 6407(b)(2), added cl. (ii).

Subsec. (a)(14). Pub. L. 111–148, § 3401(m)(3), inserted concluding provisions.

Subsec. (a)(14)(K). Pub. L. 111–148, § 3401(m)(1), struck out “2011, 2012, and 2013,” after “2010,” and inserted “and” at the end.

Subsec. (a)(14)(L), (M). Pub. L. 111–148, § 3401(m)(2), added subpar. (L) and struck out former subpars. (L) and (M) which read as follows:

“(L) for 2014—

“(i) in the case of items and services described in subparagraph (J)(i) for which a payment adjustment has not been made under subsection (a)(1)(F)(ii) in any previous year, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June 2013, plus 2.0 percentage points; or

“(ii) in the case of other items and services, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June 2013; and

“(M) for a subsequent year, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June of the previous year.”

Subsec. (a)(16)(B). Pub. L. 111–148, § 6402(g)(1), inserted “that the Secretary determines is commensurate with the volume of the billing of the supplier” after “$50,000”.

Subsec. (a)(20)(F)(i). Pub. L. 111–148, § 3109(a)(1)(B), which directed amendment by inserting “, except that the Secretary shall not require a pharmacy to have submitted to the Secretary such evidence of accreditation prior to January 1, 2011” before semicolon “at the end”, was executed by making the insertion before “; and” to reflect the probable intent of Congress.

Pub. L. 111–148, § 3109(a)(1)(A), inserted “and subparagraph (G)” after “clause (ii)”.

Subsec. (a)(20)(G). Pub. L. 111–148, § 3109(a)(2), added subpar. (G).

Subsec. (g)(2)(A). Pub. L. 111–148, § 3128(a), inserted “101 percent of” after “subparagraph (B),”.

Subsec. (g)(2)(B). Pub. L. 111–148, § 5501(b)(2), substituted “Subsections (x) and (y) of section 1395l” for “Section 1395l(x)”.

Pub. L. 111–148, § 5501(a)(2), inserted at end “Section 1395l(x) of this title shall not be taken into account in determining the amounts that would otherwise be paid pursuant to the preceding sentence.”

Subsec. (h)(4)(A). Pub. L. 111–148, § 3401(n)(1)(D), inserted concluding provisions.

Subsec. (h)(4)(A)(x). Pub. L. 111–148, § 3401(n)(1)(B)(i), substituted “for each of 2007 through 2010” for “a subsequent year”.

Subsec. (h)(4)(A)(xi). Pub. L. 111–148, § 3401(n)(1)(A), (B)(ii), (C), added cl. (xi).

Subsec. (l)(3). Pub. L. 111–148, § 3401(j)(4), inserted concluding provisions.

Subsec. (l)(3)(B). Pub. L. 111–148, § 3401(j)(2)(A), inserted “, subject to subparagraph (C) and the succeeding sentence of this paragraph,” after “increased”.

Subsec. (l)(3)(C). Pub. L. 111–148, § 3401(j)(1), (2)(B), (3), added subpar. (C).

Subsec. (l)(8). Pub. L. 111–148, § 3128(a), inserted “101 percent of” after “pay” in introductory provisions.

Subsec. (l)(12)(A). Pub. L. 111–309, § 106(c), substituted “2012” for “2011”.

Pub. L. 111–148, § 10311(c), substituted “2011” for “2010, and on or after April 1, 2010, and before January 1, 2011”.

Pub. L. 111–148, § 3105(c), substituted “2010, and on or after April 1, 2010, and before January 1, 2011” for “2010”.

Subsec. (l)(13)(A). Pub. L. 111–309, § 106(a)(1), substituted “2012,” for “2011” in introductory provisions.

Pub. L. 111–148, § 10311(a)(1), in introductory provisions, substituted “2007, and for” for “2007, for” and “2011” for “2010, and for such services furnished on or after April 1, 2010, and before January 1, 2011”.

Pub. L. 111–148, § 3105(a)(1), in introductory provisions, substituted “2007, for” for “2007, and for” and “2010, and for such services furnished on or after April 1, 2010, and before January 1, 2011,” for “2010”.

Subsec. (l)(13)(A)(i), (ii). Pub. L. 111–309, § 106(a)(2), substituted “January 1, 2012” for “January 1, 2011”.

Pub. L. 111–148, § 10311(a)(2)(B), substituted “January 1, 2011” for “January 1, 2010”.

Pub. L. 111–148, § 10311(a)(2)(A), struck out “, and on or after April 1, 2010, and before January 1, 2011” after “January 1, 2010”.

Pub. L. 111–148, § 3105(a)(2), inserted “, and on or after April 1, 2010, and before January 1, 2011” after “January 1, 2010”.

Subsec. (n). Pub. L. 111–148, § 5502(b), which directed the addition of subsec. (n) relating to development and implementation of prospective payment system, was repealed by Pub. L. 111–148, § 10501(i)(1).

Pub. L. 111–148, § 4105(a), added subsec. (n) relating to authority to modify or eliminate coverage of certain preventive services.

Subsec. (o). Pub. L. 111–148, § 10501(i)(3)(A), added subsec. (o).

2009—Subsec. (a)(20)(F)(i). Pub. L. 111–72 inserted “, except that the Secretary shall not require under this clause pharmacies to obtain such accreditation before January 1, 2010” before semicolon.

2008—Subsec. (a)(1)(E)(ii). Pub. L. 110–275, § 154(d)(2), substituted “1395x(r)” for “1395x(r)(1)”.

Subsec. (a)(1)(F). Pub. L. 110–275, § 154(a)(3), (4)(A)(i), in introductory provisions, substituted “January 1, 2011” for “January 1, 2009” and inserted “subject to subparagraph (G),” before “that are included”.

Subsec. (a)(1)(G). Pub. L. 110–275, § 154(a)(4)(A)(ii), added subpar. (G).

Subsec. (a)(5)(F). Pub. L. 110–275, § 144(b)(1), substituted “Rental cap” for “Ownership of equipment” in heading, added cl. (ii), and struck out former cl. (ii) which related to transfer of title to equipment and payments for oxygen and maintenance and servicing.

Subsec. (a)(14)(J) to (M). Pub. L. 110–275, § 154(a)(2)(A), added subpars. (J) to (L) and redesignated former subpar. (J) as (M).

Subsec. (a)(20)(B). Pub. L. 110–275, § 125(b)(5), substituted “section 1395bb(a)” for “section 1395bb(b)”.

Subsec. (a)(20)(E). Pub. L. 110–275, § 154(b)(1)(A)(i), inserted “including subparagraph (F),” after “under this paragraph,”.

Subsec. (a)(20)(F). Pub. L. 110–275, § 154(b)(1)(A)(ii), added subpar. (F).

Subsec. (e). Pub. L. 110–275, § 135(a)(1), added subsec. (e).

Subsec. (g)(4). Pub. L. 110–275, § 148(a), substituted “Treatment of” for “No beneficiary cost-sharing for” in heading and inserted at end “For purposes of the preceding sentence and section 1395x(mm)(3) of this title, clinical diagnostic laboratory services furnished by a critical access hospital shall be treated as being furnished as part of outpatient critical access services without regard to whether the individual with respect to whom such services are furnished is physically present in the critical access hospital, or in a skilled nursing facility or a clinic (including a rural health clinic) that is operated by a critical access hospital, at the time the specimen is collected.”

Subsec. (h)(1)(H). Pub. L. 110–275, § 154(a)(3), (4)(B), in introductory provisions, substituted “January 1, 2011” for “January 1, 2009” and inserted “subject to subsection (a)(1)(G),” before “that are included”.

Subsec. (l)(13)(A). Pub. L. 110–275, § 146(a)(1), inserted “and for such services furnished on or after July 1, 2008, and before January 1, 2010” after “2007,” in introductory provisions, “(or 3 percent if such service is furnished on or after July 1, 2008, and before January 1, 2010)” after “2 percent” in cl. (i), and “(or 2 percent if such service is furnished on or after July 1, 2008, and before January 1, 2010)” after “1 percent” in cl. (ii).

Subsec. (l)(13)(B). Pub. L. 110–275, § 146(a)(2), substituted “applicable period” for “2006” in heading and inserted “applicable” before “period” in text.

Subsec. (l)(14)(B)(i). Pub. L. 110–275, § 146(b)(2)(A), substituted “certifies or reasonably determines” for “reasonably determines or certifies”.

Subsec. (m)(4)(C)(ii)(VI) to (VIII). Pub. L. 110–275, § 149(a), added subcls. (VI) to (VIII).

2006—Subsec. (a)(5)(A). Pub. L. 109–171, § 5101(b)(1)(A), substituted “(E), and (F)” for “and (E)”.

Subsec. (a)(5)(F). Pub. L. 109–171, § 5101(b)(1)(B), added subpar. (F).

Subsec. (a)(7)(A). Pub. L. 109–171, § 5101(a)(1), amended heading and text of subpar. (A) generally, revising and restating as cls. (i) to (iv) provisions of former cls. (i) to (vi).

Subsec. (d)(2)(C)(ii). Pub. L. 109–171, § 5113(b), struck out “deductible and” before “coinsurance” in heading and struck out “deductible or” before “copayment” and before “coinsurance” in subcl. (I).

Subsec. (d)(3)(C)(ii). Pub. L. 109–171, § 5113(b), struck out “deductible and” before “coinsurance” in heading and struck out “deductible or” before “coinsurance” in two places in subcl. (I).

2003—Subsec. (a)(1)(B). Pub. L. 108–173, § 302(d)(1)(A), substituted “Subject to subparagraph (F)(i), the payment basis” for “The payment basis” in introductory provisions.

Subsec. (a)(1)(C). Pub. L. 108–173, § 302(d)(1)(B), substituted “Subject to subparagraph (F)(ii), this subsection” for “This subsection”.

Subsec. (a)(1)(E). Pub. L. 108–173, § 302(a)(2), added subpar. (E).

Subsec. (a)(1)(F). Pub. L. 108–173, § 302(d)(1)(C), added subpar. (F).

Subsec. (a)(10)(B). Pub. L. 108–173, § 302(d)(1)(D), inserted “in an area and with respect to covered items and services for which the Secretary does not make a payment amount adjustment under paragraph (1)(F)” after “under this subsection”.

Subsec. (a)(14)(F). Pub. L. 108–173, § 302(c)(1)(A)(ii), substituted “2003” for “a subsequent year” and “2002;” for “the previous year.”

Subsec. (a)(14)(G) to (J). Pub. L. 108–173, § 302(c)(1)(A)(i), (iii), added subpars (G) to (J).

Subsec. (a)(17), (19). Pub. L. 108–173, § 302(a)(1)(A), redesignated par. (17), relating to certain upgraded items, as (19) and transferred it to the end of subsec. (a).

Subsec. (a)(20). Pub. L. 108–173, § 302(a)(1)(B), added par. (20).

Subsec. (a)(21). Pub. L. 108–173, § 302(c)(2), added par. (21).

Subsec. (b)(4)(D)(iv). Pub. L. 108–173, § 736(b)(4), substituted “clause (vi)” for “clauses (vi)”.

Subsec. (g)(1). Pub. L. 108–173, § 405(a)(1), inserted “equal to 101 percent of” before “the reasonable costs”.

Subsec. (g)(2). Pub. L. 108–173, § 405(d)(1), inserted concluding provisions.

Subsec. (g)(5). Pub. L. 108–173, § 405(b)(1), in heading, inserted “certain” before “emergency” and substituted “providers” for “physicians”, and, in text, substituted “physicians, physician assistants, nurse practitioners, and clinical nurse specialists who are on-call (as defined by the Secretary) to provide emergency services” for “emergency room physicians who are on-call (as defined by the Secretary)” and “services covered under this subchapter” for “physicians’ services”.

Subsec. (h)(1)(B). Pub. L. 108–173, § 302(d)(2)(A), substituted “, (E), and (H)(i)” for “and (E)” in introductory provisions.

Subsec. (h)(1)(D). Pub. L. 108–173, § 302(d)(2)(B), substituted “Subject to subparagraph (H)(ii), this subsection” for “This subsection”.

Subsec. (h)(1)(H). Pub. L. 108–173, § 302(d)(2)(C), added subpar. (H).

Subsec. (h)(4)(A)(viii). Pub. L. 108–173, § 302(c)(3)(B), substituted “2003” for “a subsequent year”.

Subsec. (h)(4)(A)(ix), (x). Pub. L. 108–173, § 302(c)(3)(A), (C), added cls. (ix) and (x).

Subsec. (h)(4)(C). Pub. L. 108–173, § 627(b)(1), inserted “(and includes shoes described in section 1395x(s)(12) of this title)” after “in section 1395x(s)(9) of this title”.

Subsec. (l)(2)(E). Pub. L. 108–173, § 414(a)(1), inserted “consistent with paragraph (11)” after “in an efficient and fair manner”.

Subsec. (l)(8), (9). Pub. L. 108–173, § 414(a)(2), redesignated par. (8), relating to transitional assistance for rural providers, as (9).

Subsec. (l)(10). Pub. L. 108–173, § 414(a)(3), added par. (10).

Subsec. (l)(11). Pub. L. 108–173, § 414(b), added par. (11).

Subsec. (l)(12). Pub. L. 108–173, § 414(c)(1), added par. (12).

Subsec. (l)(13). Pub. L. 108–173, § 414(d), added par. (13).

Subsec. (l)(14). Pub. L. 108–173, § 415(a), added par. (14).

Subsec. (m)(4)(C)(ii)(III). Pub. L. 108–173, § 736(b)(5), substituted “1395x(aa)(2)” for “1395x(aa)(s)”.

2000—Subsec. (a)(14)(C). Pub. L. 106–554, § 1(a)(6) [title IV, § 425(a)(2)], substituted “through 2000” for “through 2002” and struck out “and” at end.

Subsec. (a)(14)(D) to (F). Pub. L. 106–554, § 1(a)(6) [title IV, § 425(a)(1), (3)], added subpars. (D) and (E) and redesignated former subpar. (D) as (F).

Subsec. (c). Pub. L. 106–554, § 1(a)(6) [title I, § 104(b)], amended heading and text generally, substituting present provisions for provisions which had set forth similar standards for screening mammography but had provided for payment limited to 80 percent of the least of the actual charge, a statutory fee schedule, if applicable, or the indexed dollar limit described, and which had set forth provisions relating to reduction of indexed dollar limit, application of limit in a hospital outpatient setting, and limitation of charges of nonparticipating physicians.

Subsec. (d)(2)(E)(ii). Pub. L. 106–554, § 1(a)(6) [title I, § 103(b)(1)], inserted before period at end “or, in the case of an individual who is not at high risk for colorectal cancer, if the procedure is performed within the 119 months after a previous screening colonoscopy”.

Subsec. (d)(3). Pub. L. 106–554, § 1(a)(6) [title I, § 103(b)(2)(A)], struck out “for individuals at high risk for colorectal cancer” after “colonoscopy” in heading.

Subsec. (d)(3)(A). Pub. L. 106–554, § 1(a)(6) [title I, § 103(b)(2)(B)], struck out “for individuals at high risk for colorectal cancer (as defined in section 1395x(pp)(2) of this title)” after “screening colonoscopy”.

Subsec. (d)(3)(E). Pub. L. 106–554, § 1(a)(6) [title I, § 103(b)(2)(C)], inserted before period at end “or for other individuals if the procedure is performed within the 119 months after a previous screening colonoscopy or within 47 months after a previous screening flexible sigmoidoscopy”.

Subsec. (g)(2)(B). Pub. L. 106–554, § 1(a)(6) [title II, § 202(a)], inserted “115 percent of” before “such amounts”.

Subsec. (g)(4). Pub. L. 106–554, § 1(a)(6) [title II, § 201(a)], added par. (4).

Subsec. (g)(5). Pub. L. 106–554, § 1(a)(6) [title II, § 204(a)], added par. (5).

Subsec. (h)(1)(F). Pub. L. 106–554, § 1(a)(6) [title IV, § 427(a)], added subpar. (F).

Subsec. (h)(1)(G). Pub. L. 106–554, § 1(a)(6) [title IV, § 428(a)], added subpar. (G).

Subsec. (h)(4)(A)(v). Pub. L. 106–554, § 1(a)(6) [title IV, § 426(a)(2)], substituted “through 2000” for “through 2002” and struck out “and” at end.

Subsec. (h)(4)(A)(vi) to (viii). Pub. L. 106–554, § 1(a)(6) [title IV, § 426(a)(1), (3)], added cls. (vi) and (vii) and redesignated former cl. (vi) as (viii).

Subsec. (l)(2)(E). Pub. L. 106–554, § 1(a)(6) [title IV, § 423(b)(1)], inserted before period at end “, except that such phase-in shall provide for full payment of any national mileage rate for ambulance services provided by suppliers that are paid by carriers in any of the 50 States where payment by a carrier for such services for all such suppliers in such State did not, prior to the implementation of the fee schedule, include a separate amount for all mileage within the county from which the beneficiary is transported”.

Subsec. (l)(3)(A), (B). Pub. L. 106–554, § 1(a)(6) [title IV, § 423(a)(1)], substituted “reduced in the case of 2002” for “reduced in the case of 2001 and 2002”.

Subsec. (l)(8). Pub. L. 106–554, § 1(a)(6) [title II, § 221(a)], added par. (8) relating to transitional assistance for rural providers.

Pub. L. 106–554, § 1(a)(6) [title II, § 205(a)], added par. (8) relating to services furnished by critical access hospitals.

Subsec. (m). Pub. L. 106–554, § 1(a)(6) [title II, § 223(b)], added subsec. (m).

1999—Subsec. (a)(13). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(e)(2)(A)], substituted “1395x(m)(5) of this title, but not including implantable items for which payment may be made under section 1395l(t) of this title” for “1395x(m)(5) of this title)”.

Subsec. (g). Pub. L. 106–113, § 1000(a)(6) [title IV, § 403(d)(1)], amended heading and text of subsec. (g) generally. Prior to amendment, text read as follows: “The amount of payment under this part for outpatient critical access hospital services is the reasonable costs of the critical access hospital in providing such services.”

Subsec. (h)(4)(A)(i). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(3)(A)], substituted semicolon for comma at end.

Subsec. (h)(4)(A)(v). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(3)(B)], substituted “; and” for “, and” at end.

Subsec. (h)(4)(B). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(e)(2)(B)], inserted “and does not include an implantable item for which payment may be made under section 1395l(t) of this title” before the semicolon.

1997—Subsec. (a)(2)(B)(iv). Pub. L. 105–33, § 4105(b)(2), inserted before period at end “(reduced by 10 percent, in the case of a blood glucose testing strip furnished after 1997 for an individual with diabetes)”.

Subsec. (a)(9)(B)(iv). Pub. L. 105–33, § 4552(a)(2)(A), substituted “1995, 1996, and 1997” for “each subsequent year”.

Subsec. (a)(9)(B)(v), (vi). Pub. L. 105–33, § 4552(a)(1), (2)(B), (3), added cls. (v) and (vi).

Subsec. (a)(9)(D). Pub. L. 105–33, § 4552(b), as amended by Pub. L. 116–260, § 121(b)(1), added subpar. (D).

Subsec. (a)(10)(B). Pub. L. 105–33, § 4316(b), substituted “The Secretary” for “For covered items furnished on or after January 1, 1991, the Secretary” and struck out “(other than subparagraph (D))” before “of section 1395u(b) of this title” and “as such provisions would otherwise apply to physicians’ services and physicians and a reasonable charge under section 1395u(b) of this title but for the application of section 1395w–4(i)(3) of this title. In applying such provisions to payments for an item under this subsection, the Secretary shall make adjustments to the payment basis for the item described in paragraph (1)(B) if the Secretary determines (in accordance with such provisions and on the basis of prices and costs applicable at the time the item is furnished) that such payment basis is not inherently reasonable” before period at end.

Subsec. (a)(14)(B). Pub. L. 105–33, § 4551(a)(1)(B)(i), substituted “1993, 1994, 1995, 1996, and 1997” for “a subsequent year”.

Subsec. (a)(14)(C), (D). Pub. L. 105–33, § 4551(a)(1)(A), (B)(ii), (C), added subpars. (C) and (D).

Subsec. (a)(16). Pub. L. 105–33, § 4312(c), inserted at end “The Secretary, at the Secretary’s discretion, may impose the requirements of the first sentence with respect to some or all providers of items or services under part A or some or all suppliers or other persons (other than physicians or other practitioners, as defined in section 1395u(b)(18)(C) of this title) who furnish items or services under this part.”

Pub. L. 105–33, § 4312(a), added par. (16).

Subsec. (a)(17). Pub. L. 105–33, § 4551(c)(1), added par. (17) relating to certain upgraded items.

Subsec. (c)(1)(C). Pub. L. 105–33, § 4101(c), in introductory provisions, struck out “, subject to the deductible established under section 1395l(b) of this title,” before “be equal to 80”.

Subsec. (c)(2)(A)(iii). Pub. L. 105–33, § 4101(a)(1), amended cl. (iii) generally. Prior to amendment, cl. (iii) read as follows: “In the case of a woman over 39 years of age, but under 50 years of age, who—

“(I) is at a high risk of developing breast cancer (as determined pursuant to factors identified by the Secretary), payment may not be made under this part for a screening mammography performed within the 11 months following the month in which a previous screening mammography was performed, or

“(II) is not at a high risk of developing breast cancer, payment may not be made under this part for a screening mammography performed within the 23 months following the month in which a previous screening mammography was performed.”

Subsec. (c)(2)(A)(iv), (v). Pub. L. 105–33, § 4101(a)(2), struck out cls. (iv) and (v), which read as follows:

“(iv) In the case of a woman over 49 years of age, but under 65 years of age, payment may not be made under this part for screening mammography performed within 11 months following the month in which a previous screening mammography was performed.

“(v) In the case of a woman over 64 years of age, payment may not be made for screening mammography performed within 23 months following the month in which a previous screening mammography was performed.”

Subsec. (d). Pub. L. 105–33, § 4104(b)(1), added subsec. (d).

Subsec. (g). Pub. L. 105–33, § 4201(c)(5), amended heading and text of subsec. (g) generally. Prior to amendment, text related to payment for outpatient rural primary care hospital services as determined, in par. (1), by either the cost-based facility fee plus professional charges method or the all-inclusive rate method and, in par. (2), by the prospective payment system.

Subsec. (h)(4)(A)(iv). Pub. L. 105–33, § 4551(a)(2)(B), substituted “1996 and 1997” for “a subsequent year”.

Subsec. (h)(4)(A)(v), (vi). Pub. L. 105–33, § 4551(a)(2)(A), (C), added cls. (v) and (vi).

Subsec. (k). Pub. L. 105–33, § 4541(a)(2), added subsec. (k).

Subsec. (l). Pub. L. 105–33, § 4531(b)(2), added subsec. (l).

1994—Subsec. (a)(3)(D). Pub. L. 103–432, § 135(e)(5), struck out heading and text of subpar. (D). Text read as follows: “If the reasonable useful lifetime of such an item, as established under paragraph (7)(C), has been reached during a continuous period of medical need, or the Secretary determines on the basis of investigation by the carrier that the item is lost or irreparably damaged, payment for an item serving as a replacement for such item shall be made on a monthly basis for the rental of the replacement item in accordance with subparagraph (A).”

Subsec. (a)(5)(E). Pub. L. 103–432, § 135(d)(1), substituted “pressure of 56” for “pressure of 55”.

Subsec. (a)(7). Pub. L. 103–432, § 135(e)(2), made technical amendment to directory language of Pub. L. 101–508, § 4152(c)(2). See 1990 Amendment note below.

Subsec. (a)(7)(A)(iii)(II). Pub. L. 103–432, § 135(e)(3), substituted “clause (vi)” for “clause (v)”.

Subsec. (a)(7)(C)(i). Pub. L. 103–432, § 135(e)(4), substituted “this paragraph” for “this paragraph or paragraph (3)”.

Subsec. (a)(10)(B). Pub. L. 103–432, § 134(a)(1), inserted at end “In applying such provisions to payments for an item under this subsection, the Secretary shall make adjustments to the payment basis for the item described in paragraph (1)(B) if the Secretary determines (in accordance with such provisions and on the basis of prices and costs applicable at the time the item is furnished) that such payment basis is not inherently reasonable.”

Pub. L. 103–432, § 126(g)(10)(B), substituted “would otherwise apply to physicians’ services” for “apply to physicians’ services” and inserted before period at end “but for the application of section 1395w–4(i)(3) of this title”.

Subsec. (a)(14)(A). Pub. L. 103–432, § 135(a)(1), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: “for 1991 and 1992, reduction of 1 percentage point; and”.

Subsec. (a)(15). Pub. L. 103–432, § 135(b)(1), amended heading and text of par. (15) generally. Prior to amendment, text read as follows:

“(A) Development of list of items by secretary.—The Secretary shall develop and periodically update a list of items for which payment may be made under this subsection that the Secretary determines, on the basis of prior payment experience, are frequently subject to unnecessary utilization, and shall include in such list seat-lift mechanisms, transcutaneous electrical nerve stimulators, and motorized scooters.

“(B) Determinations of coverage in advance.—A carrier shall determine in advance whether payment for an item included on the list developed by the Secretary under subparagraph (A) may not be made because of the application of section 1395y(a)(1) of this title.”