Social Security Act §1833

PAYMENT OF BENEFITS[71]Sec.1833.[42 U.S.C. 1395l](a)Except as providedin section 1876, and subject to the succeeding provisions of this section, thereshall be paid from the Federal Supplementary Medical Insurance TrustFund, in the case of each individual who is covered under the insuranceprogram established by this part and incurs expenses for serviceswith respect to which benefits are payable under this part, amountsequal to(1)in the case ofservices described in section 1832(a)(1)80 percent of thereasonable charges for the services; except that(A)an organizationwhich provides medical and other health services (or arranges fortheir availability) on a prepayment basis (and either is sponsoredby a union or employer, or does not provide, or arrange for the provisionof, any inpatient hospital services) may elect to be paid 80 percentof the reasonable cost of services for which payment may be made underthis part on behalf of individuals enrolled in such organization inlieu of 80 percent of the reasonable charges for such services ifthe organization undertakes to charge such individuals no more than20 percent of such reasonable cost plus any amounts payable by themas a result of subsection (b),(B)with respectto items and services described in section 1861(s)(10)(A), the amounts paidshall be 100 percent of the reasonable charges for such items andservices,(C)with respectto expenses incurred for those physicians services for whichpayment may be made under this part that are described in section 1862(a)(4), theamounts paid shall be subject to such limitations as may be prescribedby regulations,(D)[72]with respect to clinical diagnostic laboratorytests for which payment is made under this part(i)(I)on the basis[73]of a fee schedule under subsection(h)(1) (for tests furnished before January 1, 2017)[74]or section 1834(d)(1), the amount paid shall be equal to 80 percent (or 100 percent, inthe case of such tests for which payment is made on an assignment-relatedbasis) of the lesser of the amount determined under such fee schedule,the limitation amount for that test determined under subsection (h)(4)(B),or the amount of the charges billed for the tests, or(II)undersection 1834A (for tests furnished on or after January 1, 2017), theamount paid shall be equal to 80 percent (or 100 percent, in the caseof such tests for which payment is made on an assignment-related basis)of the lesser of the amount determined under such section or the amountof the charges billed for the tests, or(ii)[75]for tests furnished before January 1, 2017,on the basis of a negotiated rate established under subsection (h)(6),the amount paid shall be equal to 100 percent of such negotiated rate[76],(E)with respectto services furnished to individuals who have been determined to haveend stage renal disease, the amounts paid shall be determined subjectto the provisions of section 1881,(F)with respectto clinical social worker services under section 1861(s)(2)(N), the amounts paidshall be 80 percent of the lesser of(i)the actual chargefor the services or(ii)75 percentof the amount determined for payment of a psychologist under clause(L),(G)with respectto facility services furnished in connection with a surgical procedurespecified pursuant to subsection (i)(1)(A) and furnished to an individualin an ambulatory surgical center described in such subsection, forservices furnished beginning with the implementation date of a revisedpayment system for such services in such facilities specified in subsection(i)(2)(D), the amounts paid shall be 80 percent of the lesser of theactual charge for the services or the amount determined by the Secretaryunder such revised payment system,(H)with respectto services of a certified registered nurse anesthetist under section 1861(s)(11), theamounts paid shall be 80 percent of the least of the actual charge,the prevailing charge that would be recognized (or, for services furnishedon or after January 1, 1992, the fee schedule amount provided undersection 1848)if the services had been performed by an anesthesiologist, or thefee schedule for such services established by the Secretary in accordancewith subsection (1),(I)with respectto covered items (described in section 1834(a)(13)), the amounts paid shallbe the amounts described in section 1834(a)(1), and(J)with respectto expenses incurred for radiologist services (as defined in section 1834(b)(6)), subjectto section 1848, the amounts paid shall be 80 percent of the lesser of the actualcharge for the services or the amount provided under the fee scheduleestablished under section 1834(b),(K)with respectto certified nursemidwife services under section 1861(s)(2)(L),the amounts paid shall be 80 percent of the lesser of the actual chargefor the services or the amount determined by a fee schedule establishedby the Secretary for the purposes of this subparagraph (but in noevent shall such fee schedule exceed 65 percent of the prevailingcharge that would be allowed for the same service performed by a physician,or, for services furnished on or after January 1, 1992, 65 percent(or 100 per cent for services furnished on or after January 1, 2011)of the fee schedule amount provided under section 1848 for the same serviceperformed by a physician),(L)with respectto qualified psychologist services under section 1861(s)(2)(M), the amounts paidshall be 80 percent of the lesser of the actual charge for the servicesor the amount determined by a fee schedule established by the Secretaryfor the purposes of this subparagraph,(M)with respectto prosthetic devices and orthotics (as defined in section 1834(h)(4)), the amounts paid shallbe the amounts described in section 1834(h)(1),(N)with respectto expenses incurred for physicians services (as defined insection 1848(j)(3)) other than personalized prevention plan services (as defined insection 1861(hhh)(1)), theamounts paid shall be 80 percent of the payment basis determined undersection 1848(a)(1),(O)with respectto services described in section 1861(s)(2)(K) (relating to servicesfurnished by physicians assistants, nurse practitioners, or clinicalnurse specialists), the amounts paid shall be equal to 80 percentof(i)the lesser ofthe actual charge or 85 percent of the fee schedule amount providedunder section 1848, or(ii)in the caseof services as an assistant at surgery, the lesser of the actual chargeor 85 percent of the amount that would otherwise be recognized ifperformed by a physician who is serving as an assistant at surgery,(P)with respectto surgical dressings, the amounts paid shall be the amounts determinedunder section 1834(i),(Q)with respectto items or services for which fee schedules are established pursuantto section 1842(s), the amounts paid shall be 80 percent of the lesser of the actualcharge or the fee schedule established in such section,(R)with respectto ambulance services,(i)the amounts paidshall be 80 percent of the lesser of the actual charge for the servicesor the amount determined by a fee schedule established by the Secretaryunder section 1834(l) and(ii)with respectto ambulance services described in section 1834(l)(8), the amounts paid shallbe the amounts determined under section 1834(g) for outpatient critical accesshospital services ,(S)with respectto drugs and biologicals (including intravenous immune globulin (asdefined in section 1861(zz))) not paid on a cost or prospective payment basisas otherwise provided in this part (other than items and servicesdescribed in subparagraph (B)), the amounts paid shall be 80 percentof the lesser of the actual charge or the payment amount establishedin section 1842(o) (or, if applicable, under section 1847, 1847A, or 1847B),(T)with respectto medical nutrition therapy services (as defined in section 1861(vv)), the amountpaid shall be 80 percent (or 100 percent if such services are recommendedwith a grade of A or B by the United States Preventive Services TaskForce for any indication or population and are appropriate for theindividual) of the lesser of the actual charge for the services or85 percent of the amount determined under the fee schedule establishedunder section 1848(b) for the same services if furnished by a physician,(U)with respectto facility fees described in section 1834(m)(2)(B), the amounts paidshall be 80 percent of the lesser of the actual charge or the amountsspecified in such section,(V)notwithstandingsubparagraphs (I) (relating to durable medical equipment), (M) (relatingto prosthetic devices and orthotics and prosthetics), and (Q) (relatingto 1842(s) items), with respectto competitively priced items and services (described in section 1847(a)(2)) thatare furnished in a competitive area, the amounts paid shall be theamounts described in section 1847(b)(5),(W)with respectto additional preventive services (as defined in section 1861(ddd)(1) ),the amount paid shall be(i)in the case ofsuch services which are clinical diagnostic laboratory tests, theamount determined under subparagraph (D) (if such subparagraph wereapplied, by substituting 100 percent for 80percent, and(ii)in the caseof all other such services, 100 percent of the lesser of the actualcharge for the service or the amount determined under a fee scheduleestablished by the Secretary for purposes of this subparagraph;(X)with respectto personalized prevention plan services (as defined in section 1861(hhh)(1)),the amount paid shall be 100 percent of the lesser of the actual chargefor the services or the amount determined under the payment basisdetermined under section 1848,(Y)with respectto preventive services described in subparagraphs (A) and (B) of section1861(ddd)(3) that are appropriate for the individual and, in the caseof such services described in subparagraph (A), are recommended witha grade of A or B by the United States Preventive Services Task Forcefor any indication or population, the amount paid shall be 100 percentof(i)except as providedin clause (ii), the lesser of the actual charge for the services orthe amount determined under the fee schedule that applies to suchservices under this part, and(ii)in the caseof such services that are covered OPD services (as defined in subsection(t)(1)(B)), the amount determined under subsection (t),(Z)with respectto Federally qualified health center services for which payment ismade under section 1834(o), the amounts paid shall be 80 percent ofthe lesser of the actual charge or the amount determined under suchsection,(AA)with respectto an applicable disposable device (as defined in paragraph (2) ofsection 1834(s)) furnished to an individual pursuant to paragraph(1) of such section, the amount paid shall be equal to 80 percentof the lesser of the actual charge or the amount determined underparagraph (3) of such section; and[77](BB)with respectto home infusion therapy, the amount paid shall be an amount equalto 80 percent of the lesser of the actual charge for the servicesor the amount determined under section 1834(u), and[78](CC)[79]with respect toopioid use disorder treatment services furnished during an episodeof care, the amount paid shall be equal to the amount payable undersection 1834(w) less any copaymentrequired as specified by the Secretary(2)in the case ofservices described in section 1832(a)(2) (except those servicesdescribed in subparagraphs (C), (D), (E), (F), (G), (H), and (I) ofsuch section and unless otherwise specified in section 1881)(A)with respectto home health services (other than a covered osteoporosis drug) (asdefined in section 1861(kk)), the amount determined under the prospective paymentsystem under section 1895;(B)with respectto other items and services (except those described in subparagraph(C), (D), or (E) of this paragraph and except as may be provided insection 1886orsection 1888(e)(9))(i)furnished beforeJanuary 1, 1999, the lesser of(I)the reasonablecost of such services, as determined under section 1861(v), or(II)the customarycharges with respect to such services,less the amount a provider may charge as described in clause(ii) of section 1866(a)(2)(A), but in no case may the payment for such otherservices exceed 80 percent of such reasonable cost, or