Social Security Act §1862

EXCLUSIONS FROM COVERAGE AND MEDICARE AS SECONDARY PAYER[547]Sec.1862.[42 U.S.C. 1395y](a)Notwithstandingany other provision of this title, no payment may be made under partA or part B for any expenses incurred for items or services(1)(A)which, exceptfor items and services described in a succeeding subparagraph, arenot reasonable and necessary for the diagnosis or treatment of illnessor injury or to improve the functioning of a malformed body member,(B)in the caseof items and services described in section 1861(s)(10), which are not reasonableand necessary for the prevention of illness,(C)in the caseof hospice care, which are not reasonable and necessary for the palliationor management of terminal illness,(D)in the caseof clinical care items and services provided with the concurrenceof the Secretary and with respect to research and experimentationconducted by, or under contract with, the Medicare Payment AdvisoryCommission or the Secretary, which are not reasonable and necessaryto carry out the purposes of section 1886(e)(6),(E)in the caseof research conducted pursuant to section 1142, which is not reasonable and necessaryto carry out the purposes of that section,(F)in the caseof screening mammography, which is performed more frequently thanis covered under section 1834(c)(2) or which is not conductedby a facility described in section 1834(c)(1)(B), in the case of screeningpap smear and screening pelvic exam, which is performed more frequentlythan is provided under section 1861(nn), and, in the case of screeningfor glaucoma, which is performed more frequently than is providedunder section 1861(uu),(G)in the caseof prostate cancer screening tests (as defined in section 1861(oo)), whichare performed more frequently than is covered under such section,(H)in the caseof colorectal cancer screening tests, which are performed more frequentlythan is covered under section 1834(d),(I)the frequencyand duration of home health services which are in excess of normativeguidelines that the Secretary shall establish by regulation,(J)in the caseof a drug or biological specified in section 1847A(c)(6)(C) for which paymentis made under part B that is furnished in a competitive area undersection 1847B, that is not furnished by an entity under a contract under suchsection,(K)in the caseof an initial preventive physical examination, which is performedmore than 1 year after the date the individuals first coverageperiod begins under part B;(L)in the caseof cardiovascular screening blood tests (as defined in section 1861(xx)(1)), whichare performed more frequently than is covered under section 1861(xx)(2),(M)in the caseof a diabetes screening test (as defined in section 1861(yy)(1)), whichis performed more frequently than is covered under section 1861(yy)(3), and(N)in the caseof ultrasound screening for abdominal aortic aneursym which is performedmore frequently than is provided for under section 1861(s)(2)(AA),(O)in the caseof kidney disease education services (as defined in paragraph (1)of section 1861(ggg)), which are furnished in excess of the number of sessions coveredunder paragraph (4) of such section, and(P)in the caseof personalized prevention plan services (as defined in section 1861(hhh)(1)), which are performedmore frequently than is covered under such section;(2)for which theindividual furnished such items or services has no legal obligationto pay, and which no other person (by reason of such individualsmembership in a prepayment plan or otherwise) has a legal obligationto provide or pay for, except in the case of Federally qualified healthcenter services;(3)which are paidfor directly or indirectly by a governmental entity (other than underthis Act and other than under a health benefits or insurance planestablished for employees of such an entity), except in the case ofrural health clinic services, as defined in section 1861(aa)(1), inthe case of Federally qualified health center services, as definedin section 1861(aa)(3), in the case of services for which payment may be made under section 1880(e), and in suchother cases as the Secretary may specify;(4)which are notprovided within the United States (except for inpatient hospital servicesfurnished outside the United States under the conditions describedin section 1814(f) and, subject to such conditions, limitations, and requirements asare provided under or pursuant to this title, physicians servicesand ambulance services furnished an individual in conjunction withsuch inpatient hospital services but only for the period during whichsuch inpatient hospital services were furnished);(5)which are requiredas a result of war, or of an act of war, occurring after the effectivedate of such individuals current coverage under such part;(6)which constitutepersonal comfort items (except, in the case of hospice care, as isotherwise permitted under paragraph (1)(C));(7)where such expensesare for routine physical checkups, eyeglasses (other than eyeweardescribed in section 1861(s)(8)) or eye examinations for the purpose of prescribing,fitting, or changing eyeglasses, procedures performed (during thecourse of any eye examination) to determine the refractive state ofthe eyes, hearing aids or examinations therefor, or immunizations(except as otherwise allowed under section 1861(s)(10) and subparagraph (B),(F), (G), (H), or (K) or (P) of paragraph (1));(8)where such expensesare for orthopedic shoes or other supportive devices for the feet,other than shoes furnished pursuant to section 1861(s)(12);(9)where such expensesare for custodial care (except, in the case of hospice care, as isotherwise permitted under paragraph (1)(C));(10)where such expensesare for cosmetic surgery or are incurred in connection therewith,except as required for the prompt repair of accidental injury or forimprovement of the functioning of a malformed body member;(11)where such expensesconstitute charges imposed by immediate relatives of such individualor members of his household;(12)where such expensesare for services in connection with the care, treatment, filling,removal, or replacement of teeth or structures directly supportingteeth, except that payment may be made under part A in the case ofinpatient hospital services in connection with the provision of suchdental services if the individual, because of his underlying medicalcondition and clinical status or because of the severity of the dentalprocedure, requires hospitalization in connection with the provisionof such services;(13)where such expensesare for(A)the treatmentof flat foot conditions and the prescription of supportive devicestherefor,(B)the treatmentof subluxations of the foot, or(C)routinefoot care (including the cutting or removal of corns or calluses,the trimming of nails, and other routine hygienic care);(14)which are otherthan physicians services (as defined in regulations promulgatedspecifically for purposes of this paragraph), services described bysection 1861(s)(2)(K), certified nurse-midwife services, qualified psychologist services,and services of a certified registered nurse anesthetist, and whichare furnished to an individual who is a patient of a hospital or criticalaccess hospital by an entity other than the hospital or critical accesshospital, unless the services are furnished under arrangements (asdefined in section 1861(w)(1)) with the entity made by the hospital or criticalaccess hospital;(15)(A)which arefor services of an assistant at surgery in a cataract operation (includingsubsequent insertion of an intraocular lens) unless, before the surgeryis performed, the appropriate quality improvement[548]organization (under part B of titleXI) or a carrier under section 1842 has approved of the use of such anassistant in the surgical procedure based on the existence of a complicatingmedical condition, or[549](B)which arefor services of an assistant at surgery to which section 1848(i)(2)(B) applies;(16)in the casein which funds may not be used for such items and services under theAssisted Suicide Funding Restriction Act of 1997;(17)where the expensesare for an item or service furnished in a competitive acquisitionarea (as established by the Secretary under section 1847(a)) by an entityother than an entity with which the Secretary has entered into a contractunder section 1847(b) for the furnishing of such an item or service in that area, unlessthe Secretary finds that the expenses were incurred in a case of urgentneed, or in other circumstances specified by the Secretary;(18)which are coveredskilled nursing facility services described in section 1888(e)(2)(A)(i) and which are furnished to an individual who is a resident of askilled nursing facility during a period in which the resident isprovided covered post-hospital extended care services (or, for servicesdescribed in section 1861(s)(2)(D), which are furnished to such an individual withoutregard to such period), by an entity other than the skilled nursingfacility, unless the services are furnished under arrangements (asdefined in section 1861(w)(1)) with the entity made by the skilled nursing facility;or(19)which are foritems or services which are furnished pursuant to a private contractdescribed in section 1802(b);(20)in the caseof outpatient physical therapy services, outpatient speech-languagepathology services, or outpatient occupational  therapy services[550]furnished as an incident to a physicians professionalservices (as described in section 1861(s)(2)(A)), that do not meetthe standards and conditions (other than any licensing requirementspecified by the Secretary) under the second sentence of section 1861(p) (or undersuch sentence through the operation of subsection (g) or (ll)(2) of section 1861(g)) as such standards and conditionswould apply to such therapy services if furnished by a therapist;(21)where such expensesare for home health services (including medical supplies describedin section 1861(m)(5), but excluding durable medical equipment to the extent providedfor in such section), furnished to an individual who is under a planof care of the home health agency if the claim for payment for suchservices is not submitted by the agency; or(22)subject to subsection(h), for which a claim is submitted other than in an electronic formspecified by the Secretary;(23)[551]which are the technical component of advanceddiagnostic imaging services described in section 1834(e)(1)(B) forwhich payment is made under the fee schedule established under section1848(b) and that are furnished by a supplier (as defined in section1861(d)), if such supplier is not accredited by an accreditation organizationdesignated by the Secretary under section 1834(e)(2)(B);(24)where such expensesare for renal dialysis services (as defined in subparagraph (B) ofsection 1881(b)(14)) for which payment is made under such section unless such paymentis made under such section to a provider of services or a renal dialysisfacility for such services; or(25)[552]not later than January 1, 2014, for whichthe payment is other than by electronic funds transfer (EFT) or anelectronic remittance in a form as specified in ASC X12 835 HealthCare Payment and Remittance Advice[553]or subsequent standard.Paragraph (7) shall not apply to Federally qualified healthcenter services described in section 1861(aa)(3)(B). In making a nationalcoverage determination (as defined in paragraph (1)(B) of section 1869(f)) the Secretaryshall ensure consistent with subsection (l) that the public is affordednotice and opportunity to comment prior to implementation by the Secretaryof the determination; meetings of advisory committees with respectto the determination are made on the record; in making the determination,the Secretary has considered applicable information (including clinicalexperience and medical, technical, and scientific evidence) with respectto the subject matter of the determination; and in the determination,provide a clear statement of the basis for the determination (includingresponses to comments received from the public), the assumptions underlyingthat basis, and make available to the public the data (other thanproprietary data) considered in making the determination.(b)Medicareas Secondary Payer.(1)Requirementsof group health plans.(A)Working aged under group health plans.(i)Ingeneral.A group health plan(I)may nottake into account that an individual (or the individuals spouse)who is covered under the plan by virtue of the individualscurrent employment status with an employer is entitled to benefitsunder this title under section 226(a), and(II)shallprovide that any individual age 65 or older (and the spouse age 65or older of any individual) who has current employment status withan employer shall be entitled to the same benefits under the planunder the same conditions as any such individual (or spouse) underage 65.