Social Security Act §1833

(I)on the basis[80]of a fee schedule determinedunder subsection (h)(1) (for tests furnished before January 1, 2017[81]) or section 1834(d)(1), the amount paid shall be equal to 80 percent (or100 percent, in the case of such tests for which payment is made onan assignment-related basis or to a provider having an agreement undersection 1866 ofthe lesser of the amount determined under such fee schedule, the limitationamount for that test determined under subsection (h)(4)(B), or theamount 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 basisor to a provider having an agreement under section 1866) of the lesserof the amount determined under such section or the amount of the chargesbilled for the tests, or(ii)[82]for testsfurnished before January 1, 2017, on the basis[83]ofa negotiated rate established under subsection (h)(6), the amountpaid shall be equal to 100 percent of such negotiated rate for suchtests; or (iii) on the basis of a rate established under a demonstrationproject under section 1847(e), the amount paid shall be equal to 100 percent ofsuch rate,(E)with respectto(i)outpatient hospitalradiology services (including diagnostic and therapeutic radiology,nuclear medicine and CAT scan procedures, magnetic resonance imaging,and ultrasound and other imaging services, but excluding screeningmammography and, for services furnished on or after January 1, 2005,diagnostic mammography), and(ii)effective forprocedures performed on or after October 1, 1989, diagnostic procedures(as defined by the Secretary) described in section 1861(s)(3) (otherthan diagnostic x-ray tests and diagnostic laboratory tests),the amount determined under subsection (n) or, for servicesor procedures performed on or after January 1, 1999, subsection (t);(F)with respectto a covered osteoporosis drug (as defined in section 1861(kk)) furnishedby a home health agency, 80 percent of the reasonable cost of suchservice, as determined under section 1861(v);(G)with respectto items and services described in section 1861(s)(10)(A), the lesser of(i)the reasonablecost of such services, as determined under section 1861(v), or(ii)the customarycharges with respect to such services; andor, if such services are furnished by a public provider of services,or by another provider which demonstrates to the satisfaction of theSecretary that a significant portion of its patients are low-income(and requests that payment be made under this provision), free ofcharge or at nominal charges to the public, the amount determinedin accordance with section 1814(b)(2);(H)with respectto personalized prevention plan services (as defined in section 1861(hhh)(1)) furnished by an outpatientdepartment of a hospital, the amount determined under paragraph (1)(X),(3)in the case ofservices described in section 1832(a)(2)(D)(A)except asprovided in subparagraph (B), the costs which are reasonable and relatedto the cost of furnishing such services or which are based on suchother tests of reasonableness as the Secretary may prescribe in regulations,including those authorized under section 1861(v)(1)(A), less the amount aprovider may charge as described in clause (ii) of section 1866(a)(2)(A),but in no case may the payment for such services (other than for itemsand services described in section 1861(s)(10)(A)) exceed 80 percentof such costs; or(B)with respectto the services described in clause (ii) of section 1832(a)(2)(D) thatare furnished to an individual enrolled with a MA plan under partC pursuant to a written agreement described in section 1853(a)(4), theamount (if any) by which(i)the amount ofpayment that would have otherwise been provided (I) under subparagraph(A) (calculated as if 100 percent were substitutedfor 80 percent in such subparagraph) for such servicesif the individual had not been so enrolled, or (II) in the case ofsuch services furnished on or after the implementation date of theprospective payment system under section 1834(o), under such section (calculated as if 100 percent were substituted for 80 percent in such section)for such services if the individual had not been so enrolled; exceeds(ii)the amountof the payments received under such written agreement for such services(not including any financial incentives provided for in such agreementsuch as risk pool payments, bonuses, or withholds), less the amountthe federally qualified health center may charge as described in section 1857(e)(3)(B);(4)in the case offacility services described in section 1832(a)(2)(F), and outpatient hospitalfacility services furnished in connection with surgical proceduresspecified by the Secretary pursuant to section 1833(i)(1)(A), the applicable amountas determined under paragraph (2) or (3) of subsection (i) or subsection(t);(5)in the case ofcovered items (described in section 1834(a)(13)) the amounts describedin section 1834(a)(1);(6)in the case ofoutpatient critical access hospital services, the amounts describedin section 1834(g);(7)in the case ofprosthetic devices and orthotics and prosthetics (as described insection 1834(h)(4)), the amounts described in section 1834(h);(8)in the case of(A)outpatientphysical therapy services, outpatient speech-language pathology servicesand outpatient occupational therapy services furnished(i)by a rehabilitationagency, public health agency, clinic, comprehensive outpatient rehabilitationfacility, or skilled nursing facility,(ii)by a home healthagency to an individual who is not homebound, or(iii)by anotherentity under an arrangement with an entity described in clause (i)or (ii); and(B)outpatientphysical therapy services, outpatient speech-language pathology services)and outpatient occupational therapy services furnished(i)by a hospitalto an outpatient or to a hospital inpatient who is entitled to benefitsunder part A but has exhausted benefits for inpatient hospital servicesduring a spell of illness or is not so entitled to benefits underpart A, or(ii)by anotherentity under an arrangement with a hospital described in clause (i),the amounts described in section 1834(k); and(9)in the case ofservices described in section 1832(a)(2)(E) that are not describedin paragraph (8), the amounts described in section 1834(k).Paragraph (3)(A) shall not apply to Federally qualified healthcenter services furnished on or after the implementation date of theprospective payment system under section 1834(0)[84].(b)Before applyingsubsection (a) with respect to expenses incurred by an individualduring any calendar year, the total amount of the expenses incurredby such individual during such year (which would, except for thissubsection, constitute incurred expenses from which benefits payableunder subsection (a) are determinable) shall be reduced by a deductibleof $75 for calendar years before 1991, $100 for 1991 through 2004,$110 for 2005, and for a subsequent year the amount of such deductiblefor the previous year increased by the annual percentage increasein the monthly actuarial rate under section 1839(a)(1) ending with such subsequentyear (rounded to the nearest $1); except that(1)such total amountshall not include expenses incurred for preventive services describedin subparagraph (A) of section 1861(ddd)(3) that 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.[85],(2)such deductibleshall not apply with respect to home health services (other than acovered osteoporosis drug (as defined in section 1861(kk)),(3)such deductibleshall not apply with respect to clinical diagnostic laboratory testsfor which payment is made under this part(A)under subsection(a)(1)(D)(i) or (a)(2)(D)(i) on an assignment-related basis, or toa provider having an agreement under section 1866, or(B)for testsfurnished before January 1, 2017, on the basis[86]ofa negotiated rate determined under subsection (h)(6),(4)such deductibleshall not apply to Federally qualified health center services. Thetotal amount of the expenses incurred by an individual as determinedunder the preceding sentence shall, after the reduction specifiedin such sentence, be further reduced by an amount equal to the expensesincurred for the first three pints of whole blood (or equivalent quantitiesof packed red blood cells, as defined under regulations) furnishedto the individual during the calendar year, except that such deductiblefor such blood shall in accordance with regulations be appropriatelyreduced to the extent that there has been a replacement of such blood(or equivalent quantities of packed red blood cells, as so defined);and for such purposes blood (or equivalent quantities of packed redblood cells, as so defined) furnished such individual shall be deemedreplaced when the institution or other person furnishing such blood(or such equivalent quantities of packed red blood cells, as so defined)is given one pint of blood for each pint of blood (or equivalent quantitiesof packed red blood cells, as so defined) furnished such individualwith respect to which a deduction is made under this sentence. Thedeductible under the previous sentence for blood or blood cells furnishedan individual in a year shall be reduced to the extent that a deductiblehas been imposed under section 1813(a)(2) to blood or blood cellsfurnished the individual in the year,(5)such deductibleshall not apply with respect to screening mammography (as describedin section 1861(jj)),(6)such deductibleshall not apply with respect to screening pap smear and screeningpelvic exam (as described in section 1861(nn)),(7)such deductibleshall not apply with respect to ultrasound screening for abdominalaortic aneursym (as defined in section 1861(bbb)),(8)such deductibleshall not apply with respect to colorectal cancer screening tests(as described in section 1861(pp)(1)) , and(9)such deductibleshall not apply with respect to an initial preventive physical examination(as defined in section 1861(ww), and(10)such deductibleshall not apply with respect to personalized prevention plan services(as defined in section 1861(hhh)(1)) The total amount of the expenses incurred by an individual as determinedunder the preceding sentence shall, after the reduction specifiedin such sentence, be further reduced by an amount equal to the expensesincurred for the first three pints of whole blood (or equivalent quantitiesof packed red blood cells, as defined under regulations) furnishedto the individual during the calendar year, except that such deductiblefor such blood shall in accordance with regulations be appropriatelyreduced to the extent that there has been a replacement of such blood(or equivalent quantities of packed red blood cells, as so defined);and for such purposes blood (or equivalent quantities of packed redblood cells, as so defined) furnished such individual shall be deemedreplaced when the institution or other person furnishing such blood(or such equivalent quantities of packed red blood cells, as so defined)is given one pint of blood for each pint of blood (or equivalent quantitiesof packed red blood cells, as so defined) furnished such individualwith respect to which a deduction is made under this sentence. Thedeductible under the previous sentence for blood or blood cells furnishedan individual in a year shall be reduced to the extent that a deductiblehas been imposed under section 1813(a)(2) to blood or blood cells furnished the individual in the year. Paragraph(1) of the first sentence of this subsection shall apply with respectto a colorectal cancer screening test regardless of the code thatis billed for the establishment of a diagnosis as a result of thetest, or for the removal of tissue or other matter or other procedurethat is furnished in connection with, as a result of, and in the sameclinical encounter as the screening test.(c)