evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1861
(A)nursingcare provided by or under the supervision of a registered professionalnurse,(B)physicalor occupational therapy, or speech-language pathology services,(C)medicalsocial services under the direction of a physician,(D)(i)services ofa home health aide who has successfully completed a training programapproved by the Secretary and(ii)homemakerservices,(E)medicalsupplies (including drugs and biologicals) and the use of medicalappliances, while under such a plan,(F)physiciansservices,(G)short-terminpatient care (including both respite care and procedures necessaryfor pain control and acute and chronic symptom management) in an inpatientfacility meeting such conditions as the Secretary determines to beappropriate to provide such care, but such respite care may be providedonly on an intermittent, nonroutine, and occasional basis and maynot be provided consecutively over longer than five days,(H)counseling(including dietary counseling) with respect to care of the terminallyill individual and adjustment to his death, and(I)any otheritem or service which is specified in the plan and for which paymentmay otherwise be made under this title.The care and services described in subparagraphs (A) and (D)may be provided on a 24-hour, continuous basis only during periodsof crisis (meeting criteria established by the Secretary) and onlyas necessary to maintain the terminally ill individual at home.(2)Theterm hospice program means a public agency or privateorganization (or a subdivision thereof) which(A)(i)is primarilyengaged in providing the care and services described in paragraph(1) and makes such services available (as needed) on a 24-hour basisand which also provides bereavement counseling for the immediate familyof terminally ill individuals and services described in section 1812(a)(5),(ii)provides forsuch care and services in individuals homes, on an outpatientbasis, and on a short-term inpatient basis, directly or under arrangementsmade by the agency or organization, except that(I)the agencyor organization must routinely provide directly substantially allof each of the services described in subparagraphs (A), (C), and (H)of paragraph (1), except as otherwise provided in paragraph (5), and
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(II)in thecase of other services described in paragraph (1) which are not provideddirectly by the agency or organization, the agency or organizationmust maintain professional management responsibility for all suchservices furnished to an individual, regardless of the location orfacility in which such services are furnished; and(iii)providesassurances satisfactory to the Secretary that the aggregate numberof days of inpatient care described in paragraph (1)(G) provided inany 12-month period to individuals who have an election in effectunder section 1812(d) with respect to that agency or organization does not exceed 20 percentof the aggregate number of days during that period on which such electionsfor such individuals are in effect;(B)has an interdisciplinarygroup of personnel which(i)includes atleast(I)one physician(as defined in subsection (r)(1)),(II)one registeredprofessional nurse, and(III)onesocial worker,employed by or, in the case of a physician described in subclause(I), under contract with the agency or organization, and also includesat least one pastoral or other counselor,(ii)provides (orsupervises the provision of) the care and services described in paragraph(1), and(iii)establishesthe policies governing the provision of such care and services;(C)maintainscentral clinical records on all patients;(D)does notdiscontinue the hospice care it provides with respect to a patientbecause of the inability of the patient to pay for such care;(E)(i)utilizes volunteersin its provision of care and services in accordance with standardsset by the Secretary, which standards shall ensure a continuing levelof effort to utilize such volunteers, and(ii)maintainsrecords on the use of these volunteers and the cost savings and expansionof care and services achieved through the use of these volunteers;(F)in the caseof an agency or organization in any State in which State or applicablelocal law provides for the licensing of agencies or organizationsof this nature, is licensed pursuant to such law; and(G)meets suchother requirements as the Secretary may find necessary in the interestof the health and safety of the individuals who are provided careand services by such agency or organization.(3)(A)An individualis considered to be terminally ill if the individualhas a medical prognosis that the individuals life expectancyis 6 months or less.
Social Security Act §1861
(3)(A)An individualis considered to be terminally ill if the individualhas a medical prognosis that the individuals life expectancyis 6 months or less.(B)The term attending physician means, with respect to an individual,the physician (as defined in subsection (r)(1)), the nurse practitioner(as defined in subsection (aa)(5)) or the physician assistant (asdefined in such subsection), who may be employed by a hospice program,whom the individual identifies as having the most significant rolein the determination and delivery of medical care to the individualat the time the individual makes an election to receive hospice care.[528](4)(A)An entitywhich is certified as a provider of services other than a hospiceprogram shall be considered, for purposes of certification as a hospiceprogram, to have met any requirements under paragraph (2) which arealso the same requirements for certification as such other type ofprovider. The Secretary shall coordinate surveys for determining certificationunder this title so as to provide, to the extent feasible, for simultaneoussurveys of an entity which seeks to be certified as a hospice programand as a provider of services of another type.(B)Any entitywhich is certified as a hospice program and as a provider of anothertype shall have separate provider agreements under section 1866 and shall fileseparate cost reports with respect to costs incurred in providinghospice care and in providing other services and items under thistitle.(C)[529]Any entity that is certified as a hospice program shall besubject to a standard survey by an appropriate State or local surveyagency, or an approved accreditation agency, as determined by theSecretary, not less frequently than once every 36 months beginning6 months after the date of the enactment of this subparagraph andending September 30, 2025.(5)(A)The Secretarymay waive the requirements of paragraph (2)(A)(ii)(I) for an agencyor organization with respect to all or part of the nursing care describedin paragraph (1)(A) if such agency or organization(i)is located inan area which is not an urbanized area (as defined by the Bureau ofthe Census);(ii)was in operationon or before January 1, 1983; and
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(i)is located inan area which is not an urbanized area (as defined by the Bureau ofthe Census);(ii)was in operationon or before January 1, 1983; and(iii)has demonstrateda good faith effort (as determined by the Secretary) to hire a sufficientnumber of nurses to provide such nursing care directly.(B)Any waiver,which is in such form and containing such information as the Secretarymay require and which is requested by an agency or organization undersubparagraph (A) or (C), shall be deemed to be granted unless suchrequest is denied by the Secretary within 60 days after the date suchrequest is received by the Secretary. The granting of a waiver undersubparagraph (A) or (C) shall not preclude the granting of any subsequentwaiver request should such a waiver again become necessary.(C)The Secretarymay waive the requirements of paragraph (2)(A)(i) and (2)(A)(ii) foran agency or organization with respect to the services described inparagraph (1)(B) and, with respect to dietary counseling, paragraph(1)(H), if such agency or organization(i)is located inan area which is not an urbanized area (as defined by the Bureau ofCensus), and(ii)demonstratesto the satisfaction of the Secretary that the agency or organizationhas been unable, despite diligent efforts, to recruit appropriatepersonnel.(D)In extraordinary,exigent, or other non-routine circumstances, such as unanticipatedperiods of high patient loads, staffing shortages due to illness orother events, or temporary travel of a patient outside a hospice programsservice area, a hospice program may enter into arrangements with anotherhospice program for the provision by that other program of servicesdescribed in paragraph (2)(A)(ii)(I). The provisions of paragraph(2)(A)(ii)(II) shall apply with respect to the services provided undersuch arrangements.(E)A hospiceprogram may provide services described in paragraph (1)(A) other thandirectly by the program if the services are highly specialized servicesof a registered professional nurse and are provided non-routinelyand so infrequently so that the provision of such services directlywould be impracticable and prohibitively expensive.Discharge Planning Process
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Discharge Planning Process(ee)(1)A discharge planningprocess of a hospital shall be considered sufficient if it is applicableto services furnished by the hospital to individuals entitled to benefitsunder this title and if it meets the guidelines and standards establishedby the Secretary under paragraph (2).(2)The Secretaryshall develop guidelines and standards for the discharge planningprocess in order to ensure a timely and smooth transition to the mostappropriate type of and setting for post-hospital or rehabilitativecare. The guidelines and standards shall include the following:(A)The hospitalmust identify, at an early stage of hospitalization, those patientswho are likely to suffer adverse health consequences upon dischargein the absence of adequate discharge planning.(B)Hospitalsmust provide a discharge planning evaluation for patients identifiedunder subparagraph (A) and for other patients upon the request ofthe patient, patients representative, or patients physician.(C)Any dischargeplanning evaluation must be made on a timely basis to ensure thatappropriate arrangements for post-hospital care will be made beforedischarge and to avoid unnecessary delays in discharge.(D)A dischargeplanning evaluation must include an evaluation of a patientslikely need for appropriate post-hospital services, including hospicecare and post-hospital extended care services and the availabilityof those services, including the availability of home health servicesthrough individuals and entities that participate in the program underthis title and that serve the area in which the patient resides andthat request to be listed by the hospital as available and, in thecase of individuals who are likely to need post-hospital extendedcare services, the availability of such services through facilitiesthat participate in the program under this title and that serve thearea in which the patient resides.(E)The dischargeplanning evaluation must be included in the patients medicalrecord for use in establishing an appropriate discharge plan and theresults of the evaluation must be discussed with the patient (or thepatients representative).(F)Upon therequest of a patients physician, the hospital must arrangefor the development and initial implementation of a discharge planfor the patient.(G)Any dischargeplanning evaluation or discharge plan required under this paragraphmust be developed by, or under the supervision of, a registered professionalnurse, social worker, or other appropriately qualified personnel.(H)Consistentwith section 1802, the discharge plan shall(i)not specifyor otherwise limit the qualified provider which may provide post-hospitalhome health services, and
Social Security Act §1861
(H)Consistentwith section 1802, the discharge plan shall(i)not specifyor otherwise limit the qualified provider which may provide post-hospitalhome health services, and(ii)identify (ina form and manner specified by the Secretary) any entity to whom theindividual is referred in which the hospital has a disclosable financialinterest (as specified by the Secretary consistent with section 1866(a)(1)(S))or which has such an interest in the hospital.(3)With respectto a discharge plan for an individual who is enrolled with a Medicare+Choiceorganization under a Medicare+Choice plan and is furnished inpatienthospital services by a hospital under a contract with the organization(A)the dischargeplanning evaluation under paragraph (2)(D) is not required to includeinformation on the availability of home health services through individualsand entities which do not have a contract with the organization; and(B)notwithstandingsubparagraph (H)(i), the plan may specify or limit the provider (orproviders) of post-hospital home health services or other post-hospitalservices under the plan.Partial Hospitalization Services(ff)(1)The term partial hospitalization services means the items and servicesdescribed in paragraph (2) prescribed by a physician and providedunder a program described in paragraph (3) under the supervision ofa physician pursuant to an individualized, written plan of treatmentestablished and periodically reviewed by a physician (in consultationwith appropriate staff participating in such program), which plansets forth the physicians diagnosis, the type, amount, frequency,and duration of the items and services provided under the plan, andthe goals for treatment under the plan.(2)The items andservices described in this paragraph are(A)individualand group therapy with physicians or psychologists (or other mentalhealth professionals to the extent authorized under State law),(B)occupationaltherapy requiring the skills of a qualified occupational therapist,(C)servicesof social workers, trained psychiatric nurses, and other staff trainedto work with psychiatric patients,(D)drugs andbiologicals furnished for therapeutic purposes (which cannot, as determinedin accordance with regulations, be self-administered),(E)individualizedactivity therapies that are not primarily recreational or diversionary,(F)family counseling(the primary purpose of which is treatment of the individualscondition),
Social Security Act §1861
(E)individualizedactivity therapies that are not primarily recreational or diversionary,(F)family counseling(the primary purpose of which is treatment of the individualscondition),(G)patienttraining and education (to the extent that training and educationalactivities are closely and clearly related to individuals careand treatment),(H)diagnosticservices, and(I)such otheritems and services as the Secretary may provide (but in no event toinclude meals and transportation);that are reasonable and necessary for the diagnosis or activetreatment of the individuals condition, reasonably expectedto improve or maintain the individuals condition and functionallevel and to prevent relapse or hospitalization, and furnished pursuantto such guidelines relating to frequency and duration of servicesas the Secretary shall by regulation establish (taking into accountaccepted norms of medical practice and the reasonable expectationof patient improvement).(3)(A)A programdescribed in this paragraph is a program which is furnished by a hospitalto its outpatients or by a community mental health center (as definedin subparagraph (B)), and which is a distinct and organized intensiveambulatory treatment service offering less than 24-hour-daily careother than in an individuals home or in an inpatient or residentialsetting.(B)For purposesof subparagraph (A), the term community mental health center means an entity that(i)(I)providesthe mental health services described in section 1913(c)(1) of thePublic Health Service Act; or(II)in thecase of an entity operating in a State that by law precludes the entityfrom providing itself the service described in subparagraph (E) ofsuch section, provides for such service by contract with an approvedorganization or entity (as determined by the Secretary);(ii)meets applicablelicensing or certification requirements for community mental healthcenters in the State in which it is located;(iii)providesat least 40 per cent of its services to individuals who are not eligiblefor benefits under this title; and(iv)meets suchadditional conditions as the Secretary shall specify to ensure (I)the health and safety of individuals being furnished such services,(II) the effective and efficient furnishing of such services, and(III) the compliance of such entity with the criteria described insection 1931(c)(1) of the Public Health Service Act.
Social Security Act §1861
Certified Nurse-Midwife Services(gg)(1)The term certified nurse-midwife services means such services furnishedby a certified nurse-midwife (as defined in paragraph (2)) and suchservices and supplies furnished as an incident to the nurse-midwifesservice which the certified nurse-midwife is legally authorized toperform under State law (or the State regulatory mechanism providedby State law) as would otherwise be covered if furnished by a physicianor as an incident to a physicians service.(2)The term certified nurse-midwife means a registered nurse who hassuccessfully completed a program of study and clinical experiencemeeting guidelines prescribed by the Secretary, or has been certifiedby an organization recognized by the Secretary.Clinical Social Worker; Clinical Social Worker Services(hh)(1)The term clinical social worker means an individual who(A)possessesa masters or doctors degree in social work;(B)after obtainingsuch degree has performed at least 2 years of supervised clinicalsocial work; and(C)(i)is licensedor certified as a clinical social worker by the State in which theservices are performed, or(ii)in the caseof an individual in a State which does not provide for licensure orcertification(I)has completedat least 2 years or 3,000 hours of post-masters degree supervisedclinical social work practice under the supervision of a masterslevel social worker in an appropriate setting (as determined by theSecretary), and(II)meetssuch other criteria as the Secretary establishes.(2)The term clinical social worker services means services performedby a clinical social worker (as defined in paragraph (1)) for thediagnosis and treatment of mental illnesses (other than services furnishedto an inpatient of a hospital and other than services furnished toan inpatient of a skilled nursing facility which the facility is requiredto provide as a requirement for participation) which the clinicalsocial worker is legally authorized to perform under State law (orthe State regulatory mechanism provided by State law) of the Statein which such services are performed as would otherwise be coveredif furnished by a physician or as an incident to a physiciansprofessional service.Qualified Psychologist Services
Social Security Act §1861
Qualified Psychologist Services(ii)The term qualified psychologist services means such services and such services and supplies furnished asan incident to his service furnished by a clinical psychologist (asdefined by the Secretary) which the psychologist is legally authorizedto perform under State law (or the State regulatory mechanism providedby State law) as would otherwise be covered if furnished by a physicianor as an incident to a physicians service.Screening Mammography(jj)The term screening mammography means a radiologic procedure provided to a woman for the purposeof early detection of breast cancer and includes a physiciansinterpretation of the results of the procedure.Covered Osteoporosis Drug(kk)The term covered osteoporosis drug means an injectable drug approved for the treatment of post-menopausalosteoporosis provided to an individual by a home health agency if,in accordance with regulations promulgated by the Secretary(1)the individualsattending physician certifies that the individual has suffered a bonefracture related to post-menopausal osteoporosis and that the individualis unable to learn the skills needed to self-administer such drugor is otherwise physically or mentally incapable of self-administeringsuch drug; and(2)the individualis confined to the individuals home (except when receivingitems and services referred to in subsection (m)(7)).Speech-Language Pathology Services; Audiology Services(ll)(1)The term speech-language pathology services means such speech, language,and related function assessment and rehabilitation services furnishedby a qualified speech-language pathologist as the speech-languagepathologist is legally authorized to perform under State law (or theState regulatory mechanism provided by the State law) as would otherwisebe covered if furnished by a physician.(2)[530]The term outpatient speech-language pathologyservices has the meaning given the term outpatientphysical therapy services in subsection (p), except that inapplying such subsection(A)speech-languagepathology shall be substituted for physical therapy each place it appears; and(B)speech-languagepathologist shall be substituted for physical therapist each place it appears.
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(A)speech-languagepathology shall be substituted for physical therapy each place it appears; and(B)speech-languagepathologist shall be substituted for physical therapist each place it appears.(3)The term audiology services means such hearing and balance assessmentservices furnished by a qualified audiologist as the audiologist islegally authorized to perform under State law (or the State regulatorymechanism provided by State law), as would otherwise be covered iffurnished by a physician.(4)In this subsection:(A)The term qualified speech-language pathologist means an individualwith a masterss or doctoral degree in speech-language pathologywho(i)is licensedas a speech-language pathologist by the State in which the individualfurnishes such services, or(ii)in the caseof an individual who furnishes services in a State which does notlicense speech-language pathologists, has successfully completed 350clock hours of supervised clinical practicum (or is in the processof accumulating such supervised clinical experience), performed notless than 9 months of supervised full-time speech-language pathologyservices after obtaining a masters or doctoral degree in speech-languagepathology or a related field, and successfully completed a nationalexamination in speech-language pathology approved by the Secretary.(B)The term qualified audiologist means an individual with a mastersor doctoral degree in audiology who(i)is licensedas an audiologist by the State in which the individual furnishes suchservices, or(ii)in the caseof an individual who furnishes services in a State which does notlicense audiologists, has successfully completed 350 clock hours ofsupervised clinical practicum (or is in the process of accumulatingsuch supervised clinical experience), performed not less than 9 monthsof supervised full-time audiology services after obtaining a mastersor doctoral degree in audiology or a related field, and successfullycompleted a national examination in audiology approved by the Secretary.Critical Access Hospital; Critical Access Hospital Services(mm)(1)The term critical access hospital means a facility certified by theSecretary as a critical access hospital under section 1820(e).