evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1861
(ii)For purposesof clause (i), the term bona fide emergency services means services provided in a hospital emergency room after the suddenonset of a medical condition manifesting itself by acute symptomsof sufficient severity (including severe pain) such that the absenceof immediate medical attention could reasonably be expected to resultin(I)placingthe patients health in serious jeopardy;(II)seriousimpairment to bodily functions; or(III)seriousdysfunction of any bodily organ or part.(L)(i)The Secretary,in determining the amount of the payments that may be made under thistitle with respect to services furnished by home health agencies,may not recognize as reasonable (in the efficient delivery of suchservices) costs for the provision of such services by an agency tothe extent these costs exceed (on the aggregate for the agency) forcost reporting periods beginning on or after(I)July 1,1985, and before July 1, 1986, 120 percent of the mean of the labor-relatedand nonlabor per visit costs for freestanding home health agencies,(II)July 1,1986, and before July 1, 1987, 115 percent of such mean,(III)July1, 1987, and before October 1, 1997, 112 percent of such mean,(IV)October1, 1997, and before October 1, 1998, 105 percent of the median ofthe labor-related and nonlabor per visit costs for freestanding homehealth agencies; or(V)October1, 1998, 106 percent of such median.(ii)Effective forcost reporting periods beginning on or after July 1, 1986, such limitationsshall be applied on an aggregate basis for the agency, rather thanon a discipline specific basis. The Secretary may provide for suchexemptions and exceptions to such limitation as he deems appropriate.[512]
Social Security Act §1861
(iii)Not laterthan July 1, 1991, and annually thereafter (but not for cost reportingperiods beginning on or after July 1, 1994, and before July 1, 1996,or on or after July 1, 1997, and before October 1, 1997), the Secretaryshall establish limits under this subparagraph for cost reportingperiods beginning on or after such date by utilizing the area wageindex applicable under section 1886(d)(3)(E) and determined usingthe survey of the most recent available wages and wage-related costsof hospitals located in the geographic area in which the home healthservice is furnished (determined without regard to whether such hospitalshave been reclassified to a new geographic area pursuant to section 1886(d)(8)(B),a decision of the Medicare Geographic Classification Review Boardunder section 1886(d)(10), or a decision of the Secretary).(iv)In establishinglimits under this subparagraph for cost reporting periods beginningafter September 30, 1997, the Secretary shall not take into accountany changes in the home health market basket, as determined by theSecretary, with respect to cost reporting periods which began on orafter July 1, 1994, and before July 1, 1996.(v)For servicesfurnished by home health agencies for cost reporting periods beginningon or after October 1, 1997, subject to clause (viii)(I), the Secretaryshall provide for an interim system of limits. Payment shall not exceedthe costs determined under the preceding provisions of this subparagraphor, if lower, the product of(I)an agency-specificper beneficiary annual limitation calculated based 75 percent on 98percent of the reasonable costs (including nonroutine medical supplies)for the agencys 12-month cost reporting period ending duringfiscal year 1994, and based 25 percent on 98 percent of the standardizedregional average of such costs for the agencys census division,as applied to such agency, for cost reporting periods ending duringfiscal year 1994, such costs updated by the home health market basketindex; and(II)the agencysunduplicated census count of patients (entitled to benefits underthis title) for the cost reporting period subject to the limitation.(vi)For servicesfurnished by home health agencies for cost reporting periods beginningon or after October 1, 1997, the following rules apply:
Social Security Act §1861
(vi)For servicesfurnished by home health agencies for cost reporting periods beginningon or after October 1, 1997, the following rules apply:(I)For newproviders and those providers without a 12-month cost reporting periodending in fiscal year 1994 subject to clauses (viii)(II) and (viii)(III),the per beneficiary limitation shall be equal to the median of theselimits (or the Secretarys best estimates thereof) applied toother home health agencies as determined by the Secretary. A homehealth agency that has altered its corporate structure or name shallnot be considered a new provider for this purpose.(II)For beneficiarieswho use services furnished by more than one home health agency, theper beneficiary limitations shall be prorated among the agencies.(vii)(I)Not laterthan January 1, 1998, the Secretary shall establish per visit limitsapplicable for fiscal year 1998, and not later than April 1, 1998,the Secretary shall establish per beneficiary limits under clause(v)(I) for fiscal year 1998.(II)Notlater than August 1 of each year (beginning in 1998) the Secretaryshall establish the limits applicable under this subparagraph forservices furnished during the fiscal year beginning October 1 of theyear.(viii)(I)In thecase of a provider with a 12-month cost reporting period ending infiscal year 1994, if the limit imposed under clause (v) (determinedwithout regard to this subclause) for a cost reporting period beginningduring or after fiscal year 1999 is less than the median describedin clause (vi)(I) (but determined as if any reference in clause (v)to 98 percent were a reference to 100 percent), the limit otherwise imposed under clause (v) for such providerand period shall be increased by 1/3 of such difference.(II)Subjectto subclause (IV), for new providers and those providers without a12-month cost reporting period ending in fiscal year 1994, but forwhich the first cost reporting period begins before fiscal year 1999,for cost reporting periods beginning during or after fiscal year 1999,the per beneficiary limitation described in clause (vi)(I) shall beequal to the median described in such clause (determined as if anyreference in clause (v) to 98 percent were a referenceto 100 percent).
Social Security Act §1861
(III)Subjectto subclause (IV), in the case of a new provider for which the firstcost reporting period begins during or after fiscal year 1999, thelimitation applied under clause (vi)(I) (but only with respect tosuch provider) shall be equal to 75 percent of the median describedin clause (vi)(I).(IV)Inthe case of a new provider or a provider without a 12-month cost reportingperiod ending in fiscal year 1994, subclause (II) shall apply, insteadof subclause (III), to a home health agency which filed an applicationfor home health agency provider status under this title before September15, 1998, or which was approved as a branch of its parent agency beforesuch date and becomes a subunit of the parent agency or a separateagency on or after such date.(V)Eachof the amounts specified in subclauses (I) through (III) are suchamounts as adjusted under clause (iii) to reflect variations in wagesamong different areas.(ix)Notwithstandingthe per beneficiary limit under clause (viii), if the limit imposedunder clause (v) (determined without regard to this clause) for acost reporting period beginning during or after fiscal year 2000 isless than the median described in clause (vi)(I) (but determined asif any reference in clause (v) to 98 percent were areference to 100 percent), the limit otherwise imposedunder clause (v) for such provider and period shall be increased by2 percent.(x)Notwithstandingany other provision of this subparagraph, in updating any limit underthis subparagraph by a home health market basket index for cost reportingperiods beginning during each of fiscal years 2000, 2002, and 2003,the update otherwise provided shall be reduced by 1.1 percentage points.With respect to cost reporting periods beginning during fiscal year2001, the update to any limit under this subparagraph shall be thehome health market basket index.(M)Such regulationsshall provide that costs respecting care provided by a provider ofservices, pursuant to an assurance under title VI or XVI of the PublicHealth Service Act[513]that the provider will make available a reasonable volume of servicesto persons unable to pay therefor, shall not be allowable as reasonablecosts.
Social Security Act §1861
(N)In determiningsuch reasonable costs, costs incurred for activities directly relatedto influencing employees respecting unionization may not be included.(O)(i)In establishingan appropriate allowance for depreciation and for interest on capitalindebtedness with respect to an asset of a provider of services whichhas undergone a change of ownership, such regulations shall provide,except as provided in clause (iii), that the valuation of the assetafter such change of ownership shall be the historical cost of theasset, as recognized under this title, less depreciation allowed,to the owner of record as of the date of enactment of the BalancedBudget Act of 1997[514](or, in the case of an assetnot in existence as of that date, the first owner of record of theasset after that date).(ii)Such regulationsshall not recognize, as reasonable in the provision of health careservices, costs (including legal fees, accounting and administrativecosts, travel costs, and the costs of feasibility studies) attributableto the negotiation or settlement of the sale or purchase of any capitalasset (by acquisition or merger) for which any payment has previouslybeen made under this title.(iii)In the caseof the transfer of a hospital from ownership by a State to ownershipby a nonprofit corporation without monetary consideration, the basisfor capital allowances to the new owner shall be the book value ofthe hospital to the State at the time of the transfer.(P)If such regulationsprovide for the payment for a return on equity capital (other thanwith respect to costs of inpatient hospital services), the rate ofreturn to be recognized, for determining the reasonable cost of servicesfurnished in a cost reporting period, shall be equal to the averageof the rates of interest, for each of the months any part of whichis included in the period, on obligations issued for purchase by theFederal Hospital Insurance Trust Fund.(Q)Except asotherwise explicitly authorized, the Secretary is not authorized tolimit the rate of increase on allowable costs of approved medicaleducational activities.(R)In determiningsuch reasonable cost, costs incurred by a provider of services representinga beneficiary in an unsuccessful appeal of a determination describedin section 1869(b) shall not be allowable as reasonable costs.(S)(i)Such regulationsshall not include provision for specific recognition of any returnon equity capital with respect to hospital outpatient departments.
Social Security Act §1861
(S)(i)Such regulationsshall not include provision for specific recognition of any returnon equity capital with respect to hospital outpatient departments.(ii)(I)Such regulationsshall provide that, in determining the amount of the payments thatmay be made under this title with respect to all the capital-relatedcosts of outpatient hospital services, the Secretary shall reducethe amounts of such payments otherwise established under this titleby 15 percent for payments attributable to portions of cost reportingperiods occurring during fiscal year 1990, by 15 percent for paymentsattributable to portions of cost reporting periods occurring duringfiscal year 1991, and by 10 percent for payments attributable to portionsof cost reporting periods occurring during fiscal years 1992 through1999 and until the first date that the prospective payment systemunder section 1833(t)is implemented.(II)The Secretaryshall reduce the reasonable cost of outpatient hospital services (otherthan the capital-related costs of such services) otherwise determinedpursuant to section 1833(a)(2)(B)(i)(I) by 5.8 percentfor payments attributable to portions of cost reporting periods occurringduring fiscal years 1991 through 1999 and until the first date thatthe prospective payment system under section 1833(t) is implemented during fiscalyear 2000 before January 1, 2000.(III)Subclauses(I) and (II) shall not apply to payments with respect to the costsof hospital outpatient services provided by any hospital that is asole community hospital (as defined in section 1886(d)(5)(D)(iii)) or a criticalaccess hospital (as defined in section 1861(mm)(1)).(IV)In applyingsubclauses (I) and (II) to services for which payment is made on thebasis of a blend amount under section 1833(i)(3)(A)(ii) or 1833(n)(1)(A)(ii), the costsreflected in the amounts described in sections 1833(i)(3)(B)(i)(I) and 1833(n)(1)(B)(i)(I), respectively,shall be reduced in accordance with such subclause.
Social Security Act §1861
(T)In determiningsuch reasonable costs for hospitals, no reduction in copayments undersection 1833(t)(8)(B) shall be treated as a bad debt and the amount of bad debts otherwisetreated as allowable costs which are attributable to the deductiblesand coinsurance amounts under this title shall be reduced(i)for cost reportingperiods beginning during fiscal year 1998, by 25 percent of such amountotherwise allowable,(ii)for cost reportingperiods beginning during fiscal year 1999, by 40 percent of such amountotherwise allowable,(iii)for costreporting periods beginning during fiscal year 2000, by 45 percentof such amount otherwise allowable[515](iv)for cost reportingperiods beginning during fiscal years 2001 through 2012[516], by 30 percentof such amount otherwise allowable, and[517](v)[518]for cost reporting periods beginning duringfiscal year 2013 or a subsequent fiscal year, by 35 percent of suchamount otherwise allowable.(U)In determiningthe reasonable cost of ambulance services (as described in subsection(s)(7)) provided during fiscal year 1998, during fiscal year 1999,and during so much of fiscal year 2000 as precedes January 1, 2000,the Secretary shall not recognize the costs per trip in excess ofcosts recognized as reasonable for ambulance services provided ona per trip basis during the previous fiscal year (after applicationof this subparagraph), increased by the percentage increase in theconsumer price index for all urban consumers (U.S. city average) asestimated by the Secretary for the 12-month period ending with themidpoint of the fiscal year involved reduced by 1.0 percentage point.For ambulance services provided after June 30, 1998, the Secretarymay provide that claims for such services must include a code (orcodes) under a uniform coding system specified by the Secretary thatidentifies the services furnished.(V)In determiningsuch reasonable costs for skilled nursing facilities and (beginningwith respect to cost reporting periods beginning during fiscal year2013) for covered skilled nursing services described in section 1888(e)(2)(A) furnishedby hospital providers of extended care services (as described in section 1883)[519], the amount ofbad debts otherwise treated as allowed costs which are attributableto the coinsurance amounts under this title for individuals who areentitled to benefits under part A and
Social Security Act §1861
(i)[520]are not described insection 1935(c)(6)(A)(ii) shall be reduced by(I)for costreporting periods beginning on or after October 1, 2005, but beforefiscal year 2013, 30 percent of such amount otherwise allowable; and(II)for costreporting periods beginning during fiscal year 2013 or a subsequentfiscal year, by 35 percent of such amount otherwise allowable.(ii)are describedin such section(I)for costreporting periods beginning on or after October 1, 2005, but beforefiscal year 2013, shall not be reduced;(II)for costreporting periods beginning during fiscal year 2013, shall be reducedby 12 percent of such amount otherwise allowable;(III)forcost reporting periods beginning during fiscal year 2014, shall bereduced by 24 percent of such amount otherwise allowable; and(IV)for costreporting periods beginning during a subsequent fiscal year, shallbe reduced by 35 percent of such amount otherwise allowable.[521](W)[522](i)In determiningsuch reasonable costs for providers described in clause (ii), theamount of bad debts otherwise treated as allowable costs which areattributable to deductibles and coinsurance amounts under this titleshall be reduced(I)for costreporting periods beginning during fiscal year 2013, by 12 percentof such amount otherwise allowable;(II)for costreporting periods beginning during fiscal year 2014, by 24 percentof such amount otherwise allowable; and(III)forcost reporting periods beginning during a subsequent fiscal year,by 35 percent of such amount otherwise allowable.(ii)A providerdescribed in this clause is a provider of services not described insubparagraph (T) or (V), a supplier, or any other type of entity thatreceives payment for bad debts under the authority under subparagraph(A).(2)(A)If the bedand board furnished as part of inpatient hospital services (includinginpatient tuberculosis hospital services and inpatient psychiatrichospital services) or post-hospital extended care services is in accommodationsmore expensive than semi-private accommodations, the amount takeninto account for purposes of payment under this title with respectto such services may not exceed the amount that would be taken intoaccount with respect to such services if furnished in such semi-privateaccommodations unless the more expensive accommodations were requiredfor medical reasons.
Social Security Act §1861
(B)Where a providerof services which has an agreement in effect under this title furnishesto an individual items or services which are in excess of or moreexpensive than the items or services with respect to which paymentmay be made under part A or part B, as the case may be, the Secretaryshall take into account for purposes of payment to such provider ofservices only the items or services with respect to which such paymentmay be made.[523](3)If the bed andboard furnished as part of inpatient hospital services (includinginpatient tuberculosis hospital services and inpatient psychiatrichospital services) or post-hospital extended care services is in accommodationsother than, but not more expensive than, semi-private accommodationsand the use of such other accommodations rather than semi-privateaccommodations was neither at the request of the patient nor for areason which the Secretary determines is consistent with the purposesof this title, the amount of the payment with respect to such bedand board under part A shall be the amount otherwise payable underthis title for such bed and board furnished in semi-private accommodationsminus the difference between the charge customarily made by the hospitalor skilled nursing facility for bed and board in semi-private accommodationsand the charge customarily made by it for bed and board in the accommodationsfurnished.(4)If a providerof services furnishes items or services to an individual which arein excess of or more expensive than the items or services determinedto be necessary in the efficient delivery of needed health servicesand charges are imposed for such more expensive items or servicesunder the authority granted in section 1866(a)(2)(B)(ii), the amountof payment with respect to such items or services otherwise due suchprovider in any fiscal period shall be reduced to the extent thatsuch payment plus such charges exceed the cost actually incurred forsuch items or services in the fiscal period in which such chargesare imposed.
Social Security Act §1861
(5)(A)Where physicaltherapy services, occupational therapy services, speech therapy services,or other therapy services or services of other health-related personnel(other than physicians) are furnished under an arrangement with aprovider of services or other organization, specified in the firstsentence of subsection (p) (including through the operation of subsection(g)) the amount included in any payment to such provider or otherorganization under this title as the reasonable cost of such services(as furnished under such arrangements) shall not exceed an amountequal to the salary which would reasonably have been paid for suchservices (together with any additional costs that would have beenincurred by the provider or other organization) to the person performingthem if they had been performed in an employment relationship withsuch provider or other organization (rather than under such arrangement)plus the cost of such other expenses (including a reasonable allowancefor traveltime and other reasonable types of expense related to anydifferences in acceptable methods of organization for the provisionof such therapy) incurred by such person, as the Secretary may inregulations determine to be appropriate.(B)Notwithstandingthe provisions of subparagraph (A), if a provider of services or otherorganization specified in the first sentence of section 1861(p) requires theservices of a therapist on a limited part-time basis, or only to performintermittent services, the Secretary may make payment on the basisof a reasonable rate per unit of service, even though such rate isgreater per unit of time than salary related amounts, where he findsthat such greater payment is, in the aggregate, less than the amountthat would have been paid if such organization had employed a therapiston a full-or part-time salary basis.(6)For purposes ofthis subsection, the term semi-private accommodations means two-bed, three-bed, or four-bed accommodations.(7)(A)For limitationon Federal participation for capital expenditures which are out ofconformity with a comprehensive plan of a State or areawide planningagency, see section 1122.(B)For furtherlimitations on reasonable cost and determination of payment amountsfor operating costs of inpatient hospital services and waivers forcertain States, see section 1886.(C)For provisionsrestricting payment for provider-based physicians servicesand for payments under certain percentage arrangements, see section 1887.