evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1833
(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),
Social Security Act §1833
(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,
Social Security Act §1833
(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(ii)if such servicesare furnished before January 1, 1999, 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 clause), free of chargeor at nominal charges to the public, 80 percent of the amount determinedin accordance with section 1814(b)(2), or(iii)if such servicesare furnished on or after January 1, 1999, the amount determined undersubsection (t), or(iv)if (and forso long as) the conditions described in section 1814(b)(3) are met, the amounts determinedunder the reimbursement system described in such section;(C)with respectto services described in the second sentence of section 1861(p), 80 percentof the reasonable charges for such services;(D)with respectto clinical diagnostic laboratory tests for which payment is madeunder this part(i)
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);
Social Security Act §1833
(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
Social Security Act §1833
(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
Social Security Act §1833
(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
Social Security Act §1833
(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)),
Social Security Act §1833
(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)
Social Security Act §1833
(1)Notwithstandingany other provision of this part, with respect to expenses incurredin a calendar year in connection with the treatment of mental, psychoneurotic,and personality disorders of an individual who is not an inpatientof a hospital at the time such expenses are incurred, there shallbe considered as incurred expenses for purposes of subsections (a)and (b)(A)for expensesincurred in years prior to 2010, only 621/2 percent of such expenses;(B)for expensesincurred in 2010 or 2011, only 683/4 percent of such expenses;(C)for expensesincurred in 2012, only 75 percent of such expenses;(D)for expensesincurred in 2013, only 811/4 percent of such expenses; and(E)for expensesincurred in 2014 or any subsequent calendar year, 100 percent of suchexpenses.(2)For purposes ofsubparagraphs (A) through (D) of paragraph (1), the term treatment does not include brief office visits (as defined by the Secretary)for the sole purpose of monitoring or changing drug prescriptionsused in the treatment of such disorders or partial hospitalizationservices that are not directly provided by a physician(d)No payment maybe made under this part with respect to any services furnished anindividual to the extent that such individual is entitled (or wouldbe entitled except for section 1813) to have payment made with respectto such services under part A.(e)No payment shallbe made to any provider of services or other person under this partunless there has been furnished such information as may be necessaryin order to determine the amounts due such provider or other personunder this part for the period with respect to which the amounts arebeing paid or for any prior period.(f)In establishinglimits under subsection (a) on payment for rural health clinic servicesprovided by rural health clinics (other than such clinics in hospitalswith less than 50 beds), the Secretary shall establish such limit,for services provided(1)in 1988, afterMarch 31, at $46 per visit, and(2)in a subsequentyear, at the limit established under this subsection for the previousyear increased by the percentage increase in the MEI (as defined insection 1842(i)(3)) applicable to primary care services (as defined in section 1842(i)(4)) furnishedas of the first day of that year.
Social Security Act §1833
(g)(1)[87](A)Subject toparagraphs (4) and (5), in the case of physical therapy services ofthe type described in section 1861(p) and speech-language pathologyservices of the type described in such section through the applicationof section 1861(ll)(2), but(except as provided in paragraph (6)) not described in section 1833(a)(8)(B),and physical therapy services and speech-language pathology servicesof such type which are furnished by a physician or as incident tophysicians services, with respect to expenses incurred in anycalendar year, no more than the amount specified in paragraph (2)for the year shall be considered as incurred expenses for purposesof subsections (a) and (b). The preceding sentence shall not applyto expenses incurred with respect to services furnished after December31, 2017.(B)With respectto services furnished during 2018 or a subsequent year, in the caseof physical therapy services of the type described in section 1861(p),speech-language pathology services of the type described in such sectionthrough the application of section 1861(ll)(2), and physical therapyservices and speech-language pathology services of such type whichare furnished by a physician or as incident to physicians' services,with respect to expenses incurred in any calendar year, any amountthat is more than the amount specified in paragraph (2) for the yearshall not be considered as incurred expenses for purposes of subsections(a) and (b) unless the applicable requirements of paragraph (7) aremet.(2)The amount specifiedin this paragraph(A)for 1999,2000, and 2001, is $1,500, and(B)for a subsequentyear is the amount specified in this paragraph for the preceding yearincreased by the percentage increase in the MEI (as defined in section 1842(i)(3)) forsuch subsequent year;except that if an increase under subparagraph (B) for a yearis not a multiple of $10, it shall be rounded to the nearest multipleof $10.(3)
Social Security Act §1833
(A)[88]Subject to paragraphs (4) and (5), in thecase of occupational therapy services (of the type that are describedin section 1861(p) (but (except as provided in paragraph (6)) not described in section 1833(a)(8)(B))through the operation of section 1861(g) and of such type which are furnishedby a physician or as incident to physicians services), withrespect to expenses incurred in any calendar year, no more than theamount specified in paragraph (2) for the year shall be consideredas incurred expenses for purposes of subsections (a) and (b). Thepreceding sentence shall not apply to expenses incurred with respectto services furnished after December 31, 2017.(B)With respectto services furnished during 2018 or a subsequent year, in the caseof occupational therapy services (of the type that are described insection 1861(p) through the operation of section 1861(g) and of suchtype which are furnished by a physician or as incident to physicians'services), with respect to expenses incurred in any calendar year,any amount that is more than the amount specified in paragraph (2)for the year shall not be considered as incurred expenses for purposesof subsections (a) and (b) unless the applicable requirements of paragraph(7) are met.(4)This subsectionshall not apply to expenses incurred with respect to services furnishedduring 2000, 2001, 2002, 2004, and 2005.(5)(A)[89]With respect to expenses incurred duringthe period beginning on January 1, 2006, and ending on December 31,2017, for services, the Secretary shall implement a process underwhich an individual enrolled under this part may, upon request ofthe individual or a person on behalf of the individual, obtain anexception from the uniform dollar limitation specified in paragraph(2), for services described in paragraphs (1) and (3) if the provisionof such services is determined to be medically necessary and if therequirement of subparagraph (B) is met. Under such process, if theSecretary does not make a decision on such a request for an exceptionwithin 10 business days of the date of the Secretarys receiptof the request made in accordance with such requirement, the Secretaryshall be deemed to have found the services to be medically necessary.