42 U.S. Code § 1395x – Definitions | U.S. Code | US Law | LII / Legal Information Institute

For purposes of this subchapter— ( a ) Spell of illness The condition “ spell of illness ” with respect to any individual means a period of back-to-back days— ( 1 ) beginning with the first day ( not included in a previous while of illness ) ( A ) on which such individual is furnished inpatient hospital services, inpatient critical access hospital services or extended wish services, and ( B ) which occurs in a month for which he is entitled to benefits under separate A, and ( 2 ) ending with the close of the beginning period of 60 straight days thereafter on each of which he is neither an inpatient of a hospital or critical access hospital nor an inpatient of a facility described in part 1395i–3 ( a ) ( 1 ) of this title or subsection ( yttrium ) ( 1 ). ( boron ) Inpatient hospital services The term “ inpatient hospital services ” means the following items and services furnished to an inpatient of a hospital and ( except a provided in paragraph ( 3 ) ) by the hospital — ( 1 ) bed and circuit board ; ( 2 ) such nurse services and other relate services, such function of hospital facilities, and such aesculapian social services as are normally furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for practice in the hospital, as are normally furnished by such hospital for the wish and discussion of inpatients ; and ( 3 ) such other diagnostic or therapeutic items or services, furnished by the hospital or by others under arrangements with them made by the hospital, as are normally furnished to inpatients either by such hospital or by others under such arrangements ; excluding, however— ( 4 ) checkup or surgical services provided by a doctor, nonmigratory, or intern, services described by subsection ( sulfur ) ( 2 ) ( K ), certified nurse-midwife services, qualified psychologist services, and services of a certify register nanny anesthesiologist ; and ( 5 ) the services of a private-duty nurse or other private-duty attendant. Paragraph ( 4 ) shall not apply to services provided in a hospital by— ( 6 ) an intern or a resident-in-training under a education platform approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association, or, in the case of services in a hospital or osteopathic hospital by an intern or resident-in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association, or in the case of services in a hospital or osteopathic hospital by an intern or resident-in-training in the field of podiatry, approved by the Council on Podiatric Medical Education of the American Podiatric Medical Association ; or ( 7 ) a doctor where the hospital has a teach program approved as specified in paragraph ( 6 ), if ( A ) the hospital elects to receive any requital due under this subchapter for fair costs of such services, and ( B ) all physicians in such hospital agree not to circular charges for professional services rendered in such hospital to individuals covered under the indemnity program established by this subchapter. ( cytosine ) Inpatient psychiatric hospital services The term “ inpatient psychiatric hospital services ” means inpatient hospital services furnished to an inpatient of a psychiatric hospital. ( vitamin d ) Supplier The term “ supplier ” means, unless the context otherwise requires, a doctor or other practitioner, a adeptness, or early entity ( other than a provider of services ) that furnishes items or services under this subchapter. ( e ) Hospital The condition “ hospital ” ( except for purposes of sections 1395f ( five hundred ), 1395f ( fluorine ), and 1395n ( boron ) of this deed, subsection ( a ) ( 2 ) of this segment, paragraph ( 7 ) of this subsection, and subsection ( one ) of this part ) means an institution which— ( 1 ) is primarily engaged in providing, by or under the supervision of physicians, to inpatients ( A ) diagnostic services and curative services for medical diagnosis, treatment, and worry of injured, disabled, or nauseated persons, or ( B ) rehabilitation services for the rehabilitation of hurt, disabled, or ghastly persons ; ( 2 ) maintains clinical records on all patients ; ( 3 ) has bylaws in effect with respect to its staff of physicians ; ( 4 ) has a prerequisite that every patient with respect to whom requital may be made under this subchapter must be under the care of a doctor, except that a patient receiving dependent psychologist services ( as defined in subsection ( two ) ) may be under the care of a clinical psychologist with respect to such services to the extent permitted under State law ; ( 5 ) provides 24-hour nursing service rendered or supervised by a register professional nurse, and has a license practical nanny or registered professional nurse on duty at all times ; except that until, the Secretary is authorized to waive the necessity of this paragraph for any annual period with respect to any mental hospital, insofar as such prerequisite relates to the planning of twenty-four-hour nurse serve rendered or supervised by a record master nanny ( except that in any consequence a file professional nurse must be present on the premises to render or supervise the nursing service provided, during at least the regular day stir ), where immediately preceding such annual period he finds that— ( A ) such initiation is located in a rural area and the supply of hospital services in such area is not sufficient to meet the needs of individuals residing therein, ( B ) the failure of such institution to qualify as a hospital would badly reduce the handiness of such services to such individuals, and ( C ) such institution has made and continues to make a good religion effort to comply with this paragraph, but such complaisance is impeded by the miss of qualify nursing personnel in such area ; ( 6 ) ( A ) has in effect a hospital utilization inspection plan which meets the requirements of subsection ( kelvin ) and ( B ) has in place a discharge plan summons that meets the requirements of subsection ( electrical engineering ) ; ( 7 ) in the case of an institution in any State in which State or applicable local jurisprudence provides for the license of hospitals, ( A ) is licensed pursuant to such police or ( B ) is approved, by the means of such State or vicinity creditworthy for licensing hospitals, as meeting the standards established for such license ; ( 8 ) has in effect an overall plan and budget that meets the requirements of subsection ( omega ) ; and ( 9 ) meets such early requirements as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the institution. For purposes of subsection ( a ) ( 2 ), such term includes any institution which meets the requirements of paragraph ( 1 ) of this subsection. For purposes of sections 1395f ( five hundred ) and 1395n ( barn ) of this title ( including decision of whether an individual received inpatient hospital services or diagnostic services for purposes of such sections ), section 1395f ( farad ) ( 2 ) of this championship, and subsection ( one ) of this section, such term includes any institution which ( one ) meets the requirements of paragraph ( 5 ) and ( 7 ) of this subsection, ( two ) is not chiefly engaged in providing the services described in subsection ( j ) ( 1 ) ( A ) and ( three ) is primarily engaged in providing, by or under the supervision of individuals referred to in paragraph ( 1 ) of subsection ( gas constant ), to inpatients diagnostic services and curative services for checkup diagnosis, treatment, and care of hurt, disabled, or pale persons, or rehabilitation services for the rehabilitation of hurt, disable, or nauseated persons. For purposes of department 1395f ( f ) ( 1 ) of this deed, such term includes an institution which ( iodine ) is a hospital for purposes of sections 1395f ( five hundred ), 1395f ( fluorine ) ( 2 ), and 1395n ( barn ) of this entitle and ( two ) is accredited by a national accreditation body recognized by the Secretary under section 1395bb ( a ) of this title, or is accredited by or approved by a program of the country in which such institution is located if the Secretary finds the accreditation or comparable blessing standards of such plan to be basically equivalent to those of such a national accreditation body.. Notwithstanding the preceding provisions of this subsection, such condition shall not, except for purposes of subsection ( a ) ( 2 ), include any initiation which is chiefly for the care and discussion of genial diseases unless it is a psychiatric hospital ( as defined in subsection ( degree fahrenheit ) ). The term “ hospital ” besides includes a religious nonmedical health care initiation ( as defined in subsection ( randomness ) ( 1 ) ), but alone with deference to items and services normally furnished by such institution to inpatients, and requital may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements ( in addition to or in stead of the conditions, limitations, and requirements otherwise applicable ) as may be provided in regulations reproducible with incision 1395i–5 of this deed. For provisions deeming certain requirements of this subsection to be met in the sheath of accredit institutions, see section 1395bb of this deed. The terminus “ hospital ” besides includes a facility of fifty dollar bill beds or less which is located in an area determined by the Secretary to meet the definition relating to a rural area described in subparagraph ( A ) of paragraph ( 5 ) of this subsection and which meets the other requirements of this subsection, except that— ( A ) with esteem to the requirements for nursing services applicable after, such requirements shall provide for irregular release of the requirements, for such period as the Secretary deem allow, where ( one ) the facility ’ s failure to fully comply with the requirements is attributable to a irregular deficit of qualify harbor personnel in the area in which the facility is located, ( two ) a register professional nurse is show on the premises to render or supervise the breastfeed service provided during at least the regular day shift, and ( three ) the Secretary determines that the use of such harbor personnel as are available to the adeptness during such impermanent period will not adversely affect the health and safety of patients ; ( B ) with respect to the health and condom requirements promulgated under paragraph ( 9 ), such requirements shall be applied by the Secretary to a facility herein defined in such manner as to assure that personnel department requirements take into report the handiness of technical personnel and the educational opportunities for technical personnel in the area in which such facility is located, and the telescope of services rendered by such facility ; and the Secretary, by regulations, shall provide for the stay participation of such a facility where such personnel requirements are not fully met, for such period as the Secretary determines that ( iodine ) the facility is making good religion efforts to in full comply with the personnel requirements, ( two ) the use by the adeptness of such personnel as are available to the facility will not adversely affect the health and safety of patients, and ( three ) if the Secretary has determined that because of the facility ’ s waiver under this subparagraph the adeptness should limit its scope of services in order not to adversely affect the health and guard of the facility ’ south patients, the facility is so limiting the telescope of services it provides ; and ( C ) with esteem to the fuel and safety requirements promulgated under paragraph ( 9 ), the Secretary ( one ) may waive, for such period as he deems appropriate, specific provisions of such requirements which if rigidly applied would result in excessive adversity for such a facility and which, if not applied, would not jeopardize the health and safety of patients, and ( two ) may accept a facility ’ s complaisance with all applicable State codes relating to fire and base hit in stead of conformity with the fire and safety requirements promulgated under paragraph ( 9 ), if he determines that such State has in effect fire and guard codes, imposed by State law, which adequately protect patients. The term “ hospital ” does not include, unless the context otherwise requires, a critical access hospital ( as defined in subsection ( millimeter ) ( 1 ) ) or a rural emergency hospital ( as defined in subsection ( ku klux klan ) ( 2 ) ). ( farad ) Psychiatric hospital The term “ psychiatric hospital ” means an institution which— ( 1 ) is primarily engaged in providing, by or under the supervision of a doctor, psychiatric services for the diagnosis and treatment of mentally ill persons ; ( 2 ) satisfies the requirements of paragraph ( 3 ) through ( 9 ) of subsection ( einsteinium ) ; ( 3 ) maintains clinical records on all patients and maintains such records as the Secretary finds to be necessity to determine the degree and volume of the treatment provided to individuals entitled to hospital indemnity benefits under contribution A ; and ( 4 ) meets such staff requirements as the Secretary finds necessary for the initiation to carry out an active program of discussion for individuals who are furnished services in the institution. In the case of an institution which satisfies paragraph ( 1 ) and ( 2 ) of the preceding sentence and which contains a distinct separate which besides satisfies paragraph ( 3 ) and ( 4 ) of such sentence, such discrete part shall be considered to be a “ psychiatric hospital ”. ( thousand ) Outpatient occupational therapy services The term “ outpatient occupational therapy services ” has the mean given the term “ outpatient physical therapy services ” in subsection ( phosphorus ), except that “ occupational ” shall be substituted for “ physical ” each place it appears therein. ( planck’s constant ) Extended worry services The term “ extended concern services ” means the watch items and services furnished to an inpatient of a skilled nurse adeptness and ( except deoxyadenosine monophosphate provided in paragraph ( 3 ), ( 6 ), and ( 7 ) ) by such skilled breastfeed facility — ( 1 ) nursing care provided by or under the supervision of a register professional nanny ; ( 2 ) bed and board in connection with the supply of such breastfeed worry ; ( 3 ) physical or occupational therapy or speech-language pathology services furnished by the skilled nurse facility or by others under arrangements with them made by the facility ; ( 4 ) medical social services ; ( 5 ) such drugs, biologicals, supplies, appliances, and equipment, furnished for habit in the skilled breastfeed facility, as are normally furnished by such adeptness for the care and treatment of inpatients ; ( 6 ) medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement ( meeting the requirements of subsection ( liter ) ), under a education program of such hospital approved as provided in the last conviction of subsection ( b ), and other diagnostic or curative services provided by a hospital with which the facility has such an agreement in effect ; and ( 7 ) such other services necessity to the health of the patients as are by and large provided by skilled nurse facilities, or by others under arrangements with them made by the facility ; excluding, however, any item or service if it would not be included under subsection ( bel ) if furnished to an inpatient of a hospital. ( one ) Post-hospital extended care services The term “ post- hospital extended worry services ” means extended caution services furnished an individual after transmit from a hospital in which he was an inpatient for not less than 3 straight days before his dispatch from the hospital in connection with such transfer. For purposes of the preceding prison term, items and services shall be deemed to have been furnished to an individual after transfer from a hospital, and he shall be deemed to have been an inpatient in the hospital immediately before transfer thence, if he is admitted to the skilled nurse facility ( A ) within 30 days after discharge from such hospital, or ( B ) within such time as it would be medically allow to begin an active class of treatment, in the case of an person whose condition is such that skilled nursing facility care would not be medically appropriate within 30 days after dispatch from a hospital ; and an individual shall be deemed not to have been discharged from a skilled nurse facility if, within 30 days after fire thence, he is admitted to such facility or any other skilled nurse facility. ( j ) Skilled harbor adeptness The term “ skilled nurse facility ” has the meaning given such term in section 1395i–3 ( a ) of this title. ( k ) Utilization review A utilization review plan of a hospital or skilled nursing facility shall be considered sufficient if it is applicable to services furnished by the institution to individuals entitled to policy benefits under this subchapter and if it provides— ( 1 ) for the follow-up, on a sample or early footing, of admissions to the institution, the duration of stays therein, and the professional services ( including drugs and biologicals ) furnished, ( A ) with obedience to the aesculapian necessity of the services, and ( B ) for the purpose of promoting the most effective practice of available health facilities and services ; ( 2 ) for such review to be made by either ( A ) a staff committee of the institution composed of two or more physicians ( of which at least two must be physicians described in subsection ( roentgen ) ( 1 ) of this section ), with or without participation of other master personnel, or ( B ) a group outside the initiation which is similarly composed and ( iodine ) which is established by the local medical society and some or all of the hospitals and skilled nursing facilities in the vicinity, or ( two ) if ( and for equally long as ) there has not been established such a group which serves such mental hospital, which is established in such early manner as may be approved by the Secretary ; ( 3 ) for such review, in each case of inpatient hospital services or extended manage services furnished to such an individual during a continuous menstruation of extended duration, as of such days of such period ( which may differ for unlike classes of cases ) as may be specified in regulations, with such follow-up to be made american samoa promptly as possible, after each day so specified, and in no event later than one workweek following such day ; and ( 4 ) for immediate notification to the mental hospital, the individual, and his attending doctor of any discover ( made after opportunity for consultation to such attendance doctor ) by the doctor members of such committee or group that any further stay in the institution is not medically necessary. The follow-up committee must be composed as provided in clause ( B ) of paragraph ( 2 ) rather than vitamin a provided in clause ( A ) of such paragraph in the case of any hospital or skilled nurse adeptness where, because of the small size of the institution, or ( in the case of a skilled nursing adeptness ) because of lack of an organized medical staff, or for such other reason or reasons as may be included in regulations, it is impracticable for the institution to have a by rights officiate staff committee for the purposes of this subsection. If the Secretary determines that the use reappraisal procedures established pursuant to subchapter XIX are superscript in their effectiveness to the procedures required under this department, he may, to the extent that he deems it appropriate, require for purposes of this subchapter that the procedures established pursuant to subchapter XIX be utilized alternatively of the procedures required by this segment. ( liter ) Agreements for transfer between skilled nursing facilities and hospitals A hospital and a skilled nurse facility shall be considered to have a transfer agreement in effect if, by reason of a written agreement between them or ( in case the two institutions are under common manipulate ) by reason of a written undertake by the person or body which controls them, there is fair assurance that— ( 1 ) transfer of patients will be effected between the hospital and the skilled nursing facility whenever such transfer is medically appropriate as determined by the attending doctor ; and ( 2 ) there will be interchange of medical and other data necessity or utilitarian in the care and treatment of individuals transferred between the institutions, or in determining whether such individuals can be adequately cared for differently than in either of such institutions. Any skilled nurse facility which does not have such an agreement in effect, but which is found by a State agency ( of the State in which such facility is situated ) with which an agreement under section 1395aa of this deed is in effect ( or, in the encase of a State in which no such representation has an agreement under section 1395aa of this title, by the Secretary ) to have attempted in good religion to enter into such an agreement with a hospital sufficiently airless to the adeptness to make feasible the transfer between them of patients and the information referred to in paragraph ( 2 ), shall be considered to have such an agreement in effect if and for indeed long as such representation ( or the Secretary, as the encase may be ) finds that to do sol is in the public interest and all-important to assuring extended care services for persons in the community who are eligible for payments with regard to such services under this subchapter. ( megabyte ) Home health services The term “ family health services ” means the follow items and services furnished to an individual, who is under the caution of a doctor, a nurse practitioner or a clinical nanny specialist ( as those terms are defined in subsection ( associate in arts ) ( 5 ) ), or a doctor assistant ( as defined in subsection ( aa ) ( 5 ) ), by a home health means or by others under arrangements with them made by such means, under a plan ( for furnishing such items and services to such individual ) established and sporadically reviewed by a doctor, a nurse practitioner, a clinical nanny specialist, or a doctor assistant, which items and services are, except vitamin a provided in paragraph ( 7 ), provided on a visiting basis in a place of mansion used as such individual ’ second home— ( 1 ) half-time or intermittent nurse worry provided by or under the supervision of a read professional nanny ; ( 2 ) physical or occupational therapy or speech-language pathology services ; ( 3 ) aesculapian social services under the direction of a doctor, a nurse practitioner, a clinical breastfeed specialist, or a doctor assistant ; ( 4 ) to the extent permitted in regulations, part-time or intermittent services of a home health aide who has successfully completed a trail broadcast approved by the Secretary ; ( 5 ) medical supplies ( including catheters, catheter supplies, ostomy bags, and supplies related to ostomy concern, and a cover osteoporosis drug ( as defined in subsection ( kk ) ), but excluding early drugs and biologicals ) and durable medical equipment and applicable disposable devices ( as defined in section 1395m ( randomness ) ( 2 ) of this title ) while under such a plan ; ( 6 ) in the casing of a dwelling health agency which is affiliated or under coarse dominance with a hospital, medical services provided by an intern or resident-in-training of such hospital, under a teaching program of such hospital approved as provided in the death sentence of subsection ( bel ) ; and ( 7 ) any of the foregoing items and services which are provided on an outpatient basis, under arrangements made by the home health means, at a hospital or skilled breastfeed facility, or at a rehabilitation center which meets such standards as may be prescribed in regulations, and— ( A ) the furnishing of which involves the use of equipment of such a nature that the items and services can not readily be made available to the individual in such locate of residency, or ( B ) which are furnished at such facility while he is there to receive any such item or service described in clause ( A ), but not including transportation of the individual in association with any such token or service ; excluding, however, any item or avail if it would not be included under subsection ( b-complex vitamin ) if furnished to an inpatient of a hospital and home infusion therapy ( as defined in subsection ( three ) ( i ) ). For purposes of paragraph ( 1 ) and ( 4 ), the condition “ half-time or intermittent services ” means skilled nurse and home health adjutant services furnished any number of days per week deoxyadenosine monophosphate long as they are furnished ( combined ) less than 8 hours each day and 28 or fewer hours each workweek ( or, subject to review on a individual footing as to the need for care, less than 8 hours each day and 35 or fewer hours per week ). For purposes of sections 1395f ( a ) ( 2 ) ( C ) and 1395n ( a ) ( 2 ) ( A ) of this title, “ intermittent ” means skilled harbor wish that is either put up or needed on fewer than 7 days each week, or less than 8 hours of each day for periods of 21 days or less ( with extensions in exceptional circumstances when the want for extra care is finite and predictable ). ( normality ) Durable aesculapian equipment The term “ durable medical equipment ” includes iron lungs, oxygen tents, hospital beds, and wheelchairs ( which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the practice of such a vehicle is determined to be necessary on the basis of the person ’ s medical and physical condition and the vehicle meets such condom requirements as the Secretary may prescribe ) used in the patient ’ s home ( including an initiation used as his home other than an institution that meets the requirements of subsection ( east ) ( 1 ) of this section or section 1395i–3 ( a ) ( 1 ) of this claim ), whether furnished on a rental footing or purchased, and includes blood-testing strips and blood glucose monitors for individuals with diabetes without regard to whether the individual has Type I or Type II diabetes or to the individual ’ mho habit of insulin ( as determined under standards established by the Secretary in consultation with the appropriate organizations ) and eye track and gaze interaction accessories for speech generating devices furnished to individuals with a demonstrate medical motivation for such accessories ; except that such terminus does not include such equipment furnished by a supplier who has used, for the demonstration and habit of particular equipment, an individual who has not met such minimal trail standards as the Secretary may establish with regard to the demonstration and use of such particular equipment. With esteem to a seat-lift electric chair, such term includes only the seat-lift mechanism and does not include the electric chair. ( o ) Home health agency The term “ family health representation ” means a public agency or secret organization, or a subdivision of such an agency or organization, which— ( 1 ) is chiefly engaged in providing skilled breastfeed services and other curative services ; ( 2 ) has policies, established by a group of professional personnel ( associated with the agency or organization ), including one or more physicians, nanny practitioners or clinical breastfeed specialists ( as those terms are defined in subsection ( associate in arts ) ( 5 ) ), certified nurse-midwives ( as defined in subsection ( gg ) ), or doctor assistants ( as defined in subsection ( associate in arts ) ( 5 ) ) and one or more record professional nurses, to govern the services ( referred to in paragraph ( 1 ) ) which it provides, and provides for supervision of such services by a doctor, nanny practitioner, clinical nurse specialist, certified nurse-midwife, doctor adjunct, or registered professional harbor ; ( 3 ) maintains clinical records on all patients ; ( 4 ) in the case of an agency or organization in any State in which State or applicable local anesthetic police provides for the license of agencies or organizations of this nature, ( A ) is licensed pursuant to such law, or ( B ) is approved, by the agency of such State or vicinity responsible for licensing agencies or organizations of this nature, as meeting the standards established for such license ; ( 5 ) has in consequence an overall plan and budget that meets the requirements of subsection ( z ) ; ( 6 ) meets the conditions of participation specified in section 1395bbb ( a ) of this entitle and such other conditions of engagement as the Secretary may find necessary in the interest of the health and safety of individuals who are furnished services by such representation or constitution ; ( 7 ) provides the Secretary with a hostage bond— ( A ) in a kind specified by the Secretary and in an sum that is not less than the minimum of $ 50,000 ; and ( B ) that the Secretary determines is commensurate with the volume of payments to the base health agency ; and ( 8 ) meets such extra requirements ( including conditions relating to bonding or establishing of escrow accounts as the Secretary finds necessary for the fiscal security of the course of study ) as the Secretary finds necessity for the effective and efficient operation of the program ; except that for purposes of part A such condition shall not include any means or organization which is primarily for the caution and treatment of mental diseases. The Secretary may waive the prerequisite of a security attachment under paragraph ( 7 ) in the sheath of an agency or constitution that provides a comparable security bond under State law. ( p ) Outpatient physical therapy services The term “ outpatient physical therapy services ” means physical therapy services furnished by a supplier of services, a clinic, reclamation agency, or a public health agency, or by others under an agreement with, and under the supervision of, such provider, clinic, rehabilitation agency, or public health representation to an individual as an outpatient— ( 1 ) who is under the care of a doctor ( as defined in paragraph ( 1 ), ( 3 ), or ( 4 ) of subsection ( radius ) ), and ( 2 ) with deference to whom a plan prescribing the type, amount, and duration of forcible therapy services that are to be furnished such individual has been established by a doctor ( as indeed defined ) or by a qualify forcible therapist and is sporadically reviewed by a doctor ( as so define ) ; excluding, however— ( 3 ) any detail or service if it would not be included under subsection ( boron ) if furnished to an inpatient of a hospital ; and ( 4 ) any such service— ( A ) if furnished by a clinic or rehabilitation agency, or by others under arrangements with such clinic or representation, unless such clinic or rehabilitation agency— ( one ) provides an adequate program of physical therapy services for outpatients and has the facilities and personnel required for such program or required for the supervision of such a program, in accordance with such requirements as the Secretary may specify, ( two ) has policies, established by a group of professional personnel, including one or more physicians ( associated with the clinic or rehabilitation agency ) and one or more restricted physical therapists, to govern the services ( referred to in clause ( i ) ) it provides, ( three ) maintains clinical records on all patients, ( four ) if such clinic or agency is situated in a State in which State or applicable local anesthetic jurisprudence provides for the license of institutions of this nature, ( I ) is licensed pursuant to such police, or ( II ) is approved by the agency of such State or vicinity responsible for licensing institutions of this nature, as meeting the standards established for such license ; and ( vanadium ) meets such early conditions relating to the health and guard of individuals who are furnished services by such clinic or agency on an outpatient footing, as the Secretary may find necessity, and provides the Secretary on a continuing footing with a guarantor bind in a shape specified by the Secretary and in an amount that is not less than $ 50,000, or ( B ) if furnished by a populace health agency, unless such agency meets such other conditions relating to health and safety of individuals who are furnished services by such agency on an outpatient basis, as the Secretary may find necessary. The term “ outpatient physical therapy services ” besides includes physical therapy services furnished an individual by a physical therapist ( in his office or in such individual ’ s home ) who meets license and early standards prescribed by the Secretary in regulations, otherwise than under an agreement with and under the supervision of a provider of services, clinic, rehabilitation agency, or public health agency, if the furnishing of such services meets such conditions relating to health and condom as the Secretary may find necessary. In addition, such term includes forcible therapy services which meet the requirements of the first gear sentence of this subsection except that they are furnished to an individual as an inpatient of a hospital or extended concern facility. nothing in this subsection shall be construed as ask, with esteem to outpatients who are not entitled to benefits under this subchapter, a forcible therapist to provide outpatient physical therapy services only to outpatients who are under the care of a doctor or pursuant to a plan of manage established by a doctor. The Secretary may waive the prerequisite of a security adhesiveness under paragraph ( 4 ) ( A ) ( v ) in the case of a clinic or means that provides a comparable security adhesiveness under State jurisprudence. ( q ) Physicians ’ services The term “ physicians ’ services ” means professional services performed by physicians, including operating room, reference, and home, office, and institutional calls ( but not including services described in subsection ( b ) ( 6 ) ). ( gas constant ) Physician The term “ doctor ”, when used in connection with the operation of any function or carry through, means ( 1 ) a doctor of medicine or osteopathy legally authorized to commit medicine and operating room by the State in which he performs such routine or action ( including a doctor within the meaning of section 1301 ( a ) ( 7 ) of this title ), ( 2 ) a repair of alveolar consonant surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions, ( 3 ) a doctor of podiatric medicine for the purposes of subsections ( kilobyte ), ( thousand ), ( phosphorus ) ( 1 ), and ( s ) of this section and sections 1395f ( a ), 1395k ( a ) ( 2 ) ( F ) ( two ), and 1395n of this title but lone with respect to functions which he is legally authorized to perform as such by the State in which he performs them, ( 4 ) a doctor of optometry, but entirely for purposes of subsection ( p ) ( 1 ) and with respect to the provision of items or services described in subsection ( sulfur ) which he is legally authorized to perform as a doctor of optometry by the State in which he performs them, or ( 5 ) a chiropractor who is licensed as such by the State ( or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services ), and who meets uniform minimum standards promulgated by the Secretary, but only for the purpose of subsections ( south ) ( 1 ) and ( sulfur ) ( 2 ) ( A ) and only with respect to treatment by means of manual handling of the spinal column ( to correct a subluxation ) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided. For the purposes of section 1395y ( a ) ( 4 ) of this title and subject to the limitations and conditions provided in the former conviction, such term includes a doctor of one of the arts, specified in such former sentence, legally authorized to practice such art in the area in which the inpatient hospital services ( referred to in such section 1395y ( a ) ( 4 ) of this title ) are furnished. ( second ) Medical and other health services The term “ aesculapian and early health services ” means any of the keep up items or services : ( 1 ) physicians ’ services ; ( 2 ) ( A ) services and supplies ( including drugs and biologicals which are not normally self-administered by the patient ) furnished as an incident to a doctor ’ s professional service, of kinds which are normally furnished in physicians ’ offices and are normally either rendered without cathexis or included in the physicians ’ bills ( or would have been therefore include but for the application of section 1395w–3b of this title ) ; ( B ) hospital services ( including drugs and biologicals which are not normally self-administered by the affected role ) incidental to physicians ’ services rendered to outpatients and partial hospitalization services incidental to such services ; ( C ) diagnostic services which are— ( iodine ) furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital, and ( two ) normally furnished by such hospital ( or by others under such arrangements ) to its outpatients for the purpose of diagnostic sketch ; ( D ) outpatient physical therapy services, outpatient speech-language pathology services, and outpatient occupational therapy services ; ( E ) rural health clinic services and Federally qualified health center services ; ( F ) home dialysis supplies and equipment, self-care base dialysis support services, and institutional dialysis services and supplies, and, for items and services furnished on or after, nephritic dialysis services ( as defined in section 1395rr ( barn ) ( 14 ) ( B ) of this title ), including such nephritic dialysis services furnished on or after, by a nephritic dialysis facility or supplier of services paid under section 1395rr ( bel ) ( 14 ) of this title to an individual with acute kidney injury ( as defined in segment 1395m ( gas constant ) ( 2 ) of this title ) ; ( G ) antigens ( capable to quantity limitations prescribed in regulations by the Secretary ) prepared by a doctor, as defined in subsection ( roentgen ) ( 1 ), for a finical affected role, including antigens so prepare which are forwarded to another qualified person ( including a rural health clinic ) for administration to such patient, from time to meter, by or under the supervision of another such doctor ; ( H ) ( one ) services furnished pursuant to a shrink under section 1395mm of this claim to a member of an eligible constitution by a doctor assistant or by a nurse practitioner ( as defined in subsection ( associate in arts ) ( 5 ) ) and such services and supplies furnished as an incident to his overhaul to such a penis as would otherwise be covered under this part if furnished by a doctor or as an incident to a doctor ’ randomness servicing ; and ( two ) services furnished pursuant to a risk-sharing contract under section 1395mm ( guanine ) of this deed to a member of an eligible organization by a clinical psychologist ( as defined by the Secretary ) or by a clinical social worker ( as defined in subsection ( hh ) ( 2 ) ), and such services and supplies furnished as an incidental to such clinical psychologist ’ south services or clinical social actor ’ randomness services to such a member as would otherwise be covered under this part if furnished by a doctor or as an incident to a doctor ’ randomness service ; ( I ) lineage clotting factors, for hemophilia patients competent to use such factors to control bleeding without checkup or other supervision, and items related to the administration of such factors, topic to use controls deemed necessity by the Secretary for the efficient use of such factors ; ( J ) prescription drugs used in immunosuppressive therapy furnished, to an individual who receives an organ transplant for which payment is made under this subchapter ; ( K ) ( i ) services which would be physicians ’ services and services described in subsections ( ww ) ( 1 ) and ( hhh ) if furnished by a doctor ( as defined in subsection ( gas constant ) ( 1 ) ) and which are performed by a doctor adjunct ( as defined in subsection ( associate in arts ) ( 5 ) ) under the supervision of a doctor ( as therefore defined ) and which the doctor adjunct is legally authorized to perform by the State in which the services are performed, and such services and supplies furnished as incident to such services as would be covered under subparagraph ( A ) if furnished incident to a doctor ’ s professional service, but lone if no facility or early provider charges or is paid any amounts with deference to the supply of such services, ( two ) services which would be physicians ’ services and services described in subsections ( ww ) ( 1 ) and ( hhh ) if furnished by a doctor ( as defined in subsection ( r ) ( 1 ) ) and which are performed by a nurse practitioner or clinical nurse specialist ( as defined in subsection ( alcoholics anonymous ) ( 5 ) ) working in collaboration ( as defined in subsection ( associate in arts ) ( 6 ) ) with a doctor ( as defined in subsection ( radius ) ( 1 ) ) which the nurse practitioner or clinical nanny specialist is legally authorized to perform by the State in which the services are performed, and such services and supplies furnished as an incidental to such services as would be covered under subparagraph ( A ) if furnished incident to a doctor ’ s master serve, but only if no adeptness or other supplier charges or is paid any amounts with respect to the furnishing of such services ; ( L ) certified nurse-midwife services ; ( M ) qualified psychologist services ; ( N ) clinical social proletarian services ( as defined in subsection ( hh ) ( 2 ) ) ; ( O ) erythropoietin for dialysis patients competent to use such drug without medical or other supervision with respect to the government of such drug, subject to methods and standards established by the Secretary by regulation for the safe and effective habit of such drug, and items related to the administration of such drug ; ( P ) prostate cancer screening tests ( as defined in subsection ( oo ) ) ; ( Q ) an oral drug ( which is approved by the Federal Food and Drug Administration ) prescribed for consumption as an anticancer chemotherapeutic agentive role for a given indication, and containing an active agent ingredient ( or ingredients ), which is the lapp indication and active ingredient ( or ingredients ) as a drug which the carrier determines would be covered pursuant to subparagraph ( A ) or ( B ) if the drug could not be self-administered ; ( R ) colorectal cancer screening tests ( as defined in subsection ( pp ) ) ; and ( S ) diabetes outpatient self-management train services ( as defined in subsection ( qq ) ) ; ( T ) an oral drug ( which is approved by the Federal Food and Drug Administration ) prescribed for use as an acute anti-emetic used as part of an anticancer chemotherapeutic regimen if the drug is administered by a doctor ( or as prescribed by a doctor ) — ( one ) for manipulation immediately before, at, or within 48 hours after the time of the government of the anticancer chemotherapeutic agent ; and ( two ) as a full successor for the anti-emetic therapy which would otherwise be administered intravenously ; ( U ) screening for glaucoma ( as defined in subsection ( uu ) ) for individuals determined to be at high risk for glaucoma, individuals with a family history of glaucoma and individuals with diabetes ; ( V ) aesculapian nutriment therapy services ( as defined in subsection ( vv ) ( 1 ) ) in the shell of a beneficiary with diabetes or a nephritic disease who— ( iodine ) has not received diabetes outpatient self-management educate services within a time period determined by the Secretary ; ( two ) is not receiving alimony dialysis for which payment is made under section 1395rr of this style ; and ( three ) meets such other criteria determined by the Secretary after consideration of protocols established by dietician or nutrition professional organizations ; ( W ) an initial hindrance physical examen ( as defined in subsection ( ww ) ) ; ( X ) cardiovascular screening blood tests ( as defined in subsection ( twenty ) ( 1 ) ) ; ( Y ) diabetes screening tests ( as defined in subsection ( yy ) ) ; ( Z ) intravenous immune globulin for the treatment of primary immune insufficiency diseases in the home ( as defined in subsection ( zz ) ) ; ( AA ) ultrasound screening for abdominal aortal aneurysm ( as defined in subsection ( bbb ) ) for an individual— ( iodine ) who receives a referral for such an sonography shield as a leave of an initial contraceptive physical interrogation ( as defined in subsection ( ww ) ( 1 ) ) ; ( two ) who has not been previously furnished such an ultrasound riddle under this subchapter ; and ( three ) who— ( I ) has a family history of abdominal aortal aneurysm ; or ( II ) manifests risk factors included in a benefactive role category recommended for screening by the United States Preventive Services Task Force regarding abdominal aortal aneurysms ; ( BB ) extra hindrance services ( described in subsection ( ddd ) ( 1 ) ) ; ( CC ) items and services furnished under a cardiac rehabilitation program ( as defined in subsection ( eee ) ( 1 ) ) or under a pneumonic rehabilitation plan ( as defined in subsection ( fff ) ( 1 ) ) ; ( DD ) items and services furnished under an intensive cardiac rehabilitation plan ( as defined in subsection ( eee ) ( 4 ) ) ; ( EE ) kidney disease department of education services ( as defined in subsection ( ggg ) ) ; ( FF ) personalized prevention plan services ( as defined in subsection ( hhh ) ) ; ( GG ) home infusion therapy ( as defined in subsection ( three ) ( 1 ) ) ; and ( HH ) opioid use perturb treatment services ( as defined in subsection ( jjj ) ). ( 3 ) diagnostic x ray tests ( including tests under the supervision of a doctor, furnished in a topographic point of mansion used as the patient ’ s home, if the operation of such tests meets such conditions relating to health and base hit as the Secretary may find necessity and including diagnostic mammography if conducted by a facility that has a security ( or probationary certificate ) issued under section 354 of the Public Health Service Act [ 42 U.S.C. 263b ] ), diagnostic lab tests, and other diagnostic tests ; ( 4 ) x ray, radium, and radioactive isotope therapy, including materials and services of technicians ; ( 5 ) surgical dressings, and splints, casts, and other devices used for decrease of fractures and dislocations ; ( 6 ) durable medical equipment ; ( 7 ) ambulance serve where the practice of other methods of transportation is contra­indicated by the individual ’ sulfur condition, but, discipline to section 1395m ( l ) ( 14 ) of this title, only to the extent provided in regulations ; ( 8 ) prosthetic devices ( other than dental ) which replace all or region of an inner consistency organ ( including colostomy bags and supplies directly related to colostomy care ), including replacement of such devices, and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens ; ( 9 ) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a deepen in the patient ’ s physical condition ; ( 10 ) ( A ) pneumococcal vaccine and its administration and, subject to section 4071 ( b ) of the Omnibus Budget Reconciliation Act of 1987, influenza vaccine and its government, and COVID–19 vaccine and its administration ; and ( B ) hepatitis B vaccine and its administration, furnished to an individual who is at high or intermediate risk of contracting hepatitis B ( as determined by the Secretary under regulations ) ; ( 11 ) services of a certify registered nurse anesthesiologist ( as defined in subsection ( bb ) ) ; ( 12 ) capable to section 4072 ( einsteinium ) of the Omnibus Budget Reconciliation Act of 1987, extra-depth shoes with inserts or custom molded shoes with inserts for an individual with diabetes, if— ( A ) the doctor who is managing the person ’ sulfur diabetic circumstance ( i ) documents that the individual has peripheral neuropathy with evidence of callosity formation, a history of pre-ulcerative calluses, a history of previous ulcer, foot deformity, or former amputation, or poor circulation, and ( two ) certifies that the individual needs such shoes under a comprehensive plan of worry related to the individual ’ randomness diabetic circumstance ; ( B ) the particular type of shoes are prescribed by a chiropodist or other dependent doctor ( as established by the Secretary ) ; and ( C ) the shoes are fitted and furnished by a chiropodist or other qualified individual ( such as a pedorthist or orthotist, as established by the Secretary ) who is not the doctor described in subparagraph ( A ) ( unless the Secretary finds that the doctor is the only such qualified individual in the area ) ; ( 13 ) riddle mammography ( as defined in subsection ( jj ) ) ; ( 14 ) screening soft diet smear and screening pelvic examination ; and ( 15 ) bone mass measurement ( as defined in subsection ( rr ) ). No diagnostic tests performed in any lab, including a lab that is separate of a rural health clinic, or a hospital ( which, for purposes of this prison term, means an institution considered a hospital for purposes of section 1395f ( d ) of this style ) shall be included within paragraph ( 3 ) unless such laboratory— ( 16 ) if situated in any State in which State or applicable local anesthetic law provides for license of establishments of this nature, ( A ) is licensed pursuant to such law, or ( B ) is approved, by the agency of such State or vicinity creditworthy for licensing establishments of this nature, as meeting the standards established for such license ; and ( 17 ) ( A ) meets the certificate requirements under section 353 of the Public Health Service Act [ 42 U.S.C. 263a ] ; and ( B ) meets such other conditions relating to the health and condom of individuals with deference to whom such tests are performed as the Secretary may find necessary. There shall be excluded from the diagnostic services specified in paragraph ( 2 ) ( C ) any detail or overhaul ( except services referred to in paragraph ( 1 ) ) which would not be included under subsection ( bel ) if it were furnished to an inpatient of a hospital. none of the items and services referred to in the precede paragraph ( early than paragraphs ( 1 ) and ( 2 ) ( A ) ) of this subsection which are furnished to a patient of an mental hospital which meets the definition of a hospital for purposes of department 1395f ( d ) of this deed shall be included unless such other conditions are met as the Secretary may find necessary relating to health and safety of individuals with deference to whom such items and services are furnished. ( metric ton ) Drugs and biologicals ( 1 ) The term “ drugs ” and the condition “ biologicals ”, except for purposes of subsection ( meter ) ( 5 ) of this section and paragraph ( 2 ), include merely such drugs ( including contrast agents ) and biologicals, respectively, as are included ( or approved for inclusion body ) in the United States Pharmacopoeia, the National Formulary, or the United States Homeopathic Pharmacopoeia, or in New Drugs or Accepted Dental Remedies ( except for any drugs and biologicals unfavorably evaluated therein ), or as are approved by the drugstore and drug therapeutics committee ( or equivalent committee ) of the medical staff of the hospital furnish such drugs and biologicals for habit in such hospital. ( 2 ) ( A ) For purposes of paragraph ( 1 ), the term “ drugs ” besides includes any drugs or biologicals used in an anticancer chemotherapeutic regimen for a medically accepted indication ( as described in subparagraph ( B ) ). ( B ) In subparagraph ( A ), the term “ medically accepted reading ”, with respect to the use of a drug, includes any use which has been approved by the Food and Drug Administration for the drug, and includes another use of the drug if— ( iodine ) the drug has been approved by the Food and Drug Administration ; and ( two ) ( I ) such use is supported by one or more citations which are included ( or approved for inclusion body ) in one or more of the come compendia : the american Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluations, the United States Pharmacopoeia-Drug Information ( or its successor publications ), and early authoritative compendia as identified by the Secretary, unless the Secretary has determined that the use is not medically appropriate or the manipulation is identified as not indicated in one or more such compendia, or ( II ) the carrier involved determines, based upon guidance provided by the Secretary to carriers for determining accept uses of drugs, that such practice is medically accepted based on supportive clinical tell in peer reviewed aesculapian literature appearing in publications which have been identified for purposes of this subclause by the Secretary. The Secretary may revise the list of compendia in clause ( two ) ( I ) as is allow for identifying medically accepted indications for drugs. On and after, no compendia may be included on the list of compendia under this subparagraph unless the compendia has a publicly diaphanous summons for evaluating therapies and for identifying potential conflicts of interests. ( uranium ) provider of services The term “ supplier of services ” means a hospital, critical access hospital, rural emergency hospital, skilled nursing adeptness, comprehensive outpatient reclamation adeptness, dwelling health means, hospice program, or, for purposes of section 1395f ( g ) and incision 1395n ( east ) of this title, a fund. ( volt ) fair costs ( 1 ) ( A ) The reasonable cost of any services shall be the monetary value actually incurred, excluding therefrom any separate of receive price found to be unnecessary in the efficient delivery of needed health services, and shall be determined in accord with regulations establishing the method or methods to be used, and the items to be included, in determining such costs for diverse types or classes of institutions, agencies, and services ; except that in any lawsuit to which paragraph ( 2 ) or ( 3 ) applies, the amount of the requital determined under such paragraph with deference to the services involved shall be considered the reasonable cost of such services. In prescribing the regulations referred to in the precede conviction, the Secretary shall consider, among other things, the principles generally applied by national organizations or established prepayment organizations ( which have developed such principles ) in computing the amount of requital, to be made by persons other than the recipients of services, to providers of services on account of services furnished to such recipients by such providers. such regulations may provide for decision of the costs of services on a per diem, per unit, per head, or other footing, may provide for using different methods in different circumstances, may provide for the use of estimates of costs of particular items or services, may provide for the institution of limits on the direct or indirect overall incurred costs or receive costs of particular items or services or groups of items or services to be recognized as reasonable based on estimates of the costs necessary in the effective delivery of needed health services to individuals covered by the indemnity programs established under this subchapter, and may provide for the function of charges or a percentage of charges where this method acting sanely reflects the costs. such regulations shall ( i ) take into account both lead and indirect costs of providers of services ( excluding therefrom any such costs, including standby costs, which are determined in accord with regulations to be unnecessary in the effective delivery of services covered by the insurance programs established under this subchapter ) in orderliness that, under the methods of determining costs, the necessary costs of efficiently delivering covered services to individuals covered by the policy programs established by this subchapter will not be borne by individuals not therefore cover, and the costs with regard to individuals not thus covered will not be borne by such policy programs, and ( two ) provide for the do of desirable ex post facto corrective adjustments where, for a supplier of services for any fiscal menstruation, the sum reimbursement produced by the methods of determining costs proves to be either inadequate or excessive. ( B ) In the case of extended care services, the regulations under subparagraph ( A ) shall not include provision for specific recognition of a return on equity capital. ( C ) Where a hospital has an agreement with a checkup school under which the staff of such educate provides services at such hospital, an amount not in surfeit of the fair price of such services to the medical school shall be included in determining the reasonable cost to the hospital of furnishing services— ( one ) for which payment may be made under part A, but entirely if— ( I ) payment for such services as furnished under such arrangement would be made under part A to the hospital had such services been furnished by the hospital, and ( II ) such hospital pays to the medical educate at least the fair cost of such services to the checkup school, or ( two ) for which payment may be made under depart B, but only if such hospital pays to the medical school at least the fair monetary value of such services to the medical educate. ( D ) Where ( i ) physicians supply services which are either inpatient hospital services ( including services in conjunction with the teaching programs of such hospital ) by reason of paragraph ( 7 ) of subsection ( bacillus ) or for which entitlement exists by reason of clause ( II ) of section 1395k ( a ) ( 2 ) ( B ) ( i ) of this style, and ( two ) such hospital ( or medical school under musical arrangement with such hospital ) incurs no actual cost in the furnishing of such services, the reasonable cost of such services shall ( under regulations of the Secretary ) be deemed to be the price such hospital or medical school would have incurred had it paid a wage to such physicians rendering such services approximately equivalent to the average wage paid to all physicians employed by such hospital ( or if such employment does not exist, or is minimal in such hospital, by similar hospitals in a geographic area of sufficient size to assure fair inclusion of sufficient physicians in exploitation of such average wage ). ( E ) such regulations may, in the case of skilled breastfeed facilities in any State, provide for the use of rates, developed by the State in which such facilities are located, for the requital of the cost of skilled nurse facility services furnished under the State ’ sulfur plan approved under subchapter XIX ( and such rates may be increased by the Secretary on a class or size of initiation or on a geographic basis by a share factor not in overindulgence of 10 percentage to take into account determinable items or services or other requirements under this subchapter not otherwise included in the calculation of such State rates ), if the Secretary finds that such rates are sanely related to ( but not necessarily limited to ) analyses undertaken by such State of costs of care in comparable facilities in such State. Notwithstanding the previous conviction, such regulations with deference to skilled nursing facilities shall take into report ( in a manner coherent with subparagraph ( A ) and based on patient-days of services furnished ) the costs ( including the costs of services required to attain or maintain the highest operable physical, mental, and psychosocial wellbeing of each nonmigratory eligible for benefits under this subchapter ) of such facilities complying with the requirements of subsections ( b ), ( deoxycytidine monophosphate ), and ( d ) of section 1395i–3 of this championship ( including the costs of conducting nurse adjutant train and competence evaluation programs and competence evaluation programs ). ( F ) such regulations shall require each provider of services ( other than a fund ) to make reports to the Secretary of data described in section 1320a ( a ) of this championship in accordance with the uniform report system ( established under such section ) for that type of supplier. ( G ) ( i ) In any case in which a hospital provides inpatient services to an individual that would constitute post- hospital extended wish services if provided by a skilled nurse adeptness and a quality improvement organization ( or, in the absence of such a qualified organization, the Secretary or such agent as the Secretary may designate ) determines that inpatient hospital services for the person are not medically necessary but post- hospital extended concern services for the person are medically necessary and such extended care services are not otherwise available to the individual ( as determined in accord with criteria established by the Secretary ) at the time of such decision, payment for such services provided to the individual shall continue to be made under this subchapter at the requital rate described in clause ( two ) during the period in which— ( I ) such post- hospital extended care services for the individual are medically necessary and not otherwise available to the individual ( as so determined ), ( II ) inpatient hospital services for the individual are not medically necessary, and ( III ) the individual is entitled to have requital made for post- hospital extended care services under this subchapter, except that if the Secretary determines that there is not an excess of hospital beds in such hospital and ( subjugate to clause ( intravenous feeding ) ) there is not an overindulgence of hospital beds in the area of such hospital, such requital shall be made ( during such time period ) on the footing of the sum otherwise account payable under part A with deference to inpatient hospital services. ( two ) ( I ) Except deoxyadenosine monophosphate provided in subclause ( II ), the payment rate referred to in clause ( i ) is a rate equal to the estimated adjusted State -wide average rate per patient-day paid for services provided in skilled harbor facilities under the State plan approved under subchapter nineteen for the State in which such hospital is located, or, if the State in which the hospital is located does not have a State design approved under subchapter XIX, the estimated adjusted State- wide average allowable costs per patient-day for extended care services under this subchapter in that State. ( II ) If a hospital has a unit which is a skilled nurse facility, the payment rate referred to in article ( i ) for the hospital is a rate adequate to the less of the rate described in subclause ( I ) or the allowable costs in effect under this subchapter for extended wish services provided to patients of such whole. ( three ) Any day on which an individual receives inpatient services for which payment is made under this subparagraph shall, for purposes of this chapter ( early than this subparagraph ), be deemed to be a day on which the individual received inpatient hospital services. ( four ) In determining under article ( iodine ), in the subject of a public hospital, whether or not there is an excess of hospital beds in the area of such hospital, such determination shall be made on the footing of only the public hospitals ( including the hospital ) which are in the sphere of the hospital and which are under common ownership with that hospital. ( H ) In determining such reasonable monetary value with deference to home health agencies, the Secretary may not include— ( one ) any costs incurred in connection with bond or establishing an escrow account by any such means as a consequence of the security bond prerequisite described in subsection ( oxygen ) ( 7 ) and the fiscal security requirement described in subsection ( o ) ( 8 ) ; ( two ) in the encase of dwelling health agencies to which the security adhere necessity described in subsection ( oxygen ) ( 7 ) and the fiscal security necessity described in subsection ( o ) ( 8 ) give, any costs attributed to interest charged such an means in connection with amounts borrowed by the representation to repay overpayments made under this subchapter to the means, except that such costs may be included in fair cost if the Secretary determines that the means was acting in good religion in borrowing the amounts ; ( three ) in the font of contracts entered into by a dwelling health representation after, for the aim of having services furnished for or on behalf of such agency, any cost incurred by such agency pursuant to any such contract which is entered into for a time period exceeding five years ; and ( intravenous feeding ) in the casing of contracts entered into by a home health agency before, for the aim of having services furnished for or on behalf of such representation, any cost incurred by such agency pursuant to any such contract, which determines the sum account payable by the home health agency on the footing of a percentage of the representation ’ second reimbursement or claim for reimbursement for services furnished by the means, to the extent that such cost exceeds the reasonable prize of the services furnished on behalf of such representation. ( I ) In determining such reasonable price, the Secretary may not include any costs incurred by a provider with respect to any services furnished in association with matters for which requital may be made under this subchapter and furnished pursuant to a abridge between the supplier and any of its subcontractors which is entered into after, and the value or cost of which is $ 10,000 or more over a twelve-month time period unless the contract contains a clause to the effect that— ( iodine ) until the passing of four years after the supply of such services pursuant to such contract, the subcontractor shall make available, upon written request by the Secretary, or upon request by the Comptroller General, or any of their punctually authorized representatives, the contract, and books, documents and records of such subcontractor that are necessary to certify the nature and extent of such costs, and ( two ) if the subcontractor carries out any of the duties of the abridge through a subcontract, with a value or cost of $ 10,000 or more over a twelve-month time period, with a associate organization, such subcontract shall contain a clause to the impression that until the exhalation of four years after the supply of such services pursuant to such subcontract, the related organization shall make available, upon written request by the Secretary, or upon request by the Comptroller General, or any of their punctually authorized representatives, the subcontract, and books, documents and rec­ords of such organization that are necessary to verify the nature and extent of such costs. The Secretary shall prescribe in regulation criteria and procedures which the Secretary shall use in obtaining access to books, documents, and records under clauses required in contracts and subcontracts under this subparagraph. ( J ) such regulations may not provide for any inpatient routine wage cost differential as a reimbursable monetary value for hospitals and skilled nurse facilities. ( K ) ( i ) The Secretary shall issue regulations that provide, to the extent feasible, for the administration of limitations on the amount of any costs or charges that shall be considered reasonable with esteem to services provided on an outpatient basis by hospitals ( other than bona fide hand brake services as defined in article ( two ) ) or clinics ( other than rural health clinics ), which are reimbursed on a monetary value basis or on the basis of price related charges, and by physicians utilizing such outpatient facilities. such limitations shall be reasonably related to the charges in the lapp area for exchangeable services provided in physicians ’ offices. such regulations shall provide for exceptions to such limitations in cases where alike services are not broadly available in physicians ’ offices in the area to individuals entitled to benefits under this subchapter. ( two ) For purposes of article ( iodine ), the term “ bona fide hand brake services ” means services provided in a hospital emergency room after the sudden onset of a medical condition manifesting itself by acuate symptoms of sufficient asperity ( including dangerous pain ) such that the absence of immediate medical care could sanely be expected to result in— ( I ) placing the patient ’ s health in serious hazard ; ( II ) unplayful impairment to bodily functions ; or ( III ) serious dysfunction of any bodily organ or part. ( L ) ( i ) The Secretary, in determining the sum of the payments that may be made under this subchapter with deference to services furnished by family health agencies, may not recognize as fair ( in the effective delivery of such services ) costs for the provision of such services by an agency to the extent these costs exceed ( on the aggregate for the agency ) for price report periods beginning on or after— ( I ), and before, 120 percentage of the intend of the labor-related and nonlabor per visit costs for freestanding base health agencies, ( II ), and before, 115 percentage of such mean, ( III ), and before, 112 percentage of such mean, ( IV ), and before, 105 percentage of the medial of the labor-related and nonlabor per visit costs for freestanding home health agencies, or ( V ), 106 percentage of such median. ( two ) Effective for price coverage periods beginning on or after, such limitations shall be applied on an aggregate basis for the means, rather than on a discipline specific footing. The Secretary may provide for such exemptions and exceptions to such limit as he deems appropriate. ( three ) not later than, and annually thereafter ( but not for cost report periods beginning on or after, and before, or on or after, and before ), the Secretary shall establish limits under this subparagraph for cost coverage periods beginning on or after such date by utilizing the sphere engage index applicable under section 1395ww ( vitamin d ) ( 3 ) ( E ) of this deed and determined using the survey of the most recent available wages and wage-related costs of hospitals located in the geographic area in which the dwelling health service is furnished ( determined without see to whether such hospitals have been reclassified to a new geographic area pursuant to section 1395ww ( five hundred ) ( 8 ) ( B ) of this claim, a decision of the Medicare Geographic Classification Review Board under section 1395ww ( five hundred ) ( 10 ) of this title, or a decision of the Secretary ). ( intravenous feeding ) In establishing limits under this subparagraph for price coverage periods beginning after, the Secretary shall not take into report any changes in the family health market basket, as determined by the Secretary, with deference to cost report periods which began on or after, and before. ( vanadium ) For services furnished by home plate health agencies for cost coverage periods beginning on or after, subject to clause ( eight ) ( I ), the Secretary shall provide for an interim system of limits. Payment shall not exceed the costs determined under the preceding provisions of this subparagraph or, if lower, the intersection of— ( I ) an agency-specific per beneficiary annual restriction calculated based 75 percentage on 98 percentage of the reasonable costs ( including nonroutine aesculapian supplies ) for the means ’ s 12-month price report period ending during fiscal year 1994, and based 25 percentage on 98 percentage of the standardized regional average of such costs for the agency ’ second census division, as applied to such agency, for cost report periods ending during fiscal class 1994, such costs updated by the home health market basket index ; and ( II ) the agency ’ sulfur unduplicated census count of patients ( entitled to benefits under this subchapter ) for the cost report period discipline to the limitation. ( six ) For services furnished by home health agencies for monetary value report periods beginning on or after, the following rules apply : ( I ) For new providers and those providers without a 12-month cost report period ending in fiscal year 1994 submit to clauses ( eight ) ( II ) and ( eight ) ( III ), the per benefactive role limitation shall be equal to the median of these limits ( or the Secretary ’ s best estimates thereof ) applied to other home plate health agencies as determined by the Secretary. A home health means that has altered its corporate structure or name shall not be considered a new supplier for this purpose. ( II ) For beneficiaries who use services furnished by more than one base health agency, the per beneficiary limitations shall be prorated among the agencies. ( seven ) ( I ) not later than, the Secretary shall establish per visit limits applicable for fiscal year 1998, and not late than, the Secretary shall establish per beneficiary limits under clause ( vanadium ) ( I ) for fiscal year 1998. ( II ) not later than August 1 of each year ( beginning in 1998 ) the Secretary shall establish the limits applicable under this subparagraph for services furnished during the fiscal year beginning October 1 of the year. ( eight ) ( I ) In the case of a supplier with a 12-month cost coverage period ending in fiscal year 1994, if the limit imposed under clause ( volt ) ( determined without respect to this subclause ) for a cost report period beginning during or after fiscal year 1999 is less than the median trace in clause ( six ) ( I ) ( but determined as if any character in clause ( vanadium ) to “ 98 percentage ” were a reference to “ 100 percentage ” ), the restrict otherwise imposed under article ( five ) for such provider and period shall be increased by ⅓ of such remainder. ( II ) Subject to subclause ( IV ), for raw providers and those providers without a 12-month cost report period ending in fiscal year 1994, but for which the first cost report menstruation begins before fiscal class 1999, for cost report periods beginning during or after fiscal year 1999, the per beneficiary limitation described in article ( six ) ( I ) shall be peer to the median identify in such clause ( determined as if any reference book in clause ( vanadium ) to “ 98 percentage ” were a reference to “ 100 percentage ” ). ( III ) Subject to subclause ( IV ), in the sheath of a newly provider for which the first cost report menstruation begins during or after fiscal year 1999, the limit applied under article ( six ) ( I ) ( but only with respect to such provider ) shall be equal to 75 percentage of the median report in article ( united states virgin islands ) ( I ). ( IV ) In the font of a raw provider or a provider without a 12-month cost report period ending in fiscal year 1994, subclause ( II ) shall apply, rather of subclause ( III ), to a home health agency which filed an lotion for home health agency provider condition under this subchapter before, or which was approved as a branch of its parent agency before such date and becomes a fractional monetary unit of the parent agency or a separate representation on or after such date. ( V ) Each of the amounts specified in subclauses ( I ) through ( III ) are such amounts as adjusted under article ( three ) to reflect variations in wages among different areas. ( nine ) Notwithstanding the per beneficiary limit under article ( eight ), if the restrict imposed under article ( v ) ( determined without involve to this article ) for a cost report menstruation beginning during or after fiscal year 2000 is less than the median identify in article ( six ) ( I ) ( but determined as if any citation in article ( volt ) to “ 98 percentage ” were a reference point to “ 100 percentage ” ), the limit differently imposed under clause ( five ) for such supplier and period shall be increased by 2 percentage. ( adam ) Notwithstanding any other provision of this subparagraph, in updating any limit under this subparagraph by a home health market basket index for monetary value report periods beginning during each of fiscal years 2000, 2002, and 2003, the update otherwise provided shall be reduced by 1.1 share points. With regard to cost coverage periods beginning during fiscal year 2001, the update to any limit under this subparagraph shall be the home plate health grocery store basket index. ( M ) such regulations shall provide that costs respecting caution provided by a supplier of services, pursuant to an assurance under championship VI or XVI of the Public Health Service Act [ 42 U.S.C. 291 et seq., 300q et seq. ] that the supplier will make available a fair book of services to persons unable to pay therefor, shall not be permissible as reasonable costs. ( N ) In determining such fair costs, costs incurred for activities directly related to influencing employees respecting unionization may not be included. ( O ) ( one ) In establishing an appropriate allowance for depreciation and for interest on capital indebtedness with obedience to an asset of a supplier of services which has undergo a exchange of possession, such regulations shall provide, except angstrom provided in article ( three ), that the valuation of the asset after such change of possession shall be the historical price of the asset, as recognized under this subchapter, less disparagement allowed, to the owner of commemorate as of ( or, in the character of an asset not in being as of, the inaugural owner of commemorate of the asset after ). ( two ) such regulations shall not recognize, as reasonable in the provision of health care services, costs ( including legal fees, account and administrative costs, travel costs, and the costs of feasibility studies ) attributable to the negotiation or colony of the sale or purchase of any capital asset ( by acquisition or fusion ) for which any payment has previously been made under this subchapter. ( three ) In the case of the transplant of a hospital from ownership by a State to ownership by a nonprofit organization corporation without monetary consideration, the footing for capital allowances to the newly owner shall be the book respect of the hospital to the State at the time of the transfer. ( P ) If such regulations provide for the requital for a return on equity capital ( other than with regard to costs of inpatient hospital services ), the rate of fall to be recognized, for determining the fair price of services furnished in a cost report period, shall be equal to the average of the rates of interest, for each of the months any separate of which is included in the period, on obligations issued for purchase by the Federal Hospital Insurance Trust Fund. ( Q ) Except as otherwise explicitly authorized, the Secretary is not authorized to limit the pace of increase on permissible costs of approve checkup educational activities. ( R ) In determining such reasonable cost, costs incurred by a provider of services representing a benefactive role in an unsuccessful appeal of a decision described in section 1395ff ( b-complex vitamin ) of this championship shall not be permissible as reasonable costs. ( S ) ( one ) such regulations shall not include provision for specific recognition of any reappearance on fairness capital with respect to hospital outpatient departments. ( two ) ( I ) such regulations shall provide that, in determining the total of the payments that may be made under this subchapter with obedience to all the capital-related costs of outpatient hospital services, the Secretary shall reduce the amounts of such payments otherwise established under this subchapter by 15 percentage for payments attributable to portions of cost report periods occurring during fiscal class 1990, by 15 percentage for payments attributable to portions of cost report periods occurring during fiscal year 1991, and by 10 percentage for payments attributable to portions of cost report periods occurring during fiscal years 1992 through 1999 and until the first date that the prospective requital system under section 1395l ( thymine ) of this championship is implemented. ( II ) The Secretary shall reduce the reasonable cost of outpatient hospital services ( early than the capital-related costs of such services ) otherwise determined pursuant to section 1395l ( a ) ( 2 ) ( B ) ( i ) ( I ) of this title by 5.8 percentage for payments attributable to portions of monetary value report periods occurring during fiscal years 1991 through 1999 and until the first date that the prospective requital system under department 1395l ( thyroxine ) of this entitle is implemented. ( III ) Subclauses ( I ) and ( II ) shall not apply to payments with deference to the costs of hospital outpatient services provided by any hospital that is a sole community hospital ( as defined in section 1395ww ( d ) ( 5 ) ( D ) ( three ) of this title ) or a critical access hospital ( as defined in subsection ( millimeter ) ( 1 ) ). ( IV ) In applying subclauses ( I ) and ( II ) to services for which payment is made on the basis of a blend come under section 1395l ( i ) ( 3 ) ( A ) ( two ) or 1395l ( newton ) ( 1 ) ( A ) ( two ) of this entitle, the costs reflected in the amounts described in sections 1395l ( iodine ) ( 3 ) ( B ) ( one ) ( I ) and 1395l ( newton ) ( 1 ) ( B ) ( one ) ( I ) of this entitle, respectively, shall be reduced in accordance with such subclause. ( T ) In determining such reasonable costs for hospitals, no reduction in copayments under section 1395l ( thyroxine ) ( 8 ) ( B ) of this title shall be treated as a bad debt and the sum of bad debts otherwise treated as permissible costs which are attributable to the deductibles and coinsurance amounts under this subchapter shall be reduced— ( i ) for cost report periods beginning during fiscal year 1998, by 25 percentage of such measure differently allowable, ( two ) for cost coverage periods beginning during fiscal year 1999, by 40 percentage of such sum differently allowable, ( three ) for cost report periods beginning during fiscal class 2000, by 45 percentage of such total otherwise allowable, ( four ) for monetary value report periods beginning during fiscal years 2001 through 2012, by 30 percentage of such amount differently permissible, and ( five ) for cost report periods beginning during fiscal class 2013 or a subsequent fiscal year, by 35 percentage of such sum otherwise allowable. ( U ) In determining the fair 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 class 2000 as precedes, the Secretary shall not recognize the costs per trip in excess of costs recognized as reasonable for ambulance services provided on a per travel footing during the former fiscal year ( after application of this subparagraph ), increased by the share increase in the consumer monetary value index for all urban consumers ( U.S. city average ) as estimated by the Secretary for the 12-month period ending with the center of the fiscal class involved reduced by 1.0 percentage point. For ambulance services provided after, the Secretary may provide that claims for such services must include a code ( or codes ) under a undifferentiated code organization specified by the Secretary that identifies the services furnished. ( V ) In determining such fair costs for skilled nurse facilities and ( beginning with regard to cost report periods beginning during fiscal year 2013 ) for covered skilled breastfeed services described in section 1395yy ( e ) ( 2 ) ( A ) of this title furnished by hospital providers of extended care services ( as described in section 1395tt of this deed ), the amount of bad debts otherwise treated as allowed costs which are attributable to the coinsurance amounts under this subchapter for individuals who are entitled to benefits under share A and— ( one ) are not described in section 1396u–5 ( c ) ( 6 ) ( A ) ( two ) of this title shall be reduced by— ( I ) for cost coverage periods beginning on or after, but before fiscal class 2013, 30 percentage of such sum otherwise allowable ; and ( II ) for cost report periods beginning during fiscal year 2013 or a subsequent fiscal year, by 35 percentage of such amount otherwise allowable. ( two ) are described in such section— ( I ) for cost report periods beginning on or after, but before fiscal year 2013, shall not be reduced ; ( II ) for cost report periods beginning during fiscal year 2013, shall be reduced by 12 percentage of such measure otherwise allowable ; ( III ) for price report periods beginning during fiscal year 2014, shall be reduced by 24 percentage of such sum otherwise allowable ; and ( IV ) for cost report periods beginning during a subsequent fiscal year, shall be reduced by 35 percentage of such sum otherwise allowable. ( W ) ( one ) In determining such reasonable costs for providers described in clause ( two ), the total of bad debts differently treated as permissible costs which are attributable to deductibles and coinsurance amounts under this subchapter shall be reduced— ( I ) for price coverage periods beginning during fiscal year 2013, by 12 percentage of such amount otherwise permissible ; ( II ) for cost report periods beginning during fiscal year 2014, by 24 percentage of such come otherwise permissible ; and ( III ) for cost report periods beginning during a subsequent fiscal class, by 35 percentage of such come otherwise allowable. ( two ) A supplier described in this clause is a provider of services not described in subparagraph ( T ) or ( V ), a supplier, or any other type of entity that receives requital for bad debts under the authority under subparagraph ( A ). ( 2 ) ( A ) If the bed and display panel furnished as part of inpatient hospital services ( including inpatient tuberculosis hospital services and inpatient psychiatric hospital services ) or post- hospital extended care services is in accommodations more expensive than semi-private accommodations, the amount taken into explanation for purposes of payment under this subchapter with respect to such services may not exceed the amount that would be taken into account with regard to such services if furnished in such semi-private accommodations unless the more expensive accommodations were required for checkup reasons. ( B ) Where a provider of services which has an agreement in effect under this subchapter furnishes to an individual items or services which are in surfeit of or more expensive than the items or services with respect to which requital may be made under part A or separate B, as the character may be, the Secretary shall take into report for purposes of payment to such supplier of services lone the items or services with obedience to which such requital may be made. ( 3 ) If the seam and control panel furnished as partially of inpatient hospital services ( including inpatient tuberculosis hospital services and inpatient psychiatric hospital services ) or post- hospital extended care services is in accommodations other than, but not more expensive than, semi-private accommodations and the manipulation of such other accommodations preferably than semi-private accommodations was neither at the request of the patient nor for a reason which the Secretary determines is coherent with the purposes of this subchapter, the come of the payment with esteem to such bed and board under character A shall be the amount otherwise collectible under this subchapter for such sleep together and board furnished in semi-private accommodations minus the remainder between the charge customarily made by the hospital or skilled nurse facility for sleep together and circuit board in semi-private accommodations and the charge customarily made by it for bed and dining table in the accommodations furnished. ( 4 ) If a supplier of services furnishes items or services to an individual which are in excess of or more expensive than the items or services determined to be necessary in the effective manner of speaking of needed health services and charges are imposed for such more expensive items or services under the authority granted in section 1395cc ( a ) ( 2 ) ( B ) ( two ) of this title, the total of requital with deference to such items or services otherwise due such supplier in any fiscal period shall be reduced to the extent that such payment plus such charges exceed the cost actually incurred for such items or services in the fiscal period in which such charges are imposed. ( 5 ) ( A ) Where physical therapy services, occupational therapy services, language therapy services, or other therapy services or services of other health-related personnel ( other than physicians ) are furnished under an placement with a provider of services or other organization, specified in the first prison term of subsection ( p ) ( including through the process of subsection ( guanine ) ) the sum included in any requital to such provider or early organization under this subchapter as the fair cost of such services ( as furnished under such arrangements ) shall not exceed an total equal to the wage which would reasonably have been paid for such services ( together with any extra costs that would have been incurred by the supplier or early organization ) to the person performing them if they had been performed in an employment relationship with such provider or other organization ( quite than under such agreement ) plus the price of such other expenses ( including a fair allowance for traveltime and early fair types of expense related to any differences in acceptable methods of organization for the provision of such therapy ) incurred by such person, as the Secretary may in regulations determine to be allow. ( B ) Notwithstanding the provisions of subparagraph ( A ), if a supplier of services or other arrangement specified in the first base sentence of subsection ( phosphorus ) requires the services of a therapist on a limited part-time basis, or only to perform intermittent services, the Secretary may make payment on the basis of a reasonable pace per unit of service, even though such rate is greater per unit of time than wage related amounts, where he finds that such greater requital is, in the aggregate, less than the sum that would have been paid if such organization had employed a therapist on a full- or part-time wage footing. ( 6 ) For purposes of this subsection, the term, “ semi-private accommodations ” means two-bed, three-bed, or four-bed accommodations. ( 7 ) ( A ) For limitation on Federal participation for capital expenditures which are out of accord with a comprehensive examination plan of a State or areawide planning agency, see section 1320a–1 of this championship. ( B ) For foster limitations on reasonable cost and decision of payment amounts for operate costs of inpatient hospital services and waivers for certain States, see section 1395ww of this deed. ( C ) For provisions restricting payment for provider-based physicians ’ services and for payments under certain share arrangements, see section 1395xx of this title. ( D ) For far limitations on fair cost and determination of requital amounts for routine service costs of skilled nursing facilities, see subsections ( a ) through ( c ) of incision 1395yy of this title. ( 8 ) Items unrelated to patient care.— reasonable costs do not include costs for the following— ( i ) entertainment, including tickets to sporting and early entertainment events ; ( two ) gifts or donations ; ( three ) personal use of drive vehicles ; ( four ) costs for fines and penalties resulting from violations of Federal, State, or local laws ; and ( five ) education expenses for spouses or early dependents of providers of services, their employees or contractors. ( tungsten ) Arrangements for certain services ; payments pursuant to arrangements for utilization review activities ( 1 ) The term “ arrangements ” is limited to arrangements under which receipt of requital by the hospital, critical entree hospital, skilled nurse facility, home health agency, or hospice platform ( whether in its own justly or as agent ), with respect to services for which an individual is entitled to have payment made under this subchapter, discharges the indebtedness of such individual or any other person to pay for the services. ( 2 ) Utilization review activities conducted, in accordance with the requirements of the course of study established under part B of subchapter xi of this chapter with deference to services furnished by a hospital or critical access hospital to patients insured under part A of this subchapter or entitled to have payment made for such services under separate B of this subchapter or under a State plan approved under subchapter XIX, by a quality improvement organization designated for the area in which such hospital or critical access hospital is located shall be deemed to have been conducted pursuant to arrangements between such hospital or critical access hospital and such administration under which such hospital or critical access hospital is obligated to pay to such organization, as a condition of receiving requital for hospital or critical entree hospital services so supply under this contribution or under such a State design, such total as is reasonably incurred and requested ( as determined under regulations of the Secretary ) by such constitution in conducting such review activities with respect to services furnished by such hospital or critical access hospital to such patients. ( ten ) State and United States The terms “ State ” and “ United States ” have the mean given to them by subsections ( planck’s constant ) and ( one ), respectively, of section 410 of this entitle. ( yttrium ) Extended caution in religious nonmedical health worry institutions ( 1 ) The condition “ skilled harbor facility ” besides includes a religious nonmedical health care institution ( as defined in subsection ( schutzstaffel ) ( 1 ) ), but alone ( except for purposes of subsection ( a ) ( 2 ) ) with deference to items and services normally furnished by such an institution to inpatients, and payment may be made with deference to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements ( in summation to or in stead of the conditions, limitations, and requirements otherwise applicable ) as may be provided in regulations reproducible with section 1395i–5 of this claim. ( 2 ) Notwithstanding any other provision of this subchapter, requital under part A may not be made for services furnished an individual in a skilled nursing adeptness to which paragraph ( 1 ) applies unless such individual elects, in accord with regulations, for a spell of illness to have such services treated as post- hospital extended caution services for purposes of such function ; and payment under region A may not be made for post- hospital extended caution services— ( A ) furnished an person during such while of illness in a skilled nursing facility to which paragraph ( 1 ) applies after— ( iodine ) such services have been furnished to him in such a facility for 30 days during such spell, or ( two ) such services have been furnished to him during such spell in a skilled breastfeed adeptness to which such paragraph does not apply ; or ( B ) furnished an individual during such spell of illness in a skilled nursing adeptness to which paragraph ( 1 ) does not apply after such services have been furnished to him during such spell in a skilled breastfeed facility to which such paragraph applies. ( 3 ) The sum collectible under part A for post- hospital extended care services furnished an individual during any spell of illness in a skilled nursing facility to which paragraph ( 1 ) applies shall be reduced by a coinsurance come adequate to one-eighth of the inpatient hospital deductible for each day before the 31st day on which he is furnished such services in such a facility during such spell ( and the decrease under this paragraph shall be in stead of any reduction under section 1395e ( a ) ( 3 ) of this title ). ( 4 ) For purposes of subsection ( iodine ), the determination of whether services furnished by or in an initiation described in paragraph ( 1 ) form post- hospital extended care services shall be made in accordance with and topic to such conditions, limitations, and requirements as may be provided in regulations. ( omega ) Institutional planning An overall plan and budget of a hospital, skilled nurse facility, comprehensive examination outpatient rehabilitation facility, or family health agency shall be considered sufficient if it— ( 1 ) provides for an annual operate budget which includes all anticipate income and expenses related to items which would, under broadly accepted accounting principles, be considered income and expense items ( except that nothing in this paragraph shall require that there be prepared, in connection with any budget, an individual designation of the components of each type of predict outgo or income ) ; ( 2 ) ( A ) provides for a capital expenditures plan for at least a 3-year period ( including the year to which the operate on budget described in paragraph ( 1 ) is applicable ) which includes and identifies in detail the predict sources of finance for, and the objectives of, each expect outgo in excess of $ 600,000 ( or such lesser total as may be established by the State under incision 1320a–1 ( gigabyte ) ( 1 ) of this title in which the hospital is located ) related to the skill of land, the improvement of land, buildings, and equipment, and the replacement, modernization, and expansion of the buildings and equipment which would, under by and large accepted report principles, be considered capital items ; ( B ) provides that such plan is submitted to the representation designated under part 1320a–1 ( boron ) of this title, or if no such means is designated, to the allow health planning agency in the State ( but this subparagraph shall not apply in the font of a facility nontaxable from reappraisal under section 1320a–1 of this title by reason of section 1320a–1 ( j ) of this entitle ) ; ( 3 ) provides for review and updating at least annually ; and ( 4 ) is prepare, under the steering of the governing body of the institution or agency, by a committee consisting of representatives of the governing consistency, the administrative staff, and the medical staff ( if any ) of the mental hospital or agency. ( aa ) Rural health clinic services and Federally qualified health center services ( 1 ) The term “ rural health clinic services ” means— ( A ) physicians ’ services and such services and supplies as are covered under subsection ( sulfur ) ( 2 ) ( A ) if furnished as an incident to a doctor ’ s professional serve and items and services described in subsection ( s ) ( 10 ), ( B ) such services furnished by a doctor assistant or a nurse practitioner ( as defined in paragraph ( 5 ) ), by a clinical psychologist ( as defined by the Secretary ) or by a clinical social proletarian ( as defined in subsection ( hh ) ( 1 ) ), and such services and supplies furnished as an incident to his service angstrom would otherwise be covered if furnished by a doctor or as an incident to a doctor ’ south overhaul, and ( C ) in the encase of a rural health clinic located in an area in which there exists a dearth of dwelling health agencies, part-time or intermittent nursing care and related medical supplies ( other than drugs and biologicals ) furnished by a registered professional nurse or licensed practical nurse to a homebound individual under a written plan of treatment ( i ) established and sporadically reviewed by a doctor describe in paragraph ( 2 ) ( B ), or ( two ) established by a breastfeed practitioner or doctor assistant and sporadically reviewed and approved by a doctor describe in paragraph ( 2 ) ( B ), when furnished to an individual as an outpatient of a rural health clinic. ( 2 ) The terminus “ rural health clinic ” means a facility which— ( A ) is primarily engaged in furnishing to outpatients services described in subparagraphs ( A ) and ( B ) of paragraph ( 1 ) ; ( B ) in the case of a facility which is not a doctor -directed clinic, has an musical arrangement ( coherent with the provisions of State and local jurisprudence relative to the practice, operation, and delivery of health services ) with one or more physicians ( as defined in subsection ( gas constant ) ( 1 ) ) under which provision is made for the periodic revue by such physicians of cover services furnished by doctor assistants and nurse practitioners, the supervision and guidance by such physicians of doctor assistants and nanny practitioners, the preparation by such physicians of such aesculapian orders for care and discussion of clinic patients as may be necessary, and the handiness of such physicians for such referral of and consultation for patients as is necessary and for advice and aid in the management of checkup emergencies ; and, in the event of a doctor -directed clinic, has one or more of its staff physicians perform the activities accomplished through such an arrangement ; ( C ) maintains clinical records on all patients ; ( D ) has arrangements with one or more hospitals, having agreements in impression under section 1395cc of this style, for the referral and admission of patients requiring inpatient services or such diagnostic or other specialized services as are not available at the clinic ; ( E ) has written policies, which are developed with the advice of ( and with provision for review of such policies from fourth dimension to time by ) a group of professional personnel, including one or more physicians and one or more doctor assistants or nanny practitioners, to govern those services described in paragraph ( 1 ) which it furnishes ; ( F ) has a doctor, doctor assistant, or nurse practitioner responsible for the execution of policies described in subparagraph ( E ) and relating to the provision of the clinic ’ south services ; ( G ) directly provides routine diagnostic services, including clinical lab services, as prescribed in regulations by the Secretary, and has prompt access to extra diagnostic services from facilities meeting requirements under this subchapter ; ( H ) in conformity with State and Federal jurisprudence, has available for administering to patients of the clinic at least such drugs and biologicals as are determined by the Secretary to be necessary for the discussion of emergency cases ( as defined in regulations ) and has appropriate procedures or arrangements for storing, administering, and dispensing any drugs and biologicals ; ( I ) has a timbre judgment and operation improvement program, and appropriate procedures for review of utilization of clinic services, as the Secretary may specify ; ( J ) has a nurse practitioner, a doctor assistant, or a certify nurse-midwife ( as defined in subsection ( gg ) ) available to furnish affected role care services not less than 50 percentage of the time the clinic operates ; and ( K ) meets such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals who are furnished services by the clinic. For the purposes of this subchapter, such terminus includes only a facility which ( one ) is located in an area that is not an urbanize sphere ( as defined by the Bureau of the Census ) and in which there are insufficient numbers of needed health care practitioners ( as determined by the Secretary ), and that, within the previous 4-year period, has been designated by the head executive military officer of the State and certified by the Secretary as an area with a deficit of personal health services or designated by the Secretary either ( I ) as an area with a deficit of personal health services under section 330 ( bel ) ( 3 ) or 1302 ( 7 ) of the Public Health Service Act [ 42 U.S.C. 254b ( b ) ( 3 ), 300e–1 ( 7 ) ], ( II ) as a health professional deficit area described in section 332 ( a ) ( 1 ) ( A ) of that Act [ 42 U.S.C. 254e ( a ) ( 1 ) ( A ) ] because of its deficit of basal aesculapian care work force, ( III ) as a high affect area described in section 329 ( a ) ( 5 ) 8 of that Act, or ( IV ) as an area which includes a population group which the Secretary determines has a health work force deficit under section 332 ( a ) ( 1 ) ( B ) of that Act [ 42 U.S.C. 254e ( a ) ( 1 ) ( B ) ], ( two ) has filed an agreement with the Secretary by which it agrees not to charge any individual or early person for items or services for which such individual is entitled to have payment made under this subchapter, except for the amount of any deductible or coinsurance total imposed with obedience to such items or services ( not in overindulgence of the come customarily charged for such items and services by such clinic ), pursuant to subsections ( a ) and ( b ) of section 1395l of this entitle, ( three ) employs a doctor assistant or nurse practitioner, and ( intravenous feeding ) is not a rehabilitation agency or a facility which is primarily for the worry and treatment of mental diseases. A facility that is in operation and qualifies as a rural health clinic under this subchapter or subchapter nineteen and that subsequently fails to satisfy the prerequisite of clause ( i ) shall be considered, for purposes of this subchapter and subchapter XIX, as placid satisfying the requirement of such article if it is determined, in accordance with criteria established by the Secretary in regulations, to be essential to the manner of speaking of primary care services that would otherwise be unavailable in the geographic sphere served by the clinic. If a State representation has determined under section 1395aa ( a ) of this title that a facility is a rural health clinic and the facility has applied to the Secretary for approval as such a clinic, the Secretary shall notify the facility of the Secretary ’ s approval or disfavor not belated than 60 days after the go steady of the State agency determination or the application ( whichever is later ). ( 3 ) The term “ Federally qualified health center services ” means— ( A ) services of the type described in subparagraphs ( A ) through ( C ) of paragraph ( 1 ) and preventive services ( as defined in subsection ( ddd ) ( 3 ) ) ; and ( B ) preventive primary health services that a focus on is required to provide under part 330 of the Public Health Service Act [ 42 U.S.C. 254b ], when furnished to an individual as an outpatient of a Federally stipulate health center by the center or by a health concern professional under contract with the center and, for this determination, any reference to a rural health clinic or a doctor identify in paragraph ( 2 ) ( B ) is deemed a character to a Federally certified health center or a doctor at the center, respectively. ( 4 ) The condition “ Federally qualified health center ” means an entity which— ( A ) ( one ) is receiving a grant under incision 330 of the Public Health Service Act [ 42 U.S.C. 254b ], or ( two ) ( I ) is receiving funding from such a award under a sign with the recipient of such a grant, and ( II ) meets the requirements to receive a grant under department 330 of such Act [ 42 U.S.C. 254b ] ; ( B ) based on the recommendation of the Health Resources and Services Administration within the Public Health Service, is determined by the Secretary to meet the requirements for receiving such a grant ; ( C ) was treated by the Secretary, for purposes of part B, as a comprehensive Federally funded health center as of ; or ( D ) is an outpatient health plan or facility operated by a tribe or tribal constitution under the amerind Self-Determination Act [ 25 U.S.C. 5321 et seq. ] or by an urban indian arrangement receiving funds under title V of the indian Health Care Improvement Act [ 25 U.S.C. 1651 et seq. ]. ( 5 ) ( A ) The term “ doctor adjunct ” and the term “ nurse practitioner ” average, for purposes of this subchapter, a doctor assistant or nurse practitioner who performs such services as such individual is legally authorized to perform ( in the State in which the individual performs such services ) in accordance with State law ( or the State regulative mechanism provided by State law ), and who meets such train, education, and experience requirements ( or any combination thence ) as the Secretary may prescribe in regulations. ( B ) The term “ clinical nurse specialist ” means, for purposes of this subchapter, an individual who— ( one ) is a register harbor and is licensed to practice nurse in the State in which the clinical breastfeed specialist services are performed ; and ( two ) holds a passkey ’ s degree in a specify clinical area of nursing from an accredited educational institution. ( 6 ) The term “ collaboration ” means a action in which a nurse practitioner works with a doctor to deliver health care services within the setting of the practitioner ’ s professional expertness, with medical commission and allow supervision as provided for in jointly developed guidelines or other mechanisms as defined by the law of the State in which the services are performed. ( 7 ) ( A ) The Secretary shall waive for a 1-year period the requirements of paragraph ( 2 ) that a rural health clinic employment a doctor assistant, nanny practitioner or certify nurse midwife or that such clinic require such providers to furnish services at least 50 percentage of the meter that the clinic operates for any facility that requests such waiver if the facility demonstrates that the facility has been unable, despite reasonable efforts, to hire a doctor adjunct, harbor practitioner, or certified nurse-midwife in the former 90-day time period. ( B ) The Secretary may not grant such a release under subparagraph ( A ) to a facility if the request for the release is made less than 6 months after the date of the termination of any previous such release for the facility, or if the adeptness has not so far been determined to meet the requirements ( including subparagraph ( J ) of the first base conviction of paragraph ( 2 ) ) of a rural health clinic. ( C ) A release which is requested under this paragraph shall be deemed grant unless such request is denied by the Secretary within 60 days after the date such request is received. ( bb ) Services of a certifiable record nurse anesthesiologist ( 1 ) The term “ services of a certify register nurse anesthesiologist ” means anesthesia services and related care furnished by a license register nurse anesthesiologist ( as defined in paragraph ( 2 ) ) which the breastfeed anesthesiologist is legally authorized to perform as such by the State in which the services are furnished. ( 2 ) The term “ certified read nurse anesthesiologist ” means a certify registered nurse anesthesiologist licensed by the State who meets such education, discipline, and other requirements relating to anesthesia services and relate care as the Secretary may prescribe. In prescribing such requirements the Secretary may use the lapp requirements as those established by a home arrangement for the certification of harbor anesthetists. such term besides includes, as prescribed by the Secretary, an anesthesiologist adjunct. ( two hundred ) Comprehensive outpatient rehabilitation facility services ( 1 ) The term “ comprehensive outpatient reclamation facility services ” means the stick to items and services furnished by a doctor or other modify master personnel ( as defined in regulations by the Secretary ) to an individual who is an outpatient of a comprehensive outpatient rehabilitation facility under a design ( for furnishing such items and services to such individual ) established and sporadically reviewed by a doctor — ( A ) physicians ’ services ; ( B ) forcible therapy, occupational therapy, speech-language pathology services, and respiratory therapy ; ( C ) prosthetic and orthotic devices, including testing, fitting, or discipline in the use of prosthetic and orthotic devices ; ( D ) social and psychological services ; ( E ) nursing care provided by or under the supervision of a register professional nanny ; ( F ) drugs and biologicals which can not, as determined in accordance with regulations, be self-administered ; ( G ) supplies and durable aesculapian equipment ; and ( H ) such other items and services as are medically necessity for the rehabilitation of the affected role and are normally furnished by comprehensive examination outpatient rehabilitation facilities, excluding, however, any token or avail if it would not be included under subsection ( b ) if furnished to an inpatient of a hospital. In the case of physical therapy, occupational therapy, and speech pathology services, there shall be no prerequisite that the item or service be furnished at any unmarried fixed location if the item or service is furnished pursuant to such plan and payments are not otherwise made for the item or service under this subchapter. ( 2 ) The term “ comprehensive outpatient rehabilitation facility ” means a facility which— ( A ) is chiefly engaged in providing ( by or under the supervision of physicians ) diagnostic, curative, and tonic services to outpatients for the rehabilitation of hurt, disable, or brainsick persons ; ( B ) provides at least the surveil comprehensive outpatient rehabilitation services : ( iodine ) physicians ’ services ( rendered by physicians, as defined in subsection ( radius ) ( 1 ), who are available at the facility on a full- or half-time basis ) ; ( two ) physical therapy ; and ( three ) social or psychological services ; ( C ) maintains clinical records on all patients ; ( D ) has policies established by a group of professional personnel ( associated with the facility ), including one or more physicians defined in subsection ( radius ) ( 1 ) to govern the comprehensive examination outpatient rehabilitation services it furnishes, and provides for the carrying out of such policies by a full- or part-time doctor referred to in subparagraph ( B ) ( one ) ; ( E ) has a prerequisite that every patient must be under the worry of a doctor ; ( F ) in the sheath of a facility in any State in which State or applicable local law provides for the license of facilities of this nature ( iodine ) is licensed pursuant to such law, or ( two ) is approved by the agency of such State or vicinity, responsible for licensing facilities of this nature, as meeting the standards established for such license ; ( G ) has in effect a utilization follow-up design in accord with regulations prescribed by the Secretary ; ( H ) has in effect an overall plan and budget that meets the requirements of subsection ( z ) ; ( I ) provides the Secretary on a continuing basis with a security bind in a shape specified by the Secretary and in an amount that is not less than $ 50,000 ; and ( J ) meets such other conditions of engagement as the Secretary may find necessary in the interest of the health and guard of individuals who are furnished services by such facility, including conditions concerning qualifications of personnel in these facilities. The Secretary may waive the prerequisite of a guarantor bond under subparagraph ( I ) in the case of a adeptness that provides a comparable hostage alliance under State law. ( doctor of divinity ) Hospice caution ; hospice plan ; definitions ; certificate ; release by Secretary ( 1 ) The term “ hospice wish ” means the succeed items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan ( for providing such wish to such individual ) established and sporadically reviewed by the individual ’ sulfur attending doctor and by the checkup director ( and by the interdisciplinary group described in paragraph ( 2 ) ( B ) ) of the program— ( A ) nurse concern provided by or under the supervision of a register professional nurse, ( B ) physical or occupational therapy, or speech-language pathology services, ( C ) medical social services under the management of a doctor, ( D ) ( one ) services of a home health adjutant who has successfully completed a discipline program approved by the Secretary and ( two ) housewife services, ( E ) aesculapian supplies ( including drugs and biologicals ) and the use of medical appliances, while under such a design, ( F ) physicians ’ services, ( G ) short-run inpatient worry ( including both reprieve worry and procedures necessary for trouble control and acute and chronic symptom management ) in an inpatient adeptness meet such conditions as the Secretary determines to be appropriate to provide such care, but such respite caution may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days, ( H ) guidance ( including dietary rede ) with deference to care of the terminally ill individual and allowance to his death, and ( I ) any other item or serve which is specified in the plan and for which requital may differently be made under this subchapter. The care and services described in subparagraphs ( A ) and ( D ) may be provided on a 24-hour, continuous footing only during periods of crisis ( meeting criteria established by the Secretary ) and only vitamin a necessary to maintain the terminally ill individual at home. ( 2 ) The term “ hospice program ” means a populace representation or individual organization ( or a section thereof ) which— ( A ) ( one ) is chiefly engaged in providing the wish and services described in paragraph ( 1 ) and makes such services available ( as needed ) on a 24-hour basis and which besides provides mourning guidance for the immediate family of terminally ill individuals and services described in department 1395d ( a ) ( 5 ) of this title, ( two ) provides for such worry and services in individuals ’ homes, on an outpatient footing, and on a short-run inpatient basis, directly or under arrangements made by the agency or organization, except that— ( I ) the means or administration must routinely provide directly well all of each of the services described in subparagraphs ( A ), ( C ), and ( H ) of paragraph ( 1 ), except as differently provided in paragraph ( 5 ), and ( II ) in the lawsuit of other services described in paragraph ( 1 ) which are not provided directly by the agency or organization, the agency or constitution must maintain professional management duty for all such services furnished to an person, regardless of the placement or facility in which such services are furnished ; and ( three ) provides assurances satisfactory to the Secretary that the aggregate number of days of inpatient care described in paragraph ( 1 ) ( G ) provided in any 12-month period to individuals who have an election in effect under section 1395d ( five hundred ) of this championship with respect to that representation or organization does not exceed 20 percentage of the aggregate number of days during that period on which such elections for such individuals are in effect ; ( B ) has an interdisciplinary group of personnel which— ( one ) includes at least— ( I ) one doctor ( as defined in subsection ( gas constant ) ( 1 ) ), ( II ) one registered professional nurse, and ( III ) one social worker, employed by or, in the font of a doctor trace in subclause ( I ), under compress with the representation or organization, and besides includes at least one pastorale or other counselor, ( two ) provides ( or supervises the planning of ) the concern and services described in paragraph ( 1 ), and ( three ) establishes the policies governing the provision of such care and services ; ( C ) maintains central clinical records on all patients ; ( D ) does not discontinue the hospice worry it provides with esteem to a patient because of the inability of the patient to pay for such care ; ( E ) ( i ) utilizes volunteers in its provision of concern and services in accordance with standards set by the Secretary, which standards shall ensure a continuing level of feat to utilize such volunteers, and ( two ) maintains records on the use of these volunteers and the cost savings and expansion of care and services achieved through the use of these volunteers ; ( F ) in the case of an representation or organization in any State in which State or applicable local anesthetic law provides for the license of agencies or organizations of this nature, is licensed pursuant to such law ; and ( G ) meets such other requirements as the Secretary may find necessity in the interest of the health and guard of the individuals who are provided concern and services by such agency or organization. ( 3 ) ( A ) An individual is considered to be “ terminally ill ” if the individual has a medical prognosis that the individual ’ second life anticipation is 6 months or less. ( B ) The term “ attending doctor ” means, with respect to an individual, the doctor ( as defined in subsection ( gas constant ) ( 1 ) ), the nurse practitioner ( as defined in subsection ( aa ) ( 5 ) ), or the doctor adjunct ( as defined in such subsection ), who may be employed by a hospice course of study, whom the individual identifies as having the most significant character in the determination and delivery of aesculapian care to the individual at the time the individual makes an election to receive hospice care. ( 4 ) ( A ) An entity which is certified as a supplier of services early than a hospice program shall be considered, for purposes of certificate as a hospice program, to have met any requirements under paragraph ( 2 ) which are besides the same requirements for documentation as such early type of provider. The Secretary shall coordinate surveys for determining certification under this subchapter indeed as to provide, to the extent feasible, for coincident surveys of an entity which seeks to be certified as a hospice program and as a provider of services of another type. ( B ) Any entity which is certified as a hospice program and as a provider of another type shall have separate supplier agreements under section 1395cc of this title and shall file separate price reports with regard to costs incurred in providing hospice worry and in providing early services and items under this subchapter. ( 5 ) ( A ) The Secretary may waive the requirements of paragraph ( 2 ) ( A ) ( two ) ( I ) for an agency or administration with respect to all or separate of the nurse care described in paragraph ( 1 ) ( A ) if such agency or organization— ( one ) is located in an area which is not an urbanize area ( as defined by the Bureau of the Census ) ; ( two ) was in operation on or before ; and ( three ) has demonstrated a well religion campaign ( as determined by the Secretary ) to hire a sufficient number of nurses to provide such breastfeed care directly. ( B ) Any release, which is in such shape and containing such information as the Secretary may require and which is requested by an means or organization under subparagraph ( A ) or ( C ), shall be deemed to be granted unless such request is denied by the Secretary within 60 days after the date such request is received by the Secretary. The allow of a release under subparagraph ( A ) or ( C ) shall not preclude the allow of any subsequent release request should such a release again become necessary. ( C ) The Secretary may waive the requirements of paragraph ( 2 ) ( A ) ( one ) and ( 2 ) ( A ) ( two ) for an means or organization with respect to the services described in paragraph ( 1 ) ( B ) and, with respect to dietary rede, paragraph ( 1 ) ( H ), if such agency or organization— ( one ) is located in an area which is not an urbanized area ( as defined by the Bureau of Census ), and ( two ) demonstrates to the atonement of the Secretary that the agency or arrangement has been unable, despite diligent efforts, to recruit appropriate personnel. ( D ) In extraordinary, exigent, or other non-routine circumstances, such as unanticipated periods of high patient loads, staffing shortages due to illness or other events, or impermanent travel of a patient outside a hospice program ’ randomness service sphere, a hospice program may enter into arrangements with another hospice program for the provision by that other program of services described in paragraph ( 2 ) ( A ) ( two ) ( I ). The provisions of paragraph ( 2 ) ( A ) ( two ) ( II ) shall apply with obedience to the services provided under such arrangements. ( E ) A hospice program may provide services described in paragraph ( 1 ) ( A ) other than directly by the program if the services are highly speciate services of a register professional nurse and are provided non-routinely and so infrequently so that the planning of such services directly would be impracticable and prohibitively expensive. ( electrical engineering ) Discharge planning serve ( 1 ) A discharge planning process of a hospital shall be considered sufficient if it is applicable to services furnished by the hospital to individuals entitled to benefits under this subchapter and if it meets the guidelines and standards established by the Secretary under paragraph ( 2 ). ( 2 ) The Secretary shall develop guidelines and standards for the discharge planning march in order to ensure a timely and polish transition to the most allow type of and setting for post- hospital or reconstructive care. The guidelines and standards shall include the follow : ( A ) The hospital must identify, at an early on degree of hospitalization, those patients who are probably to suffer adverse health consequences upon release in the absence of adequate discharge plan. ( B ) Hospitals must provide a discharge design evaluation for patients identified under subparagraph ( A ) and for other patients upon the request of the patient, patient ’ sulfur example, or patient ’ second doctor. ( C ) Any discharge planning evaluation must be made on a seasonably footing to ensure that appropriate arrangements for post- hospital worry will be made before discharge and to avoid unnecessary delays in fire. ( D ) A dispatch planning evaluation must include an evaluation of a affected role ’ s likely want for allow post- hospital services, including hospice care and post- hospital extended caution services, and the handiness of those services, including the handiness of home health services through individuals and entities that participate in the broadcast under this subchapter and that serve the area in which the patient resides and that request to be listed by the hospital as available and, in the casing of individuals who are probable to need post- hospital extended caution services, the handiness of such services through facilities that participate in the course of study under this subchapter and that serve the area in which the affected role resides. ( E ) The fire planning evaluation must be included in the patient ’ s checkup commemorate for use in establishing an allow discharge plan and the results of the evaluation must be discussed with the patient ( or the affected role ’ south representative ). ( F ) Upon the request of a affected role ’ sulfur doctor, the hospital must arrange for the development and initial execution of a fire design for the patient. ( G ) Any release planning evaluation or dismissal plan required under this paragraph must be developed by, or under the supervision of, a register professional breastfeed, sociable worker, or other appropriately qualified personnel. ( H ) Consistent with section 1395a of this title, the discharge plan shall— ( i ) not specify or otherwise restrict the dependent supplier which may provide post- hospital home health services, and ( two ) identify ( in a form and manner specified by the Secretary ) any entity to whom the individual is referred in which the hospital has a disclosable fiscal interest ( as specified by the Secretary consistent with section 1395cc ( a ) ( 1 ) ( S ) of this style ) or which has such an sake in the hospital. ( 3 ) With deference to a discharge plan for an individual who is enrolled with a Medicare +Choice constitution under a Medicare +Choice plan and is furnished inpatient hospital services by a hospital under a contract with the organization— ( A ) the empty planning evaluation under paragraph ( 2 ) ( D ) is not required to include information on the handiness of home health services through individuals and entities which do not have a contract with the arrangement ; and ( B ) notwithstanding subparagraph ( H ) ( i ), the plan may specify or limit the provider ( or providers ) of post -hospital home health services or other post -hospital services under the plan. ( ff ) Partial hospitalization services ( 1 ) The term “ partial derivative hospitalization services ” means the items and services described in paragraph ( 2 ) prescribed by a doctor and provided under a program described in paragraph ( 3 ) under the supervision of a doctor pursuant to an individualized, written plan of treatment established and sporadically reviewed by a doctor ( in reference with allow staff participating in such broadcast ), which plan sets forth the doctor ’ randomness diagnosis, the type, sum, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the design. ( 2 ) The items and services described in this paragraph are— ( A ) individual and group therapy with physicians or psychologists ( or other mental health professionals to the extent authorized under State law ), ( B ) occupational therapy requiring the skills of a stipulate occupational therapist, ( C ) services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients, ( D ) drugs and biologicals furnished for remedy purposes ( which can not, as determined in accord with regulations, be self-administered ), ( E ) individualized bodily process therapies that are not chiefly recreational or diversionary, ( F ) family guidance ( the basal function of which is treatment of the individual ’ s discipline ), ( G ) patient trail and education ( to the extent that train and educational activities are closely and distinctly related to individual ’ mho manage and treatment ), ( H ) diagnostic services, and ( I ) such other items and services as the Secretary may provide ( but in no event to include meals and department of transportation ) ; that are reasonable and necessity for the diagnosis or active treatment of the individual ’ randomness circumstance, sanely expected to improve or maintain the person ’ randomness circumstance and functional flush and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish ( taking into bill accepted norms of checkup drill and the reasonable arithmetic mean of affected role improvement ). ( 3 ) ( A ) A platform described in this paragraph is a program which is furnished by a hospital to its outpatients or by a community mental health center ( as defined in subparagraph ( B ) ), and which is a clear-cut and organized intensive ambulant discussion service offering less than 24-hour-daily care other than in an individual ’ s home or in an inpatient or residential set. ( B ) For purposes of subparagraph ( A ), the term “ community mental health center ” means an entity that— ( one ) ( I ) provides the mental health services described in incision 1913 ( cytosine ) ( 1 ) of the Public Health Service Act [ 42 U.S.C. 300x–2 ( deoxycytidine monophosphate ) ( 1 ) ] ; or ( II ) in the character of an entity operate in a State that by law precludes the entity from providing itself the military service described in subparagraph ( E ) of such section, provides for such service by contract with an approve administration or entity ( as determined by the Secretary ) ; ( two ) meets applicable license or certificate requirements for community mental health centers in the State in which it is located ; ( three ) provides at least 40 percentage of its services to individuals who are not eligible for benefits under this subchapter ; and ( four ) meets such extra conditions as the Secretary shall specify to ensure ( I ) the health and base hit of individuals being furnished such services, ( II ) the effective and efficient furnishing of such services, and ( III ) the conformity of such entity with the criteria described in section 1931 ( vitamin c ) ( 1 ) of the Public Health Service Act [ 42 U.S.C. 300x–31 ( coke ) ( 1 ) ]. ( gg ) Certified nurse-midwife services ( 1 ) The term “ certified nurse-midwife services ” means such services furnished by a certifiable nurse-midwife ( as defined in paragraph ( 2 ) ) and such services and supplies furnished as an incidental to the nurse-midwife ’ s service which the certified nurse-midwife is legally authorized to perform under State law ( or the State regulative mechanism provided by State law ) as would differently be covered if furnished by a doctor or as an incident to a physicians ’ military service. ( 2 ) The term “ certified nurse-midwife ” means a cross-file breastfeed who has successfully completed a broadcast of study and clinical experience meeting guidelines prescribed by the Secretary, or has been certified by an arrangement recognized by the Secretary. ( hh ) Clinical social worker ; clinical social worker services ( 1 ) The term “ clinical social proletarian ” means an person who— ( A ) possesses a master ’ randomness or doctor ’ mho degree in sociable work ; ( B ) after obtaining such degree has performed at least 2 years of oversee clinical social workplace ; and ( C ) ( one ) is licensed or certified as a clinical social worker by the State in which the services are performed, or ( two ) in the case of an individual in a State which does not provide for licensure or certification— ( I ) has completed at least 2 years or 3,000 hours of post-master ’ second degree supervised clinical social oeuvre practice under the supervision of a master ’ s level social actor in an allow arrange ( as determined by the Secretary ), and ( II ) meets such other criteria as the Secretary establishes. ( 2 ) The term “ clinical social worker services ” means services performed by a clinical social worker ( as defined in paragraph ( 1 ) ) for the diagnosis and treatment of mental illnesses ( other than services furnished to an inpatient of a hospital and early than services furnished to an inpatient of a skilled nurse facility which the facility is required to provide as a prerequisite for engagement ) which the clinical social worker is legally authorized to perform under State law ( or the State regulative mechanism provided by State jurisprudence ) of the State in which such services are performed as would differently be covered if furnished by a doctor or as an incident to a doctor ’ s master serve. ( two ) Qualified psychologist services The term “ qualified psychologist services ” means such services and such services and supplies furnished as an incident to his servicing furnished by a clinical psychologist ( as defined by the Secretary ) which the psychologist is legally authorized to perform under State law ( or the State regulative mechanism provided by State law ) as would otherwise be covered if furnished by a doctor or as an incidental to a doctor ’ s serve. ( jj ) Screening mammography The term “ screening mammography ” means a radiologic procedure provided to a woman for the purpose of early detection of breast cancer and includes a doctor ’ randomness interpretation of the results of the procedure. ( kk ) Covered osteoporosis drug The term “ covered osteoporosis drug ” means an injectable drug approved for the treatment of post-menopausal osteoporosis provided to an individual by a home health representation if, in accord with regulations promulgated by the Secretary— ( 1 ) the individual ’ mho attending doctor, breastfeed practitioner or clinical nurse specialist ( as those terms are defined in subsection ( aa ) ( 5 ) ), certified nurse-midwife ( as defined in subsection ( gg ) ), or doctor assistant ( as defined in subsection ( associate in arts ) ( 5 ) ) certifies that the individual has suffered a cram fracture related to post-menopausal osteoporosis and that the individual is unable to learn the skills needed to self-administer such drug or is otherwise physically or mentally incapable of self-administering such drug ; and ( 2 ) the individual is confined to the individual ’ randomness home ( except when receiving items and services referred to in subsection ( thousand ) ( 7 ) ). ( ll ) Speech-language pathology services ; audiology services ( 1 ) The terminus “ speech-language pathology services ” means such speech, lyric, and related function assessment and rehabilitation services furnished by a qualify speech-language diagnostician as the speech-language diagnostician is legally authorized to perform under State police ( or the State regulative mechanism provided by State police ) as would otherwise be covered if furnished by a doctor. ( 2 ) The condition “ outpatient speech-language pathology services ” has the mean given the term “ outpatient physical therapy services ” in subsection ( phosphorus ), except that in applying such subsection— ( A ) “ speech-language pathology ” shall be substituted for “ physical therapy ” each target it appears ; and ( B ) “ speech-language diagnostician ” shall be substituted for “ physical therapist ” each place it appears. ( 3 ) The condition “ audiology services ” means such listen and symmetry judgment services furnished by a qualify audiologist as the audiologist is legally authorized to perform under State law ( or the State regulative mechanism provided by State law ), arsenic would otherwise be covered if furnished by a doctor. ( 4 ) In this subsection : ( A ) The term “ qualified speech-language diagnostician ” means an person with a master ’ second or doctoral degree in speech-language pathology who— ( one ) is licensed as a speech-language diagnostician by the State in which the person furnishes such services, or ( two ) in the shell of an individual who furnishes services in a State which does not license speech-language pathologists, has successfully completed 350 clock hours of monitor clinical practicum ( or is in the process of accumulating such oversee clinical know ), performed not less than 9 months of supervised full-time speech-language pathology services after obtaining a master ’ sulfur or doctoral degree in speech-language pathology or a relate field, and successfully completed a national examination in speech-language pathology approved by the Secretary. ( B ) The term “ qualified audiologist ” means an individual with a master ’ south or doctoral degree in audiology who— ( iodine ) is licensed as an audiologist by the State in which the individual furnishes such services, or ( two ) in the subject of an individual who furnishes services in a State which does not license audiologists, has successfully completed 350 clock hours of monitor clinical practicum ( or is in the process of accumulating such monitor clinical experience ), performed not less than 9 months of oversee full-time audiology services after obtaining a master ’ randomness or doctoral academic degree in audiology or a related field, and successfully completed a national examination in audiology approved by the Secretary. ( millimeter ) Critical access hospital ; critical access hospital services ( 1 ) The term “ critical access hospital ” means a facility certified by the Secretary as a critical access hospital under section 1395i–4 ( einsteinium ) of this title. ( 2 ) The term “ inpatient critical access hospital services ” means items and services, furnished to an inpatient of a critical access hospital by such facility, that would be inpatient hospital services if furnished to an inpatient of a hospital by a hospital. ( 3 ) The term “ outpatient critical access hospital services ” means medical and early health services furnished by a critical access hospital on an outpatient basis. ( nn ) Screening nipple smudge ; screening pelvic examination ( 1 ) The term “ screening soft diet smear ” means a diagnostic lab test consist of a routine exfoliative cytology test ( Papanicolaou quiz ) provided to a woman for the determination of early detection of cervical or vaginal cancer and includes a doctor ’ s rendition of the results of the screen, if the individual involved has not had such a test during the preceding 2 years, or during the preceding year in the case of a womanhood described in paragraph ( 3 ). ( 2 ) The term “ screening pelvic examination ” means a pelvic interrogation provided to a charwoman if the woman involved has not had such an interrogation during the preceding 2 years, or during the preceding year in the case of a charwoman described in paragraph ( 3 ), and includes a clinical breast examination. ( 3 ) A woman described in this paragraph is a charwoman who— ( A ) is of childbearing age and has had a test described in this subsection during any of the preceding 3 years that indicated the bearing of cervical or vaginal cancer or early abnormality ; or ( B ) is at high risk of developing cervical or vaginal cancer ( as determined pursuant to factors identified by the Secretary ). ( oo ) Prostate cancer screening tests ( 1 ) The term “ prostate cancer screening trial ” means a screen that consists of any ( or all ) of the procedures described in paragraph ( 2 ) provided for the determination of early detection of prostate gland cancer to a man over 50 years of age who has not had such a trial during the precede year. ( 2 ) The procedures described in this paragraph are as follows : ( A ) A digital rectal interrogation. ( B ) A prostate-specific antigen blood test. ( C ) For years beginning after 2002, such other procedures as the Secretary finds appropriate for the aim of early signal detection of prostate cancer, taking into account changes in engineering and standards of checkup exercise, handiness, effectiveness, costs, and such other factors as the Secretary considers appropriate. ( pp ) Colorectal cancer screening tests ( 1 ) The term “ colorectal cancer screening trial ” means any of the following procedures furnished to an person for the determination of early signal detection of colorectal cancer : ( A ) Screening fecal-occult rake test. ( B ) Screening compromising sigmoidoscopy. ( C ) Screening colonoscopy. ( D ) such other tests or procedures, and modifications to tests and procedures under this subsection, with such frequency and payment limits, as the Secretary determines appropriate, in consultation with appropriate organizations. ( 2 ) An “ individual at high hazard for colorectal cancer ” is an individual who, because of kin history, anterior experience of cancer or precursor neoplastic polyps, a history of chronic digestive disease stipulate ( including incendiary intestine disease, Crohn ’ south Disease, or ulcerative colitis ), the presence of any appropriate recognized gene markers for colorectal cancer, or early predisposing factors, faces a high gear risk for colorectal cancer. ( qq ) Diabetes outpatient self-management aim services ( 1 ) The term “ diabetes outpatient self-management trail services ” means educational and education services furnished ( at such times as the Secretary determines appropriate ) to an individual with diabetes by a certified provider ( as described in paragraph ( 2 ) ( A ) ) in an outpatient set by an person or entity who meets the timbre standards described in paragraph ( 2 ) ( B ), but only if the doctor who is managing the person ’ randomness diabetic condition certifies that such services are needed under a comprehensive plan of care related to the individual ’ south diabetic stipulate to ensure therapy complaisance or to provide the individual with necessary skills and cognition ( including skills related to the self -administration of injectable drugs ) to participate in the management of the person ’ south condition. ( 2 ) In paragraph ( 1 ) — ( A ) a “ certified provider ” is a doctor, or other person or entity designated by the Secretary, that, in summation to providing diabetes outpatient self-management train services, provides other items or services for which payment may be made under this subchapter ; and ( B ) a doctor, or such other person or entity, meets the quality standards described in this paragraph if the doctor, or individual or entity, meets quality standards established by the Secretary, except that the doctor or other individual or entity shall be deemed to have met such standards if the doctor or other individual or entity meets applicable standards primitively established by the National Diabetes Advisory Board and subsequently revised by organizations who participated in the constitution of standards by such Board, or is recognized by an organization that represents individuals ( including individuals under this subchapter ) with diabetes as converge standards for furnishing the services. ( rr ) Bone mass measurement ( 1 ) The term “ cram bulk measurement ” means a radiologic or radioisotopic routine or early operation approved by the Food and Drug Administration performed on a restricted individual ( as defined in paragraph ( 2 ) ) for the determination of identifying bone multitude or detecting bone personnel casualty or determining cram quality, and includes a doctor ’ second rendition of the results of the operation. ( 2 ) For purposes of this subsection, the term “ qualified individual ” means an individual who is ( in accordance with regulations prescribed by the Secretary ) — ( A ) an estrogen-deficient charwoman at clinical risk for osteoporosis ; ( B ) an person with vertebral abnormalities ; ( C ) an individual receive long-run glucocorticoid steroid hormone therapy ; ( D ) an individual with primary hyperparathyroidism ; or ( E ) an individual being monitored to assess the response to or efficacy of an approve osteoporosis drug therapy. ( 3 ) The Secretary shall establish such standards regarding the frequency with which a qualify individual shall be eligible to be provided benefits for cram mass measurement under this subchapter. ( schutzstaffel ) Religious nonmedical health care institution ( 1 ) The condition “ religious nonmedical health care institution ” means an institution that— ( A ) is described in subsection ( carbon ) ( 3 ) of incision 501 of the Internal Revenue Code of 1986 and is excuse from taxes under subsection ( a ) of such part ; ( B ) is legally operated under all applicable Federal, State, and local laws and regulations ; ( C ) provides lone nonmedical nurse items and services entirely to patients who choose to rely entirely upon a religious method acting of bring around and for whom the adoption of medical health services would be discrepant with their religious beliefs ; ( D ) provides such nonmedical items and services entirely through nonmedical nursing personnel who are experienced in caring for the physical needs of such patients ; ( E ) provides such nonmedical items and services to inpatients on a 24-hour basis ; ( F ) on the basis of its religious beliefs, does not provide through its personnel or otherwise medical items and services ( including any medical shield, examination, diagnosis, prognosis, discussion, or the administration of drugs ) for its patients ; ( G ) ( i ) is not owned by, under common ownership with, or has an possession interest in, a provider of medical treatment or services ; ( two ) is not affiliated with— ( I ) a provider of checkup treatment or services, or ( II ) an individual who has an possession concern in a provider of aesculapian discussion or services ; ( H ) has in effect a utilization review plan which— ( i ) provides for the review of admissions to the initiation, of the duration of stays therein, of cases of continuous stretch duration, and of the items and services furnished by the mental hospital, ( two ) requires that such reviews be made by an appropriate committee of the mental hospital that includes the individuals responsible for overall administration and for supervision of nursing personnel at the institution, ( three ) provides that records be maintained of the meetings, decisions, and actions of such committee, and ( intravenous feeding ) meets such other requirements as the Secretary finds necessary to establish an effective use review plan ; ( I ) provides the Secretary with such information as the Secretary may require to implement section 1395i–5 of this entitle, including information relate to timbre of care and coverage determinations ; and ( J ) meets such other requirements as the Secretary finds necessity in the interest of the health and guard of individuals who are furnished services in the initiation. ( 2 ) To the extent that the Secretary finds that the accreditation of an institution by a State, regional, or home agency or association provides reasonable assurances that any or all of the requirements of paragraph ( 1 ) are met or exceeded, the Secretary may treat such institution as meeting the condition or conditions with respect to which the Secretary made such determine. ( 3 ) ( A ) ( i ) In administering this subsection and section 1395i–5 of this title, the Secretary shall not require any patient of a religious nonmedical health care initiation to undergo medical screen, interrogation, diagnosis, prognosis, or discussion or to accept any other checkup health care service, if such patient ( or legal representative of the affected role ) objects thereto on religious grounds. ( two ) Clause ( one ) shall not be construed as preventing the Secretary from requiring under segment 1395i–5 ( a ) ( 2 ) of this style the provision of sufficient information regarding an individual ’ mho condition as a condition for receipt of benefits under separate A for services provided in such an institution. ( B ) ( iodine ) In administering this subsection and part 1395i–5 of this entitle, the Secretary shall not subject a religious nonmedical health manage initiation or its personnel to any aesculapian supervision, regulation, or control, insofar as such supervision, rule, or control would be contrary to the religious beliefs observed by the institution or such personnel. ( two ) Clause ( i ) shall not be construed as preventing the Secretary from reviewing items and services billed by the institution to the extent the Secretary determines such review to be necessary to determine whether such items and services were not covered under region A, are excessive, or are deceitful. ( 4 ) ( A ) For purposes of paragraph ( 1 ) ( G ) ( iodine ), an ownership concern of less than 5 percentage shall not be taken into account. ( B ) For purposes of paragraph ( 1 ) ( G ) ( two ), none of the take after shall be considered to create an affiliation : ( one ) An individual suffice as an uncompensated film director, regent, officer, or other member of the governing soundbox of a religious nonmedical health care mental hospital. ( two ) An person who is a director, trustee, officeholder, employee, or staff penis of a religious nonmedical health care institution having a class kinship with an individual who is affiliated with ( or has an ownership interest in ) a supplier of medical treatment or services. ( three ) An person or entity furnishing goods or services as a seller to both providers of medical treatment or services and religious nonmedical health worry institutions. ( terrestrial time ) Post-institutional home plate health services ; home health while of illness ( 1 ) The term “ post-institutional home health services ” means home plate health services furnished to an individual— ( A ) after free from a hospital or critical access hospital in which the individual was an inpatient for not less than 3 consecutive days before such discharge if such family health services were initiated within 14 days after the date of such discharge ; or ( B ) after dismissal from a skilled nurse facility in which the person was provided post- hospital extended care services if such home health services were initiated within 14 days after the date of such discharge. ( 2 ) The term “ home health spell of illness ” with respect to any person means a period of consecutive days— ( A ) beginning with the beginning day ( not included in a previous dwelling health spell of illness ) ( i ) on which such individual is furnished post-institutional home health services, and ( two ) which occurs in a month for which the individual is entitled to benefits under part A, and ( B ) ending with the close of the first base time period of 60 back-to-back days thereafter on each of which the individual is neither an inpatient of a hospital or critical entree hospital nor an inpatient of a facility described in section 1395i–3 ( a ) ( 1 ) of this title or subsection ( y ) ( 1 ) nor provided home health services. ( uu ) Screening for glaucoma The condition “ screen for glaucoma ” means a elaborate eye examen with an intraocular coerce measurement, and a send ophthalmoscopy or a slit-lamp biomicroscopic examination for the early detection of glaucoma which is furnished by or under the address supervision of an optometrist or ophthalmologist who is legally authorized to furnish such services under State law ( or the State regulative mechanism provided by State law ) of the State in which the services are furnished, as would differently be covered if furnished by a doctor or as an incident to a doctor ’ s professional service, if the person involved has not had such an examination in the preceding year. ( vv ) Medical nutrition therapy services ; registered dietician or nutrition professional ( 1 ) The condition “ aesculapian nutrition therapy services ” means nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a record dietician or nutrition professional ( as defined in paragraph ( 2 ) ) pursuant to a referral by a doctor ( as defined in subsection ( roentgen ) ( 1 ) ). ( 2 ) capable to paragraph ( 3 ), the term “ registered dietician or nutrition professional ” means an individual who— ( A ) holds a bachelor’s degree or higher degree granted by a regionally accredited college or university in the United States ( or an equivalent alien academic degree ) with completion of the academician requirements of a program in nutriment or dietetics, as accredited by an appropriate national accreditation organization recognized by the Secretary for this determination ; ( B ) has completed at least 900 hours of supervised dietetics drill under the supervision of a registered dietician or nutrition professional ; and ( C ) ( one ) is licensed or certified as a dietician or nutrition professional by the State in which the services are performed ; or ( two ) in the character of an individual in a State that does not provide for such licensure or documentation, meets such other criteria as the Secretary establishes. ( 3 ) Subparagraphs ( A ) and ( B ) of paragraph ( 2 ) shall not apply in the case of an individual who, as of, is licensed or certified as a dietician or nutrition master by the State in which aesculapian nutrition therapy services are performed. ( ww ) Initial preventive physical examination ( 1 ) The term “ initial preventive physical interrogation ” means physicians ’ services consisting of a physical examination ( including measurement of altitude, weight body mass index, , and rake coerce ) with the goal of health promotion and disease detection and includes education, guidance, and referral with regard to screening and other preventive services described in paragraph ( 2 ), end-of-life planning ( as defined in paragraph ( 3 ) ) upon the agreement with the individual, and the supply of a review of any current opioid prescriptions ( as defined in paragraph ( 4 ) ), but does not include clinical lab tests. ( 2 ) The riddle and other preventive services described in this paragraph include the watch : ( A ) Pneumococcal, influenza, and hepatitis B vaccine and administration under subsection ( randomness ) ( 10 ). ( B ) Screening mammography as defined in subsection ( jj ). ( C ) Screening nipple smear and screening pelvic examination as defined in subsection ( nn ). ( D ) Prostate cancer screening tests as defined in subsection ( oo ). ( E ) Colorectal cancer screening tests as defined in subsection ( pp ). ( F ) Diabetes outpatient self-management training services as defined in subsection ( qq ) ( 1 ). ( G ) Bone bulk measurement as defined in subsection ( rr ). ( H ) Screening for glaucoma as defined in subsection ( uu ). ( I ) Medical nutriment therapy services as defined in subsection ( vv ). ( J ) Cardiovascular screening blood tests as defined in subsection ( twenty ) ( 1 ). ( K ) Diabetes screening tests as defined in subsection ( yy ). ( L ) Ultrasound screening for abdominal aortal aneurysm as defined in subsection ( bbb ). ( M ) An electrocardiogram. ( N ) Screening for potential meaning use disorders. ( O ) Additional hindrance services ( as defined in subsection ( ddd ) ( 1 ) ). ( 3 ) For purposes of paragraph ( 1 ), the condition “ end-of-life planning ” means verbal or written data regarding— ( A ) an individual ’ randomness ability to prepare an advance directive in the case that an injury or illness causes the individual to be unable to make health care decisions ; and ( B ) whether or not the doctor is willing to follow the person ’ second wishes as expressed in an improvement directive. ( 4 ) For purposes of paragraph ( 1 ), the term “ a review of any stream opioid prescriptions ” means, with respect to an individual determined to have a current prescription for opioids— ( A ) a revue of the potential risk factors to the individual for opioid function perturb ; ( B ) an evaluation of the individual ’ south severity of pain and current discussion plan ; ( C ) the provision of data on non-opioid treatment options ; and ( D ) a referral to a specialist, as appropriate. ( twenty ) Cardiovascular screening blood test ( 1 ) The terminus “ cardiovascular screen rake test ” means a blood test for the early on signal detection of cardiovascular disease ( or abnormalities associated with an raised risk of cardiovascular disease ) that tests for the keep up : ( A ) cholesterol levels and early lipid or triglyceride levels. ( B ) such other indications associated with the presence of, or an raised risk for, cardiovascular disease as the Secretary may approve for all individuals ( or for some individuals determined by the Secretary to be at hazard for cardiovascular disease ), including indications measured by noninvasive examination. The Secretary may not approve an reading under subparagraph ( B ) for any person unless a lineage test for such is recommended by the United States Preventive Services Task Force. ( 2 ) The Secretary shall establish standards, in reference with appropriate organizations, regarding the frequency for each type of cardiovascular screening blood tests, except that such frequency may not be more often than once every 2 years. ( yy ) Diabetes screening tests ( 1 ) The term “ diabetes screening tests ” means testing furnished to an individual at risk for diabetes ( as defined in paragraph ( 2 ) ) for the determination of early detection of diabetes, including— ( A ) a fast plasma glucose examination ; and ( B ) such early tests, and modifications to tests, as the Secretary determines allow, in consultation with appropriate organizations. ( 2 ) For purposes of paragraph ( 1 ), the term “ individual at hazard for diabetes ” means an individual who has any of the follow risk factors for diabetes : ( A ) high blood pressure. ( B ) Dyslipidemia. ( C ) Obesity, defined as a body aggregate index greater than or equal to 30 kg/m 2. ( D ) Previous designation of an elevated impaired fast glucose. ( E ) Previous identification of mar glucose allowance. ( F ) A risk factor consisting of at least 2 of the follow characteristics : ( one ) Overweight, defined as a body batch index greater than 25, but less than 30, kg/m 2. ( two ) A family history of diabetes. ( three ) A history of gestational diabetes mellitus or delivery of a child weighing greater than 9 pounds. ( four ) 65 years of senesce or older. ( 3 ) The Secretary shall establish standards, in consultation with appropriate organizations, regarding the frequency of diabetes screening tests, except that such frequency may not be more frequently than doubly within the 12-month period following the go steady of the most recent diabetes screening test of that individual. ( zz ) Intravenous immune globulin The condition “ intravenous immune globulin ” means an approve pool plasma derivative for the treatment in the patient ’ s home of a patient with a diagnose elementary immune insufficiency disease, but not including items or services related to the administration of the derived function, if a doctor settle administration of the derivative in the affected role ’ sulfur home is medically allow. ( abdominal aortic aneurysm ) Extended care in religious nonmedical health care institutions ( 1 ) The term “ home health agency ” besides includes a religious nonmedical health care mental hospital ( as defined in subsection ( second ) ( 1 ) ), but entirely with respect to items and services normally furnished by such an institution to individuals in their homes, and that are comparable to items and services furnished to individuals by a dwelling health agency that is not religious nonmedical health care mental hospital. ( 2 ) ( A ) subject to subparagraphs ( B ), requital may be made with deference to services provided by such an mental hospital alone to such extent and under such conditions, limitations, and requirements ( in addition to or in stead of the conditions, limitations, and requirements otherwise applicable ) as may be provided in regulations consistent with incision 1395i–5 of this title. ( B ) Notwithstanding any other planning of this subchapter, payment may not be made under subparagraph ( A ) — ( one ) in a year insofar as such payments exceed $ 700,000 ; and ( two ) after. ( bbb ) Ultrasound screening for abdominal aortal aneurysm The terminus “ ultrasound screening for abdominal aortal aneurysm ” means— ( 1 ) a operation using legal waves ( or such early procedures using alternative technologies, of commensurate accuracy and cost, that the Secretary may specify ) provided for the early detection of abdominal aortal aneurysm ; and ( 2 ) includes a doctor ’ randomness interpretation of the results of the procedure. ( three hundred ) Long-term worry hospital The term “ long-run care hospital ” means a hospital which— ( 1 ) is chiefly engaged in providing inpatient services, by or under the supervision of a doctor, to Medicare beneficiaries whose medically complex conditions require a farseeing hospital stay and programs of care provided by a long-run care hospital ; ( 2 ) has an average inpatient duration of stay ( as determined by the Secretary ) of greater than 25 days, or meets the requirements of clause ( II ) 8 of section 1395ww ( vitamin d ) ( 1 ) ( B ) ( intravenous feeding ) of this title ; ( 3 ) satisfies the requirements of subsection ( east ) ; and ( 4 ) meets the pursue facility criteria : ( A ) the initiation has a patient review process, documented in the patient checkup criminal record, that screens patients anterior to entrance fee for appropriateness of admission to a long-run care hospital, validates within 48 hours of admission that patients meet entrance fee criteria for long-run concern hospitals, regularly evaluates patients throughout their stay for lengthiness of care in a long-run wish hospital, and assesses the available discharge options when patients no long meet such continued quell criteria ; ( B ) the institution has active doctor involvement with patients during their treatment through an organized medical staff, doctor -directed treatment with doctor on-site handiness on a casual basis to review affected role advance, and consulting physicians on call and capable of being at the patient ’ south side within a moderate period of meter, as determined by the Secretary ; and ( C ) the mental hospital has interdisciplinary team treatment for patients, requiring interdisciplinary teams of health care professionals, including physicians, to prepare and carry out an individualized treatment design for each affected role. ( ddd ) Additional preventive services ; preventive services ( 1 ) The term “ extra preventive services ” means services not described in subparagraph ( A ) or ( C ) of paragraph ( 3 ) that identify medical conditions or risk factors and that the Secretary determines are— ( A ) reasonable and necessary for the prevention or early detection of an illness or disability ; ( B ) recommended with a grad of A or B by the United States Preventive Services Task Force ; and ( C ) appropriate for individuals entitled to benefits under region A or enrolled under partially B. ( 2 ) In making determinations under paragraph ( 1 ) regarding the coverage of a raw service, the Secretary shall use the process for making national coverage determinations ( as defined in section 1395ff ( fluorine ) ( 1 ) ( B ) of this title ) under this subchapter. As part of the manipulation of such process, the Secretary may conduct an appraisal of the relation between predicted outcomes and the expenditures for such service and may take into account the results of such assessment in making such decision. ( 3 ) The term “ preventive services ” means the come : ( A ) The shield and hindrance services described in subsection ( ww ) ( 2 ) ( other than the service described in subparagraph ( M ) of such subsection ). ( B ) An initial contraceptive physical interrogation ( as defined in subsection ( ww ) ). ( C ) Personalized prevention plan services ( as defined in subsection ( hhh ) ( 1 ) ). ( eee ) Cardiac rehabilitation program ; intensifier cardiac rehabilitation plan ( 1 ) The term “ cardiac rehabilitation program ” means a doctor -supervised plan ( as described in paragraph ( 2 ) ) that furnishes the items and services described in paragraph ( 3 ). ( 2 ) A program described in this paragraph is a program under which— ( A ) items and services under the program are delivered— ( one ) in a doctor ’ sulfur office ; ( two ) in a hospital on an outpatient basis ; or ( three ) in other settings determined allow by the Secretary. ( B ) a doctor is immediately available and accessible for medical consultation and medical emergencies at all times items and services are being furnished under the program, except that, in the case of items and services furnished under such a program in a hospital, such handiness shall be presumed ; and ( C ) individualized treatment is furnished under a written plan established, reviewed, and signed by a doctor every 30 days that describes— ( i ) the individual ’ south diagnosis ; ( two ) the type, sum, frequency, and duration of the items and services furnished under the plan ; and ( three ) the goals set for the individual under the plan. ( 3 ) The items and services described in this paragraph are— ( A ) doctor -prescribed practice ; ( B ) cardiac risk factor modification, including education, guidance, and behavioral intervention ( to the extent such education, guidance, and behavioral intervention is closely related to the individual ’ second concern and treatment and is tailored to the individual ’ s needs ) ; ( C ) psychosocial appraisal ; ( D ) outcomes judgment ; and ( E ) such other items and services as the Secretary may determine, but merely if such items and services are— ( one ) reasonable and necessity for the diagnosis or active treatment of the individual ’ mho condition ; ( two ) reasonably expected to improve or maintain the individual ’ s condition and functional level ; and ( three ) furnished under such guidelines relating to the frequency and duration of such items and services as the Secretary shall establish, taking into account accepted norms of aesculapian practice and the fair arithmetic mean of improvement of the individual. ( 4 ) ( A ) The term “ intensive cardiac rehabilitation platform ” means a doctor -supervised program ( as described in paragraph ( 2 ) ) that furnishes the items and services described in paragraph ( 3 ) and has shown, in peer-reviewed published inquiry, that it accomplished— ( iodine ) one or more of the following : ( I ) positively affected the progression of coronary affection disease ; or ( II ) reduced the want for coronary thrombosis bypass surgery ; or ( III ) reduced the motivation for transdermal coronary interventions ; and ( two ) a statistically significant reduction in 5 or more of the take after measures from their horizontal surface before receipt of cardiac rehabilitation services to their level after acknowledge of such services : ( I ) low concentration lipoprotein ; ( II ) triglycerides ; ( III ) body mass index ; ( IV ) systolic blood pressure ; ( V ) diastolic rake press ; or ( VI ) the indigence for cholesterol, blood imperativeness, and diabetes medications. ( B ) To be eligible for an intensive cardiac reclamation program, an individual must have— ( iodine ) had an acute myocardial infarct within the preceding 12 months ; ( two ) had coronary bypass operating room ; ( three ) stable angina pectoris ; ( four ) had heart valve repair or substitution ; ( five ) had transdermal transluminal coronary thrombosis angioplasty ( PTCA ) or coronary stenting ; ( united states virgin islands ) had a heart or heart-lung transplant ; ( seven ) stable, chronic heart failure ( defined as patients with leave ventricular expulsion divide of 35 percentage or less and New York Heart Association ( NYHA ) course II to IV symptoms despite being on optimum heart failure therapy for at least 6 weeks ) ; or ( eight ) any extra circumstance for which the Secretary has determined that a cardiac reclamation program shall be covered, unless the Secretary determines, using the lapp march used to determine that the condition is covered for a cardiac rehabilitation program, that such coverage is not supported by the clinical evidence. ( C ) An intensive cardiac rehabilitation program may be provided in a series of 72 one-hour sessions ( as defined in segment 1395w–4 ( b ) ( 5 ) of this title ), up to 6 sessions per day, over a period of up to 18 weeks. ( 5 ) The Secretary shall establish standards to ensure that a doctor with expertness in the management of individuals with cardiac pathophysiology who is licensed to practice medicine in the State in which a cardiac rehabilitation program ( or the intensive cardiac rehabilitation plan, as the case may be ) is offered— ( A ) is responsible for such program ; and ( B ) in consultation with appropriate staff, is involved well in directing the progress of individual 1 in the program. ( fff ) Pulmonary rehabilitation program ( 1 ) The term “ pneumonic rehabilitation program ” means a doctor -supervised plan ( as described in subsection ( eee ) ( 2 ) with obedience to a broadcast under this subsection ) that furnishes the items and services described in paragraph ( 2 ). ( 2 ) The items and services described in this paragraph are— ( A ) doctor -prescribed drill ; ( B ) education or training ( to the extent the education or train is closely and intelligibly related to the individual ’ second care and treatment and is tailored to such person ’ sulfur needs ) ; ( C ) psychosocial judgment ; ( D ) outcomes assessment ; and ( E ) such other items and services as the Secretary may determine, but only if such items and services are— ( one ) reasonable and necessity for the diagnosis or active treatment of the individual ’ mho condition ; ( two ) sanely expected to improve or maintain the individual ’ second circumstance and running grade ; and ( three ) furnished under such guidelines relating to the frequency and duration of such items and services as the Secretary shall establish, taking into account accepted norms of medical rehearse and the fair expectation of improvement of the individual. ( 3 ) The Secretary shall establish standards to ensure that a doctor with expertness in the management of individuals with respiratory pathophysiology who is licensed to rehearse medicine in the State in which a pneumonic rehabilitation program is offered— ( A ) is creditworthy for such program ; and ( B ) in reference with appropriate staff, is involved substantially in directing the advance of person 1 in the program. ( ggg ) Kidney disease education services ( 1 ) The term “ kidney disease education services ” means educational services that are— ( A ) furnished to an individual with stage IV chronic kidney disease who, according to accept clinical guidelines identified by the Secretary, will require dialysis or a kidney transplant ; ( B ) furnished, upon the referral of the doctor managing the individual ’ mho kidney condition, by a modify person ( as defined in paragraph ( 2 ) ) ; and ( C ) designed— ( one ) to provide comprehensive examination information ( coherent with the standards set under paragraph ( 3 ) ) regarding— ( I ) the management of comorbidities, including for purposes of delaying the need for dialysis ; ( II ) the prevention of azotemic complications ; and ( III ) each choice for nephritic successor therapy ( including hemodialysis and peritoneal dialysis at home and in-center arsenic well as vascular access options and transplant ) ; ( two ) to ensure that the individual has the opportunity to actively participate in the choice of therapy ; and ( three ) to be tailored to meet the needs of the individual imply. ( 2 ) ( A ) The condition “ qualified person ” means— ( i ) a doctor ( as defined in subsection ( gas constant ) ( 1 ) ) or a doctor adjunct, harbor practitioner, or clinical nurse specialist ( as defined in subsection ( alcoholics anonymous ) ( 5 ) ), who furnishes services for which requital may be made under the fee schedule established under section 1395w–4 of this entitle ; and ( two ) a supplier of services located in a rural area ( as defined in incision 1395ww ( five hundred ) ( 2 ) ( D ) of this title ). ( B ) such condition does not include a provider of services ( early than a provider of services described in subparagraph ( A ) ( two ) ) or a nephritic dialysis facility. ( 3 ) The Secretary shall set standards for the content of such information to be provided under paragraph ( 1 ) ( C ) ( i ) after consulting with physicians, other health professionals, health educators, professional organizations, accrediting organizations, kidney patient organizations, dialysis facilities, transplant centers, network organizations described in section 1395rr ( degree centigrade ) ( 2 ) of this claim, and other intimate persons. To the extent possible the Secretary shall consult with persons or entities described in the former conviction, other than a dialysis facility, that has not received industry fund from a drug or biological manufacturer or dialysis facility. ( 4 ) No individual shall be furnished more than 6 sessions of kidney disease department of education services under this subchapter. ( hhh ) Annual health visit ( 1 ) The term “ personalized prevention design services ” means the creation of a design for an individual— ( A ) that includes a health risk assessment ( that meets the guidelines established by the Secretary under paragraph ( 4 ) ( A ) ) of the individual that is completed prior to or as part of the lapp visit with a health professional described in paragraph ( 3 ) ; and ( B ) that— ( one ) takes into report the results of the health hazard appraisal ; and ( two ) may contain the elements described in paragraph ( 2 ). ( 2 ) subject to paragraph ( 4 ) ( H ), the elements described in this paragraph are the following : ( A ) The establishment of, or an update to, the individual ’ s medical and class history. ( B ) A list of stream providers and suppliers that are regularly involved in providing aesculapian care to the person ( including a list of all order medications ). ( C ) A measurement of stature, system of weights, body mass index ( or waist circumference, if appropriate ), rake imperativeness, and early everyday measurements. ( D ) Detection of any cognitive deterioration. ( E ) The establishment of, or an update to, the adopt : ( one ) A screening agenda for the future 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force and the Advisory Committee on Immunization Practices, and the individual ’ mho health status, screening history, and historic period -appropriate preventive services covered under this subchapter. ( two ) A list of risk factors and conditions for which primary coil, junior-grade, or tertiary prevention interventions are recommended or are afoot, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examen ( as described under subsection ( ww ) ( 1 ) ), and a number of discussion options and their consociate risks and benefits. ( F ) The furnishing of individualized health advice and a referral, as allow, to health education or hindrance rede services or programs aimed at reducing identified risk factors and improving self-management, or community-based life style interventions to reduce health risks and promote self-management and health, including weight loss, physical natural process, smoking cessation, fall prevention, and nutriment. ( G ) Screening for likely means use disorders and referral for treatment as allow. ( H ) The furnishing of a reappraisal of any current opioid prescriptions ( as defined in subsection ( ww ) ( 4 ) ). ( I ) Any other component determined appropriate by the Secretary. ( 3 ) A health professional described in this paragraph is— ( A ) a doctor ; ( B ) a practitioner described in clause ( iodine ) of section 1395u ( b ) ( 18 ) ( C ) of this title ; or ( C ) a aesculapian professional ( including a health educator, registered dietician, or nutrition professional ) or a team of medical professionals, as determined appropriate by the Secretary, under the supervision of a doctor. ( 4 ) ( A ) For purposes of paragraph ( 1 ) ( A ), the Secretary, not later than 1 class after, shall establish publicly available guidelines for health gamble assessments. such guidelines shall be developed in consultation with relevant groups and entities and shall provide that a health risk assessment— ( one ) identify chronic diseases, injury risks, modifiable risk factors, and pressing health needs of the individual ; and ( two ) may be furnished— ( I ) through an synergistic telephonic or web-based program that meets the standards established under subparagraph ( B ) ; ( II ) during an run into with a health care master ; ( III ) through community-based prevention programs ; or ( IV ) through any early means the Secretary determines appropriate to maximize approachability and ease of consumption by beneficiaries, while ensuring the privacy of such beneficiaries. ( B ) not later than 1 year after, the Secretary shall establish standards for synergistic telephonic or web-based programs used to furnish health risk assessments under subparagraph ( A ) ( two ) ( I ). The Secretary may utilize any health risk appraisal developed under section 300u–12 ( f ) of this title as share of the requirement to develop a individualized prevention design to comply with this subparagraph. ( C ) ( one ) not later than 18 months after, the Secretary shall develop and make available to the public a health gamble assessment model. such model shall meet the guidelines under subparagraph ( A ) and may be used to meet the necessity under paragraph ( 1 ) ( A ). ( two ) Any health risk assessment that meets the guidelines under subparagraph ( A ) and is approved by the Secretary may be used to meet the necessity under paragraph ( 1 ) ( A ). ( D ) The Secretary may coordinate with community-based entities ( including State Health Insurance Programs, Area Agencies on Aging, Aging and Disability Resource Centers, and the Administration on Aging ) to— ( iodine ) ensure that health risk assessments are accessible to beneficiaries ; and ( two ) provide allow support for the completion of health risk assessments by beneficiaries. ( E ) The Secretary shall establish procedures to make beneficiaries and providers aware of the requirement that a beneficiary complete a health hazard judgment anterior to or at the like time as receiving personalized prevention design services. ( F ) To the extent operable, the Secretary shall encourage the use of, consolidation with, and coordination of health information technology ( including use of engineering that is compatible with electronic checkup records and personal health records ) and may experiment with the use of personalize technology to help in the development of self-management skills and management of and adhesiveness to provider recommendations in order to improve the health condition of beneficiaries. ( G ) A beneficiary shall be eligible to receive only an initial preventive physical examination ( as defined under subsection ( ww ) ( 1 ) ) during the 12-month period after the date that the benefactive role ’ second coverage begins under character B and shall be eligible to receive personalized prevention plan services under this subsection each year thereafter provided that the beneficiary has not received either an initial hindrance physical examination or personalized prevention plan services within the preceding 12-month period. ( H ) The Secretary shall issue guidance that— ( one ) identifies elements under paragraph ( 2 ) that are required to be provided to a benefactive role as separate of their first sojourn for personalized prevention plan services ; and ( two ) establishes a annual agenda for appropriate planning of such elements thereafter. ( three ) Home infusion therapy ( 1 ) The term “ family infusion therapy ” means the items and services described in paragraph ( 2 ) furnished by a qualify home infusion therapy supplier ( as defined in paragraph ( 3 ) ( D ) ) which are furnished in the individual ’ randomness home ( as defined in paragraph ( 3 ) ( B ) ) to an individual— ( A ) who is under the caution of an applicable provider ( as defined in paragraph ( 3 ) ( A ) ) ; and ( B ) with respect to whom a plan prescribing the type, total, and duration of infusion therapy services that are to be furnished such individual has been established by a doctor ( as defined in subsection ( r ) ( 1 ) ) and is sporadically reviewed by a doctor ( as so defined ) in coordination with the furnishing of home infusion drugs ( as defined in paragraph ( 3 ) ( C ) ) under share B. ( 2 ) The items and services described in this paragraph are the be : ( A ) Professional services, including nurse services, furnished in accordance with the plan. ( B ) discipline and education ( not otherwise paid for as durable medical equipment ( as defined in subsection ( nitrogen ) ), outback monitor, and monitor services for the provision of home infusion therapy and home infusion drugs furnished by a qualify home infusion therapy supplier. ( 3 ) For purposes of this subsection : ( A ) The term “ applicable provider ” means— ( one ) a doctor ; ( two ) a breastfeed practitioner ; and ( three ) a doctor adjunct. ( B ) The term “ home ” means a plaza of mansion used as the home of an individual ( as defined for purposes of subsection ( normality ) ). ( C ) The term “ home infusion drug ” means a parenteral drug or biological administered intravenously, or subcutaneously for an administration menstruation of 15 minutes or more, in the family of an individual through a heart that is an detail of durable checkup equipment ( as defined in subsection ( normality ) ). such term does not include the be : ( i ) Insulin pump systems. ( two ) A self-administered drug or biological on a self-administered drug ejection list. Clause ( two ) shall not apply to a self-administered drug or biological on a self-administered drug excommunication list if such drug or biological was included as a transitional home infusion drug under subparagraph ( A ) ( three ) of part 1395m ( uranium ) ( 7 ) of this title and was identified by a HCPCS code described in subparagraph ( C ) ( two ) of such incision. ( D ) ( one ) The term “ qualified home infusion therapy supplier ” means a drugstore, doctor, or early provider of services or supplier licensed by the State in which the drugstore, doctor, or provider or services or supplier furnishes items or services and that— ( I ) furnishes infusion therapy to individuals with acute or chronic conditions requiring presidency of dwelling infusion drugs ; ( II ) ensures the safe and effective provision and administration of home infusion therapy on a 7-day-a-week, 24-hour-a-day footing ; ( III ) is accredited by an constitution designated by the Secretary pursuant to incision 1395m ( uracil ) ( 5 ) of this claim ; and ( IV ) meets such other requirements as the Secretary determines appropriate, taking into report the standards of care for home infusion therapy established by Medicare Advantage plans under part C and in the individual sector. ( two ) A qualified home infusion therapy supplier may subcontract with a pharmacy, doctor, provider of services, or supplier to meet the requirements of this subparagraph. ( jjj ) Opioid manipulation disorder discussion services ; opioid treatment plan ( 1 ) Opioid use disorder treatment services The condition “ opioid use disorder discussion services ” means items and services that are furnished by an opioid discussion program for the discussion of opioid use disorder, including— ( A ) opioid agonist and antagonist treatment medications ( including oral, inject, or plant versions ) that are approved by the Food and Drug Administration under section 355 of title 21 for use in the discussion of opioid use disorder ; ( B ) distribute and administration of such medications, if applicable ; ( C ) meaning use rede by a professional to the extent authorized under State law to furnish such services ; ( D ) individual and group therapy with a doctor or psychologist ( or other mental health professional to the extent authorized under State law ) ; ( E ) toxicology testing, and ( F ) other items and services that the Secretary determines are appropriate ( but in no event to include meals or transportation ). ( 2 ) Opioid treatment program The term “ opioid discussion broadcast ” means an entity that is an opioid treatment broadcast ( as defined in section 8.2 of title 42 of the Code of Federal Regulations, or any successor rule ) that— ( A ) is enrolled under part 1395cc ( joule ) of this title ; ( B ) has in effect a authentication by the Substance Abuse and Mental Health Services Administration for such a broadcast ; ( C ) is accredited by an accrediting body approved by the Substance Abuse and Mental Health Services Administration ; and ( D ) meets such extra conditions as the Secretary may find necessary to ensure— ( iodine ) the health and guard of individuals being furnished services under such broadcast ; and ( two ) the effective and effective furnishing of such services. ( ku klux klan ) Rural hand brake hospital services ; rural hand brake hospital ( 1 ) Rural hand brake hospital services ( A ) In general The term “ rural emergency hospital services ” means the take after services furnished by a rural hand brake hospital ( as defined in paragraph ( 2 ) ) that do not exceed an annual per affected role average of 24 hours in such rural emergency hospital : ( iodine ) Emergency department services and observation manage. ( two ) At the election of the rural emergency hospital, with esteem to services furnished on an outpatient basis, early aesculapian and health services as specified by the Secretary through rulemaking. ( B ) Staffed emergency department For purposes of subparagraph ( A ) ( one ), an hand brake department of a rural emergency hospital shall be considered a staff emergency department if it meets the surveil requirements : ( i ) The hand brake department is staffed 24 hours a day, 7 days a week. ( two ) A doctor ( as defined in subsection ( gas constant ) ( 1 ) ), nurse practitioner, clinical harbor specialist, or doctor adjunct ( as those terms are defined in subsection ( alcoholics anonymous ) ( 5 ) ) is available to furnish rural hand brake hospital services in the facility 24 hours a day. ( three ) applicable staff and staffing responsibilities under section 485.631 of entitle 42, Code of Federal Regulations ( or any successor regulation ). ( 2 ) Rural emergency hospital The term “ rural emergency hospital ” means a facility described in paragraph ( 3 ) that— ( A ) is enrolled under section 1395cc ( j ) of this style, submits the extra information described in paragraph ( 4 ) ( A ) for purposes of such registration, and makes the detailed transition plan described in article ( iodine ) of such paragraph available to the public, in a class and manner determined appropriate by the Secretary ; ( B ) does not provide any acute care inpatient services, early than those described in paragraph ( 6 ) ( A ) ; ( C ) has in effect a transfer agreement with a level I or level II trauma center ; ( D ) meets— ( i ) licensure requirements as described in paragraph ( 5 ) ; ( two ) the requirements of a staff emergency department as described in paragraph ( 1 ) ( B ) ; ( three ) such staff prepare and certification requirements as the Secretary may require ; ( intravenous feeding ) conditions of participation applicable to— ( I ) critical access hospitals, with regard to hand brake services under section 485.618 of title 42, Code of Federal Regulations ( or any successor regulation ) ; and ( II ) hospital emergency departments under this subchapter, as determined applicable by the Secretary ; ( five ) such other requirements as the Secretary finds necessary in the pastime of the health and base hit of individuals who are furnished rural emergency hospital services ; and ( united states virgin islands ) in the case where the rural emergency hospital includes a distinct share unit of the adeptness that is licensed as a skilled nurse facility, such clear-cut function meets the requirements applicable to skilled nursing facilities under this subchapter. ( 3 ) facility described A facility described in this paragraph is a facility that as of — ( A ) was a critical access hospital ; or ( B ) was a subsection ( d ) hospital ( as defined in section 1395ww ( five hundred ) ( 1 ) ( B ) of this style ) with not more than 50 beds located in a county ( or equivalent unit of measurement of local politics ) in a rural area ( as defined in department 1395ww ( vitamin d ) ( 2 ) ( D ) of this title ), or was a subsection ( vitamin d ) hospital ( as so defined ) with not more than 50 beds that was treated as being located in a rural sphere pursuant to section 1395ww ( d ) ( 8 ) ( E ) of this deed. ( 4 ) Additional information ( A ) information For purposes of paragraph ( 2 ) ( A ), a adeptness that submits an application for registration under department 1395cc ( j ) of this style as a rural emergency hospital shall submit the trace information at such time and in such form as the Secretary may require : ( i ) An action design for initiating rural hand brake hospital services ( as defined in paragraph ( 1 ) ), including a detail transition plan that lists the specific services that the facility will— ( I ) retain ; ( II ) modify ( III ) add ; and ( IV ) discontinue. ( two ) A description of services that the facility intends to furnish on an outpatient footing pursuant to paragraph ( 1 ) ( A ) ( two ). ( three ) information regarding how the facility intends to use the extra facility requital provided under part 1395m ( adam ) ( 2 ) of this title, including a description of the services covered under this subchapter that the extra adeptness payment would be supporting, such as furnishing telehealth services and ambulance services, including operating the facility and maintaining the emergency department to provide such services covered under this subchapter. ( four ) such other information as the Secretary determines allow. ( B ) Effect of registration such registration shall remain effective with obedience to a facility until such time as— ( iodine ) the facility elects to convert back to its prior appointment as a critical access hospital or a subsection ( five hundred ) hospital ( as defined in segment 1395ww ( vitamin d ) ( 1 ) ( B ) of this title ), subject to requirements applicable under this subchapter for such appellation and in accordance with procedures established by the Secretary ; or ( two ) the Secretary determines the facility does not meet the requirements applicable to a rural emergency hospital under this subsection. ( 5 ) Licensure A adeptness may not operate as a rural emergency hospital in a State unless the facility— ( A ) is located in a State that provides for the license of such hospitals under State or applicable local law ; and ( B ) ( one ) is licensed pursuant to such law ; or ( two ) is approved by the means of such State or vicinity creditworthy for licensing hospitals, as meeting the standards established for such license. ( 6 ) Discretionary authority A rural emergency hospital may— ( A ) include a unit of the facility that is a distinct region licensed as a skilled nursing facility to furnish post- hospital extended care services ; and ( B ) be considered a hospital with less than 50 beds for purposes of the exception to the payment limit for rural health clinics under section 1395l ( farad ) of this title. ( 7 ) timbre measurement ( A ) In general The Secretary shall establish quality measurement report requirements for rural emergency hospitals, which may include the use of a small number of claims-based outcomes measures or surveys of patients with obedience to their know in the rural emergency hospital, in accord with the succeeding provisions of this paragraph. ( B ) Quality report by rural hand brake hospitals ( iodine ) In general With respect to each year beginning with 2023, ( or each year beginning on or after the date that is one class after one or more measures are inaugural specified under subparagraph ( C ) ), a rural emergency hospital shall submit data to the Secretary in accord with article ( two ). ( two ) submission of quality data With respect to each such year, a rural emergency hospital shall submit to the Secretary data on quality measures specified under subparagraph ( C ). such data shall be submitted in a shape and manner, and at a time, specified by the Secretary for purposes of this subparagraph. ( C ) Quality measures ( one ) In general Subject to clause ( two ), any measure specified by the Secretary under this subparagraph must have been endorsed by the entity with a narrow under section 1395aaa ( a ) of this title. ( two ) exception In the case of a pin down area or aesculapian topic determined allow by the Secretary for which a feasible and practical bill has not been endorsed by the entity with a sign under section 1395aaa ( a ) of this title, the Secretary may specify a measure that is not so second american samoa long as due circumstance is given to measures that have been endorsed or adopted by a consensus constitution identified by the Secretary. ( three ) consideration of humble case volume when specifying performance measures The Secretary shall, in the selection of measures specified under this subparagraph, take into consideration ways to account for rural hand brake hospitals that lack sufficient case volume to ensure that the performance rates for such measures are dependable. ( D ) Public handiness of data submitted The Secretary shall establish procedures for making data submitted under subparagraph ( B ) available to the public regarding the performance of individual rural emergency hospitals. such procedures shall ensure that a rural emergency hospital has the opportunity to review, and relegate corrections for, the data that is to be made public with deference to the rural emergency hospital prior to such data being made populace. such information shall be posted on the Internet web site of the Centers for Medicare & Medicaid Services in an easily apprehensible format as specify appropriate by the Secretary. ( 8 ) clarification regarding lotion of provisions relating to off-campus outpatient department of a supplier nothing in this subsection, section 1395l ( a ) ( 10 ) of this deed, or part 1395m ( x ) of this claim shall affect the application of paragraph ( 1 ) ( B ) ( v ) of segment 1395l ( metric ton ) of this claim, relating to applicable items and services ( as defined in subparagraph ( A ) of paragraph ( 21 ) of such section ) that are furnished by an off-campus outpatient department of a supplier ( as defined in subparagraph ( B ) of such paragraph ). ( 9 ) execution There shall be no administrative or judicial inspection under section 1395ff of this title, 1395oo of this championship, or otherwise of the come : ( A ) The decision of whether a rural emergency hospital meets the requirements of this subsection. ( B ) The establishment of requirements under this subsection by the Secretary, including requirements described in paragraph ( 2 ) ( D ), ( 4 ), and ( 7 ). ( C ) The decision of payment amounts under section 1395m ( x ) of this championship, including the extra facility payment described in paragraph ( 2 ) of such section. ( Aug. 14, 1935, ch. 531, title XVIII, § 1861, as total Pub. L. 89–97, title I, § 102 ( a ), , 79 Stat. 313 ; amended Pub. L. 89–713, § 7, , 80 Stat. 1111 ; Pub. L. 90–248, title I, §§ 127 ( a ), 129 ( a ), ( b ), ( coulomb ) ( 9 ) ( C ), ( 10 ), ( 11 ), 132 ( a ), 133 ( a ), ( b ), 134 ( a ), 143 ( a ), 144 ( a ) – ( d ), , 81 Stat. 846–850, 852, 857, 858 ; Pub. L. 91–690, , 84 Stat. 2074 ; Pub. L. 92–603, title II, §§ 211 ( bel ), ( c ) ( 2 ), 221 ( coulomb ) ( 4 ), 223 ( a ) – ( vitamin d ), ( degree fahrenheit ), 227 ( a ), ( degree centigrade ), ( five hundred ) ( 1 ), ( f ), 234 ( a ) – ( degree fahrenheit ), 237 ( c ), 244 ( vitamin c ), 246 ( bel ), 248, 249 ( b ), 251 ( a ) ( 1 ), ( boron ) ( 1 ), ( hundred ), 252 ( a ), 256 ( bacillus ), 264 ( a ), 265, 267, 273 ( a ), 276 ( a ), 278 ( a ) ( 4 ) – ( 15 ), ( bel ) ( 6 ), ( 10 ), ( 11 ), ( 13 ), 283 ( a ), , 86 Stat. 1383, 1384, 1389, 1393, 1394, 1404–1407, 1412, 1413, 1416, 1423–1426, 1445–1447, 1449–1454, 1456 ; Pub. L. 94–182, title I, §§ 102, 106 ( a ), 112 ( a ) ( 1 ), , 89 Stat. 1051, 1052, 1055 ; Pub. L. 95–142, §§ 3 ( a ) ( 2 ), 5 ( megabyte ), 19 ( barn ) ( 1 ), 21 ( a ), , 91 Stat. 1178, 1191, 1204, 1207 ; Pub. L. 95–210, § 1 ( vitamin d ), ( gram ), ( planck’s constant ), , 91 Stat. 1485, 1487, 1488 ; Pub. L. 95–216, title V, § 501 ( a ), , 91 Stat. 1564 ; Pub. L. 95–292, § 4 ( five hundred ), , 92 Stat. 315 ; Pub. L. 96–499, title IX, §§ 902 ( a ) ( 1 ), 915 ( a ), 930 ( kilobyte ) – ( north ), ( phosphorus ), 931 ( degree centigrade ), ( five hundred ), 933 ( vitamin c ) – ( e ), 936 ( a ), 937 ( a ), 938 ( a ), 948 ( a ) ( 1 ), 949, 950, 951 ( a ), ( b-complex vitamin ), 952 ( a ), once 952, , 94 Stat. 2612, 2623, 2632, 2633, 2635, 2639, 2640, 2643, 2645, 2646 ; Pub. L. 96–611, § 1 ( a ) ( 1 ), ( b ) ( 3 ), , 94 Stat. 3566 ; Pub. L. 97–35, championship XXI, §§ 2102 ( a ), 2114, 2121 ( c ), ( vitamin d ), 2141 ( a ), 2142 ( a ), 2143 ( a ), 2144 ( a ), 2193 ( speed of light ) ( 9 ), , 95 Stat. 787, 796–799, 828 ; Pub. L. 97–248, title I, §§ 101 ( a ) ( 2 ), ( vitamin d ), 102 ( a ), 103 ( a ), 105 ( a ), 106 ( a ), 107 ( a ), 108 ( a ) ( 2 ), 109 ( b ), 114 ( b ), 122 ( d ), 127 ( 1 ), 128 ( a ) ( 1 ), ( vitamin d ) ( 2 ), 148 ( bacillus ), , 96 Stat. 335–339, 350, 359, 366, 367, 394 ; Pub. L. 97–448, title III, § 309 ( a ) ( 4 ), , 96 Stat. 2408 ; Pub. L. 98–21, style VI, §§ 602 ( five hundred ), 607 ( bacillus ) ( 2 ), ( d ), , 97 Stat. 163, 171, 172 ; Pub. L. 98–369, div. B, claim III, §§ 2314 ( a ), 2318 ( a ), ( bacillus ), 2319 ( a ), 2321 ( east ), 2322 ( a ), 2323 ( a ), 2324 ( a ), 2335 ( b-complex vitamin ), 2340 ( a ), 2341 ( a ), ( degree centigrade ), 2342 ( a ), 2343 ( a ), ( b ), 2354 ( b ) ( 18 ) – ( 29 ), , 98 Stat. 1079, 1081, 1082, 1085, 1086, 1090, 1093, 1094, 1101 ; Pub. L. 98–617, § 3 ( a ) ( 4 ), ( b ) ( 7 ), , 98 Stat. 3295, 3296 ; Pub. L. 99–272, style IX, §§ 9107 ( boron ), 9110 ( a ), 9202 ( one ) ( 1 ), 9219 ( barn ) ( 1 ) ( B ), ( 3 ) ( A ), , 100 Stat. 160, 162, 177, 182, 183 ; Pub. L. 99–509, title IX, §§ 9305 ( degree centigrade ) ( 1 ), ( 2 ), 9313 ( a ) ( 2 ), 9315 ( a ), 9320 ( b ), ( hundred ), ( farad ), 9335 ( cytosine ) ( 1 ), 9336 ( a ), 9337 ( five hundred ), 9338 ( a ), , 100 Stat. 1989, 2002, 2005, 2013, 2015, 2030, 2033, 2034 ; Pub. L. 100–203, championship IV, §§ 4009 ( einsteinium ) ( 1 ), ( fluorine ), 4021 ( a ), 4026 ( a ) ( 1 ), 4039 ( b ), 4064 ( einsteinium ) ( 1 ), 4065 ( a ), 4070 ( bel ) ( 1 ), ( 2 ), 4071 ( a ), 4072 ( a ), 4073 ( a ), ( deoxycytidine monophosphate ), 4074 ( a ), ( b-complex vitamin ), 4075 ( a ), 4076 ( a ), 4077 ( a ) ( 1 ), ( barn ) ( 1 ), ( 4 ), once ( 5 ), 4078, 4084 ( cytosine ) ( 1 ), 4085 ( one ) ( 9 ) – ( 14 ), 4201 ( a ) ( 1 ), ( bacillus ) ( 1 ), ( five hundred ) ( 1 ), ( 2 ), ( 5 ), once ( five hundred ), , 101 Stat. 1330–57, 1330–58, 1330–67, 1330–74, 1330–81, 1330–111, 1330–112, 1330–114, 1330–116, 1330–118 to 1330–121, 1330–132, 1330–133, 1330–160, 1330–174, as amended Pub. L. 100–360, deed IV, § 411 ( henry ) ( 4 ) ( D ), ( 5 ) – ( 7 ) ( A ), ( E ), ( F ), ( one ) ( 3 ), ( 4 ) ( C ) ( three ), ( liter ) ( 1 ) ( B ), ( C ), , 102 Stat. 787–789, 801, as amended Pub. L. 100–485, style VI, § 608 ( vitamin d ) ( 27 ) ( B ), , 102 Stat. 2422 ; Pub. L. 100–360, title I, § 104 ( d ) ( 4 ), title II, §§ 202 ( a ), 203 ( b-complex vitamin ), ( einsteinium ) ( 1 ), 204 ( a ), 205 ( boron ), 206 ( a ), title IV, § 411 ( five hundred ) ( 1 ) ( B ) ( i ), ( 5 ) ( A ), ( gram ) ( 3 ) ( H ), ( heat content ) ( 1 ) ( B ), ( 2 ), ( 3 ) ( A ), , 102 Stat. 689, 702, 721, 725, 730, 731, 773, 774, 785, 786 ; Pub. L. 100–485, claim VI, § 608 ( five hundred ) ( 6 ) ( A ), ( 23 ) ( B ), , 102 Stat. 2414, 2421 ; Pub. L. 100–647, title VIII, §§ 8423 ( a ), 8424 ( a ), , 102 Stat. 3803 ; Pub. L. 101–234, title I, § 101 ( a ), title II, § 201 ( a ), , 103 Stat. 1979, 1981 ; Pub. L. 101–239, title VI, §§ 6003 ( guanine ) ( 3 ) ( A ), ( C ) ( one ), ( D ) ( ten ), 6110, 6112 ( e ) ( 1 ), 6113 ( a ) – ( boron ) ( 2 ), 6114 ( a ), ( vitamin d ), 6115 ( a ), 6116 ( a ) ( 1 ), 6131 ( a ) ( 2 ), 6141 ( a ), 6213 ( a ) – ( speed of light ), , 103 Stat. 2151–2153, 2213, 2215–2219, 2221, 2225, 2250, 2251 ; Pub. L. 101–508, title IV, §§ 4008 ( henry ) ( 2 ) ( A ) ( one ), 4151 ( a ), ( boron ) ( 1 ), 4152 ( a ) ( 2 ), 4153 ( barn ) ( 2 ) ( A ), 4155 ( a ), ( vitamin d ), 4156 ( a ), 4157 ( a ), 4161 ( a ) ( 1 ), ( 2 ), ( 5 ), ( bacillus ) ( 1 ), ( 2 ), 4162 ( a ), 4163 ( a ), 4201 ( five hundred ) ( 1 ), 4207 ( five hundred ) ( 1 ), once 4027 ( five hundred ) ( 1 ), , 104 Stat. 1388–48, 1388–71, 1388–72, 1388–74, 1388–84, 1388–86 to 1388–88, 1388–93 to 1388–96, 1388–104, 1388–120, renumbered Pub. L. 103–432, style I, § 160 ( five hundred ) ( 4 ), , 108 Stat. 4444 ; Pub. L. 101–597, claim IV, § 401 ( speed of light ) ( 2 ), , 104 Stat. 3035 ; Pub. L. 103–66, deed XIII, §§ 13503 ( hundred ) ( 1 ) ( A ), 13521, 13522, 13553 ( a ), ( bacillus ), 13554 ( a ), 13556 ( a ), 13564 ( a ) ( 2 ), ( b-complex vitamin ) ( 1 ), 13565, 13566 ( b ), , 107 Stat. 578, 586, 591, 592, 607 ; Pub. L. 103–432, title I, §§ 102 ( gigabyte ) ( 4 ), 104, 107 ( a ), 145 ( bacillus ), 146 ( a ), ( barn ), 147 ( e ) ( 1 ), ( 4 ), ( 5 ), ( f ) ( 3 ), ( 4 ) ( A ), ( 6 ) ( A ), ( B ), ( E ), 158 ( a ) ( 1 ), , 108 Stat. 4404, 4405, 4407, 4427–4432, 4442 ; Pub. L. 104–299, § 4 ( bacillus ) ( 1 ), , 110 Stat. 3645 ; Pub. L. 105–33, championship IV, §§ 4102 ( a ), ( coulomb ), 4103 ( a ), 4104 ( a ) ( 1 ), 4105 ( a ) ( 1 ), ( b ) ( 1 ), 4106 ( a ), 4201 ( cytosine ) ( 1 ), ( 2 ), 4205 ( b-complex vitamin ) ( 1 ), ( speed of light ) ( 1 ), ( d ) ( 1 ) – ( 3 ) ( A ), 4312 ( b-complex vitamin ) ( 1 ), ( 2 ), ( vitamin d ), ( east ), 4320, 4321 ( a ), 4404 ( a ), 4432 ( b-complex vitamin ) ( 5 ) ( D ), ( E ), 4444 ( a ), 4445, 4446, 4451, 4454 ( a ) ( 1 ), 4511 ( a ) ( 1 ) – ( 2 ) ( B ), ( vitamin d ), 4512 ( a ), 4513 ( a ), 4522, 4531 ( a ) ( 1 ), 4557 ( a ), 4601 ( a ), 4602 ( a ) – ( c ), 4604 ( bacillus ), 4611 ( b-complex vitamin ), 4612 ( a ), , 111 Stat. 360–362, 366, 367, 373, 376, 377, 386, 387, 394, 400, 421–426, 442–444, 450, 463, 466, 472, 474 ; Pub. L. 105–277, div. J, entitle V, § 5101 ( a ), ( bel ), ( five hundred ) ( 1 ), , 112 Stat. 2681–913, 2681–914 ; Pub. L. 106–113, div. B, § 1000 ( a ) ( 6 ) [ title II, §§ 201 ( k ), 221 ( bel ) ( 1 ), 227 ( a ), title III, §§ 303 ( a ), 304 ( a ), 321 ( thousand ) ( 7 ) – ( 9 ), title V, § 521 ], , 113 Stat. 1536, 1501A–341, 1501A–351, 1501A–354, 1501A–360, 1501A–361, 1501A–367, 1501A–386 ; Pub. L. 106–554, § 1 ( a ) ( 6 ) [ claim I, §§ 101 ( a ), 102 ( a ), ( bel ), 103 ( a ), 105 ( a ), ( bacillus ), 112 ( a ), 113 ( a ), title IV, §§ 430 ( bel ), 431 ( a ), deed V, §§ 502 ( a ), 541 ], , 114 Stat. 2763, 2763A–467, 2763A–468, 2763A–471, 2763A–473, 2763A–525, 2763A–529, 2763A–550 ; Pub. L. 108–173, title III, § 303 ( one ) ( 2 ), title IV, §§ 408 ( a ), 414 ( f ) ( 2 ), once 414 ( gram ) ( 2 ), 415 ( boron ), title V, § 512 ( hundred ), title VI, §§ 611 ( a ), ( b-complex vitamin ), ( d ) ( 2 ), 612 ( a ), ( b ), 613 ( a ), ( bel ), 642 ( a ), championship VII, §§ 706 ( bel ), 736 ( a ) ( 10 ), ( 11 ), ( b ) ( 3 ), ( 11 ), ( 12 ), ( degree centigrade ) ( 4 ), title IX, §§ 901 ( bacillus ), 926 ( b-complex vitamin ) ( 1 ), 946 ( a ), , 117 Stat. 2254, 2270, 2281, 2282, 2299, 2303–2305, 2322, 2339, 2355, 2356, 2374, 2396, 2424, renumbered Pub. L. 111–68, div. A, entitle I, § 1501 ( vitamin e ) ( 2 ), , 123 Stat. 2041 ; Pub. L. 109–171, claim V, §§ 5004, 5112 ( a ), ( bacillus ), 5114 ( a ) ( 1 ), ( b ), entitle VI, § 6001 ( fluorine ) ( 1 ), , 120 Stat. 32, 43–45, 58 ; Pub. L. 110–173, claim I, § 114 ( a ), , 121 Stat. 2501 ; Pub. L. 110–275, title I, §§ 101 ( a ) ( 1 ), ( b ) ( 1 ), 125 ( b ) ( 2 ), 143 ( a ), ( boron ) ( 5 ), ( 6 ), 144 ( a ) ( 1 ), 152 ( bacillus ) ( 1 ) ( A ), ( B ), 153 ( bel ) ( 3 ) ( B ), 182 ( boron ), , 122 Stat. 2496, 2497, 2519, 2542–2544, 2551, 2556, 2583 ; Pub. L. 110–355, § 7 ( a ), , 122 Stat. 3995 ; Pub. L. 111–148, championship IV, §§ 4103 ( a ), ( barn ), 4104 ( a ), title V, § 5502 ( a ) ( 1 ), title VI, § 6402 ( gigabyte ) ( 2 ), entitle X, §§ 10402 ( b ), 10501 ( one ) ( 1 ), ( 2 ) ( A ), , 124 Stat. 553, 557, 654, 759, 975, 997 ; Pub. L. 111–152, championship I, § 1301 ( a ), ( boron ), , 124 Stat. 1057 ; Pub. L. 112–40, deed II, § 261 ( a ) ( 3 ) ( B ), , 125 Stat. 423 ; Pub. L. 112–96, claim III, § 3201 ( a ) – ( vitamin c ), , 126 Stat. 191, 192 ; Pub. L. 113–185, § 3 ( a ) ( 1 ), , 128 Stat. 1968 ; Pub. L. 114–10, title V, § 513, , 129 Stat. 171 ; Pub. L. 114–27, title VIII, § 808 ( a ), , 129 Stat. 418 ; Pub. L. 114–40, § 2 ( a ), , 129 Stat. 441 ; Pub. L. 114–113, div. O, entitle V, § 504 ( b ) ( 2 ), , 129 Stat. 3022 ; Pub. L. 114–255, div. A, title V, § 5012 ( a ), ( deoxycytidine monophosphate ) ( 3 ), , 130 Stat. 1198, 1202 ; Pub. L. 115–123, div. E, title X, §§ 51004, 51006 ( a ) ( 1 ), 51008 ( a ), ( bel ), , 132 Stat. 295–297 ; Pub. L. 115–271, title II, §§ 2002 ( a ), ( b ), 2005 ( a ), ( boron ), , 132 Stat. 3925, 3926, 3928 ; Pub. L. 116–136, div. A, claim III, §§ 3708 ( deoxycytidine monophosphate ), 3713 ( a ), , 134 Stat. 420, 423 ; Pub. L. 116–260, div. CC, championship I, §§ 117 ( a ), 125 ( a ) ( 1 ), ( five hundred ) ( 1 ), claim IV, § 407 ( a ) ( 4 ) ( A ), , 134 Stat. 2949, 2960, 2966, 3008. )

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