Sec. 5. Eligibility for Medicare payment for orthotics and prosthetics based on supplier qualifications and complexity of care
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/bill/114/hr/1530/ih/section-5A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 1834(h) of the Social Security Act ( 42 U.S.C. 1395m(h) ) is amended— in paragraph (1)(F)(iii), in the matter preceding subclause (I), by striking other individual who and inserting other individual who, with respect to the provision of orthotics and prosthetics furnished on or after January 1, 2016, and subject to paragraph (5)(A), satisfies all applicable criteria of the provider qualification designation for such category described in the respective clause, and who ; in paragraph (1)(F)(iv), by inserting before the period the following: and, with respect to the provision of orthotics and prosthetics furnished on or after January 1, 2016, and subject to paragraph (5)(A), satisfies all applicable criteria of the provider qualification designation for such orthotic or prosthetic ; and by adding at the end the following new paragraph:
In applying clauses
(iii)and
(iv)of paragraph (1)(F) for purposes of determining whether payment may be made under this subsection for orthotics and prosthetics furnished on or after January 1, 2016, the Secretary shall take into account the complexity of the respective item and, subject to clauses (ii), (iii), and (iv), the qualifications of the individual or entity furnishing and fabricating such respective item in accordance with this paragraph. With respect to the provision of orthotics or prosthetics, any criteria for supplier qualifications shall not apply to physicians, occupational therapists, or physical therapists who are licensed or otherwise regulated by the State in which they are practicing and who receive payment under this title, including regulations promulgated pursuant to this subsection, for the provision of orthotics and prosthetics. In the case of a qualified supplier who is eligible to receive payment under this title before January 1, 2016, with respect to the provision of orthotics and prosthetics, any new criteria for provider qualifications established after such date shall not apply to such supplier, for the furnishing or fabrication of such an item. The Secretary shall, in consultation with the Boards and programs described in paragraph (1)(F)(iv), periodically review the criteria for supplier qualifications and may implement by regulation any modifications to such criteria, as determined appropriate in accordance with such consultation. Any such modifications shall take effect no earlier than January 1, 2016. For purposes of subparagraph (A), the Secretary, in consultation with representatives of the fields of occupational therapy, physical therapy, orthotics, and prosthetics, shall utilize and incorporate the set of L-codes listed, as of the date of enactment of this paragraph, in the Centers for Medicare & Medicaid Services document entitled Transmittal 656 (CMS Pub. 100–04, Change Request 3959, August 19, 2005). Transmittal 656 shall be the controlling source of category, product, and code assignments for the orthotics and prosthetics care, using the supplier qualification designation for each HCPCS code as stated in such document. In the case that Transmittal 656 is updated, reissued, or replaced by a subsequent document, the previous sentence shall be applied with respect to the most recent update, reissuance, or replacement of such document. .
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Sec. 5
Eligibility for Medicare payment for orthotics and prosthetics based on supplier qualifications and complexity of care
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