Sec. 301. Codification of limitation on charges for health care professional services and non-hospital-based care source

1,856 words·~8 min read·/bill/114/hr/5406/ih/section-301·

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

The requirements of this section shall apply to— health programs operated by the Indian Health Service; health programs operated by an urban Indian organization through a contract or grant under title V of the Indian Health Care Improvement Act, Public Law 94–437 , as amended; and health programs operated by an Indian tribe or tribal organization pursuant to a contract or compact with the Indian Health Service under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450 et seq. ), provided that the Indian tribe or tribal organization has agreed in such contract or compact to be bound by this section pursuant to section 108 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450l ) and section 517(e) of such Act ( 25 U.S.C. 458aaa–16(e) ), as applicable.

For purposes of this section, the following definitions apply: The term notification of a claim means, the submission of a claim, with respect to services for an individual, that meets the requirements of section 136.24 of title 42, Code of Federal Regulations, in accordance with the following: Such claim is submitted within the applicable period specified under such section 136.24, or if applicable, section 406 of the Indian Health Care Improvement Act ( 25 U.S.C. 1646 ), and includes information necessary to determine the relative medical need for the services and the individual’s eligibility.

The information submitted with the claim is sufficient to— identify the individual as eligible for Indian Health Service services (such as name, address, home or referring service unit, tribal affiliation); identify the medical care provided (such as the date of service and description of services); and verify prior authorization by the Indian Health Service for services provided (such as the IHS purchase order number or medical referral form) or exemption from prior authorization (such as copies of pertinent clinical information for emergency care that was not prior-authorized).

To be considered sufficient notification of a claim, a claim submitted by a provider or supplier for payment shall be in a format that complies with the format required for submission of claims under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) or recognized under section 1175 of such Act ( 42 U.S.C. 1320d–4 ). The term provider means a provider of services not governed by or subject to subpart D of part 136 of title 42, Code of Federal Regulations, and may include a skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or hospice program.

The term referral means an authorization for medical care by the appropriate ordering official in accordance with subpart C of part 136 of title 42, Code of Federal Regulations. The term repricing agent means an entity that offers the Indian Health Service or a tribe, tribal organization, or urban Indian organization discounted rates from public and private providers that are not the Indian Health Service or a tribe, tribal organization, or urban Indian organization as a result of existing contracts that the public or private provider other than the Indian Health Service or a tribe, tribal organization, or urban Indian organization may have within the commercial health care industry.

The term supplier means a physician or other practitioner, a facility, or other entity (other than a provider) not already governed by or subject to subpart D of part 136 of title 42, Code of Federal Regulations, that furnishes items or services under this section. Payment to providers and suppliers for any level of care authorized under subpart C of part 136 of title 42, Code of Federal Regulations, by a Purchased/Referred Care program of the Indian Health Service, authorized by a tribe or tribal organization carrying out such a program of the Indian Health Service under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450 et seq. ), authorized for purchase under section 136.31 of such title 42, Code of Federal Regulations, by an urban Indian organization (as that term is defined in 25 U.S.C. 1603(h) ) (hereafter collectively referred to as the I/T/U ), shall, subject to subsection (e), be determined based on one of the methods described in the following subparagraphs, as applicable:

The method described in this subparagraph is that, subject to clause (ii), in the case a specific amount for an item or service has been negotiated with a specific provider or supplier or its agent by the I/T/U, the I/T/U shall pay that amount for such item or service. The amount applied under clause

(i)for an item or service shall be an amount that is at least the amount of the provider’s or supplier’s most favored customer rate, as defined by the Secretary of Health and Human Services, for an item or service, as evidenced by commercial price lists or paid invoices and other related pricing and discount data to ensure that the I/T/U is receiving a fair and reasonable price. The limitation under the previous sentence shall not apply with respect to an item or service if— the amount offered to the I/T/U under the negotiation under clause

(i)is fair and reasonable, as determined by the I/T/U, even though comparable discounts were not negotiated; and the amount is otherwise in the best interest of the I/T/U, as determined by the I/T/U. The method described in this subparagraph is that, in the case that an amount for an item or service has not been negotiated in accordance with subparagraph (A), the I/T/U will pay the lowest of the following amounts for the item or service: The amount that is the applicable payment amount under the Medicare program under title XVIII of the Social Security Act for such item or service, including payment according to a fee schedule, a prospective payment system or based on reasonable cost for the period in which the service was provided, or in the event of a Medicare waiver, the payment amount will be calculated in accordance with such waiver. For purposes of this paragraph, the amount described in this clause shall be referred to as the Medicare rate . An amount negotiated by a repricing agent if the provider or supplier is participating within the repricing agent’s network and the I/T/U has a pricing arrangement or contract with that repricing agent. An amount not to exceed the provider or supplier’s most favored customer rate described in subparagraph (A)(ii) for such item or service, as evidenced by commercial price lists or paid invoices and other related pricing and discount data to ensure that the I/T/U is receiving a fair and reasonable price, but only to the extent such evidence is reasonably accessible and available to the I/T/U. The method described in this subparagraph is that, in the case that a Medicare rate does not exist for an item or service, and no other method described in a previous subparagraph is accessible or available, the amount shall be deemed to be 65 percent of authorized charges for such item or service. If an I/T/U has authorized payment for items and services provided to an individual who is eligible for benefits under title XVIII of the Social Security Act, title XIX of such Act, or another third-party payer, the following shall apply: The I/T/U shall be the payer of last resort under section 2901(b) of the Patient Protection and Affordable Care Act ( 25 U.S.C. 1623(b) ). If there are any third-party payers, the I/T/U shall pay the amount for which the patient is being held responsible after the provider or supplier of services has coordinated benefits and all other alternate resources have been considered and paid, including applicable copayments, deductibles, and coinsurance that are owed by the patient. The maximum payment by the I/T/U shall be only the portion of the payment amount determined under this section not covered by any other payer. The I/T/U payment may not exceed the rate calculated in accordance with paragraph

(1)of this section (plus applicable cost sharing). In the case payment is made under such title XIX for an item or service such payment shall be considered payment in full and there shall be no additional payment made by the I/T/U for such item or service. Payment shall be made only for those items and services authorized by an I/T/U consistent with this section or section 503(a) of the Indian Health Care Improvement Act ( 25 U.S.C. 1653(a) ). If an amount has not been negotiated under paragraph (1)(A) for an item or service, the provider or supplier shall be deemed to have accepted the applicable payment amount under paragraph (1)(B) for such item or service as payment in full if— the item or service was provided based on a referral; the provider or supplier submits a notification of a claim for payment to the I/T/U; or the provider or supplier accepts payment for the provision of such item or service from the I/T/U. A payment made and accepted in accordance with this section shall constitute payment in full and the provider or its agent, or supplier or its agent, may not impose any additional charge— on the individual for I/T/U authorized items and services; or for information requested by the I/T/U or its agent or fiscal intermediary for the purposes of payment determinations or quality assurance. The Indian Health Service shall not adjudicate a notification of a claim that does not contain the information described in subsection (b)(1) with an approval or denial, except that the Service may request further information from the individual, or as applicable, the provider or supplier, necessary to make a decision. A notification of a claim meeting the requirements specified herein does not guarantee payment. No service shall be authorized and no payment shall be issued under this section in excess of the rate authorized by this section. An urban Indian organization may authorize for purchase items and services for an eligible urban Indian as those terms are defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ) according to section 503 of such Act ( 25 U.S.C. 1653 ) and applicable regulations. Services and items furnished by physicians and other health care professionals and non-hospital-based entities shall be subject to the payment methodology set forth in this section. In the case of a payment described in subsection

(c)that is with respect to a rare specialty service, as specified by the Secretary of Health and Human Services, or a service furnished in highly rural and medically underserved areas, as specified by the Secretary, the Indian Health Service or tribe or tribal organization involved may negotiate an amount for such payment for such service that is greater than the payment amount that would be recognized under title XVIII of the Social Security for such service. Not later than two years after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the Director of the Indian Health Service, shall submit to Congress a report on the impact of this section on access to care under the Purchased/Referred Care program, including recommendations for such legislative actions as the Secretary determines appropriate.

Connectionstraces to 7

Traces to 7 documents

U.S. Code