42 USC 1395kk - Administration of insurance programs

U.S Code last checked for updates: Nov 26, 2024

§ 1395kk.

Administration of insurance programs

(a)

Functions of Secretary; performance directly or by contract

(b)

Contracts to secure special data, actuarial information, etc.

(c)

Oaths and affirmations

(d)

Inclusion of Medicare provider and supplier payments in Federal Payment Levy Program

(1)

In general

The Centers for Medicare & Medicaid Services shall take all necessary steps to participate in the Federal Payment Levy Program under section 6331(h) of the Internal Revenue Code of 1986 as soon as possible and shall ensure that—

(A)

at least 50 percent of all payments under parts A and B are processed through such program beginning within 1 year after July 15, 2008; 1

 See References in Text note below.

(B)

at least 75 percent of all payments under parts A and B are processed through such program beginning within 2 years after July 15, 2008; and

(C)

all payments under parts A and B are processed through such program beginning not later than September 30, 2011.

(2)

Assistance

(e)

Availability of data

(1)

In general

(2)

Qualified entities

For purposes of this subsection, the term “qualified entity” means a public or private entity that—

(A)

is qualified (as determined by the Secretary) to use claims data to evaluate the performance of providers of services and suppliers on measures of quality, efficiency, effectiveness, and resource use; and

(B)

agrees to meet the requirements described in paragraph (4) and meets such other requirements as the Secretary may specify, such as ensuring security of data.

(3)

Data described

(4)

Requirements

(A)

Fee

(B)

Specification of uses and methodologies

A qualified entity requesting data under this subsection shall—

(i)

submit to the Secretary a description of the methodologies that such qualified entity will use to evaluate the performance of providers of services and suppliers using such data;

(ii)

(I)

except as provided in subclause (II), if available, use standard measures, such as measures endorsed by the entity with a contract under section 1395aaa(a) of this title and measures developed pursuant to section 299b–31 of this title; or

(II)

use alternative measures if the Secretary, in consultation with appropriate stakeholders, determines that use of such alternative measures would be more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by such standard measures;

(iii)

include data made available under this subsection with claims data from sources other than claims data under this subchapter in the evaluation of performance of providers of services and suppliers;

(iv)

only include information on the evaluation of performance of providers and suppliers in reports described in subparagraph (C);

(v)

make available to providers of services and suppliers, upon their request, data made available under this subsection; and

(vi)

prior to their release, submit to the Secretary the format of reports under subparagraph (C).

(C)

Reports

Any report by a qualified entity evaluating the performance of providers of services and suppliers using data made available under this subsection shall—

(i)

include an understandable description of the measures, which shall include quality measures and the rationale for use of other measures described in subparagraph (B)(ii)(II), risk adjustment methods, physician attribution methods, other applicable methods, data specifications and limitations, and the sponsors, so that consumers, providers of services and suppliers, health plans, researchers, and other stakeholders can assess such reports;

(ii)

be made available confidentially, to any provider of services or supplier to be identified in such report, prior to the public release of such report, and provide an opportunity to appeal and correct errors;

(iii)

only include information on a provider of services or supplier in an aggregate form as determined appropriate by the Secretary; and

(iv)

except as described in clause (ii), be made available to the public.

(D)

Approval and limitation of uses

(f)

Requirement for the Secretary to establish policies and claims edits relating to incarcerated individuals, individuals not lawfully present, and deceased individuals

The Secretary shall establish and maintain procedures, including procedures for using claims processing edits, updating eligibility information to improve provider accessibility, and conducting recoupment activities such as through recovery audit contractors, in order to ensure that payment is not made under this subchapter for items and services furnished to an individual who is one of the following:

(1)

An individual who is incarcerated.

(2)

An individual who is not lawfully present in the United States and who is not eligible for coverage under this subchapter.

(3)

A deceased individual.

(g)

Requirement for enrollment data reporting

(1)

In general

Each year (beginning with 2016), the Secretary shall submit to the Committees on Ways and Means and Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on Medicare enrollment data (and, in the case of part A, on data on individuals receiving benefits under such part) as of a date in such year specified by the Secretary. Such data shall be presented—

(A)

by Congressional district and State; and

(B)

in a manner that provides for such data based on—

(i)

fee-for-service enrollment (as defined in paragraph (2));

(ii)

enrollment under part C (including separate for aggregate enrollment in MA–PD plans and aggregate enrollment in MA plans that are not MA–PD plans); and

(iii)

enrollment under part D.

(2)

Fee-for-service enrollment defined

For purpose of paragraph (1)(B)(i), the term “fee-for-service enrollment” means aggregate enrollment (including receipt of benefits other than through enrollment) under—

(A)

part A only;

(B)

part B only; and

(C)

both part A and part B.

(Aug. 14, 1935, ch. 531, title XVIII, § 1874, as added and amended Pub. L. 89–97, title I, §§ 102(a), 111(a), July 30, 1965, 79 Stat. 332, 340; Pub. L. 92–603, title II, § 289, Oct. 30, 1972, 86 Stat. 1457; Pub. L. 93–445, title III, § 310, Oct. 16, 1974, 88 Stat. 1359; Pub. L. 110–275, title I, § 189(a), July 15, 2008, 122 Stat. 2590; Pub. L. 111–148, title X, § 10332(a), Mar. 23, 2010, 124 Stat. 968; Pub. L. 114–10, title I, § 105(c), (d), title V, § 502(a), Apr. 16, 2015, 129 Stat. 137, 165; Pub. L. 114–255, div. C, title XVII, § 17002, Dec. 13, 2016, 130 Stat. 1330.)

cite as: 42 USC 1395kk