42 USC 1395rr-1 - Medicare coverage for individuals exposed to environmental health hazards

U.S Code last checked for updates: Jan 18, 2025

§ 1395rr–1.

Medicare coverage for individuals exposed to environmental health hazards

(a)

Deeming of individuals as eligible for medicare benefits

(1)

In general

(2)

Discretionary deeming

(3)

Effective date of coverage

An Individual 1

 So in original. Probably should not be capitalized.

who is deemed eligible for benefits under this subchapter under paragraph (1) or (2) shall be—

(A)

entitled to benefits under the program under Part ¹ A as of the date of such deeming; and

(B)

eligible to enroll in the program under Part ¹ B beginning with the month in which such deeming occurs.

(b)

Pilot program for care of certain individuals residing in emergency declaration areas

(1)

Program; purpose

(A)

Primary pilot program

(B)

Optional pilot programs

(2)

Individual described

For purposes of paragraph (1), an individual described in this paragraph is an individual who enrolls in part B, submits to the Secretary an application to participate in the applicable pilot program under this subsection, and—

(A)

is an environmental exposure affected individual described in subsection (e)(2) who resides in or around the geographic area subject to an emergency declaration made as of June 17, 2009; or

(B)

is an environmental exposure affected individual described in subsection (e)(3) who—

(i)

is deemed under subsection (a)(2); and

(ii)

meets such other criteria or conditions for participation in a pilot program under paragraph (1)(B) as the Secretary specifies.

(3)

Flexible benefits and services

(4)

Innovative reimbursement methodologies

For purposes of the pilot program under this subsection, the Secretary—

(A)

shall develop and implement appropriate methodologies to reimburse providers for furnishing benefits, items, or services for which payment is not otherwise covered or authorized under this subchapter, if such benefits, items, or services are furnished pursuant to paragraph (3); and

(B)

may develop and implement innovative approaches to reimbursing providers for any benefits, items, or services furnished under this subsection.

(5)

Limitation

(6)

Waiver authority

(7)

Funding

(8)

Waiver of budget neutrality

(c)

Determinations

(1)

By the Commissioner of Social Security

(2)

By the Secretary

(d)

Emergency declaration defined

(e)

Environmental exposure affected individual defined

(1)

In general

For purposes of this section, the term “environmental exposure affected individual” means—

(A)

an individual described in paragraph (2); and

(B)

an individual described in paragraph (3).

(2)

Individual described

(A)

In general

An individual described in this paragraph is any individual who—

(i)

is diagnosed with 1 or more conditions described in subparagraph (B);

(ii)

as demonstrated in such manner as the Secretary determines appropriate, has been present for an aggregate total of 6 months in the geographic area subject to an emergency declaration specified in subsection (b)(2)(A), during a period ending—

(I)

not less than 10 years prior to such diagnosis; and

(II)

prior to the implementation of all the remedial and removal actions specified in the Record of Decision for Operating Unit 4 and the Record of Decision for Operating Unit 7;

(iii)

files an application for benefits under this subchapter (or has an application filed on behalf of the individual), including pursuant to this section; and

(iv)

is determined under this section to meet the criteria in this subparagraph.

(B)

Conditions described

For purposes of subparagraph (A), the following conditions are described in this subparagraph:

(i)

Asbestosis, pleural thickening, or pleural plaques as established by—

(I)

interpretation by a “B Reader” qualified physician of a plain chest x-ray or interpretation of a computed tomographic radiograph of the chest by a qualified physician, as determined by the Secretary; or

(II)

such other diagnostic standards as the Secretary specifies,

except that this clause shall not apply to pleural thickening or pleural plaques unless there are symptoms or conditions requiring medical treatment as a result of these diagnoses.

(ii)

Mesothelioma, or malignancies of the lung, colon, rectum, larynx, stomach, esophagus, pharynx, or ovary, as established by—

(I)

pathologic examination of biopsy tissue;

(II)

cytology from bronchioalveolar lavage; or

(III)

such other diagnostic standards as the Secretary specifies.

(iii)

Any other diagnosis which the Secretary, in consultation with the Commissioner of Social Security, determines is an asbestos-related medical condition, as established by such diagnostic standards as the Secretary specifies.

(3)

Other individual described

An individual described in this paragraph is any individual who—

(A)

is not an individual described in paragraph (2);

(B)

is diagnosed with a medical condition caused by the exposure of the individual to a public health hazard to which an emergency declaration applies, based on such medical conditions, diagnostic standards, and other criteria as the Secretary specifies;

(C)

as demonstrated in such manner as the Secretary determines appropriate, has been present for an aggregate total of 6 months in the geographic area subject to the emergency declaration involved, during a period determined appropriate by the Secretary;

(D)

files an application for benefits under this subchapter (or has an application filed on behalf of the individual), including pursuant to this section; and

(E)

is determined under this section to meet the criteria in this paragraph.

(Aug. 14, 1935, ch. 531, title XVIII, § 1881A, as added Pub. L. 111–148, title X, § 10323(a), Mar. 23, 2010, 124 Stat. 954.)

cite as: 42 USC 1395rr-1