PRIA, Government Policy, Made Personal

Summary

Allows payment for inpatient, extended stay, or home health care given in a religious nonmedical health care institution only when a person has made a written choice (an election) and would otherwise qualify for the same hospital, nursing facility, or home health benefits. The election must be on a form the Secretary requires. It must say the person objects to nonexcepted medical treatment on religious grounds and warn that getting such treatment will cancel the election. The election takes effect when signed and stays in force until the person revokes it in writing or until the person receives reimbursed nonexcepted medical care. After two revocations, the next election cannot start until 1 year after the last revocation, and later elections cannot start until 5 years after the last revocation. “Excepted” care means care given without consent, care required by law, and, beginning December 29, 2022, a COVID‑19 vaccine and its administration; “nonexcepted” means all other medical care. Before each fiscal year (starting with FY2000) the Secretary must estimate spending for these services. If spending would go over a set “trigger” amount, the Secretary must cut payments or limit coverage so spending stays at the trigger. The trigger began at $20,000,000 for FY1998 and is increased each year by the rise in the consumer price index. The Secretary monitors spending (starting FY1999) and can adjust future trigger amounts up or down by the amount of any overrun or shortfall, but yearly increases cannot exceed $50,000,000. No court or administrative review is allowed of those estimates or payment cuts. If payments are reduced, the institution may bill the patient for the reduced amount. If spending exceeds the trigger for three straight years (the first such run not before FY2002), then after the next January 1 only people who already have an election on that date can get these payments, and only while their election stays in effect. Each year (starting FY1999) the Secretary must send Congress a report showing spending, trends, and reasons for major changes.

Title 42, §1395i–5

The Public Health and Welfare, Source: USLM XML via OLRC

(a)In general

Subject to subsections (c) and (d), payment under this part may be made for inpatient hospital services or post-hospital extended care services furnished an individual in a religious nonmedical health care institution and for home health services furnished an individual by a religious nonmedical health care institution only if—

(1)the individual has an election in effect for such benefits under subsection (b); and

(2)the individual has a condition such that the individual would qualify for benefits under this part for inpatient hospital services, extended care services, or home health services, respectively, if the individual were an inpatient or resident in a hospital or skilled nursing facility, or receiving services from a home health agency, that was not such an institution.

(b)Election

(1)In general

An individual may make an election under this subsection in a form and manner specified by the Secretary consistent with this subsection. Unless otherwise provided, such an election shall take effect immediately upon its execution. Such an election, once made, shall continue in effect until revoked.

(2)Form

The election form under this subsection shall include the following:

(A)A written statement, signed by the individual (or such individual’s legal representative), that—

(i)the individual is conscientiously opposed to acceptance of nonexcepted medical treatment; and

(ii)the individual’s acceptance of nonexcepted medical treatment would be inconsistent with the individual’s sincere religious beliefs.

(B)A statement that the receipt of nonexcepted medical services shall constitute a revocation of the election and may limit further receipt of services described in subsection (a).

(3)Revocation

An election under this subsection by an individual may be revoked by voluntarily notifying the Secretary in writing of such revocation and shall be deemed to be revoked if the individual receives nonexcepted medical treatment for which reimbursement is made under this subchapter.

(4)Limitation on subsequent elections

Once an individual’s election under this subsection has been made and revoked twice—

(A)the next election may not become effective until the date that is 1 year after the date of most recent previous revocation, and

(B)any succeeding election may not become effective until the date that is 5 years after the date of the most recent previous revocation.

(5)Excepted medical treatment

For purposes of this subsection: (A) Excepted medical treatment

(B)Nonexcepted medical treatment

The term “nonexcepted medical treatment” means medical care or treatment (including medical and other health services) other than excepted medical treatment.

(c)Monitoring and safeguard against excessive expenditures

(1)Estimate of expenditures

Before the beginning of each fiscal year (beginning with fiscal year 2000), the Secretary shall estimate the level of expenditures under this part for services described in subsection (a) for that fiscal year.

(2)Adjustment in payments

(A)Proportional adjustment

If the Secretary determines that the level estimated under paragraph (1) for a fiscal year will exceed the trigger level (as defined in subparagraph (C)) for that fiscal year, the Secretary shall, subject to subparagraph (B), provide for such a proportional reduction in payment amounts under this part for services described in subsection (a) for the fiscal year involved as will assure that such level (taking into account any adjustment under subparagraph (B)) does not exceed the trigger level for that fiscal year.

(B)Alternative adjustments

The Secretary may, instead of making some or all of the reduction described in subparagraph (A), impose such other conditions or limitations with respect to the coverage of covered services (including limitations on new elections of coverage and new facilities) as may be appropriate to reduce the level of expenditures described in paragraph (1) to the trigger level.

(C)Trigger level

For purposes of this subsection

(i) In general

(ii)Unadjusted trigger level

The “unadjusted trigger level” for— (I)

(II)a succeeding fiscal year is the amount specified under this clause for the previous fiscal year increased by the percentage increase in the consumer price index for all urban consumers (all items; United States city average) for the 12-month period ending with July preceding the beginning of the fiscal year.

(D)Prohibition of administrative and judicial review

There shall be no administrative or judicial review under section 1395ff of this title, 1395oo of this title, or otherwise of the estimation of expenditures under subparagraph (A) or the application of reduction amounts under subparagraph (B).

(E)Effect on billing

Notwithstanding any other provision of this subchapter, in the case of a reduction in payment provided under this subsection for services of a religious nonmedical health care institution provided to an individual, the amount that the institution is otherwise permitted to charge the individual for such services is increased by the amount of such reduction.

(3)Monitoring expenditure level

(A)In general

The Secretary shall monitor the expenditure level described in paragraph (2)(A) for each fiscal year (beginning with fiscal year 1999).

(B)Adjustment in trigger level

(i)In general

If the Secretary determines that such level for a fiscal year exceeded, or was less than, the trigger level for that fiscal year, then, subject to clause (ii), the trigger level for the succeeding fiscal year shall be reduced, or increased, respectively, by the amount of such excess or deficit.

(ii)Limitation on carryforward

In no case may the increase effected under clause (i) for a fiscal year exceed $50,000,000.

(d)Sunset

If the Secretary determines that the level of expenditures described in subsection (c)(1) for 3 consecutive fiscal years (with the first such year being not earlier than fiscal year 2002) exceeds the trigger level for such expenditures for such years (as determined under subsection (c)(2)), benefits shall be paid under this part for services described in subsection (a) and furnished on or after the first January 1 that occurs after such 3 consecutive years only with respect to an individual who has an election in effect under subsection (b) as of such January 1 and only during the duration of such election.

(e)Annual report

At the beginning of each fiscal year (beginning with fiscal year 1999), the Secretary shall submit to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate an annual report on coverage and expenditures for services described in subsection (a) under this part and under State plans under subchapter XIX. Such report shall include—

(1)level of expenditures described in subsection (c)(1) for the previous fiscal year and estimated for the fiscal year involved;

(2)trends in such level; and

(3)facts and circumstances of any significant change in such level from the level in previous fiscal years.

Notes & Related Subsidiaries

Editorial Notes

Amendments

2022—Subsec. (b)(5)(A)(iii). Pub. L. 117–328 added cl. (iii). 2003—Subsec. (a). Pub. L. 108–173, § 706(a)(1), inserted “and for home health services furnished an individual by a religious nonmedical health care institution” after “religious nonmedical health care institution” in introductory provisions. Subsec. (a)(2). Pub. L. 108–173, § 706(a)(2), substituted “, extended care services, or home health services” for “or extended care services” and inserted “, or receiving services from a home health agency,” after “skilled nursing facility”.

Statutory Notes and Related Subsidiaries

Effective Date

Pub. L. 105–33, title IV, § 4454(d), Aug. 5, 1997, 111 Stat. 431, provided that: “The

Amendments

made by this section [enacting this section and amending section 1320a–1, 1320c–11, 1395x, 1396a, and 1396g of this title] shall take effect on the date of the enactment of this Act [Aug. 5, 1997] and shall apply to items and services furnished on or after such date. By not later than July 1, 1998, the Secretary of Health and Human Services shall first issue

Regulations

to carry out such

Amendments

. Such

Regulations

may be issued so they are effective on an interim basis pending notice and opportunity for public comment. For periods before the

Effective Date

of such

Regulations

, such

Regulations

shall recognize elections entered into in good faith in order to comply with the requirements of section 1821(b) of the Social Security Act [42 U.S.C. 1395i–5(b)].” Special Rules for COVID–19 Vaccines Relating to Revocation of Election Pub. L. 117–328, div. FF, title IV, § 4138(b), Dec. 29, 2022, 136 Stat. 5925, provided that: “Notwithstanding paragraphs (3) and (4) of section 1821(b) of the Social Security Act (42 U.S.C. 1395i–5(b)), in the case of an individual with a revocation of an election under such section prior to the date of enactment of this Act [Dec. 29, 2022] by reason of receiving a COVID–19 vaccine and its administration described in section 1861(s)(10)(A) of such Act (42 U.S.C. 1395x(s)(10)(A)), the following rules shall apply: “(1) Beginning on such date of enactment, such individual may make an election under such section, which shall take effect immediately upon its execution, if such individual would be eligible to make such an election if they had not received such COVID–19 vaccine and its administration. “(2) Such revoked election shall not be taken into account for purposes of determining the

Effective Date

for an election described in subparagraph (A) or (B) of such paragraph (4).”

§1395i–5 Conditions for Coverage of Religious Nonmedical Health Care Institutional Services

Summary

Title 42, §1395i–5

Notes & Related Subsidiaries

Editorial Notes

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Amendments

Regulations

Amendments

Regulations

Effective Date

Regulations

Regulations

Effective Date

Citations & Metadata