Page:United States Statutes at Large Volume 79.djvu/365

 79 STAT. ]

PUBLIC LAW 89-97-JULY 30, 1965

325

" T

'EXCLUSIONS FROM COVERAGE

"SEC. 1862. (a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses ^Q^"*''^^' '^^^' incurred for items or services— "(1) which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; "(2) for which the individual furnished such items or services has no legal obligation to pay, and which no other person (by reason of such individual's membership in a prepayment plan or otherwise) has a legal obligation to provide or pay for; "(3) which are paid for directly or indirectly by a governmental entity (other than under this Act and other than under a health benefits or insurance plan established for employees of such an entity), except in such cases as the Secretary may specify; "(4) which are not provided within the United States (except for emergency inpatient hospital services furnished outside the United States under the conditions described in section 1814(f)); Ante, p. 294. " (5) which are required as a result of war, or of an act of war, occurring after the effective date of such individual's current coverage under such part; "(6) which constitute personal comfort items; "(7) where such expenses are for routine physical checkups, eyeglasses or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, hearing aids or examinations therefor, or immunizations; "(8) where such expenses are for orthopedic shoes or other supportive devices for the feet; "(9) where such expenses are for custodial care; "(10) where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body memiber; "(11) where such expenses constitute charges imposed by immediate relatives of such individual or members of his household; or "(12) where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. " (b) Payment under this title may not be made with respect to any item or service to the extent that payment has been made, or can reasonably be expected to be made (as determined in accordance with regulations), with respect to such item or service, under a workmen's compensation law or plan of the United States or a State. Any payment under this title with respect to any item or service shall be conditioned on reimbursement to the appropriate Trust F u n d established by this title when notice or other information is received that payment for such item or service has been made under such a law or plan. IC

CONSULTATION W I T H STATE AGENCIES AND OTHER ORGANIZATIONS TO DEVELOP C O N D I T I O N S O F PARTICIPATION FOR PROVIDERS OF SERVICES

"SEC. 1863. I n carr;^ing out his functions, relating to determination of conditions of participation by providers of services, under subsections (e)(8), (f)(4), (g)(4), (j) (10), and (o)(5) of section 1861, the Secretary shall consult with the Health Insurance Benefits Advisory Council established by section 1867, appropriate State agencies,

�