Page:United States Statutes at Large Volume 86.djvu/1421

 86 STAT. ]

PUBLIC LAW 92-603-OCT. 30, 1972

"Where an individual who is deemed to have enrolled for medical insurance pursuant to section 1837(f) files a notice before the first day of the month in which his coverage period begins advising that he does not wish to be so enrolled, the termination of the coverage period resulting from such deemed enrollment shall take effect with the first day of the month the coverage would have been effective and such notice shall not be considered a disenrollment for the purposes of section 1837(b). Where an individual who is deemed enrolled for medical insurance benefits pursuant to section 1837(f) files a notice requesting termination of his deemed coverage in or after the month in which such coverage becomes effective, the termination of such coverage shall take effect at the close of the calendar quarter following the calendar quarter in which the notice is filed."

1379 ^"'e- P- ^378.

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I N C E N T IV E S FOR STATES TO E S T A B L I S H EFFECTIVE U T I L I Z A T I O N REVIEW PROCEDURES UNDER MEDICAID

SEC. 207. (a)(1) Section 1903 of the Social Security Act is amended giltf^ s/s"!^' by adding at the end thereof the following new subsections: 42 USC uWb. " (g)(1) With respect to amounts paid for the following services furnished under the State plan after June 30, 1973 (other than services furnished pursuant to a contract with a health maintenance organization as defined in section 1876), the Federal medical assistance per- Post, pp. 1396, centage shall be decreased as follows: After an individual has received ^'^^^' care as an inpatient in a hospital (including an institution for tuberculosis), skilled nursing home or intermediate care facility on 60 days, or in a hospital for mental diseases on 90 days (whether or not such days are consecutive), during any fiscal year, which for purposes of this section means the four calendar quarters ending with June 30, the Federal medical assistance percentage with respect to amounts paid for any such care furnished thereafter to such individual in the same fiscal year shall be decreased by 33l^ per centum thereof unless the State agency responsible for the administration of the plan makes a showing satisfactory to the Secretary that, with respect to each calendar quarter for which the State submits a request for payment at the full Federal medical assistance percentage for amounts paid for inpatient hospital services (including tuberculosis hospitals), skilled nursing home services, or intermediate care facility services furnished beyond 60 days (or inpatient mental hospital services furnished beyond 90 days), there is in operation in the State an effective program of control over utilization of such services; such a showing must include evidence that— " (A) in each case for which payment is made under the State plan, a physician certifies at the time of admission, or, if later, the time the individual applies for medical assistance under the State plan (and recertifies, where such services are furnished over a period of time, in such cases, at least every 60 days, and accompanied by such supporting material, appropriate to the case involved, as niay be provided in regulations of the Secretary), that such services are or were required to be given on an inpatient basis because the individual needs or needed such services; and " (B) in each such case, such services were furnished under a plan established and periodically reviewed and evaluated by a physician; " (C) such State has in effect a continuous program of review of utilization pursuant to section 1902(a) (30) whereby the neces- ^°^*' P- ^^le. sity for adnriission and the continued stay of each patient in such institution is periodically reviewed and evaluated (with such

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