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[Laws in effect as of January 7, 2003]
[Document not affected by Public Laws enacted between
January 7, 2003 and February 12, 2003]
[CITE: 42USC1395gg]
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 7--SOCIAL SECURITY
SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
Part D--Miscellaneous Provisions
Sec. 1395gg. Overpayment on behalf of individuals and settlement
of claims for benefits on behalf of deceased individuals
(a) Payments to providers of services or other person regarded as
payment to individuals
Any payment under this subchapter to any provider of services or
other person with respect to any items or services furnished any
individual shall be regarded as a payment to such individual.
(b) Incorrect payments on behalf of individuals; payment adjustment
Where--
(1) more than the correct amount is paid under this subchapter
to a provider of services or other person for items or services
furnished an individual and the Secretary determines (A) that,
within such period as he may specify, the excess over the correct
amount cannot be recouped from such provider of services or other
person, or (B) that such provider of services or other person was
without fault with respect to the payment of such excess over the
correct amount, or
(2) any payment has been made under section 1395f(e) of this
title to a provider of services or other person for items or
services furnished an individual,
proper adjustments shall be made, under regulations prescribed (after
consultation with the Railroad Retirement Board) by the Secretary, by
decreasing subsequent payments--
(3) to which such individual is entitled under subchapter II of
this chapter or under the Railroad Retirement Act of 1974 [45 U.S.C.
231 et seq.], as the case may be, or
(4) if such individual dies before such adjustment has been
completed, to which any other individual is entitled under
subchapter II of this chapter or under the Railroad Retirement Act
of 1974 [45 U.S.C. 231 et seq.], as the case may be, with respect to
the wages and self-employment income or the compensation
constituting the basis of the benefits of such deceased individual
under subchapter II of this chapter.
As soon as practicable after any adjustment under paragraph (3) or (4)
is determined to be necessary, the Secretary, for purposes of this
section, section 1395i(g) of this title, and section 1395t(f) of this
title, shall certify (to the Railroad Retirement Board if the adjustment
is to be made by decreasing subsequent payments under the Railroad
Retirement Act of 1974 [45 U.S.C. 231 et seq.]) the amount of the
overpayment as to which the adjustment is to be made. For purposes of
clause (B) of paragraph (1), such provider of services or such other
person shall, in the absence of evidence to the contrary, be deemed to
be without fault if the Secretary's determination that more than such
correct amount was paid was made subsequent to the third year following
the year in which notice was sent to such individual that such amount
had been paid; except that the Secretary may reduce such three-year
period to not less than one year if he finds such reduction is
consistent with the objectives of this subchapter.
(c) Exception to subsection (b) payment adjustment
There shall be no adjustment as provided in subsection (b) of this
section (nor shall there be recovery) in any case where the incorrect
payment has been made (including payments under section 1395f(e) of this
title) with respect to an individual who is without fault or where the
adjustment (or recovery) would be made by decreasing payments to which
another person who is without fault is entitled as provided in
subsection (b)(4) of this section, if such adjustment (or recovery)
would defeat the purposes of subchapter II or subchapter XVIII of this
chapter or would be against equity and good conscience. Adjustment or
recovery of an incorrect payment (or only such part of an incorrect
payment as the Secretary determines to be inconsistent with the purposes
of this subchapter) against an individual who is without fault shall be
deemed to be against equity and good conscience if (A) the incorrect
payment was made for expenses incurred for items or services for which
payment may not be made under this subchapter by reason of the
provisions of paragraph (1) or (9) of section 1395y(a) of this title and
(B) if the Secretary's determination that such payment was incorrect was
made subsequent to the third year following the year in which notice of
such payment was sent to such individual; except that the Secretary may
reduce such three-year period to not less than one year if he finds such
reduction is consistent with the objectives of this subchapter.
(d) Liability of certifying or disbursing officer for failure to recoup
No certifying or disbursing officer shall be held liable for any
amount certified or paid by him to any provider of services or other
person where the adjustment or recovery of such amount is waived under
subsection (c) of this section or where adjustment under subsection (b)
of this section is not completed prior to the death of all persons
against whose benefits such adjustment is authorized.
(e) Settlement of claims for benefits under this subchapter on behalf of
deceased individuals
If an individual, who received services for which payment may be
made to such individual under this subchapter, dies, and payment for
such services was made (other than under this subchapter), and the
individual died before any payment due him under this subchapter with
respect to such services was completed, payment of the amount due
(including the amount of any unnegotiated checks) shall be made--
(1) if the payment for such services was made (before or after
such individual's death) by a person other than the deceased
individual, to the person or persons determined by the Secretary
under regulations to have paid for such services, or if the payment
for such services was made by the deceased individual before his
death, to the legal representative of the estate of such deceased
individual, if any;
(2) if there is no person who meets the requirements of
paragraph (1), to the person, if any, who is determined by the
Secretary to be the surviving spouse of the deceased individual and
who was either living in the same household with the deceased at the
time of his death or was, for the month in which the deceased
individual died, entitled to a monthly benefit on the basis of the
same wages and self-employment income as was the deceased
individual;
(3) if there is no person who meets the requirements of
paragraph (1) or (2), or if the person who meets such requirements
dies before the payment due him under this subchapter is completed,
to the child or children, if any, of the deceased individual who
were, for the month in which the deceased individual died, entitled
to monthly benefits on the basis of the same wages and self-
employment income as was the deceased individual (and, in case there
is more than one such child, in equal parts to each such child);
(4) if there is no person who meets the requirements of
paragraph (1), (2), or (3), or if each person who meets such
requirements dies before the payment due him under this subchapter
is completed, to the parent or parents, if any, of the deceased
individual who were, for the month in which the deceased individual
died, entitled to monthly benefits on the basis of the same wages
and self-employment income as was the deceased individual (and, in
case there is more than one such parent, in equal parts to each such
parent);
(5) if there is no person who meets the requirements of
paragraph (1), (2), (3), or (4), or if each person who meets such
requirements dies before the payment due him under this subchapter
is completed, to the person, if any, determined by the Secretary to
be the surviving spouse of the deceased individual;
(6) if there is no person who meets the requirements of
paragraph (1), (2), (3), (4), or (5), or if each person who meets
such requirements dies before the payment due him under this
subchapter is completed, to the person or persons, if any,
determined by the Secretary to be the child or children of the
deceased individual (and, in case there is more than one such child,
in equal parts to each such child);
(7) if there is no person who meets the requirements of
paragraph (1), (2), (3), (4), (5), or (6), or if each person who
meets such requirements dies before the payment due him under this
subchapter is completed, to the parent or parents, if any, of the
deceased individual (and, in case there is more than one such
parent, in equal parts to each such parent); or
(8) if there is no person who meets the requirements of
paragraph (1), (2), (3), (4), (5), (6), or (7), or if each person
who meets such requirements dies before the payment due him under
this subchapter is completed, to the legal representatives of the
estate of the deceased individual, if any.
(f) Settlement of claims for section 1395k benefits on behalf of
deceased individuals
If an individual who received medical and other health services for
which payment may be made under section 1395k(a)(1) of this title dies,
and no assignment of the right to payment for such services was made by
such individual before his death, and payment for such services has not
been made--
(1) if the person or persons who furnished the services agree to
the terms of assignment specified in section 1395u(b)(3)(B)(ii) of
this title with respect to the services, payment for such services
shall be made to such person or persons, and
(2) if the person or persons who furnished the services do not
agree to the terms of assignment specified in section
1395u(b)(3)(B)(ii) of this title with respect to the services,
payment for such services shall be made on the basis of an itemized
bill to the person who has agreed to assume the legal obligation to
make payment for such services and files a request for payment (with
such accompanying evidence of such legal obligation as may be
required in regulations),
but only in such amount and subject to such conditions as would be
applicable if the individual who received the services had not died.
(g) Refund of premiums for deceased individuals
If an individual, who is enrolled under section 1395i-2(c) of this
title or under section 1395p of this title, dies, and premiums with
respect to such enrollment have been received with respect to such
individual for any month after the month of his death, such premiums
shall be refunded to the person or persons determined by the Secretary
under regulations to have paid such premiums or if payment for such
premiums was made by the deceased individual before his death, to the
legal representative of the estate of such deceased individual, if any.
If there is no person who meets the requirements of the preceding
sentence such premiums shall be refunded to the person or persons in the
priorities specified in paragraphs (2) through (7) of subsection (e) of
this section.
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1870, as added Pub. L. 89-97,
title I, Sec. 102(a), July 30, 1965, 79 Stat. 331; amended Pub. L. 90-
248, title I, Sec. 154(b), (c), Jan. 2, 1968, 81 Stat. 862; Pub. L. 92-
603, title II, Secs. 261(a), 266, 281(a), (b), Oct. 30, 1972, 86 Stat.
1448, 1450, 1454, 1455; Pub. L. 93-445, title III, Sec. 309, Oct. 16,
1974, 88 Stat. 1358; Pub. L. 96-499, title IX, Sec. 954(a), Dec. 5,
1980, 94 Stat. 2647; Pub. L. 97-248, title I, Sec. 128(d)(1), Sept. 3,
1982, 96 Stat. 367; Pub. L. 100-203, title IV, Secs. 4039(h)(7),
4096(a)(2), Dec, 22, 1987, 101 Stat. 1330-139, as amended Pub. L. 100-
360, title IV, Sec. 411(e)(3), July 1, 1988, 102 Stat. 776; Pub. L. 100-
360, title IV, Sec. 411(j)(4)(B), July 1, 1988, 102 Stat. 791.)
References in Text
The Railroad Retirement Act of 1974, referred to in subsec. (b), is
act Aug. 29, 1935, ch. 812, as amended generally by Pub. L. 93-445,
title I, Sec. 101, Oct. 16, 1974, 88 Stat. 1305, which is classified
generally to subchapter IV (Sec. 231 et seq.) of chapter 9 of Title 45,
Railroads. For further details and complete classification of this Act
to the Code, see Codification note set out preceding section 231 of
Title 45, section 231t of Title 45, and Tables.
Amendments
1988--Pub. L. 100-360, Sec. 411(e)(3), added Pub. L. 100-203,
Sec. 4039(h)(7), see 1987 Amendment note below.
Subsec. (f)(1), (2). Pub. L. 100-360, Sec. 411(j)(4)(B), substituted
``of assignment specified in'' for ``specified in subclauses (I) and
(II) of''.
1987--Pub. L. 100-203, Sec. 4039(h)(7), as added by Pub. L. 100-360,
Sec. 411(e)(3), amended section catchline generally.
Subsec. (f)(1), (2). Pub. L. 100-203, Sec. 4096(a)(2), substituted
``to the terms specified in subclauses (I) and (II) of section
1395u(b)(3)(B)(ii) of this title with respect to the services'' for
``that the reasonable charge is the full charge for the services''.
1982--Subsec. (c). Pub. L. 97-248 substituted ``section 1395y(a)''
for ``section 1395y''.
1980--Subsec. (f). Pub. L. 96-499 amended subsec. (f) generally,
inserting provision for payments to providers of medical and other
health services where the person or persons furnishing the services did
not agree that the reasonable charge was the full charge for such
services.
1974--Subsec. (b). Pub. L. 93-445 substituted ``Railroad Retirement
Act of 1974'' for ``Railroad Retirement Act of 1937'', wherever
appearing.
1972--Subsec. (b). Pub. L. 92-603, Sec. 281(a), required that
provider of services or other person be without fault with respect to
payment of excess over correct amount as prerequisite to adjustment or
recovery of incorrect payments.
Subsec. (c). Pub. L. 92-603, Secs. 261(a), 281(b), substituted ``or
where the adjustment (or recovery) would be made by decreasing payments
to which another person who is without fault is entitled as provided in
subsection (b)(4) of this section, if'' for ``and where'', inserted
reference to subchapter XVIII of this chapter, and inserted provisions
covering the adjustment or recovery of incorrect payments against
individuals who are without fault.
Subsec. (g). Pub. L. 92-603, Sec. 266, added subsec. (g).
1968--Pub. L. 90-248, Sec. 154(b), provided for settlement of claims
for benefits on behalf of deceased individuals in section catchline.
Subsecs. (e), (f). Pub. L. 90-248, Sec. 154(c), added subsecs. (e)
and (f).
Effective Date of 1988 Amendment
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by Pub. L. 100-360, as it relates to a provision in the
Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, effective as
if included in the enactment of that provision in Pub. L. 100-203, see
section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA;
Effective Date note under section 106 of Title 1, General Provisions.
Effective Date of 1987 Amendment
Amendment by section 4096(a)(2) of Pub. L. 100-203 applicable to
services furnished on or after Jan. 1, 1988, see section 4096(d) of Pub.
L. 100-203, set out as a note under section 1320c-3 of this title.
Effective Date of 1982 Amendment
Amendment by Pub. L. 97-248 effective Sept. 3, 1982, see section
128(e)(3) of Pub. L. 97-248, set out as a note under section 1395x of
this title.
Effective Date of 1980 Amendment
Section 954(b) of Pub. L. 96-499 provided that: ``The amendment made
by this section [amending this section] shall apply only to claims filed
on or after January 1, 1981.''
Effective Date of 1974 Amendment
Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section 603
of Pub. L. 93-445, set out as a note under section 402 of this title.
Effective Date of 1972 Amendment
Section 261(b) of Pub. L. 92-603 provided that: ``The amendment made
by subsection (a) [amending this section] shall apply with respect to
waiver actions considered after the date of the enactment of this Act
[Oct. 30, 1972].''
Section 281(g) of Pub. L. 92-603 provided that: ``The provisions of
subsection (a)(1) [amending this section] shall apply with respect to
notices of payment sent to individuals after the date of enactment of
this Act [Oct. 30, 1972]. The provisions of subsections (a)(2), (b),
(c), and (d) [amending this section and sections 1395u and 1395cc of
this title] shall apply in the case of notices sent to individuals after
1968. The provisions of subsections (e) and (f) [amending sections 1395f
and 1395n of this title] shall apply in the case of services furnished
(or deemed to have been furnished) after 1970.''
Waiver of Liability Limiting Recoupment in Certain Cases
Pub. L. 101-239, title VI, Sec. 6109, Dec. 19, 1989, 103 Stat. 2213,
provided that: ``In the case where more than the correct amount may have
been paid to a physician or individual under part B of title XVIII of
the Social Security Act [part B of this subchapter] with respect to
services furnished during the period beginning on July 1, 1985, and
ending on March 31, 1986, as a result of a carrier's establishing
statewide fees for certain procedure codes while the carrier was in the
process of implementing the national common procedure coding system of
the Health Care Financing Administration, the provisions of section
1870(c) of the Social Security Act [subsec. (c) of this section] shall
apply, without the need for affirmative action by such a physician or
individual, so as to prevent any recoupment, or other decrease in
subsequent payments, to the physician or individual. The previous
sentence shall apply to claims for items and services which were
reopened by carriers on or after July 31, 1987.''
Section Referred to in Other Sections
This section is referred to in sections 1395i, 1395t, 1395u of this
title; title 2 section 906.