Quick search by citation:

42 U.S. Code § 1395b–3 - Health insurance advisory service for medicare beneficiaries

U.S. Code
Notes

(a) In general

The Secretary of Health and Human Services shall establish a health insurance advisory service program (in this section referred to as the “beneficiary assistance program”) to assist medicare-eligible individuals with the receipt of services under the medicare and medicaid programs and other health insurance programs.

(b) Outreach elementsThe beneficiary assistance program shall provide assistance—

(1)

through operation using local Federal offices that provide information on the medicare program,

(2)

using community outreach programs, and

(3)

using a toll-free telephone information service.

(c) Assistance providedThe beneficiary assistance program shall provide for information, counseling, and assistance for medicare-eligible individuals with respect to at least the following:

(1) With respect to the medicare program—

(A)

eligibility,

(B)

benefits (both covered and not covered),

(C)

the process of payment for services,

(D)

rights and process for appeals of determinations,

(E)

other medicare-related entities (such as peer review organizations, fiscal intermediaries, and carriers), and

(F)

recent legislative and administrative changes in the medicare program.

(2) With respect to the medicaid program—

(A)

eligibility, benefits, and the application process,

(B)

linkages between the medicaid and medicare programs, and

(C)

referral to appropriate State and local agencies involved in the medicaid program.

(3) With respect to medicare supplemental policies—

(A)

the program under section 1395ss of this title and standards required under such program,

(B)

how to make informed decisions on whether to purchase such policies and on what criteria to use in evaluating different policies,

(C)

appropriate Federal, State, and private agencies that provide information and assistance in obtaining benefits under such policies, and

(D)

other issues deemed appropriate by the Secretary.

The beneficiary assistance program also shall provide such other services as the Secretary deems appropriate to increase beneficiary understanding of, and confidence in, the medicare program and to improve the relationship between beneficiaries and the program.

(d) Educational material

The Secretary, through the Administrator of the Centers for Medicare & Medicaid Services, shall develop appropriate educational materials and other appropriate techniques to assist employees in carrying out this section.

(e) Notice to beneficiaries

The Secretary shall take such steps as are necessary to assure that medicare-eligible beneficiaries and the general public are made aware of the beneficiary assistance program.

(f) Report

The Secretary shall include, in an annual report transmitted to the Congress, a report on the beneficiary assistance program and on other health insurance informational and counseling services made available to medicare-eligible individuals. The Secretary shall include in the report recommendations for such changes as may be desirable to improve the relationship between the medicare program and medicare-eligible individuals.

(Pub. L. 101–508, title IV, § 4359, Nov. 5, 1990, 104 Stat. 1388–137; Pub. L. 108–173, title IX, § 900(e)(6)(G), Dec. 8, 2003, 117 Stat. 2374.)

Editorial Notes

Codification

Section was enacted as part of the Omnibus Budget Reconciliation Act of 1990, and not as part of the Social Security Act which comprises this chapter.

Amendments

2003—Subsec. (d). Pub. L. 108–173 substituted “Centers for Medicare & Medicaid Services” for “Health Care Financing Administration”.

Statutory Notes and Related Subsidiaries

State Health Insurance Assistance Program Reporting Requirements

Pub. L. 115–123, div. E, title II, § 50207(b), Feb. 9, 2018, 132 Stat. 187, provided that:

“Beginning not later than April 1, 2019, and biennially thereafter, the Agency for Community Living [probably means the Administration for Community Living] shall electronically post on its website the following information, with respect to grants to States for State health insurance assistance programs, (such information to be presented by State and by entity receiving funds from the State to carry out such a program funded by such grant):

“(1)

The amount of Federal funding provided to each such State for such program for the period involved and the amount of Federal funding provided by each such State for such program to each such entity for the period involved.

“(2)

Information as the Secretary may specify, with respect to such programs carried out through such grants, consistent with the terms and conditions for receipt of such grants.”

Medicare Enrollment Assistance

Pub. L. 110–275, title I, § 119, July 15, 2008, 122 Stat. 2508, as amended by Pub. L. 111–148, title III, § 3306, Mar. 23, 2010, 124 Stat. 470; Pub. L. 112–240, title VI, § 610, Jan. 2, 2013, 126 Stat. 2351; Pub. L. 113–67, div. B, title I, § 1110, Dec. 26, 2013, 127 Stat. 1198; Pub. L. 113–93, title I, § 110, Apr. 1, 2014, 128 Stat. 1043; Pub. L. 114–10, title II, § 208, Apr. 16, 2015, 129 Stat. 145; Pub. L. 115–123, div. E, title II, § 50207(a), Feb. 9, 2018, 132 Stat. 186; Pub. L. 116–59, div. B, title IV, § 1402, Sept. 27, 2019, 133 Stat. 1106; Pub. L. 116–69, div. B, title IV, § 1402, Nov. 21, 2019, 133 Stat. 1138; Pub. L. 116–94, div. N, title I, § 103, Dec. 20, 2019, 133 Stat. 3096; Pub. L. 116–136, div. A, title III, § 3803(a), Mar. 27, 2020, 134 Stat. 428; Pub. L. 116–159, div. C, title II, § 2203, Oct. 1, 2020, 134 Stat. 730; Pub. L. 116–215, div. B, title I, § 1102, Dec. 11, 2020, 134 Stat. 1042; Pub. L. 116–260, div. CC, title I, § 103, Dec. 27, 2020, 134 Stat. 2942; Pub. L. 118–42, div. G, title I, § 302, Mar. 9, 2024, 138 Stat. 414, provided that:

“(a) Additional Funding for State Health Insurance Assistance Programs.—

“(1) Grants.—

“(A) In general.—

The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall use amounts made available under subparagraph (B) to make grants to States for State health insurance assistance programs receiving assistance under section 4360 of the Omnibus Budget Reconciliation Act of 1990 [42 U.S.C. 1395b–4].

“(B) Funding.—For purposes of making grants under this subsection, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w–23(f)), to the Centers for Medicare & Medicaid Services Program Management Account—

“(i)

for fiscal year 2009, of $7,500,000;

“(ii)

for the period of fiscal years 2010 through 2012, of $15,000,000;

“(iii)

for fiscal year 2013, of $7,500,000;

“(iv)

for fiscal year 2014, of $7,500,000;

“(v)

for fiscal year 2015, of $7,500,000;

“(vi)

for fiscal year 2016, of $13,000,000;

“(vii)

for fiscal year 2017, of $13,000,000;

“(viii)

for fiscal year 2018, of $13,000,000;

“(ix)

for fiscal year 2019, of $13,000,000;

“(x)

for fiscal year 2020, of $13,000,000;

“(xi)

for fiscal year 2021, $15,000,000;

“(xii)

for fiscal year 2022, $15,000,000;

“(xiii)

for fiscal year 2023, $15,000,000; and

“(xiv)

for the period beginning on October 1, 2023, and ending on December 31, 2024, $18,750,000.

Amounts appropriated under this subparagraph shall remain available until expended.

“(2) Amount of grants.—

The amount of a grant to a State under this subsection from the total amount made available under paragraph (1) shall be equal to the sum of the amount allocated to the State under paragraph (3)(A) and the amount allocated to the State under subparagraph (3)(B).

“(3) Allocation to states.—

“(A) Allocation based on percentage of low-income beneficiaries.—

The amount allocated to a State under this subparagraph from ⅔ of the total amount made available under paragraph (1) shall be based on the number of individuals who meet the requirement under subsection (a)(3)(A)(ii) of section 1860D–14 of the Social Security Act (42 U.S.C. 1395w–114) but who have not enrolled to receive a subsidy under such section 1860D–14 relative to the total number of individuals who meet the requirement under such subsection (a)(3)(A)(ii) in each State, as estimated by the Secretary.

“(B) Allocation based on percentage of rural beneficiaries.—

The amount allocated to a State under this subparagraph from ⅓ of the total amount made available under paragraph (1) shall be based on the number of part D eligible individuals (as defined in section 1860D–1(a)(3)(A) of such Act (42 U.S.C. 1395w–101(a)(3)(A))) residing in a rural area relative to the total number of such individuals in each State, as estimated by the Secretary.

“(4) Portion of grant based on percentage of low-income beneficiaries to be used to provide outreach to individuals who may be subsidy eligible individuals or eligible for the medicare savings program.—

Each grant awarded under this subsection with respect to amounts allocated under paragraph (3)(A) shall be used to provide outreach to individuals who may be subsidy eligible individuals (as defined in section 1860D–14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w–114(a)(3)(A))[)] or eligible for the Medicare Savings Program (as defined in subsection (f)).

“(b) Additional Funding for Area Agencies on Aging.—

“(1) Grants.—

“(A) In general.—

The Secretary, acting through the Assistant Secretary for Aging, shall make grants to States for area agencies on aging (as defined in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)) and Native American programs carried out under the Older Americans Act of 1965 (42 U.S.C. 3001 et seq.).

“(i)

for fiscal year 2009, of $7,500,000;

“(ii)

for the period of fiscal years 2010 through 2012, of $15,000,000;

“(iii)

for fiscal year 2013, of $7,500,000;

“(iv)

for fiscal year 2014, of $7,500,000;

“(v)

for fiscal year 2015, of $7,500,000;

“(vi)

for fiscal year 2016, of $7,500,000;

“(vii)

for fiscal year 2017, of $7,500,000;

“(viii)

for fiscal year 2018, of $7,500,000;

“(ix)

for fiscal year 2019, of $7,500,000;

“(x)

for fiscal year 2020, of $7,500,000;

“(xi)

for fiscal year 2021, $15,000,000;

“(xii)

for fiscal year 2022, $15,000,000;

“(xiii)

for fiscal year 2023, $15,000,000; and

“(xiv)

for the period beginning on October 1, 2023, and ending on December 31, 2024, $18,750,000.

Amounts appropriated under this subparagraph shall remain available until expended.

“(2) Amount of grant and allocation to states based on percentage of low-income and rural beneficiaries.—

The amount of a grant to a State under this subsection from the total amount made available under paragraph (1) shall be determined in the same manner as the amount of a grant to a State under subsection (a), from the total amount made available under paragraph (1) of such subsection, is determined under paragraph (2) and subparagraphs (A) and (B) of paragraph (3) of such subsection.

“(3) Required use of funds.—

“(A) All funds.—

Subject to subparagraph (B), each grant awarded under this subsection shall be used to provide outreach to eligible Medicare beneficiaries regarding the benefits available under title XVIII of the Social Security Act [this subchapter].

“(B) Outreach to individuals who may be subsidy eligible individuals or eligible for the medicare savings program.—

Subsection (a)(4) shall apply to each grant awarded under this subsection in the same manner as it applies to a grant under subsection (a).

“(c) Additional Funding for Aging and Disability Resource Centers.—

“(1) Grants.—

“(A) In general.—

The Secretary shall make grants to Aging and Disability Resource Centers under the Aging and Disability Resource Center grant program that are established centers under such program on the date of the enactment of this Act [July 15, 2008].

“(i)

for fiscal year 2009, of $5,000,000;

“(ii)

for the period of fiscal years 2010 through 2012, of $10,000,000;

“(iii)

for fiscal year 2013, of $5,000,000;

“(iv)

for fiscal year 2014, of $5,000,000;

“(v)

for fiscal year 2015, of $5,000,000;

“(vi)

for fiscal year 2016, of $5,000,000;

“(vii)

for fiscal year 2017, of $5,000,000;

“(viii)

for fiscal year 2018, of $5,000,000;

“(ix)

for fiscal year 2019, of $5,000,000;

“(x)

for fiscal year 2020, of $5,000,000;

“(xi)

for fiscal year 2021, $5,000,000;

“(xii)

for fiscal year 2022, $5,000,000;

“(xiii)

for fiscal year 2023, $5,000,000; and

“(xiv)

for the period beginning on October 1, 2023, and ending on December 31, 2024, $6,250,000.

Amounts appropriated under this subparagraph shall remain available until expended.

“(2) Required use of funds.—

Each grant awarded under this subsection shall be used to provide outreach to individuals regarding the benefits available under the Medicare prescription drug benefit under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w–101 et seq.] and under the Medicare Savings Program.

“(d) Coordination of Efforts To Inform Older Americans About Benefits Available Under Federal and State Programs.—

“(1) In general.—The Secretary, acting through the Assistant Secretary for Aging, in cooperation with related Federal agency partners, shall make a grant to, or enter into a contract with, a qualified, experienced entity under which the entity shall—

“(A)

maintain and update web-based decision support tools, and integrated, person-centered systems, designed to inform older individuals (as defined in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)) about the full range of benefits for which the individuals may be eligible under Federal and State programs;

“(B)

utilize cost-effective strategies to find older individuals with the greatest economic need (as defined in such section 102) and inform the individuals of the programs;

“(C)

develop and maintain an information clearinghouse on best practices and the most cost-effective methods for finding older individuals with greatest economic need and informing the individuals of the programs; and

“(D)

provide, in collaboration with related Federal agency partners administering the Federal programs, training and technical assistance on the most effective outreach, screening, and follow-up strategies for the Federal and State programs.

“(2) Funding.—For purposes of making a grant or entering into a contract under paragraph (1), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary determines under section 1853(f) of such Act (42 U.S.C. 1395w–23(f)), to the Administration on Aging—

“(i)

for fiscal year 2009, of $5,000,000;

“(ii)

for the period of fiscal years 2010 through 2012, of $5,000,000;

“(iii)

for fiscal year 2013, of $5,000,000;

“(iv)

for fiscal year 2014, of $5,000,000;

“(v)

for fiscal year 2015, of $5,000,000;

“(vi)

for fiscal year 2016, of $12,000,000;

“(vii)

for fiscal year 2017, of $12,000,000;

“(viii)

for fiscal year 2018, of $12,000,000;

“(ix)

for fiscal year 2019, of $12,000,000;

“(x)

for fiscal year 2020, of $12,000,000;

“(xi)

for fiscal year 2021, $15,000,000;

“(xii)

for fiscal year 2022, $15,000,000;

“(xiii)

for fiscal year 2023, $15,000,000; and

“(xiv)

for the period beginning on October 1, 2023, and ending on December 31, 2024, $18,750,000.

Amounts appropriated under this subparagraph shall remain available until expended.

“(e) Reprogramming Funds From Medicare, Medicaid, and SCHIP Extension Act of 2007.—

The Secretary shall only use the $5,000,000 in funds allocated to make grants to States for Area Agencies on Aging and Aging Disability and Resource Centers for the period of fiscal years 2008 through 2009 under section 118 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110–173) [121 Stat. 2508] for the sole purpose of providing outreach to individuals regarding the benefits available under the Medicare prescription drug benefit under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w–101 et seq.]. The Secretary shall republish the request for proposals issued on April 17, 2008, in order to comply with the preceding sentence.

“(f) Medicare Savings Program Defined.—

For purposes of this section, the term ‘Medicare Savings Program’ means the program of medical assistance for payment of the cost of medicare cost-sharing under the Medicaid program pursuant to sections 1902(a)(10)(E) and 1933 of the Social Security Act (42 U.S.C. 1396a(a)(10)(E), 1396u–3).

“(g) Secretarial Authority To Enlist Support in Conducting Certain Outreach Activities.—

The Secretary may request that an entity awarded a grant under this section support the conduct of outreach activities aimed at preventing disease and promoting wellness. Notwithstanding any other provision of this section, an entity may use a grant awarded under this subsection [probably should be “section”] to support the conduct of activities described in the preceding sentence.”

[Pub. L. 116–136, div. A, title III, § 3803(b), Mar. 27, 2020, 134 Stat. 429, provided that:

“The amendments made by subsection (a) [amending section 119 of Pub. L. 110–275, set out above] shall take effect as if included in the enactment of the Further Consolidated Appropriations Act, 2020 (Public Law 116–94).”

]

Beneficiary Outreach Demonstration Program

Pub. L. 108–173, title IX, § 924, Dec. 8, 2003, 117 Stat. 2395, provided that:

“(a) In General.—

The Secretary [of Health and Human Services] shall establish a demonstration program (in this section referred to as the ‘demonstration program’) under which medicare specialists employed by the Department of Health and Human Services provide advice and assistance to individuals entitled to benefits under part A of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], or enrolled under part B of such title [42 U.S.C. 1395j et seq.], or both, regarding the medicare program at the location of existing local offices of the Social Security Administration.

“(b) Locations.—

“(1) In general.—

The demonstration program shall be conducted in at least 6 offices or areas. Subject to paragraph (2), in selecting such offices and areas, the Secretary shall provide preference for offices with a high volume of visits by individuals referred to in subsection (a).

“(2) Assistance for rural beneficiaries.—

The Secretary shall provide for the selection of at least 2 rural areas to participate in the demonstration program. In conducting the demonstration program in such rural areas, the Secretary shall provide for medicare specialists to travel among local offices in a rural area on a scheduled basis.

“(c) Duration.—

The demonstration program shall be conducted over a 3-year period.

“(d) Evaluation and Report.—

“(1) Evaluation.—The Secretary shall provide for an evaluation of the demonstration program. Such evaluation shall include an analysis of—

“(A)

utilization of, and satisfaction of those individuals referred to in subsection (a) with, the assistance provided under the program; and

“(B)

the cost-effectiveness of providing beneficiary assistance through out-stationing medicare specialists at local offices of the Social Security Administration.

“(2) Report.—

The Secretary shall submit to Congress a report on such evaluation and shall include in such report recommendations regarding the feasibility of permanently out-stationing medicare specialists at local offices of the Social Security Administration.”

Qualified Medicare Beneficiary Outreach

Pub. L. 103–432, title I, § 154, Oct. 31, 1994, 108 Stat. 4437, provided that not later than 1 year after Oct. 31, 1994, the Secretary of Health and Human Services would establish and implement a method for obtaining information from newly eligible medicare beneficiaries that might be used to determine whether such beneficiaries may be eligible for medical assistance for medicare cost-sharing under State medicaid plans as qualified medicare beneficiaries, and for transmitting such information to the State in which such a beneficiary resides.