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U.S. Code as of:
01/19/04
Section 1320b-6. Exclusion of representatives and health care providers convicted of violations from participation in social security programs
(a) In general
The Commissioner of Social Security shall exclude from
participation in the social security programs any representative or
health care provider -
(1) who is convicted of a violation of section 408 or 1383a of
this title;
(2) who is convicted of any violation under title 18 relating
to an initial application for or continuing entitlement to, or
amount of, benefits under subchapter II of this chapter, or an
initial application for or continuing eligibility for, or amount
of, benefits under subchapter XVI of this chapter; or
(3) who the Commissioner determines has committed an offense
described in section 1320a-8(a)(1) of this title.
(b) Notice, effective date, and period of exclusion
(1) An exclusion under this section shall be effective at such
time, for such period, and upon such reasonable notice to the
public and to the individual excluded as may be specified in
regulations consistent with paragraph (2).
(2) Such an exclusion shall be effective with respect to services
furnished to any individual on or after the effective date of the
exclusion. Nothing in this section may be construed to preclude, in
determining disability under subchapter II of this chapter or
subchapter XVI of this chapter, consideration of any medical
evidence derived from services provided by a health care provider
before the effective date of the exclusion of the health care
provider under this section.
(3)(A) The Commissioner shall specify, in the notice of exclusion
under paragraph (1), the period of the exclusion.
(B) Subject to subparagraph (C), in the case of an exclusion
under subsection (a) of this section, the minimum period of
exclusion shall be 5 years, except that the Commissioner may waive
the exclusion in the case of an individual who is the sole source
of essential services in a community. The Commissioner's decision
whether to waive the exclusion shall not be reviewable.
(C) In the case of an exclusion of an individual under subsection
(a) of this section based on a conviction or a determination
described in subsection (a)(3) of this section occurring on or
after December 14, 1999, if the individual has (before, on, or
after December 14, 1999) been convicted, or if such a determination
has been made with respect to the individual -
(i) on one previous occasion of one or more offenses for which
an exclusion may be effected under such subsection, the period of
the exclusion shall be not less than 10 years; or
(ii) on two or more previous occasions of one or more offenses
for which an exclusion may be effected under such subsection, the
period of the exclusion shall be permanent.
(c) Notice to State agencies
The Commissioner shall promptly notify each appropriate State
agency employed for the purpose of making disability determinations
under section 421 or 1383b(a) of this title -
(1) of the fact and circumstances of each exclusion effected
against an individual under this section; and
(2) of the period (described in subsection (b)(3) of this
section) for which the State agency is directed to exclude the
individual from participation in the activities of the State
agency in the course of its employment.
(d) Notice to State licensing agencies
The Commissioner shall -
(1) promptly notify the appropriate State or local agency or
authority having responsibility for the licensing or
certification of an individual excluded from participation under
this section of the fact and circumstances of the exclusion;
(2) request that appropriate investigations be made and
sanctions invoked in accordance with applicable State law and
policy; and
(3) request that the State or local agency or authority keep
the Commissioner and the Inspector General of the Social Security
Administration fully and currently informed with respect to any
actions taken in response to the request.
(e) Notice, hearing, and judicial review
(1) Any individual who is excluded (or directed to be excluded)
from participation under this section is entitled to reasonable
notice and opportunity for a hearing thereon by the Commissioner to
the same extent as is provided in section 405(b) of this title, and
to judicial review of the Commissioner's final decision after such
hearing as is provided in section 405(g) of this title.
(2) The provisions of section 405(h) of this title shall apply
with respect to this section to the same extent as it is applicable
with respect to subchapter II of this chapter.
(f) Application for termination of exclusion
(1) An individual excluded from participation under this section
may apply to the Commissioner, in the manner specified by the
Commissioner in regulations and at the end of the minimum period of
exclusion provided under subsection (b)(3) of this section and at
such other times as the Commissioner may provide, for termination
of the exclusion effected under this section.
(2) The Commissioner may terminate the exclusion if the
Commissioner determines, on the basis of the conduct of the
applicant which occurred after the date of the notice of exclusion
or which was unknown to the Commissioner at the time of the
exclusion, that -
(A) there is no basis under subsection (a) of this section for
a continuation of the exclusion; and
(B) there are reasonable assurances that the types of actions
which formed the basis for the original exclusion have not
recurred and will not recur.
(3) The Commissioner shall promptly notify each State agency
employed for the purpose of making disability determinations under
section 421 or 1383b(a) of this title of the fact and circumstances
of each termination of exclusion made under this subsection.
(g) Availability of records of excluded representatives and health
care providers
Nothing in this section shall be construed to have the effect of
limiting access by any applicant or beneficiary under subchapter II
or XVI of this chapter, any State agency acting under section 421
or 1383b(a) of this title, or the Commissioner to records
maintained by any representative or health care provider in
connection with services provided to the applicant or beneficiary
prior to the exclusion of such representative or health care
provider under this section.
(h) Reporting requirement
Any representative or health care provider participating in, or
seeking to participate in, a social security program shall inform
the Commissioner, in such form and manner as the Commissioner shall
prescribe by regulation, whether such representative or health care
provider has been convicted of a violation described in subsection
(a) of this section.
(i) Delegation of authority
The Commissioner may delegate authority granted by this section
to the Inspector General.
(j) Definitions
For purposes of this section:
(1) Exclude
The term "exclude" from participation means -
(A) in connection with a representative, to prohibit from
engaging in representation of an applicant for, or recipient
of, benefits, as a representative payee under section 405(j) or
section 1383(a)(2)(A)(ii) of this title, or otherwise as a
representative, in any hearing or other proceeding relating to
entitlement to benefits; and
(B) in connection with a health care provider, to prohibit
from providing items or services to an applicant for, or
recipient of, benefits for the purpose of assisting such
applicant or recipient in demonstrating disability.
(2) Social security program
The term "social security programs" means the program providing
for monthly insurance benefits under subchapter II of this
chapter, and the program providing for monthly supplemental
security income benefits to individuals under subchapter XVI of
this chapter (including State supplementary payments made by the
Commissioner pursuant to an agreement under section 1382e(a) of
this title or section 212(b) of Public Law 93-66).
(3) Convicted
An individual is considered to have been "convicted" of a
violation -
(A) when a judgment of conviction has been entered against
the individual by a Federal, State, or local court, except if
the judgment of conviction has been set aside or expunged;
(B) when there has been a finding of guilt against the
individual by a Federal, State, or local court;
(C) when a plea of guilty or nolo contendere by the
individual has been accepted by a Federal, State, or local
court; or
(D) when the individual has entered into participation in a
first offender, deferred adjudication, or other arrangement or
program where judgment of conviction has been withheld.
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