Title 42

PART 411

Part 411 - Exclusions From Medicare And Limitations On Medicare Payment

PART 411 - EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Authority:42 U.S.C. 1302, 1395w-101 through 1395w-152, 1395hh, and 1395nn. Source:54 FR 41734, Oct. 11, 1989, unless otherwise noted. Editorial Note:Nomenclature changes to part 411 appear at 71 FR 9471, Feb. 24, 2006

42:2.0.1.2.12.1SUBPART A
Subpart A - General Exclusions and Exclusion of Particular Services
42:2.0.1.2.12.1.35.1SECTION 411.1
   411.1 Basis and scope.
42:2.0.1.2.12.1.35.2SECTION 411.2
   411.2 Conclusive effect of QIO determinations on payment of claims.
42:2.0.1.2.12.1.35.3SECTION 411.4
   411.4 Services for which neither the beneficiary nor any other person is legally obligated to pay.
42:2.0.1.2.12.1.35.4SECTION 411.6
   411.6 Services furnished by a Federal provider of services or other Federal agency.
42:2.0.1.2.12.1.35.5SECTION 411.7
   411.7 Services that must be furnished at public expense under a Federal law or Federal Government contract.
42:2.0.1.2.12.1.35.6SECTION 411.8
   411.8 Services paid for by a Government entity.
42:2.0.1.2.12.1.35.7SECTION 411.9
   411.9 Services furnished outside the United States.
42:2.0.1.2.12.1.35.8SECTION 411.10
   411.10 Services required as a result of war.
42:2.0.1.2.12.1.35.9SECTION 411.12
   411.12 Charges imposed by an immediate relative or member of the beneficiary's household.
42:2.0.1.2.12.1.35.10SECTION 411.15
   411.15 Particular services excluded from coverage.
42:2.0.1.2.12.2SUBPART B
Subpart B - Insurance Coverage That Limits Medicare Payment: General Provisions
42:2.0.1.2.12.2.35.1SECTION 411.20
   411.20 Basis and scope.
42:2.0.1.2.12.2.35.2SECTION 411.21
   411.21 Definitions.
42:2.0.1.2.12.2.35.3SECTION 411.22
   411.22 Reimbursement obligations of primary payers and entities that received payment from primary payers.
42:2.0.1.2.12.2.35.4SECTION 411.23
   411.23 Beneficiary's cooperation.
42:2.0.1.2.12.2.35.5SECTION 411.24
   411.24 Recovery of conditional payments.
42:2.0.1.2.12.2.35.6SECTION 411.25
   411.25 Primary payer's notice of primary payment responsibility.
42:2.0.1.2.12.2.35.7SECTION 411.26
   411.26 Subrogation and right to intervene.
42:2.0.1.2.12.2.35.8SECTION 411.28
   411.28 Waiver of recovery and compromise of claims.
42:2.0.1.2.12.2.35.9SECTION 411.30
   411.30 Effect of primary payment on benefit utilization and deductibles.
42:2.0.1.2.12.2.35.10SECTION 411.31
   411.31 Authority to bill primary payers for full charges.
42:2.0.1.2.12.2.35.11SECTION 411.32
   411.32 Basis for Medicare secondary payments.
42:2.0.1.2.12.2.35.12SECTION 411.33
   411.33 Amount of Medicare secondary payment.
42:2.0.1.2.12.2.35.13SECTION 411.35
   411.35 Limitations on charges to a beneficiary or other party when a workers' compensation plan, a no-fault insurer, or an employer group health plan is primary payer.
42:2.0.1.2.12.2.35.14SECTION 411.37
   411.37 Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.
42:2.0.1.2.12.2.35.15SECTION 411.39
   411.39 Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal.
42:2.0.1.2.12.3SUBPART C
Subpart C - Limitations on Medicare Payment for Services Covered Under Workers' Compensation
42:2.0.1.2.12.3.35.1SECTION 411.40
   411.40 General provisions.
42:2.0.1.2.12.3.35.2SECTION 411.43
   411.43 Beneficiary's responsibility with respect to workers' compensation.
42:2.0.1.2.12.3.35.3SECTION 411.45
   411.45 Basis for conditional Medicare payment in workers' compensation cases.
42:2.0.1.2.12.3.35.4SECTION 411.46
   411.46 Lump-sum payments.
42:2.0.1.2.12.3.35.5SECTION 411.47
   411.47 Apportionment of a lump-sum compromise settlement of a workers' compensation claim.
42:2.0.1.2.12.4SUBPART D
Subpart D - Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance
42:2.0.1.2.12.4.35.1SECTION 411.50
   411.50 General provisions.
42:2.0.1.2.12.4.35.2SECTION 411.51
   411.51 Beneficiary's responsibility with respect to no-fault insurance.
42:2.0.1.2.12.4.35.3SECTION 411.52
   411.52 Basis for conditional Medicare payment in liability cases.
42:2.0.1.2.12.4.35.4SECTION 411.53
   411.53 Basis for conditional Medicare payment in no-fault cases.
42:2.0.1.2.12.4.35.5SECTION 411.54
   411.54 Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.
42:2.0.1.2.12.5SUBPART E
Subpart E - Limitations on Payment for Services Covered Under Group Health Plans: General Provisions
42:2.0.1.2.12.5.35.1SECTION 411.100
   411.100 Basis and scope.
42:2.0.1.2.12.5.35.2SECTION 411.101
   411.101 Definitions.
42:2.0.1.2.12.5.35.3SECTION 411.102
   411.102 Basic prohibitions and requirements.
42:2.0.1.2.12.5.35.4SECTION 411.103
   411.103 Prohibition against financial and other incentives.
42:2.0.1.2.12.5.35.5SECTION 411.104
   411.104 Current employment status.
42:2.0.1.2.12.5.35.6SECTION 411.106
   411.106 Aggregation rules.
42:2.0.1.2.12.5.35.7SECTION 411.108
   411.108 Taking into account entitlement to Medicare.
42:2.0.1.2.12.5.35.8SECTION 411.110
   411.110 Basis for determination of nonconformance.
42:2.0.1.2.12.5.35.9SECTION 411.112
   411.112 Documentation of conformance.
42:2.0.1.2.12.5.35.10SECTION 411.114
   411.114 Determination of nonconformance.
42:2.0.1.2.12.5.35.11SECTION 411.115
   411.115 Notice of determination of nonconformance.
42:2.0.1.2.12.5.35.12SECTION 411.120
   411.120 Appeals.
42:2.0.1.2.12.5.35.13SECTION 411.121
   411.121 Hearing procedures.
42:2.0.1.2.12.5.35.14SECTION 411.122
   411.122 Hearing officer's decision.
42:2.0.1.2.12.5.35.15SECTION 411.124
   411.124 Administrator's review of hearing decision.
42:2.0.1.2.12.5.35.16SECTION 411.126
   411.126 Reopening of determinations and decisions.
42:2.0.1.2.12.5.35.17SECTION 411.130
   411.130 Referral to Internal Revenue Service (IRS).
42:2.0.1.2.12.6SUBPART F
Subpart F - Special Rules: Individuals Eligible or Entitled on the Basis of ESRD, Who Are Also Covered Under Group Health Plans
42:2.0.1.2.12.6.35.1SECTION 411.160
   411.160 Scope.
42:2.0.1.2.12.6.35.2SECTION 411.161
   411.161 Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.
42:2.0.1.2.12.6.35.3SECTION 411.162
   411.162 Medicare benefits secondary to group health plan benefits.
42:2.0.1.2.12.6.35.4SECTION 411.163
   411.163 Coordination of benefits: Dual entitlement situations.
42:2.0.1.2.12.6.35.5SECTION 411.165
   411.165 Basis for conditional Medicare payments.
42:2.0.1.2.12.7SUBPART G
Subpart G - Special Rules: Aged Beneficiaries and Spouses Who Are Also Covered Under Group Health Plans
42:2.0.1.2.12.7.35.1SECTION 411.170
   411.170 General provisions.
42:2.0.1.2.12.7.35.2SECTION 411.172
   411.172 Medicare benefits secondary to group health plan benefits.
42:2.0.1.2.12.7.35.3SECTION 411.175
   411.175 Basis for Medicare primary payments.
42:2.0.1.2.12.8SUBPART H
Subpart H - Special Rules: Disabled Beneficiaries Who Are Also Covered Under Large Group Health Plans
42:2.0.1.2.12.8.35.1SECTION 411.200
   411.200 Basis.
42:2.0.1.2.12.8.35.2SECTION 411.201
   411.201 Definitions.
42:2.0.1.2.12.8.35.3SECTION 411.204
   411.204 Medicare benefits secondary to LGHP benefits.
42:2.0.1.2.12.8.35.4SECTION 411.206
   411.206 Basis for Medicare primary payments and limits on secondary payments.
42:2.0.1.2.12.9SUBPART I
Subpart I [Reserved]
42:2.0.1.2.12.10SUBPART J
Subpart J - Financial Relationships Between Physicians and Entities Furnishing Designated Health Services
42:2.0.1.2.12.10.35.1SECTION 411.350
   411.350 Scope of subpart.
42:2.0.1.2.12.10.35.2SECTION 411.351
   411.351 Definitions.
42:2.0.1.2.12.10.35.3SECTION 411.352
   411.352 Group practice.
42:2.0.1.2.12.10.35.4SECTION 411.353
   411.353 Prohibition on certain referrals by physicians and limitations on billing.
42:2.0.1.2.12.10.35.5SECTION 411.354
   411.354 Financial relationship, compensation, and ownership or investment interest.
42:2.0.1.2.12.10.35.6SECTION 411.355
   411.355 General exceptions to the referral prohibition related to both ownership/investment and compensation.
42:2.0.1.2.12.10.35.7SECTION 411.356
   411.356 Exceptions to the referral prohibition related to ownership or investment interests.
42:2.0.1.2.12.10.35.8SECTION 411.357
   411.357 Exceptions to the referral prohibition related to compensation arrangements.
42:2.0.1.2.12.10.35.9SECTION 411.361
   411.361 Reporting requirements.
42:2.0.1.2.12.10.35.10SECTION 411.362
   411.362 Additional requirements concerning physician ownership and investment in hospitals.
42:2.0.1.2.12.10.35.11SECTION 411.370
   411.370 Advisory opinions relating to physician referrals.
42:2.0.1.2.12.10.35.12SECTION 411.372
   411.372 Procedure for submitting a request.
42:2.0.1.2.12.10.35.13SECTION 411.373
   411.373 Certification.
42:2.0.1.2.12.10.35.14SECTION 411.375
   411.375 Fees for the cost of advisory opinions.
42:2.0.1.2.12.10.35.15SECTION 411.377
   411.377 Expert opinions from outside sources.
42:2.0.1.2.12.10.35.16SECTION 411.378
   411.378 Withdrawing a request.
42:2.0.1.2.12.10.35.17SECTION 411.379
   411.379 When CMS accepts a request.
42:2.0.1.2.12.10.35.18SECTION 411.380
   411.380 When CMS issues a formal advisory opinion.
42:2.0.1.2.12.10.35.19SECTION 411.382
   411.382 CMS' right to rescind advisory opinions.
42:2.0.1.2.12.10.35.20SECTION 411.384
   411.384 Disclosing advisory opinions and supporting information.
42:2.0.1.2.12.10.35.21SECTION 411.386
   411.386 CMS's advisory opinions as exclusive.
42:2.0.1.2.12.10.35.22SECTION 411.387
   411.387 Effect of an advisory opinion.
42:2.0.1.2.12.10.35.23SECTION 411.388
   411.388 When advisory opinions are not admissible evidence.
42:2.0.1.2.12.10.35.24SECTION 411.389
   411.389 Range of the advisory opinion.
42:2.0.1.2.12.11SUBPART K
Subpart K - Payment for Certain Excluded Services
42:2.0.1.2.12.11.35.1SECTION 411.400
   411.400 Payment for custodial care and services not reasonable and necessary.
42:2.0.1.2.12.11.35.2SECTION 411.402
   411.402 Indemnification of beneficiary.
42:2.0.1.2.12.11.35.3SECTION 411.404
   411.404 Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
42:2.0.1.2.12.11.35.4SECTION 411.406
   411.406 Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
42:2.0.1.2.12.11.35.5SECTION 411.408
   411.408 Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.