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Electronic Code of Federal Regulations

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e-CFR Data is current as of July 29, 2014

TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER B—MEDICARE PROGRAM

PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

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Subpart A—GENERAL EXCLUSIONS AND EXCLUSION OF PARTICULAR SERVICES

§411.1
Basis and scope.
§411.2
Conclusive effect of QIO determinations on payment of claims.
§411.4
Services for which neither the beneficiary nor any other person is legally obligated to pay.
§411.6
Services furnished by a Federal provider of services or other Federal agency.
§411.7
Services that must be furnished at public expense under a Federal law or Federal Government contract.
§411.8
Services paid for by a Government entity.
§411.9
Services furnished outside the United States.
§411.10
Services required as a result of war.
§411.12
Charges imposed by an immediate relative or member of the beneficiary's household.
§411.15
Particular services excluded from coverage.
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Subpart B—INSURANCE COVERAGE THAT LIMITS MEDICARE PAYMENT: GENERAL PROVISIONS

§411.20
Basis and scope.
§411.21
Definitions.
§411.22
Reimbursement obligations of primary payers and entities that received payment from primary payers.
§411.23
Beneficiary's cooperation.
§411.24
Recovery of conditional payments.
§411.25
Primary payer's notice of primary payment responsibility.
§411.26
Subrogation and right to intervene.
§411.28
Waiver of recovery and compromise of claims.
§411.30
Effect of primary payment on benefit utilization and deductibles.
§411.31
Authority to bill primary payers for full charges.
§411.32
Basis for Medicare secondary payments.
§411.33
Amount of Medicare secondary payment.
§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.
§411.37
Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.
§411.39
Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal.
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Subpart C—LIMITATIONS ON MEDICARE PAYMENT FOR SERVICES COVERED UNDER WORKERS' COMPENSATION

§411.40
General provisions.
§411.43
Beneficiary's responsibility with respect to workers' compensation.
§411.45
Basis for conditional Medicare payment in workers' compensation cases.
§411.46
Lump-sum payments.
§411.47
Apportionment of a lump-sum compromise settlement of a workers' compensation claim.
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Subpart D—LIMITATIONS ON MEDICARE PAYMENT FOR SERVICES COVERED UNDER LIABILITY OR NO-FAULT INSURANCE

§411.50
General provisions.
§411.51
Beneficiary's responsibility with respect to no-fault insurance.
§411.52
Basis for conditional Medicare payment in liability cases.
§411.53
Basis for conditional Medicare payment in no-fault cases.
§411.54
Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.
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Subpart E—LIMITATIONS ON PAYMENT FOR SERVICES COVERED UNDER GROUP HEALTH PLANS: GENERAL PROVISIONS

§411.100
Basis and scope.
§411.101
Definitions.
§411.102
Basic prohibitions and requirements.
§411.103
Prohibition against financial and other incentives.
§411.104
Current employment status.
§411.106
Aggregation rules.
§411.108
Taking into account entitlement to Medicare.
§411.110
Basis for determination of nonconformance.
§411.112
Documentation of conformance.
§411.114
Determination of nonconformance.
§411.115
Notice of determination of nonconformance.
§411.120
Appeals.
§411.121
Hearing procedures.
§411.122
Hearing officer's decision.
§411.124
Administrator's review of hearing decision.
§411.126
Reopening of determinations and decisions.
§411.130
Referral to Internal Revenue Service (IRS).
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Subpart F—SPECIAL RULES: INDIVIDUALS ELIGIBLE OR ENTITLED ON THE BASIS OF ESRD, WHO ARE ALSO COVERED UNDER GROUP HEALTH PLANS

§411.160
Scope.
§411.161
Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.
§411.162
Medicare benefits secondary to group health plan benefits.
§411.163
Coordination of benefits: Dual entitlement situations.
§411.165
Basis for conditional Medicare payments.
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Subpart G—SPECIAL RULES: AGED BENEFICIARIES AND SPOUSES WHO ARE ALSO COVERED UNDER GROUP HEALTH PLANS

§411.170
General provisions.
§411.172
Medicare benefits secondary to group health plan benefits.
§411.175
Basis for Medicare primary payments.
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Subpart H—SPECIAL RULES: DISABLED BENEFICIARIES WHO ARE ALSO COVERED UNDER LARGE GROUP HEALTH PLANS

§411.200
Basis.
§411.201
Definitions.
§411.204
Medicare benefits secondary to LGHP benefits.
§411.206
Basis for Medicare primary payments and limits on secondary payments.
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Subpart I—[RESERVED]

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Subpart J—FINANCIAL RELATIONSHIPS BETWEEN PHYSICIANS AND ENTITIES FURNISHING DESIGNATED HEALTH SERVICES

§411.350
Scope of subpart.
§411.351
Definitions.
§411.352
Group practice.
§411.353
Prohibition on certain referrals by physicians and limitations on billing.
§411.354
Financial relationship, compensation, and ownership or investment interest.
§411.355
General exceptions to the referral prohibition related to both ownership/investment and compensation.
§411.356
Exceptions to the referral prohibition related to ownership or investment interests.
§411.357
Exceptions to the referral prohibition related to compensation arrangements.
§411.361
Reporting requirements.
§411.362
Additional requirements concerning physician ownership and investment in hospitals.
§411.370
Advisory opinions relating to physician referrals.
§411.372
Procedure for submitting a request.
§411.373
Certification.
§411.375
Fees for the cost of advisory opinions.
§411.377
Expert opinions from outside sources.
§411.378
Withdrawing a request.
§411.379
When CMS accepts a request.
§411.380
When CMS issues a formal advisory opinion.
§411.382
CMS's right to rescind advisory opinions.
§411.384
Disclosing advisory opinions and supporting information.
§411.386
CMS's advisory opinions as exclusive.
§411.387
Parties affected by advisory opinions.
§411.388
When advisory opinions are not admissible evidence.
§411.389
Range of the advisory opinion.
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Subpart K—PAYMENT FOR CERTAIN EXCLUDED SERVICES

§411.400
Payment for custodial care and services not reasonable and necessary.
§411.402
Indemnification of beneficiary.
§411.404
Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
§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.
§411.408
Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.


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