42 CFR Part 411
PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
- PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- 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 Items and 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.
- 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.
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- Subpart I [Reserved]
- 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.
- § 411.363 Process for requesting an exception from the prohibition on facility expansion.
- § 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' right to rescind advisory opinions.
- § 411.384 Disclosing advisory opinions and supporting information.
- § 411.386 CMS's advisory opinions as exclusive.
- § 411.387 Effect of an advisory opinion.
- § 411.388 When advisory opinions are not admissible evidence.
- § 411.389 Range of the advisory opinion.
- 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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