[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.108]

[Page 850-851]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
             Subpart C--Benefits and Beneficiary Protections
 
Sec. 422.108  Medicare secondary payer (MSP) procedures.

    (a) Basic rule. CMS does not pay for services to the extent that 
Medicare is not the primary payer under section 1862(b) of the Act and 
part 411 of this chapter.
    (b) Responsibilities of the M+C organization. The M+C organization 
must, for each M+C plan--
    (1) Identify payers that are primary to Medicare under section 
1862(b) of the Act and part 411 of this chapter;
    (2) Identify the amounts payable by those payers; and
    (3) Coordinate its benefits to Medicare enrollees with the benefits 
of the primary payers.
    (c) Collecting from other entities. The M+C organization may bill, 
or authorize a provider to bill, other individuals or entities for 
covered Medicare services for which Medicare is not the primary payer, 
as specified in paragraphs (d) and (e) of this section.
    (d) Collecting from other insurers or the enrollee. If a Medicare 
enrollee receives from an M+C organization covered services that are 
also covered under State or Federal workers' compensation, any no-fault 
insurance, or any liability insurance policy or plan, including a self-
insured plan, the M+C organization may bill, or authorize a provider to 
bill any of the following--
    (1) The insurance carrier, the employer, or any other entity that is 
liable for payment for the services under section 1862(b) of the Act and 
part 411 of this chapter.
    (2) The Medicare enrollee, to the extent that he or she has been 
paid by the

[[Page 851]]

carrier, employer, or entity for covered medical expenses.
    (e) Collecting from group health plans (GHPs) and large group health 
plans (LGHPs). An M+C organization may bill a GHP or LGHP for services 
it furnishes to a Medicare enrollee who is also covered under the GHP or 
LGHP and may bill the Medicare enrollee to the extent that he or she has 
been paid by the GHP or LGHP.
    (f) MSP rules and State laws. Consistent with Sec. 422.402 
concerning the Federal preemption of State law, the rules established 
under this section supersede any State laws, regulations, contract 
requirements, or other standards that would otherwise apply to M+C plans 
only to the extent that those State laws are inconsistent with the 
standards established under this part. A State cannot take away an M+C 
organization's right under Federal law and the MSP regulations to bill, 
or to authorize providers and suppliers to bill, for services for which 
Medicare is not the primary payer. Section 1852(a)(4) of the Social 
Security Act does not prohibit a State from limiting the amount of the 
recovery; thus, State law could modify, but not negate, an M+C 
organization's rights in this regard.

[63 FR 35077, June 26, 1998, as amended at 65 FR 40320, June 29, 2000]