[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR411.100]



[Page 396-397]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 411_EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

--Table of Contents

 

Subpart E_Limitations on Payment for Services Covered Under Group Health 

                        Plans: General Provisions

 

Sec. 411.100  Basis and scope.



    Source: 60 FR 45362, Aug. 31, 1995, unless otherwise noted.





    (a) Statutory basis. (1) Section 1862(b) of the Act provides in part 

that Medicare is secondary payer, under specified conditions, for 

services covered under any of the following:

    (i) Group health plans of employers that employ at least 20 

employees and that cover Medicare beneficiaries age 65 or older who are 

covered under the plan by virtue of the individual's current employment 

status with an employer or the current employment status of a spouse of 

any age. (Section 1862(b)(1)(A))

    (ii) Group health plans (without regard to the number of individuals 

employed and irrespective of current employment status) that cover 

individuals who have ESRD. Except as provided in Sec. 411.163, group 

health plans are always primary payers throughout the first 18 months of 

ESRD-based Medicare eligibility or entitlement. (Section 1862(b)(1)(C))

    (iii) Large group health plans (that is, plans of employers that 

employ at least 100 employees) and that cover Medicare beneficiaries who 

are under age 65, entitled to Medicare on the basis of disability, and 

covered under the plan by virtue of the individual's or a family 

member's current employment status with an employer. (Section 

1862(b)(1)(B))

    (2) Sections 1862(b)(1)(A), (B), and (C) of the Act provide that 

group health plans and large group health plans may not take into 

account that the individuals described in paragraph (a)(1) of this 

section are entitled to Medicare on the basis of age or disability, or 

eligible for, or entitled to Medicare on the basis of ESRD.

    (3) Section 1862(b)(1)(A)(i)(II) of the Act provides that group 

health plans of employers of 20 or more employees must provide to any 

employee or spouse age 65 or older the same benefits, under the same 

conditions, that it provides to employees and spouses under 65. The 

requirement applies regardless of whether the individual or spouse 65 or 

older is entitled to Medicare.

    (4) Section 1862(b)(1)(C)(ii) of the Act provides that group health 

plans may not differentiate in the benefits they provide between 

individuals who have ESRD and other individuals covered under the plan 

on the basis of the existence of ESRD, the need for renal dialysis, or 

in any other manner. Actions that constitute ``differentiating'' are 

listed in Sec. 411.161(b).

    (b) Scope. This subpart sets forth general rules pertinent to--

    (1) Medicare payment for services that are covered under a group 

health plan and are furnished to certain beneficiaries who are entitled 

on the basis of ESRD, age, or disability.

    (2) The prohibition against taking into account Medicare entitlement 

based on age or disability, or Medicare eligibility or entitlement based 

on ESRD.

    (3) The prohibition against differentiation in benefits between 

individuals who have ESRD and other individuals covered under the plan.

    (4) The requirement to provide to those 65 or over the same benefits 

under the same conditions as are provided to those under 65.



[[Page 397]]



    (5) The appeals procedures for group health plans that CMS 

determines are nonconforming plans.