[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: 42CFR411.101]



[Page 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. 411.101  Definitions.



    As used in this subpart and in subparts F through H of this part--

    COBRA stands for Consolidated Omnibus Budget Reconciliation Act of 

1985.

    Days means calendar days.

    Employee (subject to the special rules in Sec. 411.104) means an 

individual who--

    (1) Is working for an employer; or

    (2) Is not working for an employer but is receiving payments that 

are subject to FICA taxes, or would be subject to FICA taxes except that 

the employer is exempt from those taxes under the Internal Revenue Code.

    Employer means, in addition to individuals (including self-employed 

persons) and organizations engaged in a trade or business, other 

entities exempt from income tax such as religious, charitable, and 

educational institutions, the governments of the United States, the 

individual States, Puerto Rico, the Virgin Islands, Guam, American 

Samoa, the Northern Mariana Islands, and the District of Columbia, and 

the agencies, instrumentalities, and political subdivisions of these 

governments.

    FICA stands for the Federal Insurance Contributions Act, the law 

that imposes social security taxes on employers and employees under 

section 21 of the Internal Revenue Code.

    Group health plan (GHP) means any arrangement made by one or more 

employers or employee organizations to provide health care directly or 

through other methods such as insurance or reimbursement, to current or 

former employees, the employer, others associated or formerly associated 

with the employer in a business relationship, or their families, that--

    (1) Is of, or contributed to by, one or more employers or employee 

organizations.

    (2) If it involves more than one employer or employee organization, 

provides for common administration.

    (3) Provides substantially the same benefits or the same benefit 

options to all those enrolled under the arrangement.



The term includes self-insured plans, plans of governmental entities 

(Federal, State and local), and employee organization plans; that is, 

union plans, employee health and welfare funds or other employee 

organization plans. The term also includes employee-pay-all plans, which 

are plans under the auspices of one or more employers or employee 

organizations but which receive no financial contributions from them. 

The term does not include a plan that is unavailable to employees; for 

example, a plan only for self-employed persons.

    IRC stands for Internal Revenue Code.

    IRS stands for Internal Revenue Service.

    Large group health plan (LGHP) means a GHP that covers employees of 

either--

    (1) A single employer or employee organization that employed at 

least 100 full-time or part-time employees on 50 percent or more of its 

regular business days during the previous calendar year; or

    (2) Two or more employers, or employee organizations, at least one 

of which employed at least 100 full-time or part-time employees on 50 

percent or more of its regular business days during the previous 

calendar year.

    MSP stands for Medicare secondary payer.

    Multi-employer plan means a plan that is sponsored jointly by two or 

more employers (sometimes called a multiple-employer plan) or by 

employers and unions (sometimes under the Taft-Hartley law).

    Self-employed person encompasses consultants, owners of businesses, 

and directors of corporations, and members of the clergy and religious 

orders who are paid for their services by a religious body or other 

entity.

    Similarly situated individual means--

    (1) In the case of employees, other employees enrolled or seeking to 

enroll in the plan; and

    (2) In the case of other categories of individuals, other persons in 

any of those categories who are enrolled or seeking to enroll in the 

plan.



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