[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: 42CFR411.102]



[Page 398]

 

                         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. 411.102  Basic prohibitions and requirements.



    (a) ESRD. (1) A group health plan of any size--(i) May not take into 

account the ESRD-based Medicare eligibility or entitlement of any 

individual who is covered or seeks to be covered under the plan; and

    (ii) May not differentiate in the benefits it provides between 

individuals with ESRD and other individuals covered under the plan, on 

the basis of the existence of ESRD, or the need for dialysis, or in any 

other manner.

    (2) The prohibitions of paragraph (a) of this section do not 

prohibit a plan from paying benefits secondary to Medicare after the 

first 18 months of ESRD-based eligibility or entitlement.

    (b) Age. A GHP of an employer or employee organization of at least 

20 employees--

    (1) May not take into account the age-based Medicare entitlement of 

an individual or spouse age 65 or older who is covered (or seeks to be 

covered) under the plan by virtue of current employment status; and

    (2) Must provide, to employees age 65 or older and to spouses age 65 

or older of employees of any age, the same benefits under the same 

conditions as it provides to employees and spouses under age 65.

    (c) Disability. A GHP of an employer or employee organization of at 

least 100 employees may not take into account the disability-based 

Medicare entitlement of any individual who is covered (or seeks to be 

covered) under the plan by virtue of current employment status.