[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: 42CFR411.110]



[Page 400-401]

 

                         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. 411.110  Basis for determination of nonconformance.



    (a) A ``determination of nonconformance'' is a CMS determination 

that a



[[Page 401]]



GHP or LGHP is a nonconforming plan as provided in this section.

    (b) CMS makes a determination of nonconformance for a GHP or LGHP 

that, at any time during a calendar year, fails to comply with any of 

the following statutory provisions:

    (1) The prohibition against taking into account that a beneficiary 

who is covered or seeks to be covered under the plan is entitled to 

Medicare on the basis of ESRD, age, or disability, or eligible on the 

basis of ESRD.

    (2) The nondifferentiation clause for individuals with ESRD.

    (3) The equal benefits clause for the working aged.

    (4) The obligation to refund conditional Medicare primary payments.

    (c) CMS may make a determination of nonconformance for a GHP or LGHP 

that fails to respond to a request for information, or to provide 

correct information, either voluntarily or in response to a CMS request, 

on the plan's primary payment obligation with respect to a given 

beneficiary, if that failure contributes to either or both of the 

following:

    (1) Medicare erroneously making a primary payment.

    (2) A delay or foreclosure of CMS's ability to recover an erroneous 

primary payment.