[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: 42CFR411.12]



[Page 380-381]

 

                         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 A_General Exclusions and Exclusion of Particular Services

 

Sec. 411.12  Charges imposed by an immediate relative or member of the 

beneficiary's household.



    (a) Basic rule. Medicare does not pay for services usually covered 

under Medicare if the charges for those services are imposed by--

    (1) An immediate relative of the beneficiary; or

    (2) A member of the beneficiary's household.

    (b) Definitions. As used in this section--

    Immediate relative means any of the following:

    (1) Husband or wife.

    (2) Natural or adoptive parent, child, or sibling.

    (3) Stepparent, stepchild, stepbrother, or stepsister.



[[Page 381]]



    (4) Father-in-law, mother-in-law, son-in-law, daughter-in-law, 

brother-in-law, or sister-in-law.

    (5) Grandparent or grandchild.

    (6) Spouse of grandparent or grandchild.

    Member of the household means any person sharing a common abode as 

part of a single family unit, including domestic employees and others 

who live together as part of a family unit, but not including a mere 

roomer or boarder.

    Professional corporation means a corporation that is completely 

owned by one or more physicians and is operated for the purpose of 

conducting the practice of medicine, osteopathy dentistry, podiatry, 

optometry, or chiropractic, or is owned by other health care 

professionals as authorized by State law.

    (c) Applicability of the exclusion. The exclusion applies to the 

following charges in the specified circumstances:

    (1) Physicians' services. (i) Charges for physicians' services 

furnished by an immediate relative of the beneficiary or member of the 

beneficiary's household, even if the bill or claim is submitted by 

another individual or by an entity such as a partnership or a 

professional corporation.

    (ii) Charges for services furnished incident to a physician's 

professional services (for example by the physician's nurse or 

technician), only if the physician who ordered or supervised the 

services has an excluded relationship to the beneficiary.

    (2) Services other than physicians' services. (i) Charges imposed by 

an individually owned provider or supplier if the owner has an excluded 

relationship to the beneficiary; and

    (ii) Charges imposed by a partnership if any of the partners has an 

excluded relationship to the beneficiary.

    (d) Exception to the exclusion. The exclusion does not apply to 

charges imposed by a corporation other than a professional corporation.