[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: 42CFR411.20]



[Page 385]

 

                         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 B_Insurance Coverage That Limits Medicare Payment: General 

                               Provisions

 

Sec. 411.20  Basis and scope.





    (a) Statutory basis. (1) Section 1862(b)(2)(A)(i) of the Act 

precludes Medicare payment for services to the extent that payment has 

been made or can reasonably be expected to be made under a group health 

plan with respect to--

    (i) A beneficiary entitled to Medicare on the basis of ESRD during 

the first 18 months of that entitlement;

    (ii) A beneficiary who is age 65 or over, entitled to Medicare on 

the basis of age, and covered under the plan by virtue of his or her 

current employment status or the current employment status of a spouse 

of any age; or

    (iii) A beneficiary who is under age 65, entitled to Medicare on the 

basis of disability, and covered under the plan by virtue of his or her 

current employment status or the current employment status of a family 

member.

    (2) Section 1862(b)(2)(A)(ii) of the Act precludes Medicare payment 

for services to the extent that payment has been made or can reasonably 

be expected to be made promptly under any of the following:

    (i) Workers' compensation.

    (ii) Liability insurance.

    (iii) No-fault insurance.

    (b) Scope. This subpart sets forth general rules that apply to the 

types of insurance specified in paragraph (a) of this section. Other 

general rules that apply to group health plans are set forth in subpart 

E of this part.



[60 FR 45361, Aug. 31, 1995]