[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: 42CFR411.35]



[Page 391]

 

                         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. 411.35  Limitations on charges to a beneficiary or other party 

when a workers' compensation plan, a no-fault insurer, or an employer 

group health plan is primary payer.



    (a) Definition. As used in this section Medicare-covered services 

means services for which Medicare benefits are payable or would be 

payable except for the Medicare deductible and coinsurance provisions 

and the amounts payable by the third party payer.

    (b) Applicability. This section applies when a workers' compensation 

plan, a no-fault insurer or an employer group health plan is primary to 

Medicare.

    (c) Basic rule. Except as provided in paragraph (d) of this section, 

the amounts the provider or supplier may collect or seek to collect, for 

the Medicare-covered services from the beneficiary or any entity other 

than the workers' compensation plan, the no-fault insurer, or the 

employer plan and Medicare, are limited to the following:

    (1) The amount paid or payable by the third party payer to the 

beneficiary. If this amount exceeds the amount payable by Medicare 

(without regard to deductible or coinsurance), the provider or supplier 

may retain the third party payment in full without violating the terms 

of the provider agreement or the conditions of assignment.

    (2) The amount, if any, by which the applicable Medicare deductible 

and coinsurance amounts exceed any third party payment made or due to 

the beneficiary or to the provider or supplier for the medical services.

    (3) The amount of any charges that may be made to a beneficiary 

under Sec. 413.35 of this chapter when cost limits are applied to the 

services, or under Sec. 489.32 of this chapter when the services are 

partially covered, but only to the extent that the third party payer is 

not responsible for those charges.

    (d) Exception. The limitations of paragraph (c) of this section do 

not apply if the services were furnished by a supplier that is not a 

participating supplier and has not accepted assignment for the services 

or claimed payment under Sec. 424.64 of this chapter.