[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: 42CFR411.37]



[Page 391-392]

 

                         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. 411.37  Amount of Medicare recovery when a third party payment is 

made as a result of a judgment or settlement.



    (a) Recovery against the party that received payment--(1) General 

rule. Medicare reduces its recovery to take account of the cost of 

procuring the judgment or settlement, as provided in this section, if--

    (i) Procurement costs are incurred because the claim is disputed; 

and

    (ii) Those costs are borne by the party against which CMS seeks to 

recover.

    (2) Special rule. If CMS must file suit because the party that 

received payment opposes CMS's recovery, the recovery amount is as set 

forth in paragraph (e) of this section.

    (b) Recovery against the third party payer. If CMS seeks recovery 

from the third party payer, in accordance with Sec. 411.24(i), the 

recovery amount will be no greater than the amount determined under 

paragraph (c) or (d) or (e) of this section.

    (c) Medicare payments are less than the judgment or settlement 

amount. If Medicare payments are less than the judgment or settlement 

amount, the recovery is computed as follows:

    (1) Determine the ratio of the procurement costs to the total 

judgment or settlement payment.

    (2) Apply the ratio to the Medicare payment. The product is the 

Medicare share of procurement costs.

    (3) Subtract the Medicare share of procurement costs from the 

Medicare payments. The remainder is the Medicare recovery amount.

    (d) Medicare payments equal or exceed the judgment or settlement 

amount. If Medicare payments equal or exceed the judgment or settlement 

amount, the recovery amount is the total judgment or settlement payment 

minus the total procurement costs.

    (e) CMS incurs procurement costs because of opposition to its 

recovery. If CMS must bring suit against the party that received payment 

because that party opposes CMS's recovery, the recovery amount is the 

lower of the following:

    (1) Medicare payment.



[[Page 392]]



    (2) The total judgment or settlement amount, minus the party's total 

procurement cost.