[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: 42CFR411.46]



[Page 392-393]

 

                         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 C_Limitations on Medicare Payment for Services Covered Under 

                          Workers' Compensation

 

Sec. 411.46  Lump-sum payments.



    (a) Lump-sum commutation of future benefits. If a lump-sum 

compensation award stipulates that the amount paid is intended to 

compensate the individual for all future medical expenses required 

because of the work-related injury or disease, Medicare payments for 

such services are excluded until medical expenses related to the injury 

or disease equal the amount of the lump-sum payment.

    (b) Lump-sum compromise settlement. (1) A lump-sum compromise 

settlement is deemed to be a workers' compensation payment for Medicare 

purposes, even if the settlement agreement stipulates that there is no 

liability under the workers' compensation law or plan.

    (2) If a settlement appears to represent an attempt to shift to 

Medicare the responsibility for payment of medical expenses for the 

treatment of a work-related condition, the settlement will not be 

recognized. For example, if the parties to a settlement attempt to 

maximize the amount of disability benefits paid under workers' 

compensation by releasing the workers' compensation carrier from 

liability for medical expenses for a particular condition even though 

the facts show that the condition is work-related, Medicare



[[Page 393]]



will not pay for treatment of that condition.

    (c) Lump-sum compromise settlement: Effect on services furnished 

before the date of settlement. Medicare pays for medical expenses 

incurred before the lump-sum compromise settlement only to the extent 

specified in Sec. 411.47.

    (d) Lump-sum compromise settlement: Effect on payment for services 

furnished after the date of settlement--(1) Basic rule. Except as 

specified in paragraph (d)(2) of this section, if a lump-sum compromise 

settlement forecloses the possibility of future payment of workers' 

compensation benefits, medical expenses incurred after the date of the 

settlement are payable under Medicare.

    (2) Exception. If the settlement agreement allocates certain amounts 

for specific future medical services, Medicare does not pay for those 

services until medical expenses related to the injury or disease equal 

the amount of the lump-sum settlement allocated to future medical 

expenses.