[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: 42CFR422.108]



[Page 995-996]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

             Subpart C_Benefits and Beneficiary Protections

 

Sec. 422.108  Medicare secondary payer (MSP) procedures.



    (a) Basic rule. CMS does not pay for services to the extent that 

Medicare is not the primary payer under section 1862(b) of the Act and 

part 411 of this chapter.

    (b) Responsibilities of the MA organization. The MA organization 

must, for each MA plan--

    (1) Identify payers that are primary to Medicare under section 

1862(b) of the Act and part 411 of this chapter;

    (2) Identify the amounts payable by those payers; and

    (3) Coordinate its benefits to Medicare enrollees with the benefits 

of the primary payers.

    (c) Collecting from other entities. The MA organization may bill, or 

authorize a provider to bill, other individuals or entities for covered 

Medicare services for which Medicare is not the primary payer, as 

specified in paragraphs (d) and (e) of this section.

    (d) Collecting from other insurers or the enrollee. If a Medicare 

enrollee receives from an MA organization covered services that are also 

covered under State or Federal workers' compensation, any no-fault 

insurance, or any liability insurance policy or plan, including a self-

insured plan, the MA organization may bill, or authorize a provider to 

bill any of the following--

    (1) The insurance carrier, the employer, or any other entity that is 

liable for payment for the services under section 1862(b) of the Act and 

part 411 of this chapter.

    (2) The Medicare enrollee, to the extent that he or she has been 

paid by the carrier, employer, or entity for covered medical expenses.

    (e) Collecting from group health plans (GHPs) and large group health 

plans (LGHPs). An MA organization may bill a GHP or LGHP for services it 

furnishes to a Medicare enrollee who is also covered under the GHP or 

LGHP and may bill the Medicare enrollee to the extent that he or she has 

been paid by the GHP or LGHP.

    (f) MSP rules and State laws. Consistent with Sec. 422.402 

concerning the Federal preemption of State law, the rules established 

under this section supersede any State laws, regulations, contract 

requirements, or other standards that would otherwise apply to MA plans. 

A State cannot take away an MA organization's right under Federal law 

and the MSP regulations to bill, or to authorize providers and suppliers 

to bill, for services for which Medicare is



[[Page 996]]



not the primary payer. The MA organization will exercise the same rights 

to recover from a primary plan, entity, or individual that the Secretary 

exercises under the MSP regulations in subparts B through D of part 411 

of this chapter.



[63 FR 35077, June 26, 1998, as amended at 65 FR 40320, June 29, 2000; 

70 FR 4721, Jan. 28, 2005]