[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR1003.105]



[Page 1181]

 

                         TITLE 42--PUBLIC HEALTH

 

      GENERAL--HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

PART 1003_CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS--Table 

 

Sec.  1003.105  Exclusion from participation in Medicare, Medicaid and 



all Federal health care programs.



    (a)(1) Except as set forth in paragraph (b) of this section, the 

following persons may be subject, in lieu of or in addition to any 

penalty or assessment, to an exclusion from participation in Medicare 

for a period of time determined under Sec.  1003.107. There will be 

exclusions from Federal health care programs for the same period as the 

Medicare exclusion for any person who--

    (i) Is subject to a penalty or assessment under Sec.  1003.102(a), 

(b)(1), (b)(4), (b)(12), (b)(13) or (b)(15); or

    (ii) Commits a gross and flagrant, or repeated, violation of section 

1867 of the Act or Sec.  489.24 of this title on or after May 1, 1991. 

For purposes of this section, a gross and flagrant violation is one that 

presents an imminent danger to the health, safety or well-being of the 

individual who seeks emergency examination and treatment or places that 

individual unnecessarily in a high-risk situation.

    (b)(1)(i) With respect to any exclusion based on liability for a 

penalty or assessment under Sec.  1003.102 (a), (b)(1), or (b)(4), the 

OIG will consider an application from a State agency for a waiver if the 

person is the sole community physician or the sole source of essential 

specialized services in a community. With respect to any exclusion 

imposed under Sec.  1003.105(a)(1)(ii), the OIG will consider an 

application from a State agency for a waiver if the physician's 

exclusion from the State health care program would deny beneficiaries 

access to medical care or would otherwise cause hardship to 

beneficiaries.

    (ii) If a waiver is granted, it is applicable only to the State 

health care program for which the State requested the waiver.

    (iii) If the OIG subsequently obtains information that the basis for 

a waiver no longer exists, or the State agency submits evidence that the 

basis for the waiver no longer exists, the waiver will cease and the 

person will be excluded from the State health care program for the 

remainder of the period that the person is excluded from Medicare.

    (iv) The OIG notifies the State agency whether its request for a 

waiver has been granted or denied.

    (v) The decision to deny a waiver is not subject to administrative 

or judicial review.

    (2) For purposes of this section, the definitions contained in Sec.  

1001.2 of this chapter for ``sole community physician'' and ``sole 

source of essential specialized services in a community'' apply.

    (c) When the Inspector General proposes to exclude a nursing 

facility from the Medicare and Medicaid programs, he or she will, at the 

same time he or she notifies the respondent, notify the appropriate 

State licensing authority, the State Office of Aging, the long-term care 

ombudsman, and the State Medicaid agency of the Inspector General's 

intention to exclude the facility.



[59 FR 32125, June 22, 1994, as amended at 64 FR 39429, July 22, 1999; 

65 FR 24416, Apr. 26, 2000; 65 FR 35584, June 5, 2000]