[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: 42CFR447.20]



[Page 308]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 447_PAYMENTS FOR SERVICES--Table of Contents

 

                 Subpart A_Payments: General Provisions

 

Sec.  447.20  Provider restrictions: State plan requirements.



    A State plan must provide for the following:

    (a) In the case of an individual who is eligible for medical 

assistance under the plan for service(s) for which a third party or 

parties is liable for payment, if the total amount of the established 

liability of the third party or parties for the service is--

    (1) Equal to or greater than the amount payable under the State plan 

(which includes, when applicable, cost-sharing payments provided for in 

Sec. Sec.  447.53 through 447.56), the provider furnishing the service 

to the individual may not seek to collect from the individual (or any 

financially responsible relative or representative of that individual) 

any payment amount for that service; or

    (2) Less than the amount payable under the State plan (including 

cost sharing payments set forth in Sec. Sec.  447.53 through 447.56), 

the provider furnishing the service to that individual may collect from 

the individual (or any financially responsible relative or 

representative of the individual) an amount which is the lesser of--

    (i) Any cost-sharing payment amount imposed upon the individual 

under Sec. Sec.  447.53 through 447.56; or

    (ii) An amount which represents the difference between the amount 

payable under the State plan (which includes, where applicable, cost-

sharing payments provided for in Sec. Sec.  447.53 through 447.56) and 

the total of the established third party liability for the services.

    (b) A provider may not refuse to furnish services covered under the 

plan to an individual who is eligible for medical assistance under the 

plan on account of a third party's potential liability for the 

service(s).



[55 FR 1433, Jan. 16, 1990]