---

42 C.F.R. PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

TITLE 42--Public Health

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

SUBCHAPTER B--MEDICARE PROGRAM

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

Subpart A--GENERAL EXCLUSIONS AND EXCLUSION OF PARTICULAR SERVICES

�411.1

Basis and scope.

�411.2

Conclusive effect of QIO determinations on payment of claims.

�411.4

Services for which neither the beneficiary nor any other person is legally obligated to pay.

�411.6

Services furnished by a Federal provider of services or other Federal agency.

�411.7

Services that must be furnished at public expense under a Federal law or Federal Government contract.

�411.8

Services paid for by a Government entity.

�411.9

Services furnished outside the United States.

�411.10

Services required as a result of war.

�411.12

Charges imposed by an immediate relative or member of the beneficiary's household.

�411.15

Particular services excluded from coverage.

Subpart B--INSURANCE COVERAGE THAT LIMITS MEDICARE PAYMENT: GENERAL PROVISIONS

�411.20

Basis and scope.

�411.21

Definitions.

�411.22

Reimbursement obligations of primary payers and entities that received payment from primary payers.

�411.23

Beneficiary's cooperation.

�411.24

Recovery of conditional payments.

�411.25

Primary payer's notice of mistaken Medicare primary payment.

�411.26

Subrogation and right to intervene.

�411.28

Waiver of recovery and compromise of claims.

�411.30

Effect of primary payment on benefit utilization and deductibles.

�411.31

Authority to bill primary payers for full charges.

�411.32

Basis for Medicare secondary payments.

�411.33

Amount of Medicare secondary payment.

�411.35

Limitations on charges to a beneficiary or other party when a workers' compensation plan, a no-fault insurer, or an employer group health plan is primary payer.

�411.37

Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.

Subpart C--LIMITATIONS ON MEDICARE PAYMENT FOR SERVICES COVERED UNDER WORKERS' COMPENSATION

�411.40

General provisions.

�411.43

Beneficiary's responsibility with respect to workers' compensation.

�411.45

Basis for conditional Medicare payment in workers' compensation cases.

�411.46

Lump-sum payments.

�411.47

Apportionment of a lump-sum compromise settlement of a workers' compensation claim.

Subpart D--LIMITATIONS ON MEDICARE PAYMENT FOR SERVICES COVERED UNDER LIABILITY OR NO-FAULT INSURANCE

�411.50

General provisions.

�411.51

Beneficiary's responsibility with respect to no-fault insurance.

�411.52

Basis for conditional Medicare payment in liability cases.

�411.53

Basis for conditional Medicare payment in no-fault cases.

�411.54

Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.

Subpart E--LIMITATIONS ON PAYMENT FOR SERVICES COVERED UNDER GROUP HEALTH PLANS: GENERAL PROVISIONS

�411.100

Basis and scope.

�411.101

Definitions.

�411.102

Basic prohibitions and requirements.

�411.103

Prohibition against financial and other incentives.

�411.104

Current employment status.

�411.106

Aggregation rules.

�411.108

Taking into account entitlement to Medicare.

�411.110

Basis for determination of nonconformance.

�411.112

Documentation of conformance.

�411.114

Determination of nonconformance.

�411.115

Notice of determination of nonconformance.

�411.120

Appeals.

�411.121

Hearing procedures.

�411.122

Hearing officer's decision.

�411.124

Administrator's review of hearing decision.

�411.126

Reopening of determinations and decisions.

�411.130

Referral to Internal Revenue Service (IRS).

Subpart F--SPECIAL RULES: INDIVIDUALS ELIGIBLE OR ENTITLED ON THE BASIS OF ESRD, WHO ARE ALSO COVERED UNDER GROUP HEALTH PLANS

�411.160

Scope.

�411.161

Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.

�411.162

Medicare benefits secondary to group health plan benefits.

�411.163

Coordination of benefits: Dual entitlement situations.

�411.165

Basis for conditional Medicare payments.

Subpart G--SPECIAL RULES: AGED BENEFICIARIES AND SPOUSES WHO ARE ALSO COVERED UNDER GROUP HEALTH PLANS

�411.170

General provisions.

�411.172

Medicare benefits secondary to group health plan benefits.

�411.175

Basis for Medicare primary payments.

Subpart H--SPECIAL RULES: DISABLED BENEFICIARIES WHO ARE ALSO COVERED UNDER LARGE GROUP HEALTH PLANS

�411.200

Basis.

�411.201

Definitions.

�411.204

Medicare benefits secondary to LGHP benefits.

�411.206

Basis for Medicare primary payments and limits on secondary payments.

Subpart I--[RESERVED]

Subpart J--FINANCIAL RELATIONSHIPS BETWEEN PHYSICIANS AND ENTITIES FURNISHING DESIGNATED HEALTH SERVICES

�411.350

Scope of subpart.

�411.351

Definitions.

411.352

Group practice.

�411.353

Prohibition on certain referrals by physicians and limitations on billing.

�411.354

Financial relationship, compensation, and ownership or investment interest.

�411.355

General exceptions to the referral prohibition related to both ownership/investment and compensation.

�411.356

Exceptions to the referral prohibition related to ownership or investment interests.

�411.357

Exceptions to the referral prohibition related to compensation arrangements.

�411.361

Reporting requirements.

�411.370

Advisory opinions relating to physician referrals.

�411.372

Procedure for submitting a request.

�411.373

Certification.

�411.375

Fees for the cost of advisory opinions.

�411.377

Expert opinions from outside sources.

�411.378

Withdrawing a request.

�411.379

When CMS accepts a request.

�411.380

When CMS issues a formal advisory opinion.

�411.382

CMS's right to rescind advisory opinions.

�411.384

Disclosing advisory opinions and supporting information.

�411.386

CMS's advisory opinions as exclusive.

�411.387

Parties affected by advisory opinions.

�411.388

When advisory opinions are not admissible evidence.

�411.389

Range of the advisory opinion.

Subpart K--PAYMENT FOR CERTAIN EXCLUDED SERVICES

�411.400

Payment for custodial care and services not reasonable and necessary.

�411.402

Indemnification of beneficiary.

�411.404

Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.

�411.406

Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary.

�411.408

Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.