Code of Federal Regulations (Last Updated: October 10, 2024) |
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 primary payment responsibility. |
§ 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. |
§ 411.39 - Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal. |
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 - XXX |
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. |
§ 411.360 - Group practice attestation. |
§ 411.361 - Reporting requirements. |
§ 411.362 - Additional requirements concerning physician ownership and investment in hospitals. |
§ 411.363 - Process for requesting an exception from the prohibition on facility expansion. |
§ 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' right to rescind advisory opinions. |
§ 411.384 - Disclosing advisory opinions and supporting information. |
§ 411.386 - CMS's advisory opinions as exclusive. |
§ 411.387 - Effect of an advisory opinion. |
§ 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. |