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— Items and 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
Subpart H — Special Rules: Disabled Beneficiaries Who Are Also Covered Under Large Group Health Plans
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.
- § 411.362— 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.