C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart D—Private Contracts

42 C.F.R. § 405.455

Application to Medicare Advantage contracts

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An organization that has a contract with CMS to provide one or more Medicare Advantage (M + C) plans to beneficiaries (part 422 of this chapter):

(a) Must acquire and maintain information from Medicare carriers on physicians and practitioners who have opted-out of Medicare.

(b) Must make no payment directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a physician or practitioner who has opted-out of Medicare.

(c) May make payment to a physician or practitioner who furnishes emergency or urgent care services to a beneficiary who has not previously entered into a private contract with the physician or practitioner in accordance with § 405.440.

[63 FR 58901, Nov. 2, 1998, as amended at 79 FR 68001, Nov. 13, 2014]
Notes of Decisions
Cited in 4 cases, 1979–2000 · leading case: Montgomery Cnty. Geriatric & Rehab. Ctr. v. Commonwealth, Dep't of Pub. Welfare, 462 A.2d 325 (Pa. Commw. Ct. 1983).
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Montgomery Cnty. Geriatric & Rehab. Ctr. v. Commonwealth, Dep't of Pub. Welfare, 462 A.2d 325 (Pa. Commw. Ct. 1983). · cites it 3× “42 C.F.R. §405.455 (a). 10 Because of this test, so-called “reasonable” costs are not always reimbursed; accordingly, the federal regulations permit a facility to recapture its unreimbursed reasonable costs by carrying them forward to two successive reporting periods.”
Henry Ford Health Sys. v. Donna E. Shalala, Sec'y, Dep't of Health & Human Servs., 233 F.3d 907 (6th Cir. 2000). “See 42 C.F.R. § 405.455 (c) (1974). In 1983, Congress directed the Secretary to issue regulations eliminating the aggregation of Part A and Part B figures when applying the lesser of costs or charges rule and requiring the amount to be calculated and reported separately for each…”
Sisters of St. Francis Health Servs., Inc. v. Schweiker, 514 F. Supp. 607 (D.D.C. 1981). · cites it 3× “42 C.F.R. § 405.455 sets forth the regulations pertaining to the amount of Medicare payments to be made where charges for services furnished are less than reasonable costs.”
Montana Child.'s Home & Hosp. v. Dep't of Soc. & Rehab. Servs., 592 P.2d 481 (Mont. 1979). “On May 10, 1974, a new section, 42 CFR § 405.455 , was added to these principles stating in pertinent part: “(a) Principle.”
42 C.F.R. § 405.455(b)(1): 1 case
Sisters of St. Francis Health Servs., Inc. v. Schweiker, 514 F. Supp. 607 (D.D.C. 1981). “42 C.F.R. § 405.455 sets forth the regulations pertaining to the amount of Medicare payments to be made where charges for services furnished are less than reasonable costs.”
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