(a) Statutory basis. (1) Section 1862(b)(2)(A)(i) of the Act precludes Medicare payment for services to the extent that payment has been made or can reasonably be expected to be made under a group health plan with respect to—
(i) A beneficiary entitled to Medicare on the basis of ESRD during the first 18 months of that entitlement;
(ii) A beneficiary who is age 65 or over, entitled to Medicare on the basis of age, and covered under the plan by virtue of his or her current employment status or the current employment status of a spouse of any age; or
(iii) A beneficiary who is under age 65, entitled to Medicare on the basis of disability, and covered under the plan by virtue of his or her current employment status or the current employment status of a family member.
(2) Section 1862(b)(2)(A)(ii) of the Act precludes Medicare payment for services to the extent that payment has been made or can reasonably be expected to be made under any of the following:
(i) Workers' compensation.
(ii) Liability insurance.
(iii) No-fault insurance.
(b) Scope. This subpart sets forth general rules that apply to the types of insurance specified in paragraph (a) of this section. Other general rules that apply to group health plans are set forth in subpart E of this part.
[60 FR 45361, Aug. 31, 1995, as amended at 71 FR 9470, Feb. 24, 2006]
Notes of Decisions
Cited in
10
cases (
2 in the last 5 years), 1995–2024 · leading case:
Est. of Urso v. Thompson, 309 F. Supp. 2d 253 (D. Conn. 2004).
Est. of Urso v. Thompson, 309 F. Supp. 2d 253 (D. Conn. 2004).
“See 42 C.F.R. § 411.20 et seq. As is relevant here, the regulations establish rules for determining whether a payment under a primary plan will be deemed to be made “promptly” under subparagraph (A)(ii).”
Sexton v. Medicare, 194 F. Supp. 3d 209 (E.D.N.Y 2016).
“§ 1395y(b)(2)(A); 42 C.F.R. § 411.20 (a)(2)(i)-(iii); Manning, 254 F.”
In re Marriage of Washkowiak, 2012 IL App (3d) 110174 (Ill. App. Ct. 2012).
· cites it 2× “See 42 C.F.R. § 411.20 (a)(2) (2012). Specifically, 42 C.”
United States v. Rhode Island Insurers' Insolvency Fund, 892 F. Supp. 370 (D.R.I. 1995).
“42 C.F.R. § 411.20 et seq. These regulations define a plan as “any arrangement, oral or written, by one or more entities, to provide health benefits or medical care or assume legal liability for injury or illness.”
MAO-MSO Recovery II, LLC v. Gov't Employees Ins. Co. (GEICO) (D. Maryland 2024).
“Subparts B through D corresponds to 42 C.F.R. §§ 411.20 to 411.54. Based on the language of this provision, the rights that an MAO may exercise to recover from a primary plan include CMS’s subrogation right contained in 42 C.”
MSPA Claims 1, LLC v. Gov't Employees Ins. Co. (GEICO) (D. Maryland 2024).
“Subparts B through D corresponds to 42 C.F.R. §§ 411.20 to 411.54. Based on the language of this provision, the rights that an MAO may exercise to recover from a primary plan include CMS’s subrogation right contained in 42 C.”
In Re Marriage of Washkowiak, 966 N.E.2d 1060 (Ill. App. Ct. 2012).
· cites it 2× “See 42 C.F.R. § 411.20 (a)(2) (2012). Specifically, 42 C.”
Douglas B. Stalley v. Catholic Health (8th Cir. 2007).
“42 C.F.R. §§ 411.20 & 411.37. He contends that these regulations indicate the statute is a qui tam statute since they show that the proceeds will be split between the plaintiff and the government.”
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