In this subpart B and in subparts C through H of this part, unless the context indicates otherwise—
Conditional payment means a Medicare payment for services for which another payer is responsible, made either on the bases set forth in subparts C through H of this part, or because the intermediary or carrier did not know that the other coverage existed.
Coverage or covered services, when used in connection with primary payments, means services for which a primary payer would pay if a proper claim were filed.
Monthly capitation payment means a comprehensive monthly payment that covers all physician services associated with the continuing medical management of a maintenance dialysis patient who dialyses at home or as an outpatient in an approved ESRD facility.
Plan means 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.
Primary payer means, when used in the context in which Medicare is the secondary payer, any entity that is or was required or responsible to make payment with respect to an item or service (or any portion thereof) under a primary plan. These entities include, but are not limited to, insurers or self-insurers, third party administrators, and all employers that sponsor or contribute to group health plans or large group health plans.
Primary payment means, when used in the context in which Medicare is the secondary payer, payment by a primary payer for services that are also covered under Medicare.
Primary plan means, when used in the context in which Medicare is the secondary payer, a group health plan or large group health plan, a workers' compensation law or plan, an automobile or liability insurance policy or plan (including a self-insured plan), or no-fault insurance.
Prompt or promptly, when used in connection with primary payments, except as provided in § 411.50, for payments by liability insurers, means payment within 120 days after receipt of the claim.
Proper claim means a claim that is filed timely and meets all other claim filing requirements specified by the plan, program, or insurer.
Secondary, when used to characterize Medicare benefits, means that those benefits are payable only to the extent that payment has not been made and cannot reasonably be expected to be made under other coverage that is primary to Medicare.
Secondary payments means payments made for Medicare covered services or portions of services that are not payable under other coverage that is primary to Medicare.
[54 FR 41734, Oct. 11, 1989, as amended at 60 FR 45361, Aug. 31, 1995; 71 FR 9470, Feb. 24, 2006]
Notes of Decisions
United States v. Baxter Int'l, Inc., 345 F.3d 866 (11th Cir. 2003).
· cites it 5× “” 42 C.F.R. § 411.21 . The MSP, in its present form, originated with enactment of the Omnibus Budget Reconciliation Act (“OBRA”) of 1980, Pub.”
Fanning v. United States, 202 F.R.D. 154 (E.D. Pa. 2001).
· cites it 5× “” 42 C.F.R. § 411.21 . The Government states that it is entitled to recover payments made to Medicare beneficiaries who are also members of the AcroMed Settlement Class because AcroMed is a “self-insurer” obligated to reimburse the Government for Medicare expenditures by the…”
Jeannette D. Brown v. Tommy G. Thompson, Sec'y, Dep't of Health & Human Servs., Virginia Trial Lawyers Ass'n, Amicus Supporting, 374 F.3d 253 (4th Cir. 2004).
· cites it 3× “42 C.F.R. §§ 411.21 , 411.50 (2000). Because, in the present case, Kaiser could not reasonably have been expected to make any payment to Brown within 120 days of the medical services provided (and, indeed, Kaiser did not agree to settle with Brown for more than a year after…”
Thompson v. Goetzmann, 337 F.3d 489 (5th Cir. 2002).
· cites it 2× “42 C.F.R. § 411.21 . 25 . 42 C.F.R. § 411.”
Geneba Glover v. Philip Morris, 459 F.3d 1304 (11th Cir. 2006).
“See 42 C.F.R. § 411.21 . After the Medicare beneficiary *1310 obtains a favorable judgment or settlement of state' tort claims, Medicare is entitled to reimbursement to the extent of its conditional payments.”
Lagerstrom v. Myrtle Werth Hosp.-Mayo Health Sys., 2005 WI 124 (Wis. 2005).
· cites it 2× “42 CFR § 411.21 . If a Medicare conditional payment is made, the Center for Medicare & Medicaid *57 Services (CMS), an arm of Health Care Financing Administration (HCFA), may seek recovery of those conditional payments.”
Hearn v. Dollar Rent a Car, Inc., 726 S.E.2d 661 (Ga. Ct. App. 2012).
· cites it 3× “under a primary plan,” 42 CFR § 411.21 , and “primary plan” is broadly defined to include “a group health plan or large group health plan, a workers’ compensation law or plan, an automobile or liability insurance policy or plan (including a self-insured plan), or no-fault…”
Brown v. Thompson, 252 F. Supp. 2d 312 (E.D. Va. 2003).
· cites it 3× “” 42 C.F.R. § 411.21 . A “self-insured plan” is a “plan under which an individual, or private or governmental entity, carries its own risk instead of taking out insurance with a carrier.”
Thompson v. Goetzmann, 315 F.3d 457 (5th Cir. 2002).
· cites it 2× “42 C.F.R. § 411.21 . . 42 C.F.R. § 411.50 (b) (emphasis added).”
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