C.F.R. » Title 42 » 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 C—Limitations on Medicare Payment for Services Covered Under Workers' Compensation

42 C.F.R. § 411.40

General provisions

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(a) Definition. “Workers' compensation plan of the United States” includes the workers' compensation plans of the 50 States, the District of Columbia, American Samoa, Guam, Puerto Rico, and the Virgin Islands, as well as the systems provided under the Federal Employees' Compensation Act and the Longshoremen's and Harbor Workers' Compensation Act.

(b) Limitations on Medicare payment. (1) Medicare does not pay for any services for which—

(i) Payment has been made, or can reasonably be expected to be made under a workers' compensation law or plan of the United States or a state; or

(ii) Payment could be made under the Federal Black Lung Program, but is precluded solely because the provider of the services has failed to secure, from the Department of Labor, a provider number to include in the claim.

(2) If the payment for a service may not be made under workers' compensation because the service is furnished by a source not authorized to provide that service under the particular workers' compensation program, Medicare pays for the service if it is a covered service.

(3) Medicare makes secondary payments in accordance with §§ 411.32 and 411.33.

[54 FR 41734, Oct. 11, 1989, as amended at 71 FR 9470, Feb. 24, 2006]
Notes of Decisions
Cited in 6 cases, 2004–2019 · leading case: Terry Grimm v. Vortex Marine Constr., 921 F.3d 845 (9th Cir. 2019).
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Terry Grimm v. Vortex Marine Constr., 921 F.3d 845 (9th Cir. 2019). “§ 1395y(b)(2)(A); see § 1395y(b)(8)(F); 42 C.F.R. § 411.40 (a) (interpreting “primary plan” to include the Longshore Act).”
In Re RJF Int'l Corp. for Exoneration From or Limitation of Liab., Civil & Mar., 332 F. Supp. 2d 458 (D.R.I. 2004). “” 42 C.F.R. § 411.40 (a).' The doctrine of maintenance and cure is conspicuously absent from this list.”
California Ins. Guarantee v. Alex M. Azar, II (9th Cir. 2019). · cites it 2× “” 42 C.F.R. § 411.40 (a). While these examples are not meant to be exhaustive, CIGA, an insurer insolvency scheme, is dissimilar to all of them, suggesting that it is not a workers’ compensation plan.”
Orlando Coryell v. Liberty Mut. Ins. Compa (7th Cir. 2009). “§ 1395y(b)(2)(A)(ii); 42 C.F.R. § 411.40 (b)(1)(I); Evanston Hosp.”
Coryell v. Liberty Mut. Ins., 329 F. App'x 657 (7th Cir. 2009). “§ 1395y(b)(2)(A)(ii); 42 C.F.R. § 411.40 (b)(l)(i); Evanston Hosp.”
Coryell v. Liberty Mut. Ins., 329 F. App'x 657 (7th Cir. 2009). “§ 1395y(b)(2)(A)(ii); 42 C.F.R. § 411.40 (b)(l)(i); Evanston Hosp.”
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