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. § 411.43

Beneficiary's responsibility with respect to workers' compensation

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(a) The beneficiary is responsible for taking whatever action is necessary to obtain any payment that can reasonably be expected under workers' compensation.

(b) Except as specified in § 411.45(a), Medicare does not pay until the beneficiary has exhausted his or her remedies under workers' compensation.

(c) Except as specified in § 411.45(b), Medicare does not pay for services that would have been covered under workers' compensation if the beneficiary had filed a proper claim.

(d) However, if a claim is denied for reasons other than not being a proper claim, Medicare pays for the services if they are covered under Medicare.

Notes of Decisions
Cited in 1 case, 2013–2013 · leading case: Guadalupe Caldera v. Ins Co. of the State of PA, 716 F.3d 861 (5th Cir. 2013).
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Guadalupe Caldera v. Ins Co. of the State of PA, 716 F.3d 861 (5th Cir. 2013). “For example, ICSP cites 42 C.F.R. § 411.43 (a), which makes a beneficiary responsible “for taking whatever action is necessary to obtain any payment that can reasonably be expected under workers’ compensation.”
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