42 C.F.R. § 411.50

General provisions

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(a) Limits on applicability. The provisions of this subpart C do not apply to any services required because of accidents that occurred before December 5, 1980.

(b) Definitions.

Automobile means any self-propelled land vehicle of a type that must be registered and licensed in the State in which it is owned.

Liability insurance means insurance (including a self-insured plan) that provides payment based on legal liability for injury or illness or damage to property. It includes, but is not limited to, automobile liability insurance, uninsured motorist insurance, underinsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance, and general casualty insurance.

Liability insurance payment means a payment by a liability insurer, or an out-of-pocket payment, including a payment to cover a deductible required by a liability insurance policy, by any individual or other entity that carries liability insurance or is covered by a self-insured plan.

No-fault insurance means insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile, regardless of who may have been responsible for causing the accident. This insurance includes but is not limited to automobile, homeowners, and commercial plans. It is sometimes called “medical payments coverage”, “personal injury protection”, or “medical expense coverage”.

Prompt or promptly, when used in connection with payment by a liability insurer means payment within 120 days after the earlier of the following:

(1) The date a claim is filed with an insurer or a lien is filed against a potential liability settlement.

(2) The date the service was furnished or, in the case of inpatient hospital services, the date of discharge.

Self-insured plan means a plan under which an individual, or a private or governmental entity, carries its own risk instead of taking out insurance with a carrier. This term includes a plan of an individual or other entity engaged in a business, trade, or profession, a plan of a non-profit organization such as a social, fraternal, labor, educational, religious, or professional organization, and the plan established by the Federal government to pay liability claims under the Federal Tort Claims Act. An entity that engages in a business, trade, or profession is deemed to have a self-insured plan for purposes of liability insurance if it carries its own risk (whether by a failure to obtain insurance, or otherwise) in whole or in part.

Underinsured motorist insurance means insurance under which the policyholder's level of protection against losses caused by another is extended to compensate for inadequate coverage in the other party's policy or plan.

Uninsured motorist insurance means insurance under which the policyholder's insurer will pay for damages caused by a motorist who has no automobile liability insurance or who carries less than the amount of insurance required by law, or is underinsured.

(c) Limitation on payment for services covered under no-fault insurance. Except as provided under §§ 411.52 and 411.53 with respect to conditional payments. Medicare does not pay for the following:

(1) Services for which payment has been made or can reasonably be expected to be made under automobile no-fault insurance.

(2) Services furnished on or after November 13, 1989 for which payment has been made or can reasonably be expected to be made under any no-fault insurance other than automobile no-fault.

[54 FR 41734, Oct. 11, 1989, as amended at 55 FR 1820, Jan. 19, 1990; 71 FR 9470, Feb. 24, 2006]

Notes of Decisions

Cited in 30 cases (3 in the last 5 years), 1998–2022 · leading case: United States v. Baxter Int'l, Inc., 345 F.3d 866 (11th Cir. 2003).

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United States v. Baxter Int'l, Inc., 345 F.3d 866 (11th Cir. 2003). · cites it 7× “” 42 C.F.R. § 411.50 (b). HHS has purposefully adopted a broad definition of what it means to be self-insured.”

Rose v. via Christi Health Sys., Inc., 113 P.3d 241 (Kan. 2003). · cites it 4× “§ 1395y(b)(2)(A)(ii); 42 C.F.R. § 411.50 (2004). Although the provisions of 42 C.”

Rose v. via Christi Health Sys., Inc., 78 P.3d 798 (Kan. 2003). · cites it 4× “§ 1395y(b)(2)(A)(ii) (2000); 42 C.F.R. § 411.50 . Additionally, upon payment of benefits, Medicare obtains a right of subrogation.”

Fanning v. United States, 202 F.R.D. 154 (E.D. Pa. 2001). · cites it 4× “”) at 28 (quoting 42 C.F.R. § 411.50 (b)). It further points out that a “self-insured plan” includes an “entity engaged in a business, trade or profession.”

Bio-Med. Applications of Tennessee, Inc. v. Cent. States Se. & Sw. Areas Health & Welfare Fund, 656 F.3d 277 (6th Cir. 2011). · cites it 2× “" 42 C.F.R. § 411.50 (b). In Goetzmann , the Fifth Circuit emphasized that even under this definition, a tortfeasor would have to be a "plan," which stretched the Act too far.”

Thompson v. Goetzmann, 337 F.3d 489 (5th Cir. 2002). · cites it 2× “42 C.F.R. § 411.50 (b). 17 . A prior district court also rejected the government's attempt to rely upon the MSP statute’s legislative history, noting then that the “legislative history of the MSP Statute is cryptic and uninformative on the interpretative question now raised.”

Joiner v. Med. Ctr. East, Inc., 709 So. 2d 1209 (Ala. 1998). · cites it 4× “§ 1395y (b)(2)(A) and 42 C.F.R. § 411.50 (b), as well as on Bowen and Sullivan , *Page 1211 supra, the Joiners argue that Medical Center East lost its statutory authorization to obtain payment from Mr.”

Thompson v. Goetzmann, 315 F.3d 457 (5th Cir. 2002). · cites it 3× “42 C.F.R. § 411.50 (b). . A prior district court also rejected the government's attempt to rely upon the MSP statute's legislative history, noting then that the “legislative history of the MSP Statute is cryptic and uninformative on the interpretative question now raised.”

In Re Silicone Gel Breast Implants Liab. Litig., 174 F. Supp. 2d 1242 (N.D. Ala. 2001). · cites it 3× “" 42 C.F.R. § 411.50 (b). A "plan" is "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.”

Parkview Hosp., Inc. v. Roese, 750 N.E.2d 384 (Ind. Ct. App. 2001). · cites it 2× “42 C.F.R. § 411.50 (b) (2000). In addition, the DHHS has promulgated a regulation limiting charges a medical service provider can impose against a patient's insurance settlement or claim.”

In Re Dow Corning Corp., 250 B.R. 298 (Bankr. E.D. Mich. 2000). · cites it 2× “” 42 C.F.R. § 411.50 (b)(2). Nothing in the Joint Motion asks the Court for summary judgment on the ground that the Government has not shown that the Debt- or is a “primary plan.”

Glover v. Philip Morris USA, 380 F. Supp. 2d 1279 (M.D. Fla. 2005). “3d at 895 (quoting 42 C.F.R. § 411.50 (b)). The parties do not cite, and the Court could not locate, any regulations addressing the issue in this case.”

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Parkview Hosp., Inc. v. Roese, 750 N.E.2d 384 (Ind. Ct. App. 2001). “42 C.F.R. § 411.50 (b) (2000). In addition, the DHHS has promulgated a regulation limiting charges a medical service provider can impose against a patient's insurance settlement or claim.”

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