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 D—Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance

42 C.F.R. § 411.54

Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer

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(a) Definition. As used in this section, Medicare-covered services means services for which Medicare benefits are payable or would be payable except for applicable Medicare deductible and coinsurance provisions. Medicare benefits are payable notwithstanding potential liability insurance payments, but are recoverable in accordance with § 411.24.

(b) Applicability. This section applies when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer for injuries or illness allegedly caused by another party.

(c) Itemized bill. A hospital must, upon request, furnish to the beneficiary or his or her representative an itemized bill of the hospital's charges.

(d) Exception—(1) Prepaid health plans. If the services were furnished through an organization that has a contact under section 1876 of the Act (that is, an HMO or CMP), or through an organization that is paid under section 1833(a)(1)(A) of the Act (that is, through an HCPP) the rules of § 417.528 of this chapter apply.

(2) Special rules for Oregon. For the State of Oregon, because of a court decision, and in the absence of a reversal on appeal or a statutory clarification overturning the decision, there are the following special rules:

(i) The provider or supplier may elect to bill a liability insurer or place a lien against the beneficiary's liability settlement for Medicare covered services, rather than bill only Medicare for Medicare covered services, if the liability insurer pays within 120 days after the earlier of the following dates:

(A) The date the provider or supplier files a claim with the insurer or places a lien against a potential liability settlement.

(B) The date the services were provided or, in the case of inpatient hospital services, the date of discharge.

(ii) If the liability insurer does not pay within the 120-day period, the provider or supplier:

(A) Must withdraw its claim with the liability insurer and/or withdraw its lien against a potential liability settlement.

(B) May only bill Medicare for Medicare covered services.

(C) May bill the beneficiary only for applicable Medicare deductible and co-insurance amounts plus the amount of any charges that may be made to a beneficiary under 413.35 of this chapter (when cost limits are applied to these services) or under 489.32 of this chapter (when services are partially covered).

[54 FR 41734, Oct. 11, 1989, as amended at 68 FR 43942, July 25, 2003]
Notes of Decisions
Cited in 7 cases, 1998–2019 · leading case: Joiner v. Medical Center East, Inc.
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Joiner v. Medical Center East, Inc. (1998) ala · cites it 3× “at 41,743 (to be codified at 42 C.F.R. § 411.54 (c)(2)) (Oct. 11, 1989).”
Parkview Hospital, Inc. v. Roese (2001) indctapp · cites it 2× “42 C.F.R. § 411.54 (c)(2) (2000). In the end, we are left with two conflicting regulations: the first allowing service providers to collect from an automobile or liability insurance plan, and the other prohibiting the billing or filing of a lien against a liability insurance…”
Alegent Health v. American Family Insurance (2003) neb · cites it 3× “American Family asserted that the lien was in violation of federal law, 42 C.F.R. § 411.54 (c)(2)(i) (1997), which provides that a hospital may not bill a liability insurer nor place a lien against the beneficiary’s liability insurance settlement for Medicare-covered services.”
Wentz v. Kindred Hospitals East, L.L.C. (2004) flsd · cites it 3× “Under 42 C.F.R. § 411.54 , where a Medicare beneficiary has received liability insurance or has a claim pending against a liability insurer, a *1301 services provider may “place a lien against the beneficiary’s liability settlement for Medicare covered services, rather than bill…”
Smith v. Farmers Insurance Exchange (2000) colo “However, both cases involved liability settlements, and are accordingly governed by *340 42 CFR. § 411.54, which prohibits billing a liability insurer or a beneficiary for Medicare-covered services.”
Paul Craig Jeffries and Gerald Jeffries, as Co-Administrators of the Estate of Fanchon B. Jeffries v. Central Iowa Healt (2019) iowactapp “The district court did not err in granting the hospital’s motion for summary judgment with respect to the estate’s claim for breach of the settlement agreement.”
Smith v. Farmers Insurance Exchange (1998) coloctapp “See also 42 C.F.R. 411.54 (1997) (limitation on charges when a beneficiary has a pending claim against an insurer); Rybicki v.”
— 42 C.F.R. § 411.54(c)(2) — 1 case
Paul Craig Jeffries and Gerald Jeffries, as Co-Administrators of the Estate of Fanchon B. Jeffries v. Central Iowa Healt (2019) iowactapp “The district court did not err in granting the hospital’s motion for summary judgment with respect to the estate’s claim for breach of the settlement agreement.”
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