C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 447—PAYMENTS FOR SERVICES › Subpart A—Payments: General Provisions

42 C.F.R. § 447.20

Provider restrictions: State plan requirements

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A State plan must provide for the following:

(a) In the case of an individual who is eligible for medical assistance under the plan for service(s) for which a third party or parties is liable for payment, if the total amount of the established liability of the third party or parties for the service is—

(1) Equal to or greater than the amount payable under the State plan (which includes, when applicable, cost-sharing payments provided for in §§ 447.52 through 447.54), the provider furnishing the service to the individual may not seek to collect from the individual (or any financially responsible relative or representative of that individual) any payment amount for that service; or

(2) Less than the amount payable under the State plan (including cost sharing payments set forth in §§ 447.52 through 447.54), the provider furnishing the service to that individual may collect from the individual (or any financially responsible relative or representative of the individual) an amount which is the lesser of—

(i) Any cost-sharing payment amount imposed upon the individual under §§ 447.52 through 447.54; or

(ii) An amount which represents the difference between the amount payable under the State plan (which includes, where applicable, cost-sharing payments provided for in §§ 447.52 through 447.54) and the total of the established third party liability for the services.

(b) A provider may not refuse to furnish services covered under the plan to an individual who is eligible for medical assistance under the plan on account of a third party's potential liability for the service(s).

[55 FR 1433, Jan. 16, 1990, as amended at 78 FR 42307, July 15, 2013]
Notes of Decisions
Cited in 19 cases (5 in the last 5 years), 2000–2025 · leading case: Olszewski v. Scripps Health
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Olszewski v. Scripps Health (2003) cal · cites it 8× “[9] (Italics added; see also 42 C.F.R. § 447.20 (a).) [10] To comply with these federal requirements, Medi-Cal has imposed certain limitations on provider reimbursement.”
Miller v. Gorski Wladyslaw Estate (2008) ca5 “§ 1396a(a)(25)(C); see also 42 C.F.R. § 447.20 (a). Louisiana accordingly requires health care providers that want to participate in the state’s Medicaid program to agree to “[a]ccept payment from [Medicaid] as payment in full,” and not to bill or collect “any additional amount…”
Marquez v. State Department of Health Care Services (2015) calctapp “§ 1396a(a)(25)(D); see 42 C.F.R. § 447.20 (b) (2014) [“a third party’s potential liability for the service(s)” is not a reason for a provider to refuse to furnish Medicaid services to an eligible beneficiary].”
Terrell v. Nanda (2000) lactapp “15 ; 42 C.F.R. § 447.20 ; and La. R.S. 46:446.”
Ansley v. Banner Health (2019) arizctapp · cites it 2× “16, 1990) (codified at 42 C.F.R. § 447.20 ). The new regulation required state plans to limit what a provider could collect from a patient "or any financially responsible relative or representative" of the patient when a third party is liable for payment.”
Gist v. Atlas Staffing, Inc. (2018) minn “15 only applies when the provider is seeking additional payments from the treated individual. But sections 447.15 and 447.”
Spectrum Health Continuing Care Group v. Anna Marie Bowling Irrevocable Trust (2004) miwd · cites it 2× “The regulation implementing this statute, 42 C.F.R. § 447.20 , states: “A state plan must provide [that] .”
Conrad v. Perales (2000) nywd “Similarly, federal Medicare law at that time prohibited nursing homes from imposing charges on “any individual or any other person for items or services for which such individual is entitled to have payment made under this title.”
Bozeman v. State, Department of Transportation & Development (2003) lactapp “§ 1396a; 42 C.F.R. § 447.20 ; and La. R.S. 46:446.”
National Ass'n of Chain Drug Stores v. Schwarzenegger (2009) cacd “Plaintiffs further argue that with these recent reductions, the Department fails to offer payments “sufficient to enlist enough providers,” pursuant to 42 C.F.R. § 447.20 , because pharmacies will be economically forced to stop serving Medicaid beneficiaries.”
Ansley v. Banner Health (2018) arizctapp · cites it 2× “16, 1990) (to be codified at 42 C.F.R. § 447.20 ). The new regulation required state plans to bar a provider from collecting from a patient "or any financially responsible relative or representative" of the patient when a third party's liability is equal to or greater than the…”
Marquez v. Dept. of Health Care Services (2015) calctapp · cites it 2× “§ 1396a(a)(25)(D); see 42 C.F.R. § 447.20 (b) (2014) [“a third party’s potential liability for the service(s)” is not a reason for a provider to refuse to furnish Medicaid services to an eligible beneficiary].”
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