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
Olszewski v. Scripps Health, 69 P.3d 927 (Cal. 2003).
· 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 Est., 547 F.3d 273 (5th Cir. 2008).
“§ 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 Dep't of Health Care Servs., 240 Cal. App. 4th 87 (Cal. Ct. App. 2015).
“§ 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, 759 So. 2d 1026 (La. Ct. App. 2000).
“15 ; 42 C.F.R. § 447.20 ; and La. R.S. 46:446.”
Ansley v. Banner Health, 437 P.3d 899 (Ariz. Ct. App. 2019).
· 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., 910 N.W.2d 24 (Minn. 2018).
“15 only applies when the provider is seeking additional payments from the treated individual. But sections 447.15 and 447.”
Conrad v. Perales, 92 F. Supp. 2d 175 (W.D.N.Y. 2000).
“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.”
Nat'l Ass'n of Chain Drug Stores v. Schwarzenegger, 678 F. Supp. 2d 995 (C.D. Cal. 2009).
“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, 419 P.3d 552 (Ariz. Ct. App. 2018).
· 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 Servs. (Cal. Ct. App. 2015).
· 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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