---
kind: "range"
citation: "42 C.F.R. §§ 411.355–411.357"
title: "42"
from: "411.355"
to: "411.357"
count: 3
url: "https://uscodex.org/cfr/42/411.355..411.357"
---

# §411.355. General exceptions to the referral prohibition related to both ownership/investment and compensation.


The prohibition on referrals set forth in [§ 411.353](/cfr/42/411.353.md) does not apply to the following types of services:

- (a) **Physician services.**
  - (1) Physician services as defined at [§ 410.20(a)](/cfr/42/410.20.md?p=a) of this chapter that are furnished—
    - (i) Personally by another physician who is a member of the referring physician's group practice or is a physician in the same group practice (as defined at [§ 411.351](/cfr/42/411.351.md)) as the referring physician; or
    - (ii) Under the supervision of another physician who is a member of the referring physician's group practice or is a physician in the same group practice (as defined at [§ 411.351](/cfr/42/411.351.md)) as the referring physician, provided that the supervision complies with all other applicable Medicare payment and coverage rules for the physician services.
  - (2) For purposes of this [paragraph (a)](#a), “physician services” include only those “incident to” services (as defined at [§ 411.351](/cfr/42/411.351.md)) that are physician services under [§ 410.20(a)](/cfr/42/410.20.md?p=a) of this chapter.
- (b) **In-office ancillary services.** Services (including certain items of durable medical equipment (DME), as defined in [paragraph (b)(4)](#b-4) of this section, and infusion pumps that are DME (including external ambulatory infusion pumps), but excluding all other DME and parenteral and enteral nutrients, equipment, and supplies (such as infusion pumps used for PEN)), that meet the following conditions:
  - (1) **Individual who furnishes the service.** They are furnished personally by one of the following individuals:
    - (i) **The referring physician.**
    - (ii) **A physician who is a member of the same group practice as the referring physician.**
    - (iii) An individual who is supervised by the referring physician or, if the referring physician is in a group practice, by another physician in the group practice, provided that the supervision complies with all other applicable Medicare payment and coverage rules for the services.
  - (2) **Location where service is furnished.** They are furnished in one of the following locations:
    - (i) The same building (as defined at [§ 411.351](/cfr/42/411.351.md)), but not necessarily in the same space or part of the building, in which all of the conditions of paragraph [(b)(2)(i)(A)](#b-2-i-A), [(b)(2)(i)(B)](#b-2-i-B), or [(b)(2)(i)(C)](#b-2-i-C) of this section are satisfied:
      - (A) (1) The referring physician or his or her group practice (if any) has an office that is normally open to the physician's or group's patients for medical services at least 35 hours per week; and

        (2) The referring physician or one or more members of the referring physician's group practice regularly practices medicine and furnishes physician services to patients at least 30 hours per week. The 30 hours must include some physician services that are unrelated to the furnishing of DHS payable by Medicare, any other Federal health care payer, or a private payer, even though the physician services may lead to the ordering of DHS; or

      - (B) (1) The patient receiving the DHS usually receives physician services from the referring physician or members of the referring physician's group practice (if any);

        (2) The referring physician or the referring physician's group practice owns or rents an office that is normally open to the physician's or group's patients for medical services at least 8 hours per week; and

        (3) The referring physician regularly practices medicine and furnishes physician services to patients at least 6 hours per week. The 6 hours must include some physician services that are unrelated to the furnishing of DHS payable by Medicare, any other Federal health care payer, or a private payer, even though the physician services may lead to the ordering of DHS; or

      - (C) (1) The referring physician is present and orders the DHS during a patient visit on the premises as set forth in paragraph (b)(2)(i)(C)(2) of this section or the referring physician or a member of the referring physician's group practice (if any) is present while the DHS is furnished during occupancy of the premises as set forth in paragraph (b)(2)(i)(C)(2) of this section;

        (2) The referring physician or the referring physician's group practice owns or rents an office that is normally open to the physician's or group's patients for medical services at least 8 hours per week; and

        (3) The referring physician or one or more members of the referring physician's group practice regularly practices medicine and furnishes physician services to patients at least 6 hours per week. The 6 hours must include some physician services that are unrelated to the furnishing of DHS payable by Medicare, any other Federal health care payer, or a private payer, even though the physician services may lead to the ordering of DHS.

    - (ii) A centralized building (as defined at [§ 411.351](/cfr/42/411.351.md)) that is used by the group practice for the provision of some or all of the group practice's clinical laboratory services.
    - (iii) A centralized building (as defined at [§ 411.351](/cfr/42/411.351.md)) that is used by the group practice for the provision of some or all of the group practice's DHS (other than clinical laboratory services).
  - (3) **Billing of the service.** They are billed by one of the following:
    - (i) **The physician performing or supervising the service.**
    - (ii) The group practice of which the performing or supervising physician is a member under a billing number assigned to the group practice.
    - (iii) The group practice if the supervising physician is a “physician in the group practice” (as defined at [§ 411.351](/cfr/42/411.351.md)) under a billing number assigned to the group practice.
    - (iv) An entity that is wholly owned by the performing or supervising physician or by that physician's group practice under the entity's own billing number or under a billing number assigned to the physician or group practice.
    - (v) An independent third party billing company acting as an agent of the physician, group practice, or entity specified in [paragraphs (b)(3)(i) through (iv)](#b-3-i..b-3-iv) of this section under a billing number assigned to the physician, group practice, or entity, provided that the billing arrangement meets the requirements of [§ 424.80(b)(5)](/cfr/42/424.80.md?p=b-5) of this chapter. For purposes of this [paragraph (b)(3)](#b-3), a group practice may have, and bill under, more than one Medicare billing number, subject to any applicable Medicare program restrictions.
  - (4) **Durable Medical Equipment.** For purposes of this [paragraph (b)](#b), DME covered by the in-office ancillary services exception means canes, crutches, walkers and folding manual wheelchairs, and blood glucose monitors, that meet the following conditions:
    - (i) The item is one that a patient requires for the purpose of ambulating, a patient uses in order to depart from the physician's office, or is a blood glucose monitor (including one starter set of test strips and lancets, consisting of no more than 100 of each). A blood glucose monitor may be furnished only by a physician or employee of a physician or group practice that also furnishes outpatient diabetes self-management training to the patient.
    - (ii) The item is furnished in a building that meets the “same building” requirements in the in-office ancillary services exception as part of the treatment for the specific condition for which the patient-physician encounter occurred.
    - (iii) The item is furnished personally by the physician who ordered the DME, by another physician in the group practice, or by an employee of the physician or the group practice.
    - (iv) A physician or group practice that furnishes the DME meets all DME supplier standards set forth in [§ 424.57(c)](/cfr/42/424.57.md?p=c) of this chapter.
    - (v) [Reserved]
    - (vi) **All other requirements of the in-office ancillary services exception in this paragraph (b) are met.**
  - (5) **Furnishing a service.** A designated health service is “furnished” for purposes of this [paragraph (b)](#b) in the location where the service is actually performed upon a patient or where an item is dispensed to a patient in a manner that is sufficient to meet the applicable Medicare payment and coverage rules.
  - (6) **Special rule for home care physicians.** In the case of a referring physician whose principal medical practice consists of treating patients in their private homes, the “same building” requirements of [paragraph (b)(2)(i)](#b-2-i) of this section are met if the referring physician (or a qualified person accompanying the physician, such as a nurse or technician) provides the DHS contemporaneously with a physician service that is not a designated health service provided by the referring physician to the patient in the patient's private home. For purposes of [paragraph (b)(5)](#b-5) of this section only, a private home does not include a nursing, long-term care, or other facility or institution, except that a patient may have a private home in an assisted living or independent living facility.
  - (7) **Disclosure requirement for certain imaging services.**
    - (i) With respect to magnetic resonance imaging, computed tomography, and positron emission tomography services identified as “radiology and certain other imaging services” on the List of CPT/HCPCS Codes, the referring physician must provide written notice to the patient at the time of the referral that the patient may receive the same services from a person other than one described in [paragraph (b)(1)](#b-1) of this section. Except as set forth in [paragraph (b)(7)(ii)](#b-7-ii) of this section, the written notice must include a list of at least 5 other suppliers (as defined at [§ 400.202](/cfr/42/400.202.md) of this chapter) that provide the services for which the individual is being referred and which are located within a 25-mile radius of the referring physician's office location at the time of the referral. The notice should be written in a manner sufficient to be reasonably understood by all patients and should include for each supplier on the list, at a minimum, the supplier's name, address, and telephone number.
    - (ii) If there are fewer than 5 other suppliers located within a 25-mile radius of the physician's office location at the time of the referral, the physician must list all of the other suppliers of the imaging service that are present within a 25-mile radius of the referring physician's office location. Provision of the written list of alternate suppliers will not be required if no other suppliers provide the services for which the individual is being referred within the 25-mile radius.
- (c) **Services furnished by an organization (or its contractors or subcontractors) to enrollees.** Services furnished by an organization (or its contractors or subcontractors) to enrollees of one of the following prepaid health plans (not including services provided to enrollees in any other plan or line of business offered or administered by the same organization):
  - (1) An HMO or a CMP in accordance with a contract with CMS under section 1876 of the Act and [part 417](/cfr/42/part417.md), subparts [J](/cfr/42/subpartJ.md) through [M](/cfr/42/subpartM.md) of this chapter.
  - (2) A health care prepayment plan in accordance with an agreement with CMS under section 1833(a)(1)(A) of the Act and [part 417](/cfr/42/part417.md), [subpart U](/cfr/42/subpartU.md) of this chapter.
  - (3) An organization that is receiving payments on a prepaid basis for Medicare enrollees through a demonstration project under [section 402(a)](/cfr/42/402.md?p=a) of the Social Security Amendments of 1967 ([42 U.S.C. 1395b-1](/usc/42/1395b-1.md)) or under [section 222(a)](/cfr/42/222.md?p=a) of the Social Security Amendments of 1972 ([42 U.S.C. 1395b-1](/usc/42/1395b-1.md) note).
  - (4) **A qualified HMO (within the meaning of section 1310(d) of the Public Health Service Act).**
  - (5) A coordinated care plan (within the meaning of section 1851(a)(2)(A) of the Act) offered by a Medicare Advantage organization in accordance with a contract with CMS under section 1857 of the Act and [part 422](/cfr/42/part422.md) of this chapter.
  - (6) **A MCO contracting with a State under section 1903(m) of the Act.**
  - (7) A prepaid inpatient health plan (PIHP) or prepaid ambulance health plan (PAHP) contracting with a State under [part 438](/cfr/42/part438.md) of this chapter.
  - (8) A health insuring organization (HIO) contracting with a State under [part 438](/cfr/42/part438.md), [subpart D](/cfr/42/subpartD.md) of this chapter.
  - (9) An entity operating under a demonstration project under sections [1115(a)](/cfr/42/1115.md?p=a), [1915(a)](/cfr/42/1915.md?p=a), [1915(b)](/cfr/42/1915.md?p=b), or [1932(a)](/cfr/42/1932.md?p=a) of the Act.
- (d) [Reserved]
- (e) **Academic medical centers.**
  - (1) **Services provided by an academic medical center if all of the following conditions are met—**
    - (i) **The referring physician—**
      - (A) Is a bona fide employee of a component of the academic medical center on a full-time or substantial part-time basis. (A “component” of an academic medical center means an affiliated medical school, faculty practice plan, hospital, teaching facility, institution of higher education, departmental professional corporation, or nonprofit support organization whose primary purpose is supporting the teaching mission of the academic medical center.) The components need not be separate legal entities;
      - (B) Is licensed to practice medicine in the State(s) in which he or she practices medicine;
      - (C) Has a bona fide faculty appointment at the affiliated medical school or at one or more of the educational programs at the accredited academic hospital (as defined at [§ 411.355(e)(3)](#e-3)); and
      - (D) Provides either substantial academic services or substantial clinical teaching services (or a combination of academic services and clinical teaching services) for which the faculty member receives compensation as part of his or her employment relationship with the academic medical center. Parties should use a reasonable and consistent method for calculating a physician's academic services and clinical teaching services. A physician will be deemed to meet this requirement if he or she spends at least 20 percent of his or her professional time or 8 hours per week providing academic services or clinical teaching services (or a combination of academic services or clinical teaching services). A physician who does not spend at least 20 percent of his or her professional time or 8 hours per week providing academic services or clinical teaching services (or a combination of academic services or clinical teaching services) is not precluded from qualifying under this [paragraph (e)(1)(i)(D)](#e-1-i-D).
    - (ii) The compensation paid to the referring physician must meet all of the following conditions:
      - (A) The total compensation paid by each academic medical center component to the referring physician is set in advance.
      - (B) In the aggregate, the compensation paid by all academic medical center components to the referring physician does not exceed fair market value for the services provided.
      - (C) The total compensation paid by each academic medical center component is not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician within the academic medical center.
      - (D) If any compensation paid to the referring physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the arrangement satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
    - (iii) The academic medical center must meet all of the following conditions:
      - (A) All transfers of money between components of the academic medical center must directly or indirectly support the missions of teaching, indigent care, research, or community service.
      - (B) The relationship of the components of the academic medical center must be set forth in one or more written agreements or other written documents that have been adopted by the governing body of each component. If the academic medical center is one legal entity, this requirement will be satisfied if transfers of funds between components of the academic medical center are reflected in the routine financial reports covering the components.
      - (C) All money paid to a referring physician for research must be used solely to support bona fide research or teaching and must be consistent with the terms and conditions of the grant.
  - (2) **The “academic medical center” for purposes of this section consists of—**
    - (i) An accredited medical school (including a university, when appropriate) or an accredited academic hospital (as defined at [paragraph (e)(3)](#e-3) of this section);
    - (ii) One or more faculty practice plans affiliated with the medical school, the affiliated hospital(s), or the accredited academic hospital; and
    - (iii) One or more affiliated hospitals in which a majority of the physicians on the medical staff consists of physicians who are faculty members and a majority of all hospital admissions is made by physicians who are faculty members. The hospital for purposes of this [paragraph (e)(2)(iii)](#e-2-iii) may be the same hospital that satisfies the requirement of [paragraph (e)(2)(i)](#e-2-i) of this section. For purposes of this [paragraph (e)(2)(iii)](#e-2-iii), a faculty member is a physician who is either on the faculty of the affiliated medical school or on the faculty of one or more of the educational programs at the accredited academic hospital. In meeting this [paragraph (e)(2)(iii)](#e-2-iii), faculty from any affiliated medical school or accredited academic hospital education program may be aggregated, and residents and non-physician professionals need not be counted. Any faculty member may be counted, including courtesy and volunteer faculty. For purposes of determining whether the majority of physicians on the medical staff consists of faculty members, the affiliated hospital must include or exclude all individual physicians with the same class of privileges at the affiliated hospital (for example, physicians holding courtesy privileges).
  - (3) An accredited academic hospital for purposes of this section means a hospital or a health system that sponsors four or more approved medical education programs.
- (f) **Implants furnished by an ASC.** Implants furnished by an ASC, including, but not limited to, cochlear implants, intraocular lenses, and other implanted prosthetics, implanted prosthetic devices, and implanted DME that meet the following conditions:
  - (1) The implant is implanted by the referring physician or a member of the referring physician's group practice in an ASC that is certified by Medicare under [part 416](/cfr/42/part416.md) of this chapter and with which the referring physician has a financial relationship.
  - (2) The implant is implanted in the patient during a surgical procedure paid by Medicare to the ASC as an ASC procedure under [§ 416.65](/cfr/42/416.65.md) of this chapter.
  - (3) [Reserved]
  - (4) [Reserved]
  - (5) The exception set forth in this [paragraph (f)](#f) does not apply to any financial relationships between the referring physician and any entity other than the ASC in which the implant is furnished to, and implanted in, the patient.
- (g) **EPO and other dialysis-related drugs.** EPO and other dialysis-related drugs that meet the following conditions:
  - (1) **The EPO and other dialysis-related drugs are furnished in or by an ESRD facility.** For purposes of this [paragraph (g)(1)](#g-1), “EPO and other dialysis-related drugs” means certain outpatient prescription drugs that are required for the efficacy of dialysis and identified as eligible for this exception on the List of CPT/HCPCS Codes; and “furnished” means that the EPO or dialysis-related drugs are administered to a patient in the ESRD facility or, in the case of EPO or Aranesp (or equivalent drug identified on the List of CPT/HCPCS Codes) only, are dispensed by the ESRD facility for use at home.
  - (2) [Reserved]
  - (3) [Reserved]
  - (4) The exception set forth in this [paragraph (g)](#g) does not apply to any financial relationship between the referring physician and any entity other than the ESRD facility that furnishes the EPO and other dialysis-related drugs to the patient.
- (h) **Preventive screening tests and vaccines—** . (1) Preventive screening tests and vaccines that meet the following conditions:
- (i) The preventive screening test or vaccine is listed on the List of CPT/HCPCS Codes as a code to which the exception in this paragraph is applicable.
- (ii) **The preventive screening test or vaccine is covered by Medicare.**
- (iii) **The preventive screening test or vaccine is subject to a CMS-mandated frequency limit.**
  - (2) During such period as the vaccine is not subject to a CMS-mandated frequency limit, paragraph (h)(1)(iii) of this section does not apply to a COVID-19 vaccine identified on the List of CPT/HCPCS Codes as a code to which the exception in this paragraph is applicable.
    - (i) **Eyeglasses and contact lenses following cataract surgery.** Eyeglasses and contact lenses that are covered by Medicare when furnished to patients following cataract surgery that meet the following conditions:
  - (1) The eyeglasses or contact lenses are provided in accordance with the coverage and payment provisions set forth in §§ [410.36(a)(2)(ii)](/cfr/42/410.36.md?p=a-2-ii) and [414.228](/cfr/42/414.228.md) of this chapter, respectively.
  - (2) [Reserved]
- (j) **Intra-family rural referrals.**
  - (1) Services provided pursuant to a referral from a referring physician to his or her immediate family member or to an entity furnishing DHS with which the immediate family member has a financial relationship, if all of the following conditions are met:
    - (i) The patient who is referred resides in a rural area as defined at [§ 411.351](/cfr/42/411.351.md) of this subpart;
    - (ii) Except as provided in [paragraph (j)(1)(iii)](#j-1-iii) of this section, in light of the patient's condition, no other person or entity is available to furnish the services in a timely manner within 25 miles of or 45 minutes transportation time from the patient's residence;
    - (iii) In the case of services furnished to patients where they reside (for example, home health services or DME), no other person or entity is available to furnish the services in a timely manner in light of the patient's condition; and
  - (2) The referring physician or the immediate family member must make reasonable inquiries as to the availability of other persons or entities to furnish the DHS. However, neither the referring physician nor the immediate family member has any obligation to inquire as to the availability of persons or entities located farther than 25 miles of or 45 minutes transportation time from (whichever test the referring physician utilized for purposes of [paragraph (j)(1)(ii)](#j-1-ii)) the patient's residence.

# §411.356. Exceptions to the referral prohibition related to ownership or investment interests.


For purposes of [§ 411.353](/cfr/42/411.353.md), the following ownership or investment interests do not constitute a financial relationship:

- (a) **Publicly traded securities.** Ownership of investment securities (including shares or bonds, debentures, notes, or other debt instruments) that at the time the DHS referral was made could be purchased on the open market and that meet the requirements of paragraphs [(a)(1)](#a-1) and [(2)](#a-2) of this section.
  - (1) **They are either—**
    - (i) Listed for trading on the New York Stock Exchange, the American Stock Exchange, or any regional exchange in which quotations are published on a daily basis, or foreign securities listed on a recognized foreign, national, or regional exchange in which quotations are published on a daily basis;
    - (ii) Traded under an automated interdealer quotation system operated by the National Association of Securities Dealers; or
    - (iii) Listed for trading on an electronic stock market or over-the-counter quotation system in which quotations are published on a daily basis and trades are standardized and publicly transparent.
  - (2) They are in a corporation that had stockholder equity exceeding $75 million at the end of the corporation's most recent fiscal year or on average during the previous 3 fiscal years. “Stockholder equity” is the difference in value between a corporation's total assets and total liabilities.
- (b) **Mutual funds.** Ownership of shares in a regulated investment company as defined in section 851(a) of the Internal Revenue Code of 1986, if the company had, at the end of its most recent fiscal year, or on average during the previous 3 fiscal years, total assets exceeding $75 million.
- (c) **Specific providers.** Ownership or investment interest in the following entities, for purposes of the services specified:
  - (1) A rural provider, in the case of DHS furnished in a rural area (as defined at [§ 411.351](/cfr/42/411.351.md) of this part) by the provider. A “rural provider” is an entity that furnishes substantially all (not less than 75 percent) of the DHS that it furnishes to residents of a rural area and, for the 18-month period beginning on December 8, 2003 (or such other period as Congress may specify), is not a specialty hospital, and in the case where the entity is a hospital, the hospital meets the requirements of [§ 411.362](/cfr/42/411.362.md) no later than September 23, 2011.
  - (2) **A hospital that is located in Puerto Rico, in the case of DHS furnished by such a hospital.**
  - (3) A hospital that is located outside of Puerto Rico, in the case of DHS furnished by such a hospital, if—
    - (i) The referring physician is authorized to perform services at the hospital;
    - (ii) Effective for the 18-month period beginning on December 8, 2003 (or such other period as Congress may specify), the hospital is not a specialty hospital;
    - (iii) The ownership or investment interest is in the entire hospital and not merely in a distinct part or department of the hospital; and
    - (iv) The hospital meets the requirements described in [§ 411.362](/cfr/42/411.362.md) not later than September 23, 2011.

# §411.357. Exceptions to the referral prohibition related to compensation arrangements.


For purposes of [§ 411.353](/cfr/42/411.353.md), the following compensation arrangements do not constitute a financial relationship:

- (a) **Rental of office space.** Payments for the use of office space made by a lessee to a lessor if the arrangement meets the following requirements:
  - (1) The lease arrangement is set out in writing, is signed by the parties, and specifies the premises it covers.
  - (2) **The duration of the lease arrangement is at least 1 year.** To meet this requirement, if the lease arrangement is terminated with or without cause, the parties may not enter into a new lease arrangement for the same space during the first year of the original lease arrangement.
  - (3) The space rented or leased does not exceed that which is reasonable and necessary for the legitimate business purposes of the lease arrangement and is used exclusively by the lessee when being used by the lessee (and is not shared with or used by the lessor or any person or entity related to the lessor), except that the lessee may make payments for the use of space consisting of common areas if the payments do not exceed the lessee's pro rata share of expenses for the space based upon the ratio of the space used exclusively by the lessee to the total amount of space (other than common areas) occupied by all persons using the common areas. For purposes of this [paragraph (a)](#a), exclusive use means that the lessee (and any other lessees of the same office space) uses the office space to the exclusion of the lessor (or any person or entity related to the lessor). The lessor (or any person or entity related to the lessor) may not be an invitee of the lessee to use the office space.
  - (4) The rental charges over the term of the lease arrangement are set in advance and are consistent with fair market value.
  - (5) **The rental charges over the term of the lease arrangement are not determined—**
    - (i) In any manner that takes into account the volume or value of referrals or other business generated between the parties; or
    - (ii) **Using a formula based on—**
      - (A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated in the office space; or
      - (B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
  - (6) The lease arrangement would be commercially reasonable even if no referrals were made between the lessee and the lessor.
  - (7) If the lease arrangement expires after a term of at least 1 year, a holdover lease arrangement immediately following the expiration of the lease arrangement satisfies the requirements of [paragraph (a)](#a) of this section if the following conditions are met:
    - (i) The lease arrangement met the conditions of [paragraphs (a)(1) through (6)](#a-1..a-6) of this section when the arrangement expired;
    - (ii) The holdover lease arrangement is on the same terms and conditions as the immediately preceding arrangement; and
    - (iii) The holdover lease arrangement continues to satisfy the conditions of [paragraphs (a)(1) through (6)](#a-1..a-6) of this section.
- (b) **Rental of equipment.** Payments made by a lessee to a lessor for the use of equipment under the following conditions:
  - (1) The lease arrangement is set out in writing, is signed by the parties, and specifies the equipment it covers.
  - (2) The equipment leased does not exceed that which is reasonable and necessary for the legitimate business purposes of the lease arrangement and is used exclusively by the lessee when being used by the lessee (and is not shared with or used by the lessor or any person or entity related to the lessor). For purposes of this [paragraph (b)](#b), exclusive use means that the lessee (and any other lessees of the same equipment) uses the equipment to the exclusion of the lessor (or any person or entity related to the lessor). The lessor (or any person or entity related to the lessor) may not be an invitee of the lessee to use the equipment.
  - (3) **The duration of the lease arrangement is at least 1 year.** To meet this requirement, if the lease arrangement is terminated with or without cause, the parties may not enter into a new lease arrangement for the same equipment during the first year of the original lease arrangement.
  - (4) The rental charges over the term of the lease arrangement are set in advance, are consistent with fair market value, and are not determined—
    - (i) In any manner that takes into account the volume or value of referrals or other business generated between the parties; or
    - (ii) **Using a formula based on—**
      - (A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed on or business generated through the use of the equipment; or
      - (B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
  - (5) The lease arrangement would be commercially reasonable even if no referrals were made between the parties.
  - (6) If the lease arrangement expires after a term of at least 1 year, a holdover lease arrangement immediately following the expiration of the lease arrangement satisfies the requirements of this [paragraph (b)](#b) if the following conditions are met:
    - (i) The lease arrangement met the conditions of [paragraphs (b)(1) through (5)](#b-1..b-5) of this section when the arrangement expired;
    - (ii) The holdover lease arrangement is on the same terms and conditions as the immediately preceding lease arrangement; and
    - (iii) The holdover lease arrangement continues to satisfy the conditions of [paragraphs (b)(1) through (5)](#b-1..b-5) of this section.
- (c) **Bona fide employment relationships.** Any amount paid by an employer to a physician (or immediate family member) who has a bona fide employment relationship with the employer for the provision of services if the following conditions are met:
  - (1) **The employment is for identifiable services.**
  - (2) **The amount of the remuneration under the employment is—**
    - (i) Consistent with the fair market value of the services; and
    - (ii) Except as provided in [paragraph (c)(4)](#c-4) of this section, is not determined in any manner that takes into account the volume or value of referrals by the referring physician.
  - (3) The remuneration is provided under an arrangement that would be commercially reasonable even if no referrals were made to the employer.
  - (4) [Paragraph (c)(2)(ii)](#c-2-ii) of this section does not prohibit payment of remuneration in the form of a productivity bonus based on services performed personally by the physician (or immediate family member of the physician).
  - (5) If remuneration to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the arrangement satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
- (d) **Personal service arrangements—**
  - (1) **General.** Remuneration from an entity under an arrangement or multiple arrangements to a physician or his or her immediate family member, or to a group practice, including remuneration for specific physician services furnished to a nonprofit blood center, if the following conditions are met:
    - (i) Each arrangement is set out in writing, is signed by the parties, and specifies the services covered by the arrangement.
    - (ii) Except for services provided under an arrangement that satisfies all of the conditions of [paragraph (z)](#z) of this section, the arrangement(s) covers all of the services to be furnished by the physician (or an immediate family member of the physician) to the entity. This requirement is met if all separate arrangements between the entity and the physician and the entity and any family members incorporate each other by reference or if they cross-reference a master list of contracts that is maintained and updated centrally and is available for review by the Secretary upon request. The master list must be maintained in a manner that preserves the historical record of contracts. A physician or family member may “furnish” services through employees whom they have hired for the purpose of performing the services; through a wholly-owned entity; or through locum tenens physicians (as defined at [§ 411.351](/cfr/42/411.351.md), except that the regular physician need not be a member of a group practice).
    - (iii) The aggregate services covered by the arrangement do not exceed those that are reasonable and necessary for the legitimate business purposes of the arrangement(s).
    - (iv) **The duration of each arrangement is at least 1 year.** To meet this requirement, if an arrangement is terminated with or without cause, the parties may not enter into the same or substantially the same arrangement during the first year of the original arrangement.
    - (v) The compensation to be paid over the term of each arrangement is set in advance, does not exceed fair market value, and, except in the case of a physician incentive plan (as defined at [§ 411.351](/cfr/42/411.351.md)), is not determined in any manner that takes into account the volume or value of referrals or other business generated between the parties.
    - (vi) The services to be furnished under each arrangement do not involve the counseling or promotion of a business arrangement or other activity that violates any Federal or State law.
    - (vii) If the arrangement expires after a term of at least 1 year, a holdover arrangement immediately following the expiration of the arrangement satisfies the requirements of [paragraph (d)](#d) of this section if the following conditions are met:
      - (A) The arrangement met the conditions of [paragraphs (d)(1)(i) through (vi)](#d-1-i..d-1-vi) of this section when the arrangement expired;
      - (B) The holdover arrangement is on the same terms and conditions as the immediately preceding arrangement; and
      - (C) The holdover arrangement continues to satisfy the conditions of [paragraphs (d)(1)(i) through (vi)](#d-1-i..d-1-vi) of this section.
    - (viii) If remuneration to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the arrangement satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
  - (2) **Physician incentive plan exception.** In the case of a physician incentive plan (as defined at [§ 411.351](/cfr/42/411.351.md)) between a physician and an entity (or downstream contractor), the compensation may be determined in any manner (through a withhold, capitation, bonus, or otherwise) that takes into account the volume or value of referrals or other business generated between the parties, if the plan meets the following requirements:
    - (i) No specific payment is made directly or indirectly under the plan to a physician or a physician group as an inducement to reduce or limit medically necessary services furnished with respect to a specific individual enrolled with the entity.
    - (ii) Upon request of the Secretary, the entity provides the Secretary with access to information regarding the plan (including any downstream contractor plans), in order to permit the Secretary to determine whether the plan is in compliance with [paragraph (d)(2)](#d-2) of this section.
    - (iii) In the case of a plan that places a physician or a physician group at substantial financial risk as defined at [§ 422.208](/cfr/42/422.208.md), the entity or any downstream contractor (or both) complies with the requirements concerning physician incentive plans set forth in §§ [422.208](/cfr/42/422.208.md) and [422.210](/cfr/42/422.210.md) of this chapter.
    - (iv) If remuneration to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the arrangement satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
- (e) **Physician recruitment.**
  - (1) Remuneration provided by a hospital to recruit a physician that is paid directly to the physician and that is intended to induce the physician to relocate his or her medical practice to the geographic area served by the hospital in order to become a member of the hospital's medical staff, if all of the following conditions are met:
    - (i) The arrangement is set out in writing and signed by both parties;
    - (ii) The arrangement is not conditioned on the physician's referral of patients to the hospital;
    - (iii) The amount of remuneration under the arrangement is not determined in any manner that takes into account the volume or value of actual or anticipated referrals by the physician or other business generated between the parties; and
    - (iv) The physician is allowed to establish staff privileges at any other hospital(s) and to refer business to any other entities (except as referrals may be restricted under an employment or services arrangement that complies with [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4)).
  - (2)
    - (i) **Geographic area served by the hospital—defined.** The “geographic area served by the hospital” is the area composed of the lowest number of contiguous zip codes from which the hospital draws at least 75 percent of its inpatients. The geographic area served by the hospital may include one or more zip codes from which the hospital draws no inpatients, provided that such zip codes are entirely surrounded by zip codes in the geographic area described above from which the hospital draws at least 75 percent of its inpatients.
    - (ii) **Noncontiguous zip codes.** With respect to a hospital that draws fewer than 75 percent of its inpatients from all of the contiguous zip codes from which it draws inpatients, the “geographic area served by the hospital” will be deemed to be the area composed of all of the contiguous zip codes from which the hospital draws its inpatients.
    - (iii) **Special optional rule for rural hospitals.** In the case of a hospital located in a rural area (as defined at [§ 411.351](/cfr/42/411.351.md)), the “geographic area served by the hospital” may also be the area composed of the lowest number of contiguous zip codes from which the hospital draws at least 90 percent of its inpatients. If the hospital draws fewer than 90 percent of its inpatients from all of the contiguous zip codes from which it draws inpatients, the “geographic area served by the hospital” may include noncontiguous zip codes, beginning with the noncontiguous zip code in which the highest percentage of the hospital's inpatients resides, and continuing to add noncontiguous zip codes in decreasing order of percentage of inpatients.
    - (iv) **Relocation of medical practice.** A physician will be considered to have relocated his or her medical practice if the medical practice was located outside the geographic area served by the hospital and—
      - (A) The physician moves his or her medical practice at least 25 miles and into the geographic area served by the hospital; or
      - (B) The physician moves his medical practice into the geographic area served by the hospital, and the physician's new medical practice derives at least 75 percent of its revenues from professional services furnished to patients (including hospital inpatients) not seen or treated by the physician at his or her prior medical practice site during the preceding 3 years, measured on an annual basis (fiscal or calendar year). For the initial “start up” year of the recruited physician's practice, the 75 percent test in the preceding sentence will be satisfied if there is a reasonable expectation that the recruited physician's medical practice for the year will derive at least 75 percent of its revenues from professional services furnished to patients not seen or treated by the physician at his or her prior medical practice site during the preceding 3 years.
  - (3) The recruited physician will not be subject to the relocation requirement of this [paragraph (e)](#e), provided that he or she establishes his or her medical practice in the geographic area served by the recruiting hospital, if—
    - (i) He or she is a resident or physician who has been in practice 1 year or less;
    - (ii) He or she was employed on a full-time basis for at least 2 years immediately prior to the recruitment arrangement by one of the following (and did not maintain a private practice in addition to such full-time employment):
      - (A) A Federal or State bureau of prisons (or similar entity operating one or more correctional facilities) to serve a prison population;
      - (B) The Department of Defense or Department of Veterans Affairs to serve active or veteran military personnel and their families; or
      - (C) A facility of the Indian Health Service to serve patients who receive medical care exclusively through the Indian Health Service; or
    - (iii) The Secretary has deemed in an advisory opinion issued under section 1877(g) of the Act that the physician does not have an established medical practice that serves or could serve a significant number of patients who are or could become patients of the recruiting hospital.
  - (4) In the case of remuneration provided by a hospital to a physician either indirectly through payments made to another physician practice, or directly to a physician who joins a physician practice, the following additional conditions must be met:
    - (i) The writing in [paragraph (e)(1)](#e-1) of this section is also signed by the physician practice if the remuneration is provided indirectly to the physician through payments made to the physician practice and the physician practice does not pass directly through to the physician all of the remuneration from the hospital.
    - (ii) Except for actual costs incurred by the physician practice in recruiting the new physician, the remuneration is passed directly through to or remains with the recruited physician.
    - (iii) In the case of an income guarantee of any type made by the hospital to a recruited physician who joins a physician practice, the costs allocated by the physician practice to the recruited physician do not exceed the actual additional incremental costs attributable to the recruited physician. With respect to a physician recruited to join a physician practice located in a rural area or HPSA, if the physician is recruited to replace a physician who, within the previous 12-month period, retired, relocated outside of the geographic area served by the hospital, or died, the costs allocated by the physician practice to the recruited physician do not exceed either—
      - (A) The actual additional incremental costs attributable to the recruited physician; or
      - (B) **The lower of a <I>per capita</I> allocation or 20 percent of the practice's aggregate costs.**
    - (iv) Records of the actual costs and the passed-through amounts are maintained for a period of at least 6 years and made available to the Secretary upon request.
    - (v) The remuneration from the hospital under the arrangement is not determined in any manner that takes into account the volume or value of actual or anticipated referrals by the recruited physician or the physician practice (or any physician affiliated with the physician practice) receiving the direct payments from the hospital.
    - (vi) The physician practice may not impose on the recruited physician practice restrictions that unreasonably restrict the recruited physician's ability to practice medicine in the geographic area served by the hospital.
  - (5) Recruitment of a physician by a hospital located in a rural area (as defined at [§ 411.351](/cfr/42/411.351.md)) to an area outside the geographic area served by the hospital is permitted under this exception if the Secretary determines in an advisory opinion issued under section 1877(g) of the Act that the area has a demonstrated need for the recruited physician and all other requirements of this [paragraph (e)](#e) are met.
  - (6)
    - (i) This [paragraph (e)](#e) applies to remuneration provided by a federally qualified health center, rural health clinic, or rural emergency hospital in the same manner as it applies to remuneration provided by a hospital.
    - (ii) The “geographic area served” by a federally qualified health center, rural health clinic, or rural emergency hospital is the area composed of the lowest number of contiguous or noncontiguous zip codes from which the federally qualified health center, rural health clinic, or rural emergency hospital draws at least 90 percent of its patients, as determined on an encounter basis. The geographic area served by the federally qualified health center, rural health clinic, or rural emergency hospital may include one or more zip codes from which the federally qualified health center, rural health clinic, or rural emergency hospital draws no patients, provided that such zip codes are entirely surrounded by zip codes in the geographic area described in the preceding sentence from which the federally qualified health center, rural health clinic, or rural emergency hospital draws at least 90 percent of its patients.
- (f) **Isolated transactions.** Isolated financial transactions, such as a one-time sale of property or a practice, or a single instance of forgiveness of an amount owed in settlement of a bona fide dispute, if all of the following conditions are met:
  - (1) **The amount of remuneration under the isolated financial transaction is—**
    - (i) Consistent with the fair market value of the isolated financial transaction; and
    - (ii) Not determined in any manner that takes into account the volume or value of referrals by the referring physician or other business generated between the parties.
  - (2) The remuneration is provided under an arrangement that would be commercially reasonable even if the physician made no referrals to the entity.
  - (3) There are no additional transactions between the parties for 6 months after the isolated transaction, except for transactions that are specifically excepted under the other provisions in [§§ 411.355 through 411.357](/cfr/42/411.355..411.357.md) and except for commercially reasonable post-closing adjustments that do not take into account the volume or value of referrals or other business generated by the referring physician.
  - (4) An isolated financial transaction that is an instance of forgiveness of an amount owed in settlement of a bona fide dispute is not part of the compensation arrangement giving rise to the bona fide dispute.
- (g) **Certain arrangements with hospitals.** Remuneration provided by a hospital to a physician if the remuneration does not relate, directly or indirectly, to the furnishing of DHS. To qualify as “unrelated,” remuneration must be wholly unrelated to the furnishing of DHS and must not in any way take into account the volume or value of a physician's referrals. Remuneration relates to the furnishing of DHS if it—
  - (1) Is an item, service, or cost that could be allocated in whole or in part to Medicare or Medicaid under cost reporting principles;
  - (2) Is furnished, directly or indirectly, explicitly or implicitly, in a selective, targeted, preferential, or conditioned manner to medical staff or other persons in a position to make or influence referrals; or
  - (3) Otherwise takes into account the volume or value of referrals or other business generated by the referring physician.
- (h) **Group practice arrangements with a hospital.** An arrangement between a hospital and a group practice under which DHS are furnished by the group but are billed by the hospital if the following conditions are met:
  - (1) With respect to services furnished to an inpatient of the hospital, the arrangement is pursuant to the provision of inpatient hospital services under [section 1861(b)(3)](/cfr/42/1861.md?p=b-3) of the Act.
  - (2) The arrangement began before, and has continued in effect without interruption since, December 19, 1989.
  - (3) With respect to the DHS covered under the arrangement, at least 75 percent of these services furnished to patients of the hospital are furnished by the group under the arrangement.
  - (4) The arrangement is in accordance with a written agreement that specifies the services to be furnished by the parties and the compensation for services furnished under the agreement.
  - (5) The compensation paid over the term of the agreement is consistent with fair market value, and the compensation per unit of service is fixed in advance and is not determined in any manner that takes into account the volume or value of referrals or other business generated between the parties.
  - (6) The compensation is provided in accordance with an agreement that would be commercially reasonable even if no referrals were made to the entity.
  - (7) If remuneration to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the arrangement satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
    - (i) **Payments by a physician.** Payments made by a physician (or his or her immediate family member)—
  - (1) To a laboratory in exchange for the provision of clinical laboratory services; or
  - (2) **To an entity as compensation for any other items or services—**
    - (i) That are furnished at a price that is consistent with fair market value; and
    - (ii) **To which the exceptions in paragraphs (a) through (h) of this section are not applicable.**
  - (3) For purposes of this paragraph (i), “services” means services of any kind (not merely those defined as “services” for purposes of the Medicare program in [§ 400.202](/cfr/42/400.202.md) of this chapter).
- (j) **Charitable donations by a physician. Bona fide—** charitable donations made by a physician (or immediate family member) to an entity if all of the following conditions are satisfied:
  - (1) The charitable donation is made to an organization exempt from taxation under the Internal Revenue Code (or to a supporting organization);
  - (2) The donation is neither solicited, nor offered, in any manner that takes into account the volume or value of referrals or other business generated between the physician and the entity; and
- (k) **Nonmonetary compensation.**
  - (1) Compensation from an entity in the form of items or services (not including cash or cash equivalents) that does not exceed an aggregate of $300 per calendar year, as adjusted for inflation in accordance with [paragraph (k)(2)](#k-2) of this section, if all of the following conditions are satisfied:
    - (i) The compensation is not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician.
    - (ii) The compensation may not be solicited by the physician or the physician's practice (including employees and staff members).
  - (2) The annual aggregate nonmonetary compensation limit in this [paragraph (k)](#k) is adjusted each calendar year to the nearest whole dollar by the increase in the Consumer Price Index—Urban All Items (CPI-U) for the 12-month period ending the preceding September 30. CMS displays after September 30 each year both the increase in the CPI-U for the 12-month period and the new nonmonetary compensation limit on the physician self-referral website at http://www.cms.hhs.gov/PhysicianSelfReferral/10_CPI-U_Updates.asp.
  - (3) Where an entity has inadvertently provided nonmonetary compensation to a physician in excess of the limit (as set forth in [paragraph (k)(1)](#k-1) of this section), such compensation is deemed to be within the limit if—
    - (i) The value of the excess nonmonetary compensation is no more than 50 percent of the limit; and
    - (ii) The physician returns to the entity the excess nonmonetary compensation (or an amount equal to the value of the excess nonmonetary compensation) by the end of the calendar year in which the excess nonmonetary compensation was received or within 180 consecutive calendar days following the date the excess nonmonetary compensation was received by the physician, whichever is earlier.
    - (iii) This [paragraph (k)(3)](#k-3) may be used by an entity only once every 3 years with respect to the same referring physician.
  - (4) In addition to nonmonetary compensation up to the limit described in [paragraph (k)(1)](#k-1) of this section, an entity that has a formal medical staff may provide one local medical staff appreciation event per year for the entire medical staff. Any gifts or gratuities provided in connection with the medical staff appreciation event are subject to the limit in [paragraph (k)(1)](#k-1).
- (l) **Fair market value compensation.** Compensation resulting from an arrangement between an entity and a physician (or an immediate family member) or any group of physicians (regardless of whether the group meets the definition of a group practice set forth in [§ 411.352](/cfr/42/411.352.md)) for the provision of items or services or for the lease of office space or equipment by the physician (or an immediate family member) or group of physicians to the entity, or by the entity to the physician (or an immediate family member) or a group of physicians, if the arrangement meets the following conditions:
  - (1) The arrangement is in writing, signed by the parties, and covers only identifiable items, services, office space, or equipment. The writing specifies—
    - (i) The items, services, office space, or equipment covered under the arrangement;
    - (ii) The compensation that will be provided under the arrangement; and
    - (iii) **The timeframe for the arrangement.**
  - (2) An arrangement may be for any period of time and contain a termination clause. An arrangement may be renewed any number of times if the terms of the arrangement and the compensation for the same items, services, office space, or equipment do not change. Other than an arrangement that satisfies all of the conditions of [paragraph (z)](#z) of this section, the parties may not enter into more than one arrangement for the same items, services, office space, or equipment during the course of a year.
  - (3) The compensation must be set in advance, consistent with fair market value, and not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician. Compensation for the rental of office space or equipment may not be determined using a formula based on—
    - (i) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated in the office space or to the services performed on or business generated through the use of the equipment; or
    - (ii) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
  - (4) **The arrangement would be commercially reasonable even if no referrals were made between the parties.**
  - (5) **The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act).**
  - (6) The services to be performed under the arrangement do not involve the counseling or promotion of a business arrangement or other activity that violates a Federal or State law.
  - (7) The arrangement satisfies the requirements of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4) in the case of—
    - (i) Remuneration to the physician that is conditioned on the physician's referrals to a particular provider, practitioner, or supplier; or
    - (ii) Remuneration paid to the group of physicians that is conditioned on one or more of the group's physicians' referrals to a particular provider, practitioner, or supplier.
- (m) **Medical staff incidental benefits.** Compensation in the form of items or services (not including cash or cash equivalents) from a hospital to a member of its medical staff when the item or service is used on the hospital's campus, if all of the following conditions are met:
  - (1) The compensation is offered to all members of the medical staff practicing in the same specialty (but not necessarily accepted by every member to whom it is offered) and is not offered in any manner that takes into account the volume or value of referrals or other business generated between the parties.
  - (2) Except with respect to identification of medical staff on a hospital website or in hospital advertising, the compensation is provided only during periods when the medical staff members are making rounds or are engaged in other services or activities that benefit the hospital or its patients.
  - (3) The compensation is provided by the hospital and used by the medical staff members only on the hospital's campus. Compensation, including, but not limited to, internet access, pagers, or two-way radios, used away from the campus only to access hospital medical records or information or to access patients or personnel who are on the hospital campus, as well as the identification of the medical staff on a hospital website or in hospital advertising, meets the “on campus” requirement of this [paragraph (m)](#m).
  - (4) The compensation is reasonably related to the provision of, or designed to facilitate directly or indirectly the delivery of, medical services at the hospital.
  - (5) The compensation is of low value (that is, less than $25) with respect to each occurrence of the benefit (for example, each meal given to a physician while he or she is serving patients who are hospitalized must be of low value). The $25 limit in this [paragraph (m)(5)](#m-5) is adjusted each calendar year to the nearest whole dollar by the increase in the Consumer Price Index—Urban All Items (CPI-I) for the 12 month period ending the preceding September 30. CMS displays after September 30 each year both the increase in the CPI-I for the 12 month period and the new limits on the physician self-referral website at http://www.cms.hhs.gov/PhysicianSelfReferral/10_CPI-U_Updates.asp.
  - (6) The compensation is not determined in any manner that takes into account the volume or value of referrals or other business generated between the parties.
  - (7) [Reserved]
  - (8) Other facilities and health care clinics (including, but not limited to, federally qualified health centers) that have bona fide medical staffs may provide compensation under this [paragraph (m)](#m) on the same terms and conditions applied to hospitals under this [paragraph (m)](#m).
- (n) **Risk-sharing arrangements.** Compensation paid directly or indirectly by a MCO or an IPA to a physician pursuant to a risk-sharing arrangement (including, but not limited to, withholds, bonuses, and risk pools) for services provided by the physician to enrollees of a health plan. For purposes of this [paragraph (n)](#n), “health plan” and “enrollees” have the meanings set forth in [§ 1001.952(l)](/cfr/42/1001.952.md?p=l) of this title.
- (o) **Compliance training.** Compliance training provided by an entity to a physician (or to the physician's immediate family member or office staff) who practices in the entity's local community or service area, provided that the training is held in the local community or service area. For purposes of this [paragraph (o)](#o), “compliance training” means training regarding the basic elements of a compliance program (for example, establishing policies and procedures, training of staff, internal monitoring, or reporting); specific training regarding the requirements of Federal and State health care programs (for example, billing, coding, reasonable and necessary services, documentation, or unlawful referral arrangements); or training regarding other Federal, State, or local laws, regulations, or rules governing the conduct of the party for whom the training is provided. For purposes of this paragraph, “compliance training” includes programs that offer continuing medical education credit, provided that compliance training is the primary purpose of the program.
- (p) **Indirect compensation arrangements.** Indirect compensation arrangements, as defined at [§ 411.354(c)(2)](/cfr/42/411.354.md?p=c-2), if all of the following conditions are satisfied:
  - (1)
    - (i) The compensation received by the referring physician (or immediate family member) described in [§ 411.354(c)(2)(ii)](/cfr/42/411.354.md?p=c-2-ii) is fair market value for services and items actually provided and not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician for the entity furnishing DHS.
    - (ii) Compensation for the rental of office space or equipment may not be determined using a formula based on—
      - (A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated in the office space or to the services performed on or business generated through the use of the equipment; or
      - (B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
  - (2) The compensation arrangement described in [§ 411.354(c)(2)(ii)](/cfr/42/411.354.md?p=c-2-ii) is set out in writing, signed by the parties, and specifies the services covered by the arrangement, except in the case of a bona fide employment relationship between an employer and an employee, in which case the arrangement need not be set out in writing, but must be for identifiable services and be commercially reasonable even if no referrals are made to the employer.
  - (3) [Reserved]
  - (4) If remuneration to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the compensation arrangement described in [§ 411.354(c)(2)(ii)](/cfr/42/411.354.md?p=c-2-ii) satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
- (q) **Referral services.** Remuneration that meets all of the conditions set forth in [§ 1001.952(f)](/cfr/42/1001.952.md?p=f) of this title.
- (r) **Obstetrical malpractice insurance subsidies.** Remuneration that meets all of the conditions of paragraph [(r)(1)](#r-1) or [(2)](#r-2) of this section.
  - (1) Remuneration that meets all of the conditions set forth in [§ 1001.952(o)](/cfr/42/1001.952.md?p=o) of this title.
  - (2) A payment from a hospital, federally qualified health center, rural health clinic, or rural emergency hospital that is used to pay for some or all of the costs of malpractice insurance premiums for a physician who engages in obstetrical practice as a routine part of his or her medical practice, if all of the following conditions are met:
    - (i)
      - (A) The physician's medical practice is located in a rural area, a primary care HPSA, or an area with demonstrated need for the physician's obstetrical services as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
      - (B) At least 75 percent of the physician's obstetrical patients reside in a medically underserved area or are members of a medically underserved population.
    - (ii) The arrangement is set out in writing, is signed by the physician and the hospital, federally qualified health center, rural health clinic, or rural emergency hospital providing the payment, and specifies the payment to be made by the hospital, federally qualified health center, rural health clinic, or rural emergency hospital and the terms under which the payment is to be provided.
    - (iii) The arrangement is not conditioned on the physician's referral of patients to the hospital, federally qualified health center, rural health clinic, or rural emergency hospital providing the payment.
    - (iv) The hospital, federally qualified health center, rural health clinic, or rural emergency hospital does not determine the amount of the payment in any manner that takes into account the volume or value of referrals by the physician or any other business generated between the parties.
    - (v) The physician is allowed to establish staff privileges at any hospital(s), federally qualified health center(s), rural health clinic(s), or rural emergency hospital(s) and to refer business to any other entities (except as referrals may be restricted under an employment arrangement or services arrangement that complies with [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4)).
    - (vi) The payment is made to a person or organization (other than the physician) that is providing malpractice insurance (including a self-funded organization).
    - (vii) The physician treats obstetrical patients who receive medical benefits or assistance under any Federal health care program in a nondiscriminatory manner.
    - (viii) The insurance is a bona fide malpractice insurance policy or program, and the premium, if any, is calculated based on a bona fide assessment of the liability risk covered under the insurance.
    - (ix)
      - (A) For each coverage period (not to exceed 1 year), at least 75 percent of the physician's obstetrical patients treated under the coverage of the obstetrical malpractice insurance during the prior period (not to exceed 1 year)—

        (1) Resided in a rural area, HPSA, medically underserved area, or an area with a demonstrated need for the physician's obstetrical services as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or

        (2) Were part of a medically underserved population.

      - (B) For the initial coverage period (not to exceed 1 year), the requirements of [paragraph (r)(2)(ix)(A)](#r-2-ix-A) of this section will be satisfied if the physician certifies that he or she has a reasonable expectation that at least 75 percent of the physician's obstetrical patients treated under the coverage of the malpractice insurance will—

        (1) Reside in a rural area, HPSA, medically underserved area, or an area with a demonstrated need for the physician's obstetrical services as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or

        (2) Be part of a medically underserved population.

  - (3) For purposes of [paragraph (r)(2)](#r-2) of this section, costs of malpractice insurance premiums means:
    - (i) For physicians who engage in obstetrical practice on a full-time basis, any costs attributable to malpractice insurance; or
    - (ii) For physicians who engage in obstetrical practice on a part-time or sporadic basis, the costs attributable exclusively to the obstetrical portion of the physician's malpractice insurance, and related exclusively to obstetrical services provided—
      - (A) In a rural area, primary care HPSA, or an area with demonstrated need for the physician's obstetrical services, as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
      - (B) In any area, provided that at least 75 percent of the physician's obstetrical patients treated in the coverage period (not to exceed 1 year) resided in a medically underserved area or were part of a medically underserved population.
- (s) **Professional courtesy.** Professional courtesy (as defined at [§ 411.351](/cfr/42/411.351.md)) offered by an entity with a formal medical staff to a physician or a physician's immediate family member or office staff if all of the following conditions are met:
  - (1) The professional courtesy is offered to all physicians on the entity's bona fide medical staff or in such entity's local community or service area, and the offer does not take into account the volume or value of referrals or other business generated between the parties;
  - (2) The health care items and services provided are of a type routinely provided by the entity;
  - (3) The entity has a professional courtesy policy that is set out in writing and approved in advance by the entity's governing body; and
  - (4) The professional courtesy is not offered to a physician (or immediate family member) who is a Federal health care program beneficiary, unless there has been a good faith showing of financial need.
- (t) **Retention payments in underserved areas—**
  - (1) **Bona fide written offer.** Remuneration provided by a hospital directly to a physician on the hospital's medical staff to retain the physician's medical practice in the geographic area served by the hospital (as defined in [paragraph (e)(2)](#e-2) of this section), if all of the following conditions are met:
    - (i) The physician has a bona fide firm, written recruitment offer or offer of employment from a hospital, academic medical center (as defined at [§ 411.355(e)](/cfr/42/411.355.md?p=e)), or physician organization (as defined at [§ 411.351](/cfr/42/411.351.md)) that is not related to the hospital making the payment, and the offer specifies the remuneration being offered and requires the physician to move the location of his or her medical practice at least 25 miles and outside of the geographic area served by the hospital making the retention payment.
    - (ii) **The requirements of paragraphs (e)(1)(i) through (iv) of this section are satisfied.**
    - (iii) Any retention payment is subject to the same obligations and restrictions, if any, on repayment or forgiveness of indebtedness as the written recruitment offer or offer of employment.
    - (iv) **The retention payment does not exceed the lower of—**
      - (A) The amount obtained by subtracting the physician's current income from physician and related services from the income the physician would receive from comparable physician and related services in the written recruitment or employment offer, provided that the respective incomes are determined using a reasonable and consistent methodology, and that they are calculated uniformly over no more than a 24-month period; or
      - (B) The reasonable costs the hospital would otherwise have to expend to recruit a new physician to the geographic area served by the hospital to join the medical staff of the hospital to replace the retained physician.
    - (v) **The requirements of paragraph (t)(3) of this setion are satisfied.**
  - (2) **Written certification from physician.** Remuneration provided by a hospital directly to a physician on the hospital's medical staff to retain the physician's medical practice in the geographic area served by the hospital (as defined in [paragraph (e)(2)](#e-2) of this section), if all of the following conditions are met:
    - (i) The physician furnishes to the hospital before the retention payment is made a written certification that the physician has a bona fide opportunity for future employment by a hospital, academic medical center (as defined at [§ 411.355(e)](/cfr/42/411.355.md?p=e)), or physician organization (as defined at [§ 411.351](/cfr/42/411.351.md)) that requires the physician to move the location of his or her medical practice at least 25 miles and outside the geographic area served by the hospital. The certification contains at least the following—
      - (A) Details regarding the steps taken by the physician to effectuate the employment opportunity;
      - (B) Details of the physician's employment opportunity, including the identity and location of the physician's future employer or employment location or both, and the anticipated income and benefits (or a range for income and benefits);
      - (C) A statement that the future employer is not related to the hospital making the payment;
      - (D) The date on which the physician anticipates relocating his or her medical practice outside of the geographic area served by the hospital; and
      - (E) Information sufficient for the hospital to verify the information included in the written certification.
    - (ii) The hospital takes reasonable steps to verify that the physician has a bona fide opportunity for future employment that requires the physician to relocate outside the geographic area served by the hospital.
    - (iii) **The requirements of paragraphs (e)(1)(i) through (iv) of this section are satisfied.**
    - (iv) **The retention payment does not exceed the lower of—**
      - (A) An amount equal to 25 percent of the physician's current annual income (averaged over the previous 24 months), using a reasonable and consistent methodology that is calculated uniformly; or
      - (B) The reasonable costs the hospital would otherwise have to expend to recruit a new physician to the geographic area served by the hospital to join the medical staff of the hospital to replace the retained physician.
    - (v) **The requirements of paragraph (t)(3) of this section are satisfied.**
  - (3) **Additional requirements.** Remuneration provided under paragraph [(t)(1)](#t-1) or [(2)](#t-2) of this section must meet the following additional requirements:
    - (i)
      - (A) The physician's current medical practice is located in a rural area or HPSA (regardless of the physician's specialty) or is located in an area with demonstrated need for the physician as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
      - (B) At least 75 percent of the physician's patients reside in a medically underserved area or are members of a medically underserved population.
    - (ii) The hospital does not enter into a retention arrangement with a particular referring physician more frequently than once every 5 years.
    - (iii) The amount and terms of the retention payment are not altered during the term of the arrangement in any manner that takes into account the volume or value of referrals or other business generated by the physician.
  - (4) **Waiver of relocation requirement.** The Secretary may waive the relocation requirement of paragraphs [(t)(1)](#t-1) and [(t)(2)](#t-2) of this section for payments made to physicians practicing in a HPSA or an area with demonstrated need for the physician through an advisory opinion issued in accordance with section 1877(g)(6) of the Act, if the retention payment arrangement otherwise complies with all of the conditions of this [paragraph (t)](#t).
  - (5) **Application to other entities.** This [paragraph (t)](#t) applies to remuneration provided by a federally qualified health center, rural health clinic, or rural emergency hospital in the same manner as it applies to remuneration provided by a hospital. For purposes of this [paragraph (t)](#t), the geographic area served by a federally qualified health center, rural health clinic, or rural emergency hospital has the meaning set forth in [paragraph (e)(6)(ii)](#e-6-ii) of this section.
- (u) **Community-wide health information systems.** Items or services of information technology provided by an entity to a physician that allow access to, and sharing of, electronic health care records and any complementary drug information systems, general health information, medical alerts, and related information for patients served by community providers and practitioners, in order to enhance the community's overall health, provided that—
  - (1) The items or services are available as necessary to enable the physician to participate in a community-wide health information system, are principally used by the physician as part of the community-wide health information system, and are not provided to the physician in any manner that takes into account the volume or value of referrals or other business generated by the physician;
  - (2) The community-wide health information systems are available to all providers, practitioners, and residents of the community who desire to participate; and
    - (v) **Electronic prescribing items and services.** Nonmonetary remuneration (consisting of items and services in the form of hardware, software, or information technology and training services) necessary and used solely to receive and transmit electronic prescription information, if all of the following conditions are met:
  - (1) **The items and services are provided by a—**
    - (i) Hospital or rural emergency hospital to a physician who is a member of its medical staff;
    - (ii) Group practice (as defined at [§ 411.352](/cfr/42/411.352.md)) to a physician who is a member of the group (as defined at [§ 411.351](/cfr/42/411.351.md)); or
    - (iii) **PDP sponsor or MA organization to a prescribing physician.**
  - (2) The items and services are provided as part of, or are used to access, an electronic prescription drug program that meets the applicable standards under Medicare Part D at the time the items and services are provided.
  - (3) The donor (or any person on the donor's behalf) does not take any action to limit or restrict the use or compatibility of the items or services with other electronic prescribing or electronic health records systems.
  - (4) For items or services that are of the type that can be used for any patient without regard to payer status, the donor does not restrict, or take any action to limit, the physician's right or ability to use the items or services for any patient.
  - (5) Neither the physician nor the physician's practice (including employees and staff members) makes the receipt of items or services, or the amount or nature of the items or services, a condition of doing business with the donor.
  - (6) Neither the eligibility of a physician for the items or services, nor the amount or nature of the items or services, is determined in a manner that takes into account the volume or value of referrals or other business generated between the parties.
  - (7) **The arrangement is set forth in a written agreement that—**
    - (i) Is signed by the parties;
    - (ii) Specifies the items and services being provided and the donor's cost of the items and services; and
    - (iii) **Covers all of the electronic prescribing items and services to be provided by the donor.** This requirement is met if all separate agreements between the donor and the physician (and the donor and any family members of the physician) incorporate each other by reference or if they cross-reference a master list of agreements that is maintained and updated centrally and is available for review by the Secretary upon request. The master list must be maintained in a manner that preserves the historical record of agreements.
  - (8) The donor does not have actual knowledge of, and does not act in reckless disregard or deliberate ignorance of, the fact that the physician possesses or has obtained items or services equivalent to those provided by the donor.
- (w) **Electronic health records items and services.** Nonmonetary remuneration (consisting of items and services in the form of software or information technology and training services, including cybersecurity software and services) necessary and used predominantly to create, maintain, transmit, receive, or protect electronic health records, if all of the following conditions are met:
  - (1) The items and services are provided to a physician by an entity (as defined at [§ 411.351](/cfr/42/411.351.md)) that is not a laboratory company.
  - (2) The software is interoperable (as defined at [§ 411.351](/cfr/42/411.351.md)) at the time it is provided to the physician. For purposes of this [paragraph (w)](#w), software is deemed to be interoperable if, on the date it is provided to the physician, it is certified by a certifying body authorized by the National Coordinator for Health Information Technology to certification criteria identified in the then-applicable version of [45 CFR part 170](/cfr/45/part170.md).
  - (3) [Reserved]
  - (4)
    - (i) Before receipt of the initial donation of items and services or the donation of replacement items and services, the physician pays 15 percent of the donor's cost for the items and services.
    - (ii) Except as provided in [paragraph (w)(4)(i)](#w-4-i) of this section, with respect to items and services received from the donor after the initial donation of items and services or the donation of replacement items and services, the physician pays 15 percent of the donor's cost for the items and services at reasonable intervals.
    - (iii) The donor (or any party related to the donor) does not finance the physician's payment or loan funds to be used by the physician to pay for the items and services.
  - (5) Neither the physician nor the physician's practice (including employees and staff members) makes the receipt of items or services, or the amount or nature of the items or services, a condition of doing business with the donor.
  - (6) Neither the eligibility of a physician for the items or services, nor the amount or nature of the items or services, is determined in any manner that directly takes into account the volume or value of referrals or other business generated between the parties. For purposes of this [paragraph (w)](#w), the determination is deemed not to directly take into account the volume or value of referrals or other business generated between the parties if any one of the following conditions is met:
    - (i) The determination is based on the total number of prescriptions written by the physician (but not the volume or value of prescriptions dispensed or paid by the donor or billed to the program);
    - (ii) The determination is based on the size of the physician's medical practice (for example, total patients, total patient encounters, or total relative value units);
    - (iii) The determination is based on the total number of hours that the physician practices medicine;
    - (iv) The determination is based on the physician's overall use of automated technology in his or her medical practice (without specific reference to the use of technology in connection with referrals made to the donor);
    - (v) The determination is based on whether the physician is a member of the donor's medical staff, if the donor has a formal medical staff;
    - (vi) The determination is based on the level of uncompensated care provided by the physician; or
    - (vii) The determination is made in any reasonable and verifiable manner that does not directly take into account the volume or value of referrals or other business generated between the parties.
  - (7) **The arrangement is set forth in a written agreement that—**
    - (i) Is signed by the parties;
    - (ii) Specifies the items and services being provided, the donor's cost of the items and services, and the amount of the physician's contribution; and
    - (iii) **Covers all of the electronic health records items and services to be provided by the donor.** This requirement is met if all separate agreements between the donor and the physician (and the donor and any family members of the physician) incorporate each other by reference or if they cross-reference a master list of agreements that is maintained and updated centrally and is available for review by the Secretary upon request. The master list must be maintained in a manner that preserves the historical record of agreements.
  - (8) [Reserved]
  - (9) For items or services that are of the type that can be used for any patient without regard to payer status, the donor does not restrict, or take any action to limit, the physician's right or ability to use the items or services for any patient.
  - (10) The items and services do not include staffing of physician offices and are not used primarily to conduct personal business or business unrelated to the physician's medical practice.
    - (x) **Assistance to compensate a nonphysician practitioner.**
  - (1) Remuneration provided by a hospital to a physician to compensate a nonphysician practitioner to provide NPP patient care services, if all of the following conditions are met:
    - (i) **The arrangement—**
      - (A) Is set out in writing and signed by the hospital, the physician, and the nonphysician practitioner; and
      - (B) Commences before the physician (or the physician organization in whose shoes the physician stands under [§ 411.354(c)](/cfr/42/411.354.md?p=c)) enters into the compensation arrangement described in paragraph (x)(1)(vi)(A) of this section.
    - (ii) **The arrangement is not conditioned on—**
      - (A) The physician's referrals to the hospital; or
      - (B) **The nonphysician practitioner's NPP referrals to the hospital.**
    - (iii) **The remuneration from the hospital—**
      - (A) Does not exceed 50 percent of the actual compensation, signing bonus, and benefits paid by the physician to the nonphysician practitioner during a period not to exceed the first 2 consecutive years of the compensation arrangement between the nonphysician practitioner and the physician (or the physician organization in whose shoes the physician stands); and
      - (B) Is not determined in any manner that takes into account the volume or value of actual or anticipated referrals by—

        (1) Referrals by the physician (or any physician in the physician's practice) or other business generated between the parties; or

        (2) NPP referrals by the nonphysician practitioner (or any nonphysician practitioner in the physician's practice) or other business generated between the parties.

    - (iv) The compensation, signing bonus, and benefits paid to the nonphysician practitioner by the physician does not exceed fair market value for the NPP patient care services furnished by the nonphysician practitioner to patients of the physician's practice.
    - (v) The nonphysician practitioner has not, within 1 year of the commencement of his or her compensation arrangement with the physician (or the physician organization in whose shoes the physician stands under [§ 411.354(c)](/cfr/42/411.354.md?p=c))—
      - (A) Furnished NPP patient care services in the geographic area served by the hospital; or
      - (B) Been employed or otherwise engaged to provide NPP patient care services by a physician or a physician organization that has a medical practice site located in the geographic area served by the hospital, regardless of whether the nonphysician practitioner furnished NPP patient care services at the medical practice site located in the geographic area served by the hospital.
    - (vi)
      - (A) The nonphysician practitioner has a compensation arrangement directly with the physician or the physician organization in whose shoes the physician stands under [§ 411.354(c)](/cfr/42/411.354.md?p=c); and
      - (B) Substantially all of the NPP patient care services that the nonphysician practitioner furnishes to patients of the physician's practice are primary care services or mental health care services.
    - (vii) The physician does not impose practice restrictions on the nonphysician practitioner that unreasonably restrict the nonphysician practitioner's ability to provide NPP patient care services in the geographic area served by the hospital.
  - (2) Records of the actual amount of remuneration provided under paragraph (x)(1) of this section by the hospital to the physician, and by the physician to the nonphysician practitioner, must be maintained for a period of at least 6 years and made available to the Secretary upon request.
  - (3) For purposes of this paragraph (x), “nonphysician practitioner” means a physician assistant as defined in section 1861(aa)(5) of the Act, a nurse practitioner or clinical nurse specialist as defined in section 1861(aa)(5) of the Act, a certified nurse-midwife as defined in section 1861(gg) of the Act, a clinical social worker as defined in section 1861(hh) of the Act, or a clinical psychologist as defined at [§ 410.71(d)](/cfr/42/410.71.md?p=d) of this subchapter.
  - (4) **For purposes of this paragraph (x), the following terms have the meanings indicated.**
    - (i) “NPP patient care services” means direct patient care services furnished by a nonphysician practitioner that address the medical needs of specific patients or any task performed by a nonphysician practitioner that promotes the care of patients of the physician or physician organization with which the nonphysician practitioner has a compensation arrangement.
    - (ii) “NPP referral” means a request by a nonphysician practitioner that includes the provision of any designated health service for which payment may be made under Medicare, the establishment of any plan of care by a nonphysician practitioner that includes the provision of such a designated health service, or the certifying or recertifying of the need for such a designated health service, but does not include any designated health service personally performed or provided by the nonphysician practitioner.
  - (5) For purposes of paragraph (x)(1) of this section, “geographic area served by the hospital” has the meaning set forth in [paragraph (e)(2)](#e-2) of this section.
  - (6) For purposes of paragraph (x)(1) of this section, a “compensation arrangement” between a physician (or the physician organization in whose shoes the physician stands under [§ 411.354(c)](/cfr/42/411.354.md?p=c)) and a nonphysician practitioner—
    - (i) Means an employment, contractual, or other arrangement under which remuneration passes between the parties; and
    - (ii) Does not include a nonphysician practitioner's ownership or investment interest in a physician organization.
  - (7)
    - (i) This paragraph (x) may be used by a hospital, federally qualified health center, rural health clinic, or rural emergency hospital only once every 3 years with respect to the same referring physician.
    - (ii) Paragraph (x)(7)(i) of this section does not apply to remuneration provided by a hospital, federally qualified health center, rural health clinic, or rural emergency hospital to a physician to compensate a nonphysician practitioner to provide NPP patient care services if—
      - (A) The nonphysician practitioner is replacing a nonphysician practitioner who terminated his or her employment or contractual arrangement to provide NPP patient care services with the physician (or the physician organization in whose shoes the physician stands) within 1 year of the commencement of the employment or contractual arrangement; and
      - (B) The remuneration provided to the physician is provided during a period that does not exceed 2 consecutive years as measured from the commencement of the compensation arrangement between the nonphysician practitioner who is being replaced and the physician (or the physician organization in whose shoes the physician stands).
  - (8)
    - (i) This paragraph (x) applies to remuneration provided by a federally qualified health center, rural health clinic, or rural emergency hospital in the same manner as it applies to remuneration provided by a hospital.
    - (ii) The “geographic area served” by a federally qualified health center, rural health clinic, or rural emergency hospital has the meaning set forth in [paragraph (e)(6)(ii)](#e-6-ii) of this section.
- (y) **Timeshare arrangements.** Remuneration provided under an arrangement for the use of premises, equipment, personnel, items, supplies, or services if the following conditions are met:
  - (1) The arrangement is set out in writing, signed by the parties, and specifies the premises, equipment, personnel, items, supplies, and services covered by the arrangement.
  - (2) The arrangement is between a physician (or the physician organization in whose shoes the physician stands under [§ 411.354(c)](/cfr/42/411.354.md?p=c)) and—
    - (i) A hospital; or
    - (ii) **Physician organization of which the physician is not an owner, employee, or contractor.**
  - (3) **The premises, equipment, personnel, items, supplies, and services covered by the arrangement are used—**
    - (i) Predominantly for the provision of evaluation and management services to patients; and
    - (ii) **On the same schedule.**
  - (4) **The equipment covered by the arrangement is—**
    - (i) Located in the same building where the evaluation and management services are furnished;
    - (ii) Not used to furnish designated health services other than those incidental to the evaluation and management services furnished at the time of the patient's evaluation and management visit; and
    - (iii) Not advanced imaging equipment, radiation therapy equipment, or clinical or pathology laboratory equipment (other than equipment used to perform CLIA-waived laboratory tests).
  - (5) The arrangement is not conditioned on the referral of patients by the physician who is a party to the arrangement to the hospital or physician organization of which the physician is not an owner, employee, or contractor.
  - (6) The compensation over the term of the arrangement is set in advance, consistent with fair market value, and not determined—
    - (i) In any manner that takes into account the volume or value of referrals or other business generated between the parties; or
    - (ii) **Using a formula based on—**
      - (A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services provided while using the premises, equipment, personnel, items, supplies, or services covered by the arrangement; or
      - (B) Per-unit of service fees that are not time-based, to the extent that such fees reflect services provided to patients referred by the party granting permission to use the premises, equipment, personnel, items, supplies, or services covered by the arrangement to the party to which the permission is granted.
  - (7) **The arrangement would be commercially reasonable even if no referrals were made between the parties.**
  - (8) [Reserved]
  - (9) The arrangement does not convey a possessory leasehold interest in the office space that is the subject of the arrangement.
  - (10) This [paragraph (y)](#y) applies to remuneration provided by a rural emergency hospital in the same manner as it applies to remuneration provided by a hospital.
- (z) **Limited remuneration to a physician.**
  - (1) Remuneration from an entity to a physician for the provision of items or services provided by the physician to the entity that does not exceed an aggregate of $5,000 per calendar year, as adjusted for inflation in accordance with [paragraph (z)(3)](#z-3) of this section, if all of the following conditions are satisfied:
    - (i) The compensation is not determined in any manner that takes into account the volume or value of referrals or other business generated by the physician.
    - (ii) **The compensation does not exceed the fair market value of the items or services.**
    - (iii) **The arrangement would be commercially reasonable even if no referrals were made between the parties.**
    - (iv) **Compensation for the lease of office space or equipment is not determined using a formula based on—**
      - (A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated in the office space or to the services performed on or business generated through the use of the equipment; or
      - (B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
    - (v) **Compensation for the use of premises or equipment is not determined using a formula based on—**
      - (A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services provided while using the premises or equipment covered by the arrangement; or
      - (B) Per-unit of service fees that are not time-based, to the extent that such fees reflect services provided to patients referred by the party granting permission to use the premises or equipment covered by the arrangement to the party to which the permission is granted.
    - (vi) If remuneration to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the arrangement satisfies the conditions of [§ 411.354(d)(4)](/cfr/42/411.354.md?p=d-4).
  - (2) A physician may provide items or services through employees whom the physician has hired for the purpose of performing the services; through a wholly-owned entity; or through locum tenens physicians (as defined at [§ 411.351](/cfr/42/411.351.md), except that the regular physician need not be a member of a group practice).
  - (3) The annual aggregate remuneration limit in this [paragraph (z)](#z) is adjusted each calendar year to the nearest whole dollar by the increase in the Consumer Price Index—Urban All Items (CPI-U) for the 12-month period ending the preceding September 30. CMS displays after September 30 each year both the increase in the CPI-U for the 12-month period and the new remuneration limit on the physician self-referral website at http://www.cms.hhs.gov/PhysicianSelfReferral/10_CPI-U_Updates.asp.
- (aa) **Arrangements that facilitate value-based health care delivery and payment—**
  - (1) **Full financial risk—** Remuneration paid under a value-based arrangement, as defined at [§ 411.351](/cfr/42/411.351.md), if the following conditions are met:
    - (i) The value-based enterprise is at full financial risk (or is contractually obligated to be at full financial risk within the 12 months following the commencement of the value-based arrangement) during the entire duration of the value-based arrangement.
    - (ii) The remuneration is for or results from value-based activities undertaken by the recipient of the remuneration for patients in the target patient population.
    - (iii) The remuneration is not an inducement to reduce or limit medically necessary items or services to any patient.
    - (iv) The remuneration is not conditioned on referrals of patients who are not part of the target patient population or business not covered under the value-based arrangement.
    - (v) If remuneration paid to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the value-based arrangement complies with both of the following conditions:
      - (A) The requirement to make referrals to a particular provider, practitioner, or supplier is set out in writing and signed by the parties.
      - (B) The requirement to make referrals to a particular provider, practitioner, or supplier does not apply if the patient expresses a preference for a different provider, practitioner, or supplier; the patient's insurer determines the provider, practitioner, or supplier; or the referral is not in the patient's best medical interests in the physician's judgment.
    - (vi) Records of the methodology for determining and the actual amount of remuneration paid under the value-based arrangement must be maintained for a period of at least 6 years and made available to the Secretary upon request.
    - (vii) For purposes of this [paragraph (aa)](#aa), “full financial risk” means that the value-based enterprise is financially responsible on a prospective basis for the cost of all patient care items and services covered by the applicable payor for each patient in the target patient population for a specified period of time. For purposes of this [paragraph (aa)](#aa), “prospective basis” means that the value-based enterprise has assumed financial responsibility for the cost of all patient care items and services covered by the applicable payor prior to providing patient care items and services to patients in the target patient population.
  - (2) **Value-based arrangements with meaningful downside financial risk to the physician—** Remuneration paid under a value-based arrangement, as defined at [§ 411.351](/cfr/42/411.351.md), if the following conditions are met:
    - (i) The physician is at meaningful downside financial risk for failure to achieve the value-based purpose(s) of the value-based enterprise during the entire duration of the value-based arrangement.
    - (ii) A description of the nature and extent of the physician's downside financial risk is set forth in writing.
    - (iii) The methodology used to determine the amount of the remuneration is set in advance of the undertaking of value-based activities for which the remuneration is paid.
    - (iv) The remuneration is for or results from value-based activities undertaken by the recipient of the remuneration for patients in the target patient population.
    - (v) The remuneration is not an inducement to reduce or limit medically necessary items or services to any patient.
    - (vi) The remuneration is not conditioned on referrals of patients who are not part of the target patient population or business not covered under the value-based arrangement.
    - (vii) If remuneration paid to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the value-based arrangement complies with both of the following conditions:
      - (A) The requirement to make referrals to a particular provider, practitioner, or supplier is set out in writing and signed by the parties.
      - (B) The requirement to make referrals to a particular provider, practitioner, or supplier does not apply if the patient expresses a preference for a different provider, practitioner, or supplier; the patient's insurer determines the provider, practitioner, or supplier; or the referral is not in the patient's best medical interests in the physician's judgment.
    - (viii) Records of the methodology for determining and the actual amount of remuneration paid under the value-based arrangement must be maintained for a period of at least 6 years and made available to the Secretary upon request.
    - (ix) For purposes of this [paragraph (aa)](#aa), “meaningful downside financial risk” means that the physician is responsible to repay or forgo no less than 10 percent of the total value of the remuneration the physician receives under the value-based arrangement.
  - (3) **Value-based arrangements.** Remuneration paid under a value-based arrangement, as defined at [§ 411.351](/cfr/42/411.351.md), if the following conditions are met:
    - (i) **The arrangement is set forth in writing and signed by the parties.** The writing includes a description of—
      - (A) The value-based activities to be undertaken under the arrangement;
      - (B) How the value-based activities are expected to further the value-based purpose(s) of the value-based enterprise;
      - (C) The target patient population for the arrangement;
      - (D) The type or nature of the remuneration;
      - (E) The methodology used to determine the remuneration; and
      - (F) **The outcome measures against which the recipient of the remuneration is assessed, if any.**
    - (ii) The outcome measures against which the recipient of the remuneration is assessed, if any, are objective, measurable, and selected based on clinical evidence or credible medical support.
    - (iii) Any changes to the outcome measures against which the recipient of the remuneration will be assessed are made prospectively and set forth in writing.
    - (iv) The methodology used to determine the amount of the remuneration is set in advance of the undertaking of value-based activities for which the remuneration is paid.
    - (v) The remuneration is for or results from value-based activities undertaken by the recipient of the remuneration for patients in the target patient population.
    - (vi) **The arrangement is commercially reasonable.**
    - (vii)
      - (A) No less frequently than annually, or at least once during the term of the arrangement if the arrangement has a duration of less than 1 year, the value-based enterprise or one or more of the parties monitor:

        (1) Whether the parties have furnished the value-based activities required under the arrangement;

        (2) Whether and how continuation of the value-based activities is expected to further the value-based purpose(s) of the value-based enterprise; and

        (3) Progress toward attainment of the outcome measure(s), if any, against which the recipient of the remuneration is assessed.

      - (B) If the monitoring indicates that a value-based activity is not expected to further the value-based purpose(s) of the value-based enterprise, the parties must terminate the ineffective value-based activity. Following completion of monitoring that identifies an ineffective value-based activity, the value-based activity is deemed to be reasonably designed to achieve at least one value-based purpose of the value-based enterprise—

        (1) For 30 consecutive calendar days after completion of the monitoring, if the parties terminate the arrangement; or

        (2) For 90 consecutive calendar days after completion of the monitoring, if the parties modify the arrangement to terminate the ineffective value-based activity.

      - (C) If the monitoring indicates that an outcome measure is unattainable during the remaining term of the arrangement, the parties must terminate or replace the unattainable outcome measure within 90 consecutive calendar days after completion of the monitoring.
    - (viii) The remuneration is not an inducement to reduce or limit medically necessary items or services to any patient.
    - (ix) The remuneration is not conditioned on referrals of patients who are not part of the target patient population or business not covered under the value-based arrangement.
    - (x) If the remuneration paid to the physician is conditioned on the physician's referrals to a particular provider, practitioner, or supplier, the value-based arrangement complies with both of the following conditions:
      - (A) The requirement to make referrals to a particular provider, practitioner, or supplier is set out in writing and signed by the parties.
      - (B) The requirement to make referrals to a particular provider, practitioner, or supplier does not apply if the patient expresses a preference for a different provider, practitioner, or supplier; the patient's insurer determines the provider, practitioner, or supplier; or the referral is not in the patient's best medical interests in the physician's judgment.
    - (xi) Records of the methodology for determining and the actual amount of remuneration paid under the value-based arrangement must be maintained for a period of at least 6 years and made available to the Secretary upon request.
    - (xii) For purposes of this [paragraph (aa)(3)](#aa-3), “outcome measure” means a benchmark that quantifies:
      - (A) Improvements in or maintenance of the quality of patient care; or
      - (B) Reductions in the costs to or reductions in growth in expenditures of payors while maintaining or improving the quality of patient care.
- (bb) **Cybersecurity technology and related services.**
  - (1) Nonmonetary remuneration (consisting of technology and services) necessary and used predominantly to implement, maintain, or reestablish cybersecurity, if all of the following conditions are met:
    - (i) Neither the eligibility of a physician for the technology or services, nor the amount or nature of the technology or services, is determined in any manner that directly takes into account the volume or value of referrals or other business generated between the parties.
    - (ii) Neither the physician nor the physician's practice (including employees and staff members) makes the receipt of technology or services, or the amount or nature of the technology or services, a condition of doing business with the donor.
    - (iii) **The arrangement is documented in writing.**
  - (2) For purposes of this [paragraph (bb)](#bb), “technology” means any software or other types of information technology.