---
kind: "section"
citation: "42 C.F.R. § 417.528"
title: "42"
number: "417.528"
heading: "Payment when Medicare is not primary payer."
url: "https://uscodex.org/cfr/42/417.528"
---

# §417.528. Payment when Medicare is not primary payer.

- (a) **Limits on payments and charges.**
  - (1) CMS may not pay for services to the extent that Medicare is not the primary payer under section 1862(b) of the Act and [part 411](/cfr/42/part411.md) of this chapter.
  - (2) The circumstances under which an HMO or CMP may charge, or authorize a provider to charge, for covered Medicare services for which Medicare is not the primary payer are stated in paragraphs [(b)](#b) and [(c)](#c) of this section.
- (b) **Charge to other insurers or the enrollee.** If a Medicare enrollee receives from an HMO or CMP covered services that are also covered under State or Federal worker's compensation, automobile medical, or any no-fault insurance, or any liability insurance policy or plan, including a self-insured plan, the HMO or CMP may charge, or authorize a provider that furnished the service to charge—
  - (1) The insurance carrier, employer, or other entity that is liable to pay for these services; or
  - (2) The Medicare enrollee, to the extent that he or she has been paid by the carrier, employer, or other entity.
- (c) **Charge to group health plans (GHPs) or large group health plans (LGHPs).** An HMO or CMP may charge a GHP or LGHP for covered services it furnished to a Medicare enrollee and may charge the Medicare enrollee to the extent that he or she has been paid by the GHP or LGHP for these covered services if—
  - (1) The Medicare enrollee is covered under the plan; and
  - (2) **Under section 1862(b) of the Act, CMS is precluded from paying for the covered services .**
- (d) **Responsibilities of HMO or CMP.** An HMO or CMP must—
  - (1) Identify payers that are primary to Medicare under section 1862(b) of the Act;
  - (2) Determine the amounts payable by these payers; and
  - (3) **Coordinate the benefits of its Medicare enrollees with these payers.**

## Notes

### Amendments

[50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38080, July 15, 1993; 60 FR 46229, Sept. 6, 1995]

### Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

### Amendments

[50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38080, July 15, 1993; 60 FR 46229, Sept. 6, 1995]