General Definitions Medicare & Medicaid
Title 42: Public Health
PART 400--INTRODUCTION; DEFINITIONS
Subpart B-Definitions
§ 400.200 General definitions.
In this chapter, unless the context indicates otherwise--
Act means the Social Security Act, and titles
referred to are titles of that Act.
Administrator means the Administrator, Centers for Medicare &
Medicaid Services (CMS), formerly the Health Care Financing
Administration (HCFA).
ALJ stands for administrative law judge.
Area means the geographical area within the boundaries of a State,
or a State or other jurisdiction, designated as constituting an area
with respect to which a Professional Standards Review Organization
or a Utilization and Quality Control Peer Review Organization has
been or may be designated.
CMP stands for competitive medical plan.
Conditions of participation includes requirements for participation
as the latter term is used in part 483 of this chapter.
Condition level deficiencies includes deficiencies with respect to
"level A requirements" as the latter term is used in parts 442 and
483 of this chapter.
CORF stands for comprehensive outpatient rehabilitation facility.
CFR stands for Code of Federal Regulations.
CMS stands for Centers for Medicare & Medicaid Services, formerly
the Health Care Financing Administration (HCFA).
CY stands for calendar year.
DAB stands for Departmental Appeals Board.
Department means the Department of Health and Human Services (HHS),
formerly the Department of Health, Education, and Welfare.
ESRD stands for end-stage renal disease.
FDA stands for the Food and Drug Administration.
FQHC means Federally qualified health center.
FR stands for Federal Register.
FY stands for fiscal year.
HCPP stands for health care prepayment plan.
HHS stands for the Department of Health and Human Services.
HHA stands for home health agency.
HMO stands for health maintenance organization.
ICF stands for intermediate care facility.
ICF/MR stands for intermediate care facility for the mentally
retarded.
Medicaid means medical assistance provided under a State plan
approved under title XIX of the Act.
Medicare means the health insurance program for the aged and
disabled under title XVIII of the Act.
NCD stands for national coverage determination.
OASDI stands for the Old Age, Survivors, and Disability Insurance
program under title II of the Act.
OIG stands for the Department's Office of the Inspector General.
QDWI stands for Qualified Disabled and Working Individual.
QIO stands for quality improvement organization.
QMB stands for Qualified Medicare Beneficiary.
Qualified Disabled and Working Individual means an individual who--
(1) Is eligible to enroll for Medicare Part A under section 1818A of
the Act.
(2) Has income, as determined in accordance with SSI methodologies,
that does not exceed 200 percent of the Federal poverty guidelines
(as defined and revised annually by the Office of Management and
Budget) for a family of the size of the individual's family;
(3) Has resources, as determined in accordance with SSI
methodologies, that do not exceed twice the relevant maximum amount
established, for SSI eligibility, for an individual or for an
individual and his or her spouse; and
(4) Is not otherwise eligible for Medicaid.
Qualified Medicare Beneficiary means an individual who--
(1) Is entitled to Medicare Part A, with or without payment of
premiums, but is not entitled solely because he or she is eligible
to enroll as a QDWI;
(2) Has resources, as determined in accordance with SSI
methodologies, that do not exceed twice the maximum amount
established for SSI eligibility; and
(3) Has income, as determined in accordance with SSI methodologies,
that does not exceed 100 percent of the Federal poverty guidelines.
Quality improvement organization means an organization that has a
contract with CMS, under part B of title XI of the Act, to perform
utilization and quality control review of the health care furnished,
or to be furnished, to Medicare beneficiaries.
Regional Administrator means a Regional Administrator of CMS.
Regional Office means one of the regional offices of CMS.
RHC stands for rural health clinic.
RRB stands for Railroad Retirement Board.
Secretary means the Secretary of Health and Human Services.
SNF stands for skilled nursing facility.
Social security benefits means monthly cash benefits payable under
section 202 or 223 of the Act.
SSA stands for Social Security Administration.
United States means the fifty States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands, Guam, American
Samoa, and the Northern Mariana Islands.
U.S.C. stands for United States Code.
================================================================
DEFINITIONS SPECIFIC TO MEDICARE
§ 400.202 Definitions specific to Medicare.
As used in connection with the Medicare program, unless the context
indicates otherwise--
Beneficiary means a person who is entitled to Medicare benefits.
Carrier means an entity that has a contract with CMS to determine
and make Medicare payments for Part B benefits payable on a charge
basis and to perform other related functions.
Critical access hospital (CAH) means a facility designated by HFCA
as meeting the applicable requirements of section 1820 of the Act
and of subpart F of part 485 of this chapter.
Departmental Appeals Board means: (1) Except as provided in
paragraphs (2) and (3) of this definition, a Board established in
the office of the Secretary, whose members act in panels to provide
impartial review of disputed decisions made by operating components
of the Department or by ALJs.
(2) For purposes of review of ALJ decisions under part 405, subparts
G and H; part 417, subpart Q; part 422, subpart M; and part 478,
subpart B of this chapter, the Medicare Appeals Council designated
by the Board Chair.
(3) For purposes of part 426 of this chapter, a Member of the Board
and, at the discretion of the Board Chair, any other Board staff
appointed by the Board Chair to perform a review under that part.
Entitled means that an individual meets all the requirements for
Medicare benefits.
Essential access community hospital (EACH) means a hospital
designated by CMS as meeting the applicable requirements of section
1820 of the Act and of subpart G of part 412 of this chapter, as in
effect on September 30, 1997.
GME stands for graduate medical education.
Hospital insurance benefits means payments on behalf of, and in rare
circumstances directly to, an entitled individual for services that
are covered under Part A of title XVIII of the Act.
Intermediary means an entity that has a contract with CMS to
determine and make Medicare payments for Part A or Part B benefits
payable on a cost basis and to perform other related functions.
Local coverage determination (LCD) means a decision by a fiscal
intermediary or a carrier under Medicare Part A or Part B, as
applicable, whether to cover a particular service on an
intermediary-wide or carrier-wide basis in accordance with section
1862(a)(1)(A) of the Act. An LCD may provide that a service is not
reasonable and necessary for certain diagnoses and/or for certain
diagnosis codes. An LCD does not include a determination of which
procedure code, if any, is assigned to a service or a determination
with respect to the amount of payment to be made for the service.
Medicare Part A means the hospital insurance program authorized
under Part A of title XVIII of the Act.
Medicare Part B means the supplementary medical insurance program
authorized under Part B of title XVIII of the Act.
Medicare Part C means the choice of Medicare benefits through
Medicare Advantage plans authorized under Part C of the title XVIII
of the Act.
Medicare Part D means the voluntary prescription drug benefit
program authorized under Part D of title XVIII of the Act.
National coverage determination (NCD) means a decision that CMS
makes regarding whether to cover a particular service nationally
under title XVIII of the Act. An NCD does not include a
determination of what code, if any, is assigned to a service or a
determination with respect to the amount of payment to be made for
the service.
Nonparticipating supplier means a supplier that does not have an
agreement with CMS to participate in Part B of Medicare in effect on
the date of the service.
Participating supplier means a supplier that has an agreement with
CMS to participate in Part B of Medicare in effect on the date of
the service.
Payment on an assignment-related basis means payment for Part B
services--
(1) To a physician or other supplier that accepts assignment from
the beneficiary, in accordance with §424.55 or §424.56 of this
chapter;
(2) To a physician or other supplier after the beneficiary's death,
in accordance with §424.64(c)(1) of this chapter; or
(3) To an entity that pays the physician or other supplier under a
health benefit plan, in accordance with §424.66 of this chapter.
Provider means a hospital, a CAH, a skilled nursing facility, a
comprehensive outpatient rehabilitation facility, a home health
agency, or a hospice that has in effect an agreement to participate
in Medicare, or a clinic, a rehabilitation agency, or a public
health agency that has in effect a similar agreement but only to
furnish outpatient physical therapy or speech pathology services, or
a community mental health center that has in effect a similar
agreement but only to furnish partial hospitalization services.
Railroad retirement benefits means monthly benefits payable to
individuals under the Railroad Retirement Act of 1974 (45 U.S.C.
beginning at section 231).
Services means medical care or services and items, such as medical
diagnosis and treatment, drugs and biologicals, supplies,
appliances, and equipment, medical social services, and use of
hospital, CAH, or SNF facilities.
Supplementary medical insurance benefits means payment to or on
behalf of an entitled individual for services covered under Part B
of title XVIII of the Act.
Supplier means a physician or other practitioner, or an entity other
than a provider, that furnishes health care services under Medicare.
================================================================
DEFINITIONS SPECIFIC TO MEDICAID
§ 400.203 Definitions specific to Medicaid.
As used in connection with the Medicaid program, unless the context
indicates otherwise--
Applicant means an individual whose written application for Medicaid
has been submitted to the agency determining Medicaid eligibility,
but has not received final action. This includes an individual (who
need not be alive at the time of application) whose application is
submitted through a representative or a person acting responsibly
for the individual.
Federal financial participation (FFP) means the Federal Government's
share of a State's expenditures under the Medicaid program.
FMAP stands for the Federal medical assistance percentage, which is
used to calculate the amount of Federal share of State expenditures
for services.
Medicaid agency or agency means the single State agency
administering or supervising the administration of a State Medicaid
plan.
Nursing facility (NF), effective October 1, 1990, means an SNF or an
ICF participating in the Medicaid program.
PCCM stands for primary care case manager.
PCP stands for primary care physician.
Provider means either of the following:
(1) For the fee-for-service program, any individual or entity
furnishing Medicaid services under an agreement with the Medicaid
agency.
(2) For the managed care program, any individual or entity that is
engaged in the delivery of health care services and is legally
authorized to do so by the State in which it delivers the services.
Recipient means an individual who has been determined eligible for
Medicaid.
Services means the types of medical assistance specified in section
1905(a) of the Act and defined in subpart A of part 440 of this
chapter.
State means the several States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands, Guam, American
Samoa and the Northern Mariana Islands.
State plan or the plan means a comprehensive written commitment by a
Medicaid agency, submitted under section 1902(a) of the Act, to
administer or supervise the administration of a Medicaid program in
accordance with Federal requirements.
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