Part 405 Federal Health Insurance for the Aged and Disabled
Part 406 Hospital Insurance Eligibility and Entitlement
Part 407 Supplementary Medical Insurance (Smi) Enrollment and Entitlement
Part 408 Premiums for Supplementary Medical Insurance
Part 409 Hospital Insurance Benefits
Part 410 Supplementary Medical Insurance (Smi) Benefits
Part 411 Exclusions From Medicare and Limitations On Medicare Payment
Part 412 Prospective Payment Systems for Inpatient Hospital Services
Part 413 Principles of Reasonable Cost Reimbursement; Payment for End-Stage Renal Disease Services; Prospectively Determined Payment Rates for Skilled Nursing Facilities; Payment for Acute Kidney Injury Dialysis
Part 414 Payment for Part B Medical and Other Health Services
Part 415 Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings
Part 416 Ambulatory Surgical Services
Part 417 Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
Part 418 Hospice Care
Part 419 Prospective Payment System for Hospital Outpatient Department Services
Part 420 Program Integrity: Medicare
Part 421 Medicare Contracting
Part 422 Medicare Advantage Program
Part 423 Voluntary Medicare Prescription Drug Benefit
Part 424 Conditions for Medicare Payment
Part 425 Medicare Shared Savings Program
Part 426 Review of National Coverage Determinations and Local Coverage Determinations

Terms Used In CFR > Title 42 > Chapter IV > Subchapter B

  • Academic year: means the traditional approximately 9 month September to June annual session, except for students who attend summer session in addition to the traditional academic year during a 12 month period, for whom the academic year will be considered to be of approximately 12 months duration. See 42 CFR 136.302
  • Account: means a TreasuryDirect31 CFR 363.6
  • Act: means the Indian Health Care Improvement Act, Pub. See 42 CFR 136.302
  • Actual cost: means the negotiated price for a covered Part D drug when the drug is purchased at a network pharmacy, and the usual and customary price when a beneficiary purchases the drug at an out-of-network pharmacy consistent with §423. See 42 CFR 423.100
  • Actual costs: means the subset of prescription drug costs (not including administrative costs or return on investment, but including costs directly related to the dispensing of covered Part D drugs during the year) that are attributable to standard benefits only and that are incurred and actually paid by the sponsor or organization under the plan. See 42 CFR 423.855
  • Administrator: means the Administrator or Deputy Administrator of CMS. See 42 CFR 405.1801
  • Administrator review: means that review provided for in section 1878(f) of the Act (42 U. See 42 CFR 405.1801
  • Affected enrollee: means a Part D enrollee who is currently taking a covered Part D drug that is either being removed from a Part D plan's formulary, or whose preferred or tiered cost-sharing status is changing and such drug removal or cost-sharing change affects the Part D enrollee's access to the drug during the current plan year. See 42 CFR 423.100
  • Affected party: means any Part D sponsor or manufacturer (as defined in §423. See 42 CFR 423.1002
  • Affected party: means an MA organization impacted by an initial determination or if applicable, by any subsequent determination or decision issued under this part. See 42 CFR 422.1002
  • Affirmation: A person filing an affidavit under this part must affirm that "all information contained in the application is complete and correct and that the information does not contain a false claim, statement, or representation. See 25 CFR 39.118
  • Agent: means any person who has been delegated the authority to obligate or act on behalf of a provider. See 42 CFR 420.201
  • Aggregate net credit exposure: means the sum of all net credit exposures of a covered company and all of its subsidiaries to a single counterparty as calculated under this subpart. See 31 CFR 360.20
  • Aggregate net credit exposure: means the sum of all net credit exposures of a covered foreign entity and all of its subsidiaries to a single counterparty as calculated under this subpart. See 31 CFR 360.92
  • Agreement: means a collective bargaining agreement. See 42 CFR 417.150
  • Agriculture Pima Trust: means the Pima Agriculture Cotton Trust Fund. See 25 CFR 39.113
  • Agriculture Wool Trust: means the Agriculture Wool Apparel Manufacturers Trust Fund. See 25 CFR 39.118
  • Allowable costs: means costs that are incurred by a RHC or FQHC that is authorized to bill based on reasonable costs and are reasonable in amount and proper and necessary for the efficient delivery of RHC and FQHC services. See 42 CFR 405.2401
  • Alternative prescription drug coverage: means coverage of Part D drugs, other than standard prescription drug coverage that meets the requirements of §423. See 42 CFR 423.100
  • Appeal: means any of the procedures that deal with the review of adverse coverage determinations made by the Part D plan sponsor on the benefits under a Part D plan the enrollee believes he or she is entitled to receive, including delay in providing or approving the drug coverage (when a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for the drug coverage, as defined in §423. See 42 CFR 423.560
  • Appeal: means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service, as defined under §422. See 42 CFR 422.561
  • Applicable beneficiary: means an individual who, on the date of dispensing a covered Part D drug--

    (1) Is enrolled in a prescription drug plan or an MA-PD plan. See 42 CFR 423.100

  • Applicable discount: means 50 percent of the portion of the negotiated price (as defined in §423. See 42 CFR 423.2305
  • Appointed representative: means an individual either appointed by an enrollee or authorized under State or other applicable law to act on behalf of the enrollee in filing a grievance, obtaining a coverage determination, or in dealing with any of the levels of the appeals process. See 42 CFR 423.560
  • Appropriate Regional Director: means the director of the NCUA Regional Office having jurisdiction over federally insured credit unions in the state where the affected credit union is principally located or, for credit unions with $10 billion or more in assets, the Director of the Office of National Examinations and Supervision. See 43 CFR 2201.3-1
  • Appropriate State official: means the commission, board or other supervisory authority having jurisdiction over credit unions chartered by the State which chartered the affected credit union. See 43 CFR 2201.3-1
  • Approved CAP vendor: means an entity that has been awarded a contract by CMS to participate in the competitive acquisition program under 1847B of the Act. See 42 CFR 414.902
  • Assessment reference date: means the specific calendar day in the patient assessment process that sets the designated endpoint of the common patient observation period, with most patient assessment items usually referring back in time from this endpoint. See 42 CFR 412.602
  • At-risk determination: means a decision made under a plan sponsor's drug management program in accordance with §423. See 42 CFR 423.560
  • Authentication: means confirming that the person accessing a TreasuryDirect account is the same person whose identity was initially verified at account establishment. See 31 CFR 363.6
  • Authorized official: means an appointed official (for example, chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program. See 42 CFR 424.502
  • Bargaining representative: means an individual or entity designated or selected, under any applicable Federal, State, or local law, or public entity collective bargaining agreement, to represent employees in collective bargaining, or any other employee representative designated or selected under any law. See 42 CFR 417.150
  • Basic prescription drug coverage: means coverage of Part D drugs that is either standard prescription drug coverage or basic alternative coverage. See 42 CFR 423.100
  • Beneficiary: refers to the second individual named in the registration of a definitive savings bond, a converted definitive savings bond, or a book-entry security purchased through the TreasuryDirect system, registered, e. See 31 CFR 363.6
  • Beneficiary: means an individual enrolled in the Supplementary Medical Insurance program for the Aged and Disabled (part of title XVIII of the Act). See 42 CFR 405.2401
  • Bid: means an offer to furnish a CAP drug within a category of CAP drugs in a competitive acquisition area for a particular price and time period. See 42 CFR 414.902
  • Bioequivalent: has the meaning given such term in section 505(j)(8) of the Food, Drug, and Cosmetic Act. See 42 CFR 423.100
  • Board: means the Provider Reimbursement Review Board established in accordance with section 1878 of the Act (42 U. See 42 CFR 405.1801
  • Board hearing: means that hearing provided for in section 1878(a) of the Act (42 U. See 42 CFR 405.1801
  • Book-entry bond: means a Series EE savings bond maintained by Treasury solely as a computer record. See 31 CFR 351.3
  • Book-entry bond: means a savings bond maintained by Treasury in electronic or paperless form as a computer record. See 31 CFR 360.2
  • CAP drug: means a physician-administered drug or biological furnished on or after January 1, 2006 described in section 1842(o)(1)(C) of the Act and supplied by an approved CAP vendor under the CAP as provided in this subpart. See 42 CFR 414.902
  • Capitation payment: means a fixed per enrollee per month amount paid for contracted services without regard to the type, cost, or frequency of services furnished. See 42 CFR 422.350
  • Carrier: means a voluntary association, corporation, partnership, or other organization that is engaged in providing, paying for, or reimbursing all or part of the cost of health benefits under group insurance policies or contracts, medical or hospital service agreements, enrollment or subscription contracts, or similar group arrangements, in consideration of premiums or other periodic charges payable to the carrier. See 42 CFR 417.150
  • CCC: means the Commodity Credit Corporation. See 25 CFR 39.113
  • CCC: means the Commodity Credit Corporation. See 25 CFR 39.118
  • Centralized building: means all or part of a building, including, for purposes of this subpart only, a mobile vehicle, van, or trailer that is owned or leased on a full-time basis (that is, 24 hours per day, 7 days per week, for a term of not less than 6 months) by a group practice and that is used exclusively by the group practice. See 42 CFR 411.351
  • Class of Medicare enrollees: means a group of Medicare enrollees of an HMO or CMP that CMS constructs on the basis of actuarial factors. See 42 CFR 417.582
  • Clinical laboratory services: means the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings, including procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body, as specifically identified by the List of CPT/HCPCS Codes. See 42 CFR 411.351
  • Closed book period: means a period of four business days prior to the date a scheduled marketable security interest and/or maturity payment is made, during which time certain transactions will be delayed until after the closed book period is completed. See 31 CFR 363.6
  • CMS reviewing official: means the reviewing official provided for in §405. See 42 CFR 405.1801
  • CMS reviewing official procedure: means the review provided for in §405. See 42 CFR 405.1801
  • Coinsurance: means that portion of the RHC's charge for covered services or that portion of the FQHC's charge or PPS rate for covered services for which the beneficiary is liable (in addition to the deductible, where applicable). See 42 CFR 405.2401
  • Collective bargaining agreement: means an agreement entered into between an employing entity and the bargaining representative of its employees. See 42 CFR 417.150
  • Commercial book-entry system: refers to the book-entry system in which you hold your Treasury securities in a tiered system through securities intermediaries such as financial institutions or brokerage firms. See 31 CFR 363.6
  • Communication materials: means all information provided to current and prospective enrollees. See 42 CFR 423.2260
  • Communication materials: means all information provided to current and prospective enrollees. See 42 CFR 422.2260
  • Comorbidity: means a specific patient condition that is secondary to the patient's principal diagnosis that is the primary reason for the inpatient rehabilitation stay. See 42 CFR 412.602
  • Compensatory preprofessional education: means any preprofessional education necessary to compensate for deficiencies in an individual's prior education in order to enable that individual to qualify for enrollment in a health professions school. See 42 CFR 136.302
  • Competitive acquisition area: means a geographic area established by the Secretary for purposes of implementing the CAP required by section 1847B of the Act. See 42 CFR 414.902
  • Consultation: means a professional service furnished to a patient by a physician if the following conditions are satisfied:

    (1) The physician's opinion or advice regarding evaluation or management or both of a specific medical problem is requested by another physician. See 42 CFR 411.351

  • Contract: means an employer-employee or public entity-employee contract, or a contract for health benefits. See 42 CFR 417.150
  • Contracted pharmacy network: means licensed pharmacies, including retail, mail-order, and institutional pharmacies under contract with a Part D sponsor to provide covered Part D drugs at negotiated prices to Part D enrollees. See 42 CFR 423.100
  • Contractor determination: means the following:

    (1) With respect to a provider of services that has filed a cost report under §§413. See 42 CFR 405.1801

  • Contractor hearing: means that hearing provided for in §405. See 42 CFR 405.1801
  • Control: means that an individual, group of individuals, or entity has the power, directly or indirectly, to direct or influence significantly the actions or policies of an organization or institution. See 42 CFR 422.350
  • Converted savings bond: means a savings bond originally issued as a definitive bond that has been surrendered to us and converted to a book-entry savings bond to be maintained by Treasury solely as a computer record. See 31 CFR 363.6
  • Coowner: means either of the persons named in the registration of a definitive or a converted definitive savings bond, registered, e. See 31 CFR 363.6
  • Cost contract: means a Medicare contract under which CMS pays the HMO or CMP on a reasonable cost basis. See 42 CFR 417.401
  • Counterparty: means with respect to a credit transaction:

    (1) With respect to a natural person, the natural person, and, if the credit exposure of the covered foreign entity to such natural person exceeds 5 percent of its capital stock and surplus in the case of a U. See 31 CFR 360.92

  • Court: means a court of law with jurisdiction over the parties and the subject matter. See 31 CFR 363.6
  • Court of competent jurisdiction: means a court that has jurisdiction over the subject matter and the parties before it. See 42 CFR 424.71
  • Coverage gap: means the period in prescription drug coverage that occurs between the initial coverage limit and the out-of-pocket threshold. See 42 CFR 423.100
  • Covered Part B services: means physicians' services, diagnostic X-ray tests, laboratory, other diagnostic tests, and any additional medical and other health services, that the HCPP furnishes to its Medicare enrollees. See 42 CFR 417.800
  • Covered services: means items or services for which the beneficiary is entitled to have payment made on his or her behalf under this subpart. See 42 CFR 405.2401
  • Credit union: means a federally insured, natural person credit union, whether federally- or State-chartered, as defined by 12 U. See 43 CFR 2201.3-1
  • Current ratio: means total current assets divided by total current liabilities. See 42 CFR 422.350
  • CUSO: means a credit union service organization as described in 12 CFR 712 et seq. See 43 CFR 2201.3-1
  • Date of dispensing: means the date of service. See 42 CFR 423.2305
  • Date of receipt: means the date a document or other material is received by either of the following:

    (1) A party or an affected nonparty. See 42 CFR 405.1801

  • Days: means calendar days. See 42 CFR 411.101
  • De-link: means the online process by which all securities contained within the minor linked account are moved to the minor's primary TreasuryDirect account and the linked account is deactivated. See 31 CFR 363.6
  • Deactivate: means that the provider or supplier's billing privileges were stopped, but can be restored upon the submission of updated information. See 42 CFR 424.502
  • Deductible: means the amount incurred by the beneficiary during a calendar year as specified in §410. See 42 CFR 405.2401
  • Definitions: As used in this subpart:

    Agriculture Wool Trust means the Agriculture Wool Apparel Manufacturers Trust Fund. See 25 CFR 39.118

  • Definitive bond: means a Series EE savings bond issued in paper form. See 31 CFR 351.3
  • Delegated official: means an individual who is delegated by the "Authorized Official" the authority to report changes and updates to the enrollment record. See 42 CFR 424.502
  • Delivery: means moving a minimum amount of $25 (consisting of principal and proportionate interest) of a security held as a gift from the account of the purchaser to the account of the recipient. See 31 CFR 363.6
  • Derivative transaction: means any transaction that is a contract, agreement, swap, warrant, note, or option that is based, in whole or in part, on the value of, any interest in, or any quantitative measure or the occurrence of any event relating to, one or more commodities, securities, currencies, interest or other rates, indices, or other assets. See 31 CFR 360.20
  • Derivative transaction: means any transaction that is a contract, agreement, swap, warrant, note, or option that is based, in whole or in part, on the value of, any interest in, or any quantitative measure or the occurrence of any event relating to, one or more commodities, securities, currencies, interest or other rates, indices, or other assets. See 31 CFR 360.92
  • Designated carrier: means an entity assigned by CMS to process and pay claims for drugs and biologicals under the CAP. See 42 CFR 414.902
  • Designee: means any person or entity authorized to act on behalf of an employing entity or a group of employing entities to offer the option of enrollment in a qualified health maintenance organization to their eligible employees. See 42 CFR 417.150
  • Direct medical and surgical services: means services to individual beneficiaries that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital making the cost election described in §§415. See 42 CFR 415.152
  • Discharge: A Medicare patient in a long-term care hospital is considered discharged when--

    (1) For purposes of the long-term care hospital qualification calculation, as described in §412. See 42 CFR 412.503

  • Discharge: A Medicare patient in an inpatient rehabilitation facility is considered discharged when--

    (1) The patient is formally released from the inpatient rehabilitation facility. See 42 CFR 412.602

  • Downstream contractor: means a "first tier contractor" as defined at §1001. See 42 CFR 411.351
  • Drug: refers to both drugs and biologicals. See 42 CFR 414.704
  • Drug: means both drugs and biologicals. See 42 CFR 414.802
  • Drug: means both drugs and biologicals. See 42 CFR 414.902
  • Effective date of coverage: (1) If the individual enrolls in a month during any part of which he or she is covered under a GHP or LGHP on the basis of current employment status, or in the first full month when no longer so covered, coverage begins on the first day of the month of enrollment or, at the individual's option, on the first day of any of the three following months. See 42 CFR 406.24
  • Electronic health record: means a repository of consumer health status information in computer processable form used for clinical diagnosis and treatment for a broad array of clinical conditions. See 42 CFR 411.351
  • Eligible collateral: means collateral in which, notwithstanding the prior security interest of any custodial agent, the covered company has a perfected, first priority security interest (or the legal equivalent thereof, if outside of the United States), with the exception of cash on deposit, and is in the form of:

    (1) Cash on deposit with the covered company or a subsidiary of the covered company (including cash in foreign currency or U. See 31 CFR 360.20

  • Eligible collateral: means collateral in which, notwithstanding the prior security interest of any custodial agent, the covered foreign entity has a perfected, first priority security interest (or the legal equivalent thereof, if outside of the United States), with the exception of cash on deposit, and is in the form of:

    (1) Cash on deposit with the covered foreign entity or an affiliate of the covered foreign entity (including cash in foreign currency or U. See 31 CFR 360.92

  • Eligible credit derivative: means a single-name credit derivative or a standard, non-tranched index credit derivative, provided that:

    (1) The contract meets the requirements of an eligible guarantee and has been confirmed by the protection purchaser and the protection provider. See 31 CFR 360.20

  • Eligible credit derivative: means a single-name credit derivative or a standard, non-tranched index credit derivative, provided that:

    (1) The contract meets the requirements of an eligible guarantee and has been confirmed by the protection purchaser and the protection provider. See 31 CFR 360.92

  • Eligible employee: means an employee who meets the employer's requirements for participation in the health benefits plan. See 42 CFR 417.150
  • Eligible equity derivative: means an equity derivative, provided that:

    (1) The derivative contract has been confirmed by all relevant parties. See 31 CFR 360.20

  • Eligible equity derivative: means an equity derivative, provided that:

    (1) The derivative contract has been confirmed by all relevant parties. See 31 CFR 360.92

  • Emergency delivery: means delivery of a CAP drug within one business day in appropriate shipping and packaging, in all areas of the United States and its territories, with the exception of the Pacific Territories. See 42 CFR 414.902
  • Emergency services: means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. See 42 CFR 424.101
  • Emergency services: means covered inpatient or outpatient services that are furnished by an appropriate source other than the HMO or CMP and that meet the following conditions:

    (1) Are needed immediately because of an injury or sudden illness. See 42 CFR 417.401

  • Employee: means any individual who, under the common law rules that apply in determining the employer-employee relationship (as applied for purposes of section 3121(d)(2) of the Internal Revenue Code of 1986), is considered to be employed by, or an employee of, an entity. See 42 CFR 405.2401
  • Employee: means any individual who, under the common law rules that apply in determining the employer-employee relationship (as applied for purposes of section 3121(d)(2) of the Internal Revenue Code of 1986), is considered to be employed by, or an employee of, an entity. See 42 CFR 411.351
  • Employee: means any individual employed by an employer or public entity on a full-time or part-time basis. See 42 CFR 417.150
  • Employer: has the meaning given that term in section 3(d) of the Fair Labor Standards Act of 1938, except that it--

    (1) Includes non-appropriated fund instrumentalities of the United States Government. See 42 CFR 417.150

  • Employing entity: means an employer or public entity. See 42 CFR 417.150
  • Encode: means entering data items into the fields of the computerized patient assessment software program. See 42 CFR 412.602
  • Enrollee: means a Part D eligible individual who has elected or has been enrolled in a Part D plan. See 42 CFR 423.560
  • Enrollee: means an MA eligible individual who has elected an MA plan offered by an MA organization. See 42 CFR 422.561
  • Enrollment application: means a CMS-approved paper enrollment application or an electronic Medicare enrollment process approved by OMB. See 42 CFR 424.502
  • Entitled to Medicare on the basis of disability: means entitled or deemed entitled on the basis of entitlement to social security disability benefits or railroad retirement disability benefits. See 42 CFR 411.201
  • Entity: means a person, group, or facility that is enrolled in the Medicare program. See 42 CFR 424.71
  • Entity: means any owner of a TreasuryDirect account that is not an individual. See 31 CFR 363.6
  • Exempt counterparty: means an entity that is identified as exempt from the requirements of this subpart under §252. See 31 CFR 360.20
  • Exempt counterparty: means an entity that is identified as exempt from the requirements of this subpart under §252. See 31 CFR 360.92
  • extended maturity: refer to periods after the original maturity dates of the bonds during which owners may retain them and continue to earn interest. See 31 CFR 351.3
  • Face amount: refers to the nominal amount of a Series EE savings bond. See 31 CFR 351.3
  • Facility: means a hospital or other institution that furnishes health care services to inpatients. See 42 CFR 424.71
  • fair market value: means the value of rental property for general commercial purposes (not taking into account its intended use). See 42 CFR 411.351
  • fallback entity: means an entity that, for a particular contract period-

    (1) Is a PDP sponsor that does not have to be a risk-bearing entity (or, if applying to become a fallback entity, an entity that meets all the requirements to become a Part D plan sponsor except that it does not have to be a risk-bearing entity). See 42 CFR 423.855

  • Fallback prescription drug plan: means a prescription drug plan (PDP) offered by a fallback entity that--

    (1) Offers only defined standard or actuarially equivalent standard prescription drug coverage as defined in §423. See 42 CFR 423.855

  • Family member: means a person who is enrolled in an LGHP based on another person's enrollment. See 42 CFR 411.201
  • FAS: means the Foreign Agricultural Service. See 25 CFR 39.118
  • Federal per diem base rate: means the payment based on the average routine operating, ancillary, and capital-related cost of 1 day of hospital inpatient services in an inpatient psychiatric facility. See 42 CFR 412.402
  • Federal per diem payment amount: means the Federal per diem base rate with all applicable adjustments. See 42 CFR 412.402
  • Final adverse action: means one or more of the following actions:

    (1) A Medicare-imposed revocation of any Medicare billing privileges. See 42 CFR 424.502

  • Final maturity: refers to the date that a bond ceases to earn interest. See 31 CFR 351.3
  • Fixed dollar loss threshold amount: means a dollar amount which, when added to the Federal payment amount for a case, the estimated costs of a case must exceed in order for the case to qualify for an outlier payment. See 42 CFR 412.402
  • Functional-related groups: refers to the distinct groups under which inpatients are classified using proxy measurements of inpatient rehabilitation relative resource usage. See 42 CFR 412.602
  • General rules: Services furnished in hospitals by residents in approved GME programs are specifically excluded from being paid as "physician services" defined in §414. See 42 CFR 415.200
  • Geographic area: means the area found by CMS to be the area within which the HMO or CMP furnishes, or arranges for furnishing, the full range of services that it offers to its Medicare enrollees. See 42 CFR 417.401
  • Gift: means a Treasury security purchased for or transferred to an intended recipient, without consideration. See 31 CFR 363.6
  • Grievance: means any complaint or dispute, other than one that involves a coverage determination or at-risk determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. See 42 CFR 423.560
  • Grievance: means any complaint or dispute, other than one that constitutes an organization determination, expressing dissatisfaction with any aspect of an MA organization's or provider's operations, activities, or behavior, regardless of whether remedial action is requested. See 42 CFR 422.561
  • Group enrollment period: means the period of at least 10 working days each calendar year during which each eligible employee is given the opportunity to select among the alternatives included in a health benefits plan. See 42 CFR 417.150
  • Guarantor: means an entity that--

    (1) Has been approved by CMS as meeting the requirements to be a guarantor. See 42 CFR 422.350

  • Health benefits contract: means a contract or other agreement between an employing entity or a designee and a carrier for the provision of, or payment for, health benefits to eligible employees or to eligible employees and their eligible dependents. See 42 CFR 417.150
  • Health benefits plan: means any arrangement, to provide or pay for health services, that is offered to eligible employees, or to eligible employees and their eligible dependents, by or on behalf of an employing entity. See 42 CFR 417.150
  • Health or educational entity: means an organization, agency, or combination thereof, which has the provision of health or educational programs as one of its major functions. See 42 CFR 136.302
  • Health professions school: means any of the schools defined in paragraphs (m), (n), or (o) of this section. See 42 CFR 136.302
  • Home health services: means the services described in section 1861(m) of the Act and part 409, subpart E of this chapter. See 42 CFR 411.351
  • Hospital: means a facility that--

    (1) Is primarily engaged in providing, by or under the supervision of doctors of medicine or osteopathy, inpatient services for the diagnosis, treatment, and care or rehabilitation of persons who are sick, injured, or disabled. See 42 CFR 424.101

  • Hospital: means any entity that qualifies as a "hospital" under section 1861(e) of the Act, as a "psychiatric hospital" under section 1861(f) of the Act, or as a "critical access hospital" under section 1861(mm)(1) of the Act, and refers to any separate legally organized operating entity plus any subsidiary, related entity, or other entities that perform services for the hospital's patients and for which the hospital bills. See 42 CFR 411.351
  • HRSA: means the Health Resources and Services Administration. See 42 CFR 405.2401
  • HTS: means the Harmonized Tariff Schedule of the United States. See 25 CFR 39.118
  • HTS subheadings: All references to subheadings of the HTS in this part are to the subheadings as described in the HTS in 2014. See 25 CFR 39.118
  • incident to: means those services and supplies that meet the requirements of section 1861(s)(2)(A) of the Act, §410. See 42 CFR 411.351
  • Incompetent: means an individual who is incapable of handling his or her business affairs because of a legal, mental or medical disability, except that a minor is not an incompetent solely because of age. See 31 CFR 360.2
  • Incurred costs: means costs incurred by a Part D enrollee for--

    (1)(i) Covered Part D drugs that are not paid for under the Part D plan as a result of application of any annual deductible or other cost-sharing rules for covered Part D drugs prior to the Part D enrollee satisfying the out-of-pocket threshold under §423. See 42 CFR 423.100

  • Indian health organization: means a nonprofit corporate body composed of Indians which provides for the maximum participation of all interested Indian groups and individuals and which has the provision of health programs as its principal function. See 42 CFR 136.302
  • Indian tribe: means any Indian tribe, band, nation, or other organized group or community, including any Alaska native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (43 U. See 42 CFR 136.302
  • Indirect ownership interest: means any ownership interest in an entity that has an ownership interest in the disclosing entity. See 42 CFR 420.201
  • Individual: means a natural person. See 31 CFR 363.6
  • Initial costs of operation: means any cost incurred in the first 60 months of an operation or expansion that met any of the following requirements:

    (1) Under generally accepted accounting principles or under accounting practices prescribed or permitted by State regulatory authority, was not a capital cost. See 42 CFR 417.911

  • Inpatient hospital services: include services that are furnished either by the hospital directly or under arrangements made by the hospital with others. See 42 CFR 411.351
  • Inpatient psychiatric facilities: means hospitals that meet the requirements as specified in §§412. See 42 CFR 412.402
  • Insolvency: means a condition in which the liabilities of the debtor exceed the fair valuation of its assets. See 42 CFR 422.350
  • Institutional provider: means any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (not including physician and nonphysician practitioner organizations), CMS-855S, CMS-20134, or an associated Internet-based PECOS enrollment application. See 42 CFR 424.502
  • Insurance: means a health plan that provides, or pays the cost of Part D drugs, including, but not limited to, any of the following:

    (1) Health insurance coverage (as defined in 42 U. See 42 CFR 423.100

  • Interoperable: means able to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks, in various settings. See 42 CFR 411.351
  • Interrupted stay: means a stay at an inpatient rehabilitation facility during which a Medicare inpatient is discharged from the inpatient rehabilitation facility and returns to the same inpatient rehabilitation facility within 3 consecutive calendar days. See 42 CFR 412.602
  • Intraday credit exposure: means credit exposure of a covered company to a counterparty that by its terms is to be repaid, sold, or terminated by the end of its business day in the United States. See 31 CFR 360.20
  • Intraday credit exposure: means credit exposure of a covered foreign entity to a counterparty that by its terms is to be repaid, sold, or terminated by the end of its business day in the United States. See 31 CFR 360.92
  • Issuing agent: means an organization that has been qualified under the provisions of Department of the Treasury Circular, Fiscal Service Series No. See 31 CFR 360.2
  • Labeler code: means the first segment of the Food and Drug Administration national drug code (NDC) that identifies a particular manufacturer. See 42 CFR 423.2305
  • Laboratory: means an entity furnishing biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. See 42 CFR 411.351
  • Linked account: means an account that is a separate account from your primary account, but connected to your primary account. See 31 CFR 363.6
  • Loaded mileage: means the number of miles the Medicare beneficiary is transported in the ambulance vehicle. See 42 CFR 414.605
  • Local carrier: means an entity assigned by CMS to process and pay claims for administration of drugs and biologicals under the CAP. See 42 CFR 414.902
  • Long-term care hospital prospective payment system payment year: means the general term that encompasses both the definition of "long-term care hospital prospective payment system rate year" and "long-term care hospital prospective payment system fiscal year" specified in this section. See 42 CFR 412.503
  • Long-term care network pharmacy: means a long-term care pharmacy that is a network pharmacy. See 42 CFR 423.100
  • MA organization: has the meaning given the term in 422. See 42 CFR 422.1002
  • Major counterparty: means any counterparty that is or includes:

    (1) A major covered company. See 31 CFR 360.20

  • Major counterparty: means any counterparty that is or includes:

    (1) A U. See 31 CFR 360.92

  • Managing employee: means a general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or through some other arrangement, whether or not the individual is a W-2 employee of the provider or supplier. See 42 CFR 424.502
  • Managing employee: means a general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the institution, organization, or agency, either under contract or through some other arrangement, whether or not the individual is a W-2 employee. See 42 CFR 420.201
  • Manufacturer: means any entity which is engaged in the production, preparation, propagation, compounding, conversion or processing of prescription drug products, either directly or indirectly, by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis. See 42 CFR 423.2305
  • Manufacturer: means any entity that is engaged in the following (This term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law):

    (1) Production, preparation, propagation, compounding, conversion or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis. See 42 CFR 414.802

  • Market basket index: means an index that reflects changes over time in the prices of an appropriate mix of goods and services included in covered skilled nursing services. See 42 CFR 413.333
  • Market Participant: means an entity that qualifies as a Market Participant under §35. See 42 CFR 412.163
  • Marketable Treasury security: refers to a Treasury bill, note, or bond that is negotiable and transferable, that is, may be bought and sold in the secondary market. See 31 CFR 363.6
  • Medicare enrollee: means a Medicare beneficiary who has been identified on CMS records as an enrollee of an HMO or CMP that has a contract with CMS under section 1876 of the Act and subpart L of this part. See 42 CFR 417.401
  • Medicare enrollee: means a beneficiary under Part B of Medicare who has been identified on CMS records as an enrollee of the HCPP. See 42 CFR 417.800
  • Medicare Part D discount information: means the information sent from CMS or the TPA to the manufacturer along with each quarterly invoice that is derived from applicable data elements available on prescription drug events as determined by CMS. See 42 CFR 423.2305
  • Minor: means an individual under the age of 18 years. See 31 CFR 363.6
  • Minor account: means an account that a custodian controls on behalf of a minor, that is linked to the custodian's primary account. See 31 CFR 363.6
  • MSA: means a Metropolitan Statistical Area, as defined by the Executive Office of Management and Budget. See 42 CFR 412.503
  • MSA-dominant hospital: means a hospital that has discharged more than 25 percent of the total subsection (d) hospital Medicare discharges in the MSA (not including discharges paid by a Medicare Advantage plan) in which the hospital is located. See 42 CFR 412.503
  • Multiple source drug: means a drug described by section 1847A(c)(6)(C) of the Act. See 42 CFR 414.902
  • NCUSIF: means the National Credit Union Share Insurance Fund as defined by 12 U. See 43 CFR 2201.3-1
  • Negotiated prices: means prices for covered Part D drugs that meet all of the following:

    (1) The Part D sponsor (or other intermediary contracting organization) and the network dispensing pharmacy or other network dispensing provider have negotiated as the amount such network entity will receive, in total, for a particular drug. See 42 CFR 423.100

  • Net Worth: means (1) The retained earnings balance of the credit union at quarter-end as determined under generally accepted accounting principles, subject to paragraph (f)(3) of this section. See 43 CFR 2201.3-1
  • Net worth: means the excess of total assets over total liabilities, excluding fully subordinated debt or subordinated liabilities. See 42 CFR 422.350
  • Net worth ratio: means the ratio of the net worth of the credit union (as defined in paragraph (f) of this section) to the total assets of the credit union (as defined by a measure chosen under paragraph (j) of this section). See 43 CFR 2201.3-1
  • Network organization: The administrative governing body to the network and liaison to the Federal government. See 42 CFR 405.2102
  • Network pharmacy: means a licensed pharmacy that is under contract with a Part D sponsor to provide covered Part D drugs at negotiated prices to its Part D plan enrollees. See 42 CFR 423.100
  • New credit union: means a federally insured credit union which both has been in operation for less than ten (10) years and has $10,000,000 or less in total assets. See 43 CFR 2201.3-1
  • Non-preferred pharmacy: means a network pharmacy that offers covered Part D drugs at negotiated prices to Part D enrollees at higher cost-sharing levels than apply at a preferred pharmacy. See 42 CFR 423.100
  • Online: means use of the Internet. See 31 CFR 363.6
  • Operational: means the provider or supplier has a qualified physical practice location, is open to the public for the purpose of providing health care related services, is prepared to submit valid Medicare claims, and is properly staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered), to furnish these items or services. See 42 CFR 424.502
  • Or otherwise: means through a government-funded health program. See 42 CFR 423.100
  • Organized Wholesale Electric Market: includes an independent system operator and a regional transmission organization. See 42 CFR 412.163
  • original maturity: refers to the initial maturity period of a bond prior to any extensions of maturity. See 31 CFR 351.3
  • Other disclosing entity: means any other Medicare disclosing entity and any entity that does not participate in Medicare, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XIX, or XX of the Act. See 42 CFR 420.201
  • Other health or prescription drug coverage: means any coverage or financial assistance under other health benefit plans or programs that provide coverage or financial assistance for the purchase or provision of prescription drug coverage on behalf of applicable beneficiaries, including, in the case of employer group health or waiver plans, other than basic prescription drug coverage as defined in §423. See 42 CFR 423.2305
  • Other prescriber: means a health care professional other than a physician who is authorized under State law or other applicable law to write prescriptions. See 42 CFR 423.560
  • our: refers to the Bureau of the Fiscal Service. See 31 CFR 363.6
  • our: refers to the agency, the Bureau of the Fiscal Service. See 31 CFR 351.3
  • Out-of-network pharmacy: means a licensed pharmacy that is not under contract with a Part D sponsor to provide negotiated prices to Part D plan enrollees. See 42 CFR 423.100
  • Outlier payment: means an additional payment beyond the Federal per diem payment amount for cases with unusually high costs. See 42 CFR 412.402
  • Outlier payment: means an additional payment beyond the long-term care hospital standard Federal payment rate or the site neutral payment rate (including, when applicable, the blended payment rate), as applicable, for cases with unusually high costs. See 42 CFR 412.503
  • Outpatient prescription drugs: means all drugs covered by Medicare Part B or D, except for those drugs that are "covered ancillary services" as defined at §416. See 42 CFR 411.351
  • Owner: means any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in sections 1124 and 1124A(A) of the Act. See 42 CFR 424.502
  • Ownership interest: means the possession of equity in the capital, the stock, or the profits of the disclosing entity. See 42 CFR 420.201
  • Part D sponsor: has the meaning given the term in 423. See 42 CFR 423.1002
  • Participating CAP physician: means a physician electing to participate in the CAP, as described in this subpart. See 42 CFR 414.902
  • party: means the affected party or CMS, as appropriate. See 42 CFR 423.1002
  • Patient assessment instrument: refers to a document that contains clinical, demographic, and other information on a patient. See 42 CFR 412.602
  • Patient care services: means any task(s) performed by a physician in the group practice that address the medical needs of specific patients or patients in general, regardless of whether they involve direct patient encounters or generally benefit a particular practice. See 42 CFR 411.351
  • Paying agent: means a financial institution that has been qualified under the provisions of Department of the Treasury Circular No. See 31 CFR 360.2
  • Payment: means redemption, unless otherwise indicated by the context. See 31 CFR 360.2
  • Payroll savings plan: is a method for the purchase of savings bonds using periodic ACH credits from your employer or financial institution to purchase a payroll zero-percent certificate of indebtedness until a sufficient amount of payroll zero-percent certificate of indebtedness is accumulated to enable the purchase of a savings bond in an amount, series, and registration that you previously selected using functionality in your TreasuryDirect account. See 31 CFR 363.6
  • Payroll zero-percent certificate of indebtedness: is a restricted form of the zero-percent certificate of indebtedness that is held separately from the zero-percent certificate of indebtedness and used only for purchases made through the payroll savings plan. See 31 CFR 363.6
  • Performance period: means the calendar year that will be used to assess the quality of care furnished compared to cost. See 42 CFR 414.1205
  • Person: means a legal entity including an individual or fiduciary estate. See 31 CFR 360.2
  • Person: means an individual or an entity. See 31 CFR 363.6
  • Person with an ownership or control interest: means a person or corporation that--

    (1) Has an ownership interest totaling 5 percent or more in a disclosing entity. See 42 CFR 420.201

  • Physician: has the meaning given the term in section 1861(r) of the Act. See 42 CFR 423.560
  • Physician: means a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, as defined in section 1861(r) of the Act. See 42 CFR 411.351
  • Physician: has the meaning given the term in section 1861(r) of the Act. See 42 CFR 422.561
  • Physician in the group practice: means a member of the group practice, as well as an independent contractor physician during the time the independent contractor is furnishing patient care services (as defined in this section) for the group practice under a contractual arrangement directly with the group practice to provide services to the group practice's patients in the group practice's facilities. See 42 CFR 411.351
  • Physician incentive plan: means any compensation arrangement between an entity (or downstream contractor) and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished with respect to individuals enrolled with the entity. See 42 CFR 411.351
  • Physician or nonphysician practitioner organization: means any physician or nonphysician practitioner entity that enrolls in the Medicare program as a sole proprietorship or organizational entity. See 42 CFR 424.502
  • Physician organization: means a physician, a physician practice, or a group practice that complies with the requirements of §411. See 42 CFR 411.351
  • Physician Quality Reporting System: means the system established under section 1848(k) of the Act. See 42 CFR 414.1205
  • Plan allowance: means the amount Part D plans that offer coverage other than defined standard coverage may use to determine their payment and Part D enrollees' cost-sharing for covered Part D drugs purchased at an out-of-network pharmacy or in a physician's office in accordance with the requirements of §423. See 42 CFR 423.100
  • Plan of care: means the establishment by a physician of a course of diagnosis or treatment (or both) for a particular patient, including the ordering of services. See 42 CFR 411.351
  • Point of pick-up: means the location of the beneficiary at the time he or she is placed on board the ambulance. See 42 CFR 414.605
  • Power of attorney: means any written documents by which a principal authorizes an agent to--

    (1) Receive, in the agent's name, any payments due the principal. See 42 CFR 424.71

  • Preclusion list: means a CMS compiled list of prescribers who--

    (1) Meet all of the following requirements:

    (i) The prescriber is currently revoked from the Medicare program under §424. See 42 CFR 423.100

  • Preferred drug: means a covered Part D drug on a Part D plan's formulary for which beneficiary cost-sharing is lower than for a non-preferred drug in the plan's formulary. See 42 CFR 423.100
  • Preferred pharmacy: means a network pharmacy that offers covered Part D drugs at negotiated prices to Part D enrollees at lower levels of cost-sharing than apply at a non-preferred pharmacy under its pharmacy network contract with a Part D plan. See 42 CFR 423.100
  • Prescription order: means a written order submitted by the participating CAP physician to the approved CAP vendor that meets the requirements of this subpart. See 42 CFR 414.902
  • Primary account: means the account that you establish when you first open your TreasuryDirect account. See 31 CFR 363.6
  • Primary owner: means the first person named in the registration of a security held in TreasuryDirect registered, e. See 31 CFR 363.6
  • Principal amount: means the amount of the original investment. See 31 CFR 363.6
  • Principal diagnosis: means the condition established after study to be chiefly responsible for occasioning the admission of the patient to the inpatient psychiatric facility. See 42 CFR 412.402
  • Professional courtesy: means the provision of free or discounted health care items or services to a physician or his or her immediate family members or office staff. See 42 CFR 411.351
  • provider: includes a hospital (as described in part 482 of this chapter), hospice program (as described in §418. See 42 CFR 405.1801
  • Providers: In order to be paid for covered services furnished to Medicare beneficiaries, a provider must file a cost report with its contractor as specified in §413. See 42 CFR 405.1801
  • Public entity: means the 50 states, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands and American Samoa and their political subdivisions, the District of Columbia, and any agency or instrumentality of the foregoing, and political subdivisions include counties, parishes, townships, cities, municipalities, towns, villages, and incorporated villages. See 42 CFR 417.150
  • Qualified actuary: means a member in good standing of the American Academy of Actuaries or a person recognized by the Academy as qualified for membership, or a person who has otherwise demonstrated competency in the field of actuarial determination and is satisfactory to CMS. See 42 CFR 422.350
  • Qualified HMO: means an HMO that has in effect a determination, made under subpart D of this part, that the HMO is an operational, preoperational, or transitional qualified HMO. See 42 CFR 417.150
  • Qualified prescription drug coverage: means any standard prescription drug coverage or alternative prescription drug coverage

    Required prescription drug coverage means coverage of Part D drugs under an MA-PD plan that consists of either--

    (1) Basic prescription drug coverage. See 42 CFR 423.100

  • Qualifying emergency department: means an emergency department that is staffed and equipped to furnish a comprehensive array of emergency services and meeting the definitions of a dedicated emergency department as specified in §489. See 42 CFR 412.402
  • Qualifying plan: means a full-risk or limited-risk prescription drug plan, as defined in §423. See 42 CFR 423.855
  • Quarter-end balance: The quarter-end balance of the calendar quarter as reported on the credit union's Call Report. See 43 CFR 2201.3-1
  • Radiology and certain other imaging services: means those particular services so identified on the List of CPT/HCPCS Codes. See 42 CFR 411.351
  • Recipient: means the person to whom a gift is given. See 31 CFR 363.6
  • Reconsideration: means a review of an adverse coverage determination or at-risk determination by an independent review entity (IRE), the evidence and findings upon which it was based, and any other evidence the enrollee submits or the IRE obtains. See 42 CFR 423.560
  • Redemption value: means principal plus accrued interest of a Series EE savings bond, as of the date of potential or actual redemption. See 31 CFR 351.3
  • Redemption value: means principal plus accrued interest of a bond, or a portion of the principal plus a proportionate amount of accrued interest on the bond, as of the date of redemption. See 31 CFR 363.6
  • Redetermination: means a review of an adverse coverage determination or at-risk determination by a Part D plan sponsor, the evidence and findings upon which it is based, and any other evidence the enrollee submits or the Part D plan sponsor obtains. See 42 CFR 423.560
  • Referring physician: means a physician who makes a referral as defined in this section or who directs another person or entity to make a referral or who controls referrals made by another person or entity. See 42 CFR 411.351
  • Registered: means that the name and taxpayer identification number(s) (TIN) of the person(s) named on the security are maintained on our records. See 31 CFR 363.6
  • Registration: means that the names of all persons named on the bond and the taxpayer identification number (TIN) of the owner, first-named coowner, or purchaser of a gift bond are maintained on our records. See 31 CFR 360.2
  • Reinvestment: means using the redemption proceeds of a maturing marketable security to purchase a new marketable security of the same type and term, using the automatic reinvestment option available in TreasuryDirect. See 31 CFR 363.6
  • Reissue: means the cancellation and retirement of a bond and the issuance of a new bond or bonds of the same series, same issue date, and same total face amount. See 31 CFR 360.2
  • Remuneration: means any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind, except that the following are not considered remuneration for purposes of this section:

    (1) The forgiveness of amounts owed for inaccurate tests or procedures, mistakenly performed tests or procedures, or the correction of minor billing errors. See 42 CFR 411.351

  • Reporting period: means the period specified by CMS for which an HCPP must report its costs and utilization. See 42 CFR 417.800
  • Representative: means an individual appointed by an enrollee or other party, or authorized under State or other applicable law, to act on behalf of an enrollee or other party involved in the grievance or appeal. See 42 CFR 422.561
  • resident: is synonymous with the terms intern and fellow. See 42 CFR 415.152
  • Resident classification system: means a system for classifying SNF residents into mutually exclusive groups based on clinical, functional, and resource-based criteria. See 42 CFR 413.333
  • Retail pharmacy: means any licensed pharmacy that is open to dispense prescription drugs to the walk-in general public from which Part D enrollees could purchase a covered Part D drug without being required to receive medical services from a provider or institution affiliated with that pharmacy. See 42 CFR 423.100
  • Reviewing entity: means the contractor hearing officer(s), a CMS reviewing official, the Board, or the Administrator. See 42 CFR 405.1801
  • Risk contract: means a Medicare contract under which CMS pays the HMO or CMP on a risk basis for Medicare covered services. See 42 CFR 417.401
  • Risk score: means the beneficiary risk score derived from the CMS Hierarchical Condition Categories (HCC) model. See 42 CFR 414.1205
  • Routine care items and services: refers to items and services that are otherwise generally available to Medicare beneficiaries (that is, a benefit category exists, it is not statutorily excluded, and there is no national noncoverage decision) that are furnished during a clinical study and that would be otherwise furnished even if the beneficiary were not enrolled in a clinical study. See 42 CFR 405.201
  • Rural: means a five-digit ZIP code in which the population density is less than 1,000 individuals per square mile. See 42 CFR 423.100
  • Rural area: means an area that is not an urban area as defined at §412. See 42 CFR 411.351
  • Rural area: means for cost reporting periods beginning January 1, 2005, with respect to discharges occurring during the period covered by such cost reports but before July 1, 2006, an area as defined in §412. See 42 CFR 412.402
  • Rural area: means an area located outside an urban area, or a rural census tract within a Metropolitan Statistical Area as determined under the most recent version of the Goldsmith modification as determined by the Office of Rural Health Policy of the Health Resources and Services Administration. See 42 CFR 414.605
  • Same building: means a structure with, or combination of structures that share, a single street address as assigned by the U. See 42 CFR 411.351
  • Scope: This subpart establishes the requirements for coverage and reimbursement of rural health clinic and Federally qualified health center services under Medicare. See 42 CFR 405.2401
  • Secondary owner: means the second person named in the registration of a book-entry security held in TreasuryDirect registered, e. See 31 CFR 363.6
  • Secretary: means the Secretary of Health and Human Services or his or her delegate. See 42 CFR 405.2401
  • Secretary: means the Secretary of Agriculture. See 25 CFR 39.113
  • Secretary: means the Secretary of Health and Human Services and any other Officer or employee of the Department of Health and Human Services to whom the authority involved has been delegated. See 42 CFR 136.302
  • Securities financing transaction: means any repurchase agreement, reverse repurchase agreement, securities borrowing transaction, or securities lending transaction. See 31 CFR 360.20
  • Securities financing transaction: means any repurchase agreement, reverse repurchase agreement, securities borrowing transaction, or securities lending transaction. See 31 CFR 360.92
  • Senior executive officer: means a senior executive officer as defined by 12 CFR 701. See 43 CFR 2201.3-1
  • Series EE savings bond: is an accrual-type savings bond, offered at a discount, either in definitive (paper) form or in book-entry form, that pays interest on the principal based on rates determined by Treasury. See 31 CFR 351.3
  • Series I savings bond: is a savings bond, issued either in definitive (paper) form or in book-entry form, that accrues interest in accordance with a formula that includes a fixed component and a component indexed to the rate of inflation. See 31 CFR 363.6
  • Service: means the Indian Health Service. See 42 CFR 136.302
  • Shares: means deposits, shares, share certificates, share drafts, or any other depository account authorized by federal or state law. See 43 CFR 2201.3-1
  • Short sale: means any sale of a security which the seller does not own or any sale which is consummated by the delivery of a security borrowed by, or for the account of, the seller. See 31 CFR 360.20
  • Short sale: means any sale of a security which the seller does not own or any sale which is consummated by the delivery of a security borrowed by, or for the account of, the seller. See 31 CFR 360.92
  • Similar area: means an area similar to the HMO's or CMP's geographic area but free from special characteristics that would distort the determination of the AAPCC. See 42 CFR 417.582
  • Single owner: means the individual named in the registration of a book-entry Treasury security or a converted savings bond without a beneficiary, secondary owner, or coowner. See 31 CFR 363.6
  • Single source drug: means a drug described by section 1847A(c)(6)(D) of the Act. See 42 CFR 414.902
  • Solo practitioner: means a single Taxpayer Identification Number (TIN) with one eligible professional who is identified by an individual National Provider Identifier (NPI) billing under the TIN. See 42 CFR 414.1205
  • Specialty hospital: means a subsection (d) hospital (as defined in section 1886(d)(1)(B) of the Act) that is primarily or exclusively engaged in the care and treatment of one of the following:

    (1) Patients with a cardiac condition. See 42 CFR 411.351

  • Specialty tier: means a formulary cost-sharing tier dedicated to very high cost Part D drugs and biological products that exceed a cost threshold established by the Secretary. See 42 CFR 423.560
  • Standard prescription drug coverage: means coverage of Part D drugs that meets the requirements of §423. See 42 CFR 423.100
  • Statutory accounting practices: means those accounting principles or practices prescribed or permitted by the domiciliary State insurance department in the State that PSO operates. See 42 CFR 422.350
  • Subordinated debt: means an obligation that is owed by an organization, that the creditor of the obligation, by law, agreement, or otherwise, has a lower repayment rank in the hierarchy of creditors than another creditor. See 42 CFR 422.350
  • Subsidiary: A company is a subsidiary of another company if:

    (1) The company is consolidated by the other company under applicable accounting standards. See 31 CFR 360.20

  • Substitute bond: means a bond or book-entry bond issued as a result of a claim or application for relief under subpart F of this part. See 31 CFR 360.2
  • Suburban: means a five-digit ZIP code in which the population density is between 1,000 and 3,000 individuals per square mile. See 42 CFR 423.100
  • Supplemental benefits: means benefits offered by Part D plans, other than employer group health or waiver plans, that meet the requirements of §423. See 42 CFR 423.100
  • Surrender: means the actual receipt of a definitive bond with an appropriate request for payment or reissue by either a Federal Reserve Bank or Branch or the Bureau of the Fiscal Service, or, if a paying agent is authorized to handle the transaction, the actual receipt of the definitive bond and the request for payment by the paying agent. See 31 CFR 360.2
  • Taxpayer Identifying Number: means a social security account number or an employer identification number. See 31 CFR 360.2
  • Teaching hospital: means a hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry. See 42 CFR 415.152
  • Teaching physician: means a physician (other than another resident) who involves residents in the care of his or her patients. See 42 CFR 415.152
  • Teaching setting: means any provider, hospital-based provider, or nonprovider settings in which Medicare payment for the services of residents is made under the direct GME payment provisions of §§413. See 42 CFR 415.152
  • Terminology: As used in this subpart, the following terms have the indicated meanings. See 42 CFR 406.24
  • Therapeutically equivalent: refers to drugs that are rated as therapeutic equivalents under the Food and Drug Administration's most recent publication of "Approved Drug Products with Therapeutic Equivalence Evaluations. See 42 CFR 423.100
  • Total assets: (1) Total assets means a credit union's total assets as measured by either--

    (i) Average quarterly balance. See 43 CFR 2201.3-1

  • Total consolidated assets: A company's total consolidated assets are determined based on:

    (1) The average of the bank holding company's total consolidated assets in the four most recent consecutive quarters as reported quarterly on the FR Y-9C. See 31 CFR 360.20

  • Total consolidated assets: (1) A foreign banking organization's total consolidated assets are determined based on:

    (i) The average of the foreign banking organization's total consolidated assets in the four most recent consecutive quarters as reported quarterly on the FR Y-7Q. See 31 CFR 360.92

  • Transaction: means an instance or process of two or more persons or entities doing business. See 42 CFR 411.351
  • Transfer: means the release of a Medicare inpatient from an inpatient rehabilitation facility to another inpatient rehabilitation facility, a short-term, acute-care prospective payment hospital, a long-term care hospital as described in §412. See 42 CFR 412.602
  • Transfer: is a transaction to move a security, or a portion of a security, to or from a TreasuryDirect account. See 31 CFR 363.6
  • Tribal organization: means the elected governing body of any Indian tribe or any legally established organization of Indians which is controlled by one or more such bodies or by a board of directors elected or selected by one or more such bodies (or elected by the Indian population to be served by such organization) and which includes the maximum participation of Indians in all phases of its activities. See 42 CFR 136.302
  • TRQ: means Tariff Rate Quota. See 25 CFR 39.118
  • Uncovered expenditures: means those expenditures for health care services that are the obligation of an organization, for which an enrollee may also be liable in the event of the organization's insolvency and for which no alternative arrangements have been made that are acceptable to CMS. See 42 CFR 422.350
  • Urban: means a five-digit ZIP code in which the population density is greater than 3,000 individuals per square mile. See 42 CFR 423.100
  • Urban center: means any city, with a population of 10,000 or more as determined by the United States Census Bureau, which the Secretary determines has a sufficient urban Indian population with unmet health needs to warrant assistance under title V of the Act. See 42 CFR 136.302
  • Urban Indian: means any individual who resides in an urban center, as defined in paragraph(s) of this section, and who meets one or more of the four criteria in paragraphs (h) (1) through (4) of this section. See 42 CFR 136.302
  • Urban Indian organization: means a nonprofit corporate body situated in an urban center which:

    (1) Is governed by an Indian controlled board of directors:

    (2) Has the provision of health programs as:

    (i) Its principal function, or

    (ii) One of its major functions and such health progams are administered by a distinct organizational unit within the organization. See 42 CFR 136.302

  • Urgently needed services: means covered services that are needed by an enrollee who is temporarily absent from the HMO's or CMP's geographic area and that--

    (1) Are required in order to prevent serious deterioration of the enrollee's health as a result of unforeseen injury or illness. See 42 CFR 417.401

  • Valid prescription: means a prescription that complies with all applicable State law requirements constituting a valid prescription. See 42 CFR 423.100
  • Value-based payment modifier: means the percentage as determined under §414. See 42 CFR 414.1205
  • Verification: means confirming the identity of an online applicant for a TreasuryDirect account at account establishment using an online verification service or offline verification. See 31 CFR 363.6
  • Verification service: means a public or private service that confirms the identity of an online applicant for a TreasuryDirect account at account establishment using information provided by the applicant. See 31 CFR 363.6
  • Visiting nurse services: means part-time or intermittent nursing care and related medical supplies (other than drugs or biologicals) furnished by a registered professional nurse or licensed practical nurse to a homebound patient. See 42 CFR 405.2401
  • Voluntary guardian: means an individual who is recognized as authorized to act for an incompetent, as provided by §360. See 31 CFR 360.2
  • Voluntary representative: means the person qualified by the Department of the Treasury to request payment or distribution of a decedent's savings bonds pursuant to §360. See 31 CFR 360.2
  • Voluntary termination: means that a provider or supplier, including an individual physician or nonphysician practitioner, submits written confirmation to CMS of its decision to discontinue enrollment in the Medicare program. See 42 CFR 424.502
  • Weighted-average life: means the weighted-average time to the return of a dollar of principal, calculated by multiplying each portion of principal received by the time at which it is expected to be received (based on a reasonable and supportable estimate of that time), and then summing and dividing by the total amount of principal. See 43 CFR 2201.3-1
  • Wholly owned supplier: means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider. See 42 CFR 420.201
  • Zero-percent certificate of indebtedness: is a one-day, non-interest-bearing security that automatically matures and is rolled over each day until you request that it be redeemed. See 31 CFR 363.6