42 C.F.R. PART 1000—INTRODUCTION; GENERAL DEFINITIONS
Title 42 - Public Health
Authority: 42 U.S.C. 1320 and 1395hh.
Source: 51 FR 34766, Sept. 30, 1986, unless otherwise noted.
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). Beneficiary means any individual eligible to have benefits paid to him or her, or on his or her behalf, under Medicare or any State health care program. CFR stands for Code of Federal Regulations. CMS stands for Centers for Medicare & Medicaid Services, formerly the Health Care Financing Administration (HCFA). Department means the Department of Health and Human Services (HHS), formerly the Department of Health, Education, and Welfare. Directly, as used in the definition of “furnished” in this section, means the provision of items and services by individuals or entities (including items and services provided by them, but manufactured, ordered or prescribed by another individual or entity) who submit claims to Medicare, Medicaid or other Federal health care programs. ESRD stands for end-stage renal disease. FR stands for Furnished refers to items or services provided or supplied, directly or indirectly, by any individual or entity. This includes items and services manufactured, distributed or otherwise provided by individuals or entities that do not directly submit claims to Medicare, Medicaid or other Federal health care programs, but that supply items or services to providers, practitioners or suppliers who submit claims to these programs for such items or services. 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. Indirectly, as used in the definition of “furnished” in this section, means the provision of items and services manufactured, distributed or otherwise supplied by individuals or entities who do not directly submit claims to Medicare, Medicaid or other Federal health care programs, but that provide items and services to providers, practitioners or suppliers who submit claims to these programs for such items and services. This term does not include individuals and entities that submit claims directly to these programs for items and services ordered or prescribed by another individual or entity. Inspector General means the Inspector General for Health and Human Services. 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. OIG means the Office of Inspector General within HHS. QIO stands for Utilization and Quality Control Quality Improvement Organization. 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. [51 FR 34766, Sept. 30, 1986 as amended at 57 FR 3329, Jan. 29, 1992; 63 FR 46685, Sept. 2, 1998; 66 FR 39452, July 31, 2001] As used in connection with the Medicare program, unless the context indicates otherwise— 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. Entitled means that an individual meets all the requirements for Medicare benefits. 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. 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. Provider means a hospital, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or effective November 1, 1983 through September 30, 1986, 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 a similar agreement but only to furnish outpatient physical therapy or speech pathology 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 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. [51 FR 34766, Sept. 30, 1986, as amended at 57 FR 3329, Jan. 29, 1992] 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. Provider means any individual or entity furnishing Medicaid services under a provider agreement with the Medicaid agency. Recipient means an individual who has been determined eligible for Medicaid. Services means the types of medical assistance specified in sections 1905(a)(1) through (18) of the Act. 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.
Title 42: Public Health
PART 1000—INTRODUCTION; GENERAL DEFINITIONS
Section Contents
§ 1000.10 General definitions.
§ 1000.20 Definitions specific to Medicare.
§ 1000.30 Definitions specific to Medicaid.
Subpart A [Reserved]
top
Subpart B—Definitions
top
§ 1000.10 General definitions.
top
§ 1000.20 Definitions specific to Medicare.
top
§ 1000.30 Definitions specific to Medicaid.
top
