C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER A—GENERAL PROVISIONS › PART 400—INTRODUCTION; DEFINITIONS › Subpart B—Definitions

42 C.F.R. § 400.200

General definitions

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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.

Beneficiary means a person who is entitled to Medicare benefits and/or has been determined to be eligible for Medicaid.

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/IID stands for intermediate care facility for individuals with intellectual disabilities.

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.

Medicare Savings Programs (MSPs) has the same meaning described in § 435.4 of this chapter.

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.

Public Health Emergency (PHE) means the Public Health Emergency determined to exist nationwide as of January 27, 2020, by the Secretary pursuant to section 319 of the Public Health Service Act on January 31, 2020, as a result of confirmed cases of COVID-19, including any subsequent renewals.

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 (QMB) means an individual described in § 435.123 of this chapter.

Qualifying Individual (QI) means an individual described in § 435.125 of this chapter.

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.

Specified Low-Income Medicare Beneficiary (SLMB) means an individual described in § 435.124 of this chapter.

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.

[48 FR 12534, Mar. 25, 1983] Editorial Note:For Federal Register citations affecting § 400.200, see the List of CFR Sections Affected, which appears in the Finding Aids section of the printed volume and at www.govinfo.gov.
Notes of Decisions
Cited in 49 cases (5 in the last 5 years), 1985–2024 · leading case: Fischer v. United States
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Fischer v. United States (2000) scotus · cites it 2× “All agree Medicare is a federal assistance program, see 42 CFR § 400.200 (1999), and that WVHA, as the organization defrauded by petitioner's actions, received in excess of $10,000 in payments under the program.”
Robert Wood Johnson University Hospital, a Non-Profit Corporation v. Tommy G. Thompson, United States Department of Heal (2002) ca3 “42 C.F.R. § 400.200 . We use the prior name because it was in effect during the events relevant to this appeal.”
Pennsylvania Medical Society v. Foster (1992) pacommwct · cites it 2× “13-15, at 5; see 42 C.F.R. § 400.200 . The Commissioner has not included any affidavits from Pennsylvania Blue Shield.”
Massachusetts v. Sebelius (2011) ca1 “See 42 C.F.R. § 400.200 . In assessing the requirements of this statutory scheme, we must be mindful of any deference to which CMS may be entitled.”
Sunshine Haven Nursing Operations, LLC v. United States Department of Health & Human Services, Centers for Medicare & Me (2014) ca10 “2011) (citing 42 C.F.R. § 400.200 ¶ 2). Compliance is verified through unannounced inspections, called “surveys,” conducted on behalf of CMS by state survey agencies (SAs).”
DISTRICT HOSP. PARTNERS, LP v. Sebelius (2011) dcd “§ 1395kk; 42 C.F.R. § 400.200 et seq. When Medicare providers treat the program’s beneficiaries, they receive coinsurance and deductible payments from the patient and then seek reimbursement for remaining costs from the Medicare program.”
Cooper University Hospital v. Sebelius (2009) njd “42 C.F.R. § 400.200 . 2 . When this appeal was brought Michael O.”
Foothill Hospital-Morris L. Johnston Memorial v. Leavitt (2008) dcd “§ 1395kk; 42 C.F.R. § 400.200 . et seq. When a Medicare provider treats a beneficiary of the program, it collects coinsurance and deductible payments from the patient, and it then seeks reimbursement for the remaining costs from the Medicare program.”
Sierra Vista Regional Medical Center v. Bonta' (2003) calctapp “The statute defines “intensive care newborn nursery services” as “the provision of comprehensive and intensive care for all contingencies of the newborn infant, including intensive, intermediate, and continuing care.”
District Hospital Partners, L.P. v. Sebelius (2014) dcd “§ 1395kk; 42 C.F.R. § 400.200 et seq. When Medicare providers treat the program’s beneficiaries, they receive coinsurance and deductible payments from the patient and then seek reimbursement for remaining costs from the Medicare program.”
Turner v. Md. Dept. of Health (2020) mdctspecapp “” 42 C.F.R. § 400.200 . 19 (b) By providing proof of legal authority to act on behalf of an applicant or recipient.”
COVENANT HEALTH SYSTEM v. Sebelius (2011) dcd “42 C.F.R. § 400.200 . Therefore, the result of this adjustment is that a hospital receives a higher reimbursement per Medicare patient as it treats more Medicaid patients.”
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