Tenn. Comp. R. & Regs. 1200-13-17-.01 - DEFINITIONS

(1) COST EFFECTIVE ALTERNATIVE SERVICE is defined at Rule 1200-13-13-.01.

(2) DUAL ELIGIBLE shall mean a person who is a Medicare beneficiary and who is entitled to some form of assistance from TennCare Medicaid.

(3) FULL BENEFIT DUAL ELIGIBLE (FBDE) shall mean a Medicare beneficiary who also qualifies for TennCare benefits, except that Waiver Duals are not considered FBDEs.

(4) MANAGED CARE CONTRACTOR (MCC) is defined at Rule 1200-13-13-.01.

(5) MEDICARE ALLOWED AMOUNT shall mean the amount that Medicare considers reasonable for a Medicare-covered service, as defined on the claim for that service.

(6) MEDICARE BENEFITS shall mean the health care services available to Medicare beneficiaries through the Medicare program where payment for the services is either completely the obligation of the Medicare program or in part the obligation of the Medicare program, with the remaining payment (cost sharing) obligations belonging to the beneficiary, some other third party, or TennCare.

(7) MEDICARE COINSURANCE is defined as "Coinsurance" at Rule 1240-03-01-.02(1).

(8) MEDICARE COST-SHARING shall mean TennCare's obligation for payment of certain Medicare beneficiaries' Medicare deductibles and coinsurance.

(9) MEDICARE CROSSOVER CLAIM shall mean a claim that has been submitted to the Bureau of TennCare for Medicare cost sharing payments after the claim has been adjudicated by Medicare and paid by Medicare and Medicare has determined the enrollee's liability. Claims denied by Medicare or not submitted to Medicare are not considered Medicare crossover claims.

(10) MEDICARE DEDUCTIBLE is defined as "Deductible" at Rule 1240-03-01-.02(1).

(11) MEDICARE PAID AMOUNT is defined as the amount Medicare actually paid on a claim, which is generally a percentage of the Medicare allowed amount. The Medicare paid amount on a Medicare Part C claim is the amount that the Part C plan paid.

(12) MEDICARE PART A is defined at Rule 1240-03-01-.02(1).

(13) MEDICARE PART B is defined at Rule 1240-03-01-.02(1).

(14) MEDICARE PART C refers to the Medicare Advantage program authorized under Part C of Title XVIII of the Social Security Act, through which beneficiaries may choose to enroll in private managed care plans that contract with the Centers for Medicare and Medicaid Services (CMS). These plans may be HMO plans, PPO plans, or private fee-for-service plans. They offer combined coverage of Part A, Part B, and, in most cases, Part D benefits. Some Medicare Advantage plans offer additional benefits not otherwise covered by Medicare.

(15) MEDICARE PREMIUMS shall mean the Medicare Part A and/or Medicare Part B premiums for which TennCare is responsible, depending on the enrollee's eligibility group. TennCare does not pay for Medicare Part C premiums, Medicare Part D premiums, or any other Medicare premiums.

(16) PHARMACY PROVIDERS shall mean providers enrolled with the Medicare program and with Medicaid to provide Medicare Part B pharmacy services.

(17) PHARMACY SERVICES shall mean outpatient prescription drugs provided through Medicare Part B.

(18) PROFESSIONAL SERVICES shall mean the professional/technical component of Medicare services. These services are typically provided by non-institutional providers or suppliers such as physicians, outpatient clinics, and Durable Medical Equipment vendors. They are generally covered under Medicare Part B and billed on a CMS-1500 claim form. Services that are not billed on a CMS-1500 claim form or an ASC X12N 837P claim transaction are not considered part of this definition.

(19) QMB shall mean Qualified Medicare Beneficiary, as defined at Rule 1240-03-02-.02(2).

(20) SSI shall mean the federal Supplemental Security Income program that provides monthly income to low-income aged, blind, and disabled individuals. An "active" SSI recipient is one who is receiving monthly SSI checks.

(21) TENNCARE ALLOWABLE shall mean the lower of the TennCare maximum fee or 85% of the Medicare allowed amount on the claim.

(22) TENNCARE COVERED SERVICE shall mean any service that is listed as "covered" in Rules 1200-13-13-.04 and 1200-13-14-.04 and that is not listed specifically as an exclusion in Rules 1200-13-13-.10 and 1200-13-14-.10.

(23) TENNCARE MAXIMUM FEE shall mean the maximum amount considered by TennCare for reimbursement of a particular Medicare-covered service. The TennCare maximum fee is 85% of the Cigna Medicare fee schedule amount for participating providers that was in effect on January 1, 2008.

(24) TENNCARE PAYMENT AMOUNT shall mean the net amount paid by TennCare on a Medicare crossover claim. The TennCare payment amount will be the TennCare allowable, less the amount Medicare paid on the claim, less any third party liability. The TennCare payment amount shall not exceed the enrollee's liability on the claim.

(25) TENNCARE PHARMACY ALLOWABLE shall mean, for Medicare Part B pharmacy services provided to FBDEs by pharmacy providers, as defined in these rules, 100% of the Medicare allowed amount on the claim.

(26) WAIVER DUAL shall mean a person who was enrolled in TennCare as of December 31, 2001, as an Uninsured or Uninsurable and who also had Medicare. This category was closed for adults 19 and older on April 29, 2005. Waiver Duals are not considered Full Benefit Dual Eligibles.

Notes

Tenn. Comp. R. & Regs. 1200-13-17-.01

Public necessity rule filed July 1, 2008; effective through December 13, 2008. New rule filed September 24, 2008; effective December 8, 2008. Public necessity rules filed July 1, 2009; effective through December 13, 2009. Amendments filed September 11, 2009; effective December 10, 2009.

Authority: T.C.A. 4-5-202, 4-5-209, 71-5-105, and 71-5-109.