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Glossary

Glossary

This glossary explains terms found on the cms.hhs.gov web site, but it is not a legal document.

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S

Term Definition
SANCTIONS

Administrative remedies and actions (e.g., exclusion, Civil Monetary Penalties, etc.) available to the OIG to deal with questionable, improper, or abusive behaviors of providers under the Medicare, Medicaid, or any State health programs.

SECOND OPINION

This is when another doctor gives his or her view about what you have and how it should be treated.

SECONDARY PAYER

An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.

SECRETARY

The Secretary of Health and Human Services.

SEER - MEDICARE DATABASE

Consists of a linkage of the clinical data collected by the SEER registries with claims for health services collected by Medicare for its beneficiaries.

SEER PROGRAM

The SEER Program of the National Cancer Institute is the most authoritative source of information on cancer incidence and survival in the United States. For further information go to: http://seer.cancer.gov.

SEGMENT

Under HIPAA, this is a group of related data elements in a transaction.

SELF DIALYSIS

Dialysis performed with little or no professional assistance (except in emergency situations) by an ESRD patient who has completed an appropriate course of training, in a dialysis facility or at home.

SELF-EMPLOYMENT

Operation of a trade or business by an individual or by a partnership in which an individual is a member.

SELF-EMPLOYMENT CONTRIBUTION ACT PAYROLL TAX

Medicare's share of SECA is used to fund the HI Trust Fund. In fiscal year 1996, self-employed individuals contributed 2.9 percent of taxable annual income, with no limitation. net income of most self-employed persons to provide for the OASDI and HI programs.

SELF-INSURED

An individual or organization that assumes the financial risk of paying for health care.

SEQUESTER

The reduction of funds to be used for benefits or administrative costs from a federal account based on the requirements specified in the Gramm-Rudman-Hollings Act.

SERVICE

Medical care and items such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital RPCH or SNF facilities. (42 CFR 400.202).

SERVICE AREA

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan?s service area.

SERVICE AREA (PRIVATE FEE-FOR-SERVICE)

The area where a Medicare Private Fee-for-Service plan accepts members.

SERVICE CATEGORY DEFINITION

A general description of the types of services provided under the service and/or the characteristics that define the service category.

SHORT RANGE

The next 10 years.

SIDE EFFECT

A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy. Most treatments have side effects.

SINGLE DRUG PRICER

The SDP is a drug-pricing file containing the allowable price for each drug covered incident to a physician's service, drugs furnished by independent dialysis facilities that are separately billable from the composite rate, and clotting factors to inpatients. The SDP is, in effect, a fee schedule, similar to other CMS fee schedules.

SKILLED CARE

A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.

SKILLED NURSING CARE

A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

SKILLED NURSING FACILITY

A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

SKILLED NURSING FACILITY (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.

SKILLED NURSING FACILITY CARE

This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.

SMALL HEALTH PLAN

Under HIPAA, this is a health plan with annual receipts of $5 million or less.

SMI PREMIUM

Monthly premium paid by those individuals who have enrolled in the voluntary SMI program.

SNF COINSURANCE

For the 21st through 100th day of extended care services in a benefit period, a daily amount for which the beneficiary is responsible, equal to one-eighth of the inpatient hospital deductible.

SOCIAL HEALTH MAINTENANCE ORGANIZATION (SHMO)

A special type of health plan that provides the full range of Medicare benefits offered by standard Medicare HMOs, plus other services that include the following: prescription drug and chronic care benefits, respite care, and short-term nursing home care; homemaker, personal care services, and medical transportation; eyeglasses, hearing aids, and dental benefits.

SOCIAL SECURITY ACT

Public Law 74-271, enacted on August 14, 1935, with subsequent amendments. The Social Security Act consists of 20 titles, four of which have been repealed. The HI and SMI programs are authorized by Title XVIII of the Social Security Act.

SOCIAL SECURITY ADMINISTRATION

The Federal agency that, among other things, determines initial entitlement to and eligibility for Medicare benefits.

SPECIAL ELECTION PERIOD

A set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: you move outside the service area, your Medicare+Choice organization violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election Periods; Enrollment; Special Enrollment Period (SEP).)

SPECIAL ENROLLMENT PERIOD

A set time when you can sign up for Medicare Part B if you didn?t take Medicare Part B during the Initial Enrollment Period, because your or your spouse were working and had group health plan coverage through the employer or union. You can sign up at anytime you are covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment ends or the group health coverage ends, whichever comes first.

SPECIAL PUBLIC-DEBT OBLIGATION

Securities of the U.S. Government issued exclusively to the OASI, DI, HI, and SMI trust funds and other federal trust funds. Section 1841(a) of the Social Security Act provides that the public-debt obligations issued for purchase by the SMI trust fund shall have maturities fixed with due regard for the needs of the funds. The usual practice in the past has been to spread the holdings of special issues, as of every June 30, so that the amounts maturing in each of the next 15 years are approximately equal. Special public-debt obligations are redeemable at par at any time.

SPECIALIST

A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.

SPECIALTY CONTRACTOR

A Medicare contractor that performs a limited Medicare function, such as coordination of benefits, statistical analysis, etc.

SPECIALTY PLAN

A type of Medicare Advantage Plan that provides more focused health care for some people. These plans give you all your Medicare health care as well as more focused care to manage a disease or condition such as congestive heart failure, diabetes, or End-Stage Renal Disease.

SPECIFIED DISEASE INSURANCE

This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn?t fill gaps in your Medicare coverage.

SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB)

A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

SPEECH-LANGUAGE THERAPY

Treatment to regain and strengthen speech skills.

SPELL OF ILLNESS

A period of consecutive days, beginning with the first day on which a beneficiary is furnished inpatient hospital or extended care services, and ending with the close of the first period of 60 consecutive days thereafter in which the beneficiary is in neither a hospital nor a skilled nursing facility.

STAFF ASSISTED DIALYSIS

Dialysis performed by the staff of the renal dialysis center or facility.

STANDARD CLAIMS PROCESSING SYSTEM

Certain computer systems currently used by carriers and FIs to process Medicare claims. For physician and lab claims, the system is Electronic Data Systems (EDS); for facility and other Part A provider claims, the system is the Fiscal Intermediary Standard System (FISS), formerly known as the Florida Shared System (FSS); and for supplier claims, the system is the Viable Information Processing System (VIPS).

STANDARD TRANSACTION

Under HIPAA, this is a transaction that complies with the applicable HIPAA standard.

STATE CERTIFICATION

Inspections of Medicare provider facilities to ensure compliance with Federal health, safety, and program standards.

STATE CHILDREN'S HEALTH INSURANCE PROGRAM

Free or low-cost health insurance is available now in your state for uninsured children under age 19. State Children?s Health Insurance Programs help reach uninsured children whose families earn too much to qualify for Medicaid, but not enough to get private coverage. Information on your state?s program is available through Insure Kids Now at 1-877-KIDS NOW (1-877-543-7669). You can also look at www.insurekidsnow.gov on the web for more information.

STATE HEALTH INSURANCE ASSISTANCE PROGRAM

A State program that gets money from the Federal Government to give free local health insurance counseling to people with Medicare.

STATE INSURANCE DEPARTMENT

A state agency that regulates insurance and can provide information about Medigap policies and any insurance-related problem.

STATE LAW

A constitution, statue, regulation, rule, common law, or any other State action having the force and effect of law.

STATE LICENSURE AGENCY

A State agency that has the authority to terminate, sanction, or prosecute fraudulent providers under State law.

STATE MEDICAL ASSISTANCE OFFICE

A State agency that is in charge of the State?s Medicaid program and can give information about programs to help pay medical bills for people with low incomes. Also provides help with prescription drug coverage.

STATE OR LOCAL PUBLIC HEALTH CLINIC

A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.

STATE SURVEY

Under 1864 of the Act, CMS has entered into agreements with agencies of State governments, typically the agency that licenses health facilities within the State Health Departments, to conduct surveys of Medicare participating providers and suppliers for purposes of determining compliance with Medicare requirements for participation in the Medicare program.

STATE SURVEY AGENCY

Agency that inspects dialysis facilities and makes sure that Medicare standards are met.

STATE UNIFORM BILLING COMMITTEE

A state-specific affiliate of the NUBC.

STATUS LOCATION

An indicator on a claim record describing the queue where the claim is currently situated and the action that needs to be performed on the claim.

STOCHASTIC MODEL

An analysis involving a random variable. For example, a stochastic model may include a frequency distribution for one assumption. From the frequency distribution, possible outcomes for the assumption are selected randomly for use in an illustration.

STRATEGIC NATIONAL IMPLEMENTATION PROCESS

A national WEDI effort for helping the health care industry identify and resolve HIPAA implementation issues.

SUBSIDIZED SENIOR HOUSING

A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.

SUBSTANTIAL FINANCIAL RISK

Means an incentive arrangement that places the physician or physician group at risk for amounts beyond the risk threshold, if the risk is based on the use or costs of referral services. The risk threshold is 25%. However, if the patient panel is greater than 25,000 patients, then the physician group is not considered to be at substantial financial risk because the risk is spread over the large number of patients. Stop loss and beneficiary surveys would not be required.

SUMMARIZED COST RATE

The ratio of the present value of expenditures to the present value of the taxable payroll for the years in a given period. In this context, the expenditures are on an incurred basis and exclude costs for those uninsured persons for whom payments are reimbursed from the general fund of the Treasury, and for voluntary enrollees, who pay a premium in order to be enrolled. The summarized cost rate includes the cost of reaching and maintaining a "target" trust fund level, known as a contingency fund ratio. Because a trust fund level of about 1 year's expenditures is considered to be an adequate reserve for unforeseen contingencies, the targeted contingency fund ratio used in determining summarized cost rates is 100 percent of annual expenditures. Accordingly, the summarized cost rate is equal to the ratio of (1) the sum of the present value of the outgo during the period, plus the present value of the targeted ending trust fund level, plus the beginning trust fund level, to (2) the present value of the taxable payroll during the period.

SUMMARIZED INCOME RATE

The ratio of (1) the present value of the tax revenues incurred during a given period (from both payroll taxes and taxation of OASDI benefits), to (2) the present value of the taxable payroll for the years in the period.

SUPPLEMENTAL EDIT SOFTWARE

A system, outside the Standard Claims Processing System, which allows further automation of claim reviews. It may be designed using the logic, or "expertise" of a medical professional. Appendix P, PSC's Supplemental Edit Software.

SUPPLEMENTARY MEDICAL INSURANCE

The Medicare program that pays for a portion of the costs of physicians' services, outpatient hospital services, and other related medical and health services for voluntarily insured aged and disabled individuals. Also known as Part B.

SUPPLIER

Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.

SURVEY AND CERTIFICATION PROCESS

The activity conducted by State survey agencies or other CMS agents under the direction of CMS and within the scope of applicable regulations and operating instructions and under the provisions of 1864 of the Act whereby surveyors determine compliance or noncompliance of Medicare providers and suppliers with applicable Medicare requirements for participation. The survey and certification process for each provider and supplier is outlined in detail in the State Operations and Regional Office Manuals published by CMS.

SUSPENSION OF PAYMENTS

The withholding of payment by an FI or carrier from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists.

SUSTAINABLE GROWTH RATE

A system for establishing goals for the rate of growth in expenditures for physicians' services.

SYNTAX

The rules and conventions that one needs to know or follow in order to validly record information, or interpret previously recorded information, for a specific purpose. Thus, a syntax is a grammar. Such rules and conventions may be either explicit or implicit. In X12 transactions, the data-element separators, the sub-element separators, the segment terminators, the segment identifiers, the loops, the loop identifiers (when present), the repetition factors, etc., are all aspects of the X12 syntax. When explicit, such syntactical elements tend to be the structural, or format-related, data elements that are not required when a direct data entry architecture is used. Ultimately, though, there is not a perfectly clear division between the syntactical elements and the business data content.

SYSTEM NOTICE

A document published in the Federal Register notifying the public of a new or revised System of Records.

SYSTEM OF RECORDS

A collection of records from which an agency retrieves information by reference to an individual identifier.

SYSTEMATIC

Pursuing a defined objective(s) in a planned, step by step manner.


*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.


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