Glossary

Utilization of services that are in excess of a beneficiary's medical needs and condition (overutilization) or receiving a capitated Medicare payment and failing to provide services to meet a beneficiary's medical needs and condition (underutilization).

Values relating to future trends in certain key factors that affect the balance in the trust funds. Demographic assumptions include fertility, mortality, net immigration, marriage, divorce, retirement patterns, disability incidence and termination rates, and changes in the labor force. Economic assumptions include unemployment, average earnings, inflation, interest rates, and productivity. Three sets of economic assumptions are presented in the Trustees Report:

1. The low cost alternative, with relatively rapid economic growth, low inflation, and favorable (from the standpoint of program financing) demographic conditions;
2. The intermediate assumptions, which represent the Trustees' best estimates of likely future economic and demographic conditions; and
3. The high cost alternative, with slow economic growth, more rapid inflation and financially disadvantageous demographic conditions.

See also Hospital assumptions.

Wages and wages in kind that were not subject to the HI tax but are deemed as having been. Deemed wage credits exist for the purposes of (1) determining HI program eligibility for individuals who might not be eligible for HI coverage without payment of a premium were it not for the deemed wage credits; and (2) calculating reimbursement due the HI trust fund from the general fund of the Treasury. The first purpose applies in the case of providing coverage to persons during the transitional periods when the HI program began and when it was expanded to cover federal employees; both purposes apply in the cases of military service wage credits (see "Military service wage credits" and "Quinquennial military service determinations and adjustments") and deemed wage credits granted for the internment of persons of Japanese ancestry during World War II.

Wages paid for services rendered in covered employment up to the annual maximum taxable amount.

What you pay out-of-pocket according to your health plan coverage when you get care from a provider or service that doesn't contract with your health plan for lower in-network service rates. An out-of-network copayment is a fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health plan. Out-of-network copayments usually are more than in-network copayments. An out-of-network coinsurance is your share (for example, 40%) of the allowed amount for covered health care services to providers who don't contract with your health plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

What you pay out-of-pocket for services and care for participating providers and services through your health plan. An in-network copayment is a fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health plan. In-network copayments usually are less than out-of-network copayments. An in-network coinsurance is your share (for example, 20%) of the allowed amount for covered health care services. Your share is usually lower for in-network covered services.

When a health plan has no money or other means to stay open and give health care to patients.

When a provider bills you for the balance remaining on the bill that your plan doesn't cover. This amount is the difference between the actual billed amount and the allowed amount. This happens most often when you see an out-of-network provider (non-preferred provider). These balance bill costs are in addition to what you pay out-of-pocket for out-of-network services according to your health plan coverage. An in-network provider (preferred provider) may not balance bill you for covered services.

When a requestor formally requests permission to rerelease CMS data that has been formatted into statistical or aggregated information by the recipient. CMS is responsible for reviewing the files/reports to ensure that they contain no data elements or combination of data elements that could allow for the deduction of the identity of the Medicare beneficiary or a physician and that the level of cell size aggregation meets the stated requirement.

When another person does something on purpose that causes you mental or physical harm or pain.