Glossary

Acronyms
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ACTUARIAL STATUS

A measure of the adequacy of the financing as determined by the difference between assets and liabilities at the end of the periods for which financing was established.

ADDITIONAL BENEFITS

Health care services not covered by Medicare and reductions in premiums or cost sharing for Medicare-covered services. Additional benefits are specified by the MA Organization and are offered to Medicare beneficiaries at no additional premium. Those benefits must be at least equal in value to the adjusted excess amount calculated in the ACR. An excess amount is created when the average payment rate exceeds the adjusted community rate (as reduced by the actuarial value of coinsurance, copayments, and deductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the adjusted excess, which will be used to pay for services not covered by Medicare and/or will be used to reduce charges otherwise allowed for Medicare-covered services. Additional benefits can be subject to cost sharing by plan enrollees. Additional benefits can also be different for each MA plan offered to Medicare beneficiaries.

ADJUSTED AVERAGE PER CAPITA COST (AAPCC)

An estimate of how much Medicare will spend in a year for an average beneficiary. (See Risk Adjustment.)

ADJUSTED COMMUNITY RATING (ACR)

How premium rates are decided based on members' use of benefits and not their individual use of benefits.

ADMINISTRATIVE CODE SETS

Code sets that characterize a general business situation, rather than a medical condition or service. Under HIPAA, these are sometimes referred to as non-clinical or non-medical code sets. Compare to medical code sets.

ADMINISTRATIVE COSTS

A general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States' expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account.

ADMINISTRATIVE DATA

This refers to information that is collected, processed, and stored in automated information systems. Administrative data include enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on.

ADMINISTRATIVE EXPENSES

Expenses incurred by the Department of HHS and the Department of the Treasury in administering the SMI program and the provisions of the Internal Revenue Code relating to the collection of contributions. Such administrative expenses, which are paid from the SMI trust fund, include expenditures for contractors to determine costs of, and make payments to, providers, as well as salaries and expenses of CMS.

ADMINISTRATIVE LAW JUDGE (ALJ)

A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors.

ADMINISTRATIVE SERVICES ONLY

An arrangement whereby a self-insured entity contracts with a Third Party Administrator (TPA) to administer a health plan.