Glossary

The M+C Plan charge schedule used to base the maximum dollar coverage or coinsurance level for a service category (e.g., a $500 annual coverage limit for a prescription drug benefit may be based on a Published Retailed Price schedule, or 20% coinsurance for DME benefit may be based on a Medicare FFS fee schedule).

The CIM has been replaced by the Medicare National Coverage Determinations Manual.

A health service or item that is included in your health plan, and that is paid for either partially or fully.

Services or benefits for which a health plan makes either partial or full payment.

Earnings in employment covered by the HI program.

All employment and self-employment creditable for Social Security purposes. Almost every kind of employment and self-employment is covered under the program. In a few employment situations-for example, religious orders under a vow of poverty, foreign affiliates of American employers, or the employer must elect State and local governments-coverage. However, effective July 1991, coverage is mandatory for State and local employees who are not participating in a public employee retirement system. All new State and local employees have been covered since April 1986. In a few situations-for instance, ministers or self-employed members of certain religious groups-workers can opt out of coverage. Covered employment for HI includes all federal employees (whereas covered employment for OASDI includes some, but not all, federal employees).

Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Functions that make an entity a health plan, a health care provider, or a health care clearinghouse.

Services for which SMI pays, as defined and limited by statute. Covered services include most physician services, care in outpatient departments of hospitals, diagnostic tests, DME, ambulance services, and other health services that are not covered by the HI program.

A person who has earnings creditable for Social Security purposes on the basis of services for wages in covered employment and/or on the basis of income from covered self-employment. The number of HI covered workers is slightly larger than the number of OASDI covered workers because of different coverage status for federal employment. See "Covered employment."