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
(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.
(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.
(8) MEDICARE COST-SHARING shall mean
TennCare's obligation for payment of certain Medicare beneficiaries' Medicare
deductibles and coinsurance.
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.
(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.
(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
(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
SERVICES shall mean outpatient prescription drugs provided through Medicare
(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.
QMB shall mean Qualified Medicare
Beneficiary, as defined at Rule
(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.
ALLOWABLE shall mean the lower of the TennCare maximum fee or 85% of the
Medicare allowed amount on the claim.
(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
(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
(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.
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.