Sec.

PART 400-INTRODUCTION;

DEFINITIONS

Subpart A-[Reserved]

Subpart B-Definitions

In this chapter, unless the context indicates otherwise

"Act" means the Social Security Act, and titles referred to are titles of that Act.

"Administrator" means the Administrator, Health Care Financing Administration.

“Area" means the geographical area within the boundaries of a State or a State or other jurisdiction designated as constituting an area with respect to which a Professional Standards Review Organization or a Utilization and Quality Control Peer Review Organization has been or may be designated.

"CFR" stands for Code of Federal Regulations.

"Department" means the Department of Health and Human Services (HHS), formerly the Department of Health, Education, and Welfare.

"ESRD" stands for end-stage renal disease.

"FR" stands for Federal Register. "HCFA" stands for Health Care Financing Administration.

"HHS" stands for the Department of Health and Human Services.

"HHA" stands for home health agency.

"HMO" stands for health maintenance organization.

"ICF" stands for intermediate care facility.

"Medicaid" means medical assistance provided under a State plan approved under title XIX of the Act.

"Medicare" means the health insurance program for the aged and disabled under title XVIII of the Act.

"OASDI" stands for the Old Age, Survivors, and Disability Insurance program under title II of the Act.

"PRO" stands for Utilization and Quality Control Peer Review Organization.

"PSRO" stands for Professional Standards Review Organization.

"Regional Administrator" means a Regional Administrator of HCFA.

"Regional Office" means one of the regional offices of HCFA.

"RHC" stands for rural health clinic. "Secretary" means the Secretary of Health and Human Services.

"SNF" stands for skilled nursing facility.

"Social security benefits" means monthly cash benefits payable under section 202 or 223 of the Act.

"SSA" stands for Social Security Administration.

"United States" means the fifty States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

"U.S.C." stands for United States Code.

"Utilization and Quality Control Peer Review Organization" (PRO) means an organziation that has a contract with HCFA to review, under Part B of title XI of the Act, the health care services or items furnished or proposed to be furnished to Medicare beneficiaries.

[48 FR 12534, Mar. 25, 1983, as amended at 49 FR 7206, Feb. 27, 1984; 50 FR 15326 and 15358, Apr. 17, 1985]

§ 400.202 Definitions specific to Medicare. As used in connection with the Medicare program, unless the context indicates otherwise

"Beneficiary" means a person who is entitled to Medicare benefits.

"Carrier" means an entity that has a contract with HCFA to determine and make Medicare payments for Part B benefits payable on a charge basis and to perform other related functions.

"Entitled" means that an individual meets all the requirements for Medicare benefits.

"Hospital insurance benefits" means payments on behalf of, and in rare circumstances directly to, an entitled individual for services that are covered under Part A of title XVIII of the Act.

Intermediary" means an entity that has a contract with HCFA to determine and make Medicare payments for Part A or Part B benefits payable on a cost basis and to perform other related functions.

"Medicare Part A" means the hospital insurance program authorized under Part A of title XVIII of the Act.

"Medicare Part B" means the supplementary medical insurance program authorized under Part B of title XVIII of the Act.

"Provider" means a hospital, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or effective November 1, 1983 through September 30, 1986, a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has a similar agreement but only to furnish outpatient physical therapy or speech pathology services.

"Railroad retirement benefits" means monthly benefits payable to individuals under the Railroad Retirement Act of 1974 (45 U.S.C. beginning at section 231).

"Services" means medical care or services and items, such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital or SNF facilities.

"Supplementary medical insurance benefits" means payment to or on behalf of an entitled individual for

services covered under Part B of title XVIII of the Act.

"Supplier" means a physician or other practitioner, or an entity other than a provider, that furnishes health care services under Medicare.

[48 FR 12534, Mar. 25, 1983, as amended at 48 FR 56024, Dec. 16, 1983; 49 FR 3658, Jan. 30, 1984]

§ 400.203 Definitions specific to Medicaid.

As used in connection with the Medicaid program, unless the context indicates otherwise

"Applicant" means an individual whose written application for Medicaid has been submitted to the agency determining Medicaid eligibility, but has not received final action. This inIcludes an individual (who need not be alive at the time of application) whose application is submitted through a representative or a person acting responsibly for the individual.

"Federal financial participation" (FFP) means the Federal Government's share of a State's expenditures under the Medicaid program.

"FMAP" stands for the Federal medical assistance percentage, which is used to calculate the amount of Federal share of State expenditures for services.

"Medicaid agency" or "agency" means the single State agency administering or supervising the administration of a State Medicaid plan.

"Provider" means any individual or entity furnishing Medicaid services under a provider agreement with the Medicaid agency.

"Recipient" means an individual who has been determined eligible for Medicaid.

"Services" means the types of medical assistance specified in sections 1905(a)(1) through (18) of the Act.

"State" means the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Northern Mariana Islands.

“State plan” or “the plan” means a comprehensive written commitment by a Medicaid agency, submitted under section 1902(a) of the Act, to administer or supervise the administra

§ 401.101 Purpose and scope.

(a) The regulations in this subpart (1) Implement section 1106(a) of the Social Security Act as it applies to the Health Care Financing Administration (HCFA). The rules apply to information obtained by officers or employees of HCFA in the course of administering title XVIII of the Social Security Act (Medicare), information obtained by Medicare intermediaries or carriers in the course of carrying out agreements under sections 1816 and 1842 of the Social Security Act, and any other information subject to section 1106(a) of the Social Security Act;

(2) Relate to the availability to the public, under 5 U.S.C. 552, of records of HCFA and its components. They set out what records are available and how they may be obtained; and

(3) Supplement the regulations of the Department of Health and Human Services relating to availability of information under 5 U.S.C. 552, codified in 45 CFR Part 5, and do not replace or restrict them.

(b) Except as authorized by the rules in this subpart, no information described in paragraph (a)(1) of this section shall be disclosed. The procedural rules in this subpart (§§ 401.106 through 401.152) shall be applied to requests for information which is subject to the rules for disclosure in this subpart.

(c) Requests for information which may not be disclosed according to the

For purposes of this subpart: "Act" means the Social Security Act.

"Freedom of Information Act rules" means the substantive mandatory disclosure provisions of the Freedom of Information Act, 5 U.S.C. 552 (including the exemptions from mandatory disclosure, 5 U.S.C. 552(b), as implemented by the Department's public information regulation, 45 CFR Part 5, Subpart F and by §§ 401.106 to 401.152 of this subpart.

"Person" means a person as defined in the Administrative Procedure Act, 5 U.S.C. 551(2). This includes State or local agencies, but does not include Federal agencies or State or Federal courts.

"Record" has the same meaning as that provided in 45 CFR 5.5.

of

"Subject individual" means an individual whose record is maintained by the Department in a system records, as the terms "individual," "record", and "system of records" are defined in the Privacy Act of 1974, 5 U.S.C. 552a(a).

(a) General rule. The Freedom of Information Act rules shall be applied to every proposed disclosure of information. If, considering the circumstances of the disclosure, the information would be made available in accordance with the Freedom of Information Act rules, then the information may be disclosed regardless of whether the requester or recipient of the information has a statutory right to request the information under the Freedom of Information Act, 5 U.S.C. 552, or whether a request has been made.

(b) Application of the general rule. Pursuant to the general rule in paragraph (a) of this section,

(1) Information shall be disclosed