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New-Material

1  January 2006

Glossary of Wonky Medicaid, Medicare, VA, Health & Other Related Program Terms:

209(b) states---CT, HI, IL, IN, MN, MO, NH, ND, OH, OK and VA; retain some old, minor, slightly stricter-than-SSI aged and disabled Medicaid eligibility rules due to long-forgotten, no-longer-justified state policy decisions made over 30 years ago; hence, SSI does not confer automatic Medicaid eligibility and the aged and\ disabled must also apply separately and duplicatively for Medicaid at welfare offices, causing unnecessary, expensive welfare workloads; 209(b) states that don’t otherwise have spend downs (IN, MO, OH and OK) must in exchange allow the aged and disabled to spend down; named for Section 209(b) of Public Law 92-603.

1616---Section 1616 of the Social Scurity Act allows states to arrange to have SSA pay out their SSPs as part of, and on top of, the basic federal SSI payment; and, except for group home SSPs, almost all 1634 states arrange for SSA to do so.

1619---Section 1619 of the Social Security Act gives continued Medicaid to disabled persons who “work their way off’ SSI, so long as their earnings don’t exceed individual state threshold levels (which, roughly, vary from about $19,000 to over $30,000 yearly).

1634 states---AL, AZ, DC, DE, FL, GA, KY, LA, MA, MD, ME, MI, MS, MT, NJ, NM, NY, NC, PA, RI, SC, SD, TN, TX, VT, WA, WV, WI & WY are “1634 states’ that give Medicaid automatically to all SSI recipients; named for Section 1634 of the Social Security Act, which authorized this procedure. 

Acceleration---the process by which an individual or group life insurance policy itself pays a portion (usually up to 50% of the face benefit amount with the rest staying in place for payment to beneficiaries) of the death benefit early to an insured person who can document with medical records and physician statements that s/he is terminally ill or medically needs nursing home or home nursing care; the early payout, unlike with viatication, is not reduced actuarially or for profit, except for a small transaction fee; payments are tax-free but—unless used for nursing care—are countable by SSI, welfare, Medicaid & VA pension & medical programs; acceleration is typically paid out in lump sums, except that pay-outs for nursing care are usually monthly.

ADLs---Activities of Daily Living; patients must suffer some deficits in (inability to perform) common ADLs (bathing, dressing, eating, mobility, transferring, toileting and, sometimes, grooming and mouth care, etc.) to qualify medically for SNF, ICF, HCB, home health, personal attendant, supervised group home SSPs and VA A & A benefits. But SNF, ICF, HCB & home health patients must also need professional-level medical services.   

ADAPs---AIDS Drug Assistance Programs; federally-funded, state-run programs to provide drugs to uninsured or under-insured HIV+ persons with incomes & assets below state-set levels; within broad federal guidelines, states decide which drugs to cover (not only “anti-HIV” drugs per se, but also many for the wide range of HIV-caused secondary, opportunistic infections and conditions) and how to dispense them; almost all states add their own funds as well.

AHCCS---(pronounced “Access”); Arizona Health Care Cost Containment System; Arizona’s name for its medciad program, which is operated under a Section 1115 waiver.

Aid & Attendance---an extra $589.83 monthly (2006) added to the basic VA pension level for disabled & over-age-65 wartime veterans with significant ADL deficits; their surviving spouses, if they themselves have ADL deficits, can get A & A pension add-ons of up to $353.83. 

Allowable charges or reasonable charges or costs---the amount which Medicare, each Medicaid & CHIP program & each private insurance plan will pay, under its own individual rules, for a given medical service or item; but any deductible, co-pay or coinsurance due from the patient is subtracted from this figure.

Asset—or “resources”; the maximum amount of money & things worth money one can have to be eligible for needs-based programs; called “net worth” by the VA; virtually all programs  permit a lived-in home of any value, one vehicle, household goods, small burial funds or plots & life insurance with low cash surrender value; but “liquid” (i.e., convertible to cash) asset levels vary from program to program, state-to-state and by category (e.g., families vs. aged/ disabled).

Auxiliary Social Security benefits---smaller benefit checks given to each dependent or surviving minor child (and sometimes their other parent too) of disabled, retired or deceased Social Security-covered workers.

BCCPTA---the Breast & Cervical Cancer Prevention & Treatment Act offers states the higher CHIP matching rate to give full Medicaid (not just cancer care), but with no income or asset test, to uninsured women under 65 who screen positive for breast or cervical cancer or precursors (e.g., HPV, human papilloma virus; PID, pelvic inflammatory disease) at free, federally-funded local cancer screening centers; all states offer this coverage.

Buy-in---since 1965, the process by which states pay Medicare Part B--and, where appropriate, Part A-- premiums for their Medicare-eligible Medicaid and MSP patients; but this term is also used since 1997-99 to describe the option for states to give Medicaid, paid for by low sliding scale premiums (“buy-ins”), to working disabled, “ex-disabled” and even “pre-disabled” persons with earnings under extra-high income eligibility levels.

CAPs---Combined Application Programs, sponsored by SSA and the Food & Nutrition Service, give food stamps automatically & simultaneously to SSI recipients living independently, without need to apply at welfare offices. 

Capitation---the process by which Medicare, Medicaid or other health coverages purchase a set package of health services that may be needed from HMOs & other managed care organizations, for a per-patient price.

Caretaker—under the old AFDC welfare program---and AFDC-based Medicaid too--this was almost always the single welfare mother caring for her children, since a second parent couldn’t be covered unless he was involuntarily unemployed after a long work history or “incapacitated” (disabled under state rules more liberal than SSA’s). This was called the “man-in-the-house” rule. But states also let any other relative raising children and pooling income with them be caretakers in loco parentis and thus recipients of AFDC and Medicaid--- and this is still true. With welfare reform in 1996,  TANF replaced AFDC and states could now give TANF and Medicaid to two parent families. Few did so for TANF (they kept the previous “man-in-the-house”/unemployment/incapacity limits) but almost all now give Medicaid to two parent families: A little-known, but big liberalization buried in a conservative welfare reform law. 

Caring Program for Children—also known by other, similar names; subsidized, cheap health insurance for children (and sometimes parents too), once—and, in some cases, still now--offered by many (but not all) local Blue Cross plans.  

Categorically needy (CN) —in Medicaid eligibility, these were originally those whom states had to cover because they received, or were eligible for, AFDC (now called TANF), SSI or, at state option, SSPs. But from the very beginning, and increasingly more over the years, this principle quickly eroded, and states also had to cover, or could choose to cover, as CN, other persons who generally meet CN-type income/asset levels but who don’t or can’t get checks (e.g., Ribicoff children under AFDC/TANF income levels who can’t actually get TANF because they’re not living with a parent; aged & disabled who can’t actually get SSI because they’re in a medical facility; those too proud to take the SSI “welfare” check, but who still want Medicaid). Now (with some minor exceptions), states can and do set their CN income & asset levels as high as they want, category by category, independent of, and higher than, TANF, SSI or SSP levels. Categories include: pregnant women & infants; children 1 to 6; children 6 to 18; families (now usually both parents, or relative caretakers in loco parentis, plus children); aged; blind; disabled; TB-infected persons;  uninsured women under 65 screened positive for breast or cervical cancer or precursor conditions; the working disabled, “ex-disabled” and/or “pre-disabled”; and others.  

CHAMPVA—premium-free health insurance for dependents and survivors of 100% disabled service-connected veterans and those dying on active duty; Congress recently extended eligibility to those over age 65 coverage for secondary-to-Medicare coverage.

CHIP (or SCHIP)—State Child Health Insurance Program; federally-matched, state-run programs offering free or very-low-premium health insurance to children of the working poor with family incomes over state Medicaid levels; states’ CHIP matching rates are roughly almost 15%  higher than their Medicaid matching rates; waivers can also cover parents & other in loco parentis related caretakers (e.g., as in NJ, RI & WI); unlike Medicaid, CHIP has no spend down, but a few states let over-income families pay higher premiums to cover their children.

CMS---the Centers for Medicare and Medicaid Services, formerly called the Health Care Financing Administration, or HCFA, the federal agency responsible for running Medicare, overseeing state Medicaid and CHIP programs and administering other health programs.

COBRA---Consolidated Omnibus Budget Reconciliation Act of 1986, which requires most employers to permit former employees and dependents; their former spouses; and their children attaining majority age to purchase continued coverage in the employer health plan but fully at their own expense for 18 months (plus 11 months more if one timely reports an SSA disability application) and for 36 months for divorced or widowed spouses or majority-aged children.

Coinsurance---is the percentage of a given medical care service’s or item’s cost that the patient, rather than his health coverage, must pay; a co-payment is a fixed dollar amount portion of the cost that the patient must pay.

Conditional eligibility---the process by which applicants with somewhat “too much” in assets (e.g., non-lived-in rural property for which there’s no ready good market; property owned jointly with a non-cooperative co-owner) are given temporary SSI benefits (and, by extension) Medicaid) while they attempt to sell them and repay program payments out of the proceeds.

Coordination of benefits---see primary and secondary.

Countable income—the remaining, “net” income of an applicant which needs-based programs compare to their income eligibility levels to determine eligibility and the amount of benefits—after deducting the disregards used by that program (e.g., SSI compares countable income to its monthly income level--$603 in 2006, plus any SSP--after deducting $20 of any income; $65 and half the rest of earnings; IRWEs; and certain other amounts.

Crowd out---the concern of policymakers, and consequently their attempts to counter, the feared likelihood that parents with children who are income-eligible for CHIP would enroll them in CHIP at public expense, rather than add them as dependents (usually at some premium cost to themselves) to their available job health plans.

DAC—a disabled adult child whose disability first onsetted before the age of majority & who gets SSDI based on the Social Security record of a dead, disabled or retired parent; DAC benefit amounts equal about 60% of the parent’s own earned Social Security benefit is or would be. 

Deductible--a fixed annual amount of medical care which a patient must pay before his health coverage begins.

DIC—Disability Indemnity Compensation is paid to surviving spouses & children of service-connected disabled veterans; dependents & survivors of those rated 100% disabled also get CHAMPVA health insurance.

Date of Onset---(DO); the exact date on which an SSI, SSDI or Medicaid applicant first beomes disabled within the meaning of the Social Security Act; this may well be before the dates of application, first treatment, medical diagnosis or even work-cessation; this concept is also used by the VA compensation & pension programs and---just as is true for SSDI DACs--for VA pension, DIC and A&A payments helpless adult children must have DOs before age 18.

Disregard---an amount and/or percentage of gross, total income that’s not counted against a program’s eligibility income level; some programs have separate disregards for earned and unearned or general income.

Donut hole---yearly gap of non-coverage of drug costs, after $2250 up to $5100, for Part D patients with income over 150% FPL.

Dual eligibles—Medicare patients who are also eligible for full Medicaid coverage in their states, and not just MSP benefits.

Emergency assistance---one-time welfare payments to, or on behalf of, poor families, aged & disabled facing financial crises (eviction, rent & utility delinquency, homelessness, broken appliances & cars, etc.); offered by most liberal, “blue” states but few conservative, “red” states.

EPSDT---Early & Periodic Screening, Diagnosis & Treatment, since 1969, must be offered & provided by state Medicaid programs for eligible children; states must provide services & items like dental care, eyeglasses, hearing aids, etc., without cost-sharing, even if they’re ordinarily not covered by the state Medicaid program.

Extended period of eligibility (EPE)—15 months after the SSDI Trial Work Period (TWP), during which 1) beneficiaries may earn at SGA levels; 2) SSDI checks for those earning at SGA levels stop after 3 Grace Period months; 3) Medicare continues; and 4) those who stop earning at SGA levels can regain SSDI without full-dress applications. 

Extra Help---enhanced Part D drug benefits, with no donut hole, for those with incomes under 150%; those under 135% face no premium or deductible & co-pays of $1, $2, $3 or $5; those from 135% to 150% have low premiums, a  $50 yearly deductible & coinsurance of only 15%.

ETHA---Early Treatment for HIV Act, a bill that would offer states the higher CHIP matching rate to give Medicaid to HIV+ persons (even if they are not yet fully disabled) with incomes or even work earnings under extra-high eligibility levels.

Fair hearing---an administrative hearing, usually before an Administrative Law Judge (ALJ)  to which aggrieved welfare & Medicaid applicants and recipients can appeal if they are improperly denied eligibility or services to which they are entitled under law & regulations; SSI, Social Security, VA and other benefit programs also offer similar hearings, using similar names.    

Family Opportunity Act---a bill that would allow states to give Medicaid, using extra-high income eligibility levels & with sliding scale cost-sharing, to disabled children in middle-income families whose job health insurance doesn’t offer the rehabilitative, respite, equipment, home health & specialized care Medicaid does. 

Fee-for-service---the process by which Medicare, Medicaid and other health coverages pay for their eligible patients’ care, bill-by-individual-bill, as submitted by doctors, hospitals & other medical providers.

FFP---federal financial participation; this refers to services which are, or can be, federally-funded or  –matched, such as with Medicaid and other programs; it is also jargon for what is more generally (and clearly) called the federal matching rate; the percentage of allowable program costs which the federal government pays for.

FMAP---the federal medical assistance percentage; the federal Medicaid matching rate; see matching rate.

Formulary---a list of drugs covered by a Part D plan, Medicaid, CHIP, a private insurance plan or an HMO.

FPL---federal poverty level; family-sized income levels, which are announced yearly each February by the Department of Health & Human Services; they (and multiples of them) are used to determine eligibility for some Medicaid categories, for CHIP and for many other programs; in 2005, the FPL is $798 monthly for one person (add $272 for each additional family member).

General Assistance (GA) or Temporary Disability Assistance (TDA) or Home Relief (HR)—welfare, and often medical assistance, offered by most liberal “blue” states---but few conservative “red” states--- to destitute, unemployed, incapacitated and/or disabled childless adults, often while awaiting the long SSA disability determination process.

Grace period---the first 3 months of the EPE, after the Trial Work Period, during which SSDI beneficiaries, even if working at SGA levels, still continue to receive their full SSDI payments. 

Group homes---supervised, often-licensed sub-medical-level “assisted living”, “congregate”, “domiciliary”, “family”, “rest”, “room & board”, “adult foster”, “personal care”, “residential care” and “boarding” homes for frail aged or disabled persons, run by agencies or even private owners; their residents, in all but a few states, qualify for extra-high SSPs with which they pay their (enhanced) rents and receipt of such SSPs confers Medicaid eligibility.

HCB waivers—Home & Community-Based waivers expand on traditional, standard Medicaid services by offering intense home health services, group home care and/or case management, instead of the nursing home placement they medically qualify for, to targeted groups of the frail aged and disabled, often using extra-high income eligibility levels.

Health Insurance High Risk Pools—state-sponsored & subsidized (with general or premium taxes) health insurance for those with pre-existing conditions who can’t get Medicaid or affordable private coverage; run for states by insurance company contractors; yet even their state-subsidized rates are quite high (a few states do give discounts to those considered poor); most, but not all, deny full secondary coverage to Medicare patients.   

HIFA waivers—state Medicaid waivers promoted by the Administration to cover more persons, often giving extra up-front federal funds, but usually at the cost of less benefits for new (and sometimes even original) Medicaid patients & possibly less future funding.

Hill-Burton---this HRSA-run program offered grants & loans for hospitals & health facilities; in exchange, they must give free care to persons with incomes under 100% FPL at least until it equals the grant or loan amount; in addition, they must perpetually give medically necessary emergency and even elective care to anyone---indigent or not, insured or not—willing to sign later installment payment plans, accept Medicare and Medicaid patients & their program’s rate schedules as payment in full and require in-house physicians to do so too for in-facility care.  

HMOs---health maintenance organizations deliver pre-defined health benefits (often including extra preventive care) for capitated rates at their own outpatient facilities, or via limited participating provider networks, and at selected hospitals, with patients paying co-pays that are often below fee-for-service coinsurance amounts. 

Home health care—brief, periodic professional-care visits, ordered by a physician & given at patients’ homes, by RNs, LPNs & speech, occupational, physical, phlebotomy, infusion & other therapists which Medicare, Medicaid, the VA & some private insurances cover; often (but not always), brief, periodic supportive visits by home health aides, homemakers, etc. are covered but only when and after the underlying professional-level visits are found necessary and authorized. 

Home relief (HR)---New York term for welfare, especially General Assistance (GA).

Hospice---a medical facility or program which provides nursing, physician, palliative and pain care to terminally ill patients—at the facility itself, or even at a patient’s home; covered by Medicare, almost all Medicaid programs and many private health insurance plans.

HRSA---the federal Health Resources and Services Administration, which oversees & funds the Ryan White HIV care & ADAP programs; finances low income community health clinics; administers the Hill-Burton free hospital care & patient access rules; and runs other miscellaneous health programs.

IADLs--- see ADLs; instrumental activities of daily living: meal preparation, medication management and administration, money management, use of telephone, transportation, employment and, sometimes, chores and laundry; used, along with ADLs, to qualify clients for  long term care and other supportive services.

ICFs—intermediate care facilities; lower-level medical long term facility care paid for by Medicaid and often used by mentally-challenged, developmentally disabled and other severely disabled patients.

IDEA---Individuals with Disabilities Education Act, a 1970s law (based on several earlier precursor laws and much-amended since) which requires local schools to offer equal schooling--even some adapted- and special-education, some of it health-related --and case management to handicapped students; and offers very limited (many say too limited) funding to do so. 

Indemnity health insurance---health insurance which pays a set amount for each night in the hospital which is widely advertised (“$100 per hospital day paid directly to you!”) which is over-priced for average, healthy persons---except for chronically ill, disabled and older persons who expect periodic or even frequent hospitalizations, for whom it  IS indeed a very wise, profitable investment; Mutual of Omaha offers such policies for modest premiums with only a one year pre-existing condition waiting period; but the AARP offers those over age 50 $100/$150 per day benefits for about $35 monthly with only a 3 month pre-existing condition period waiting period.

IRWEs---Impairment Related Work Expenses are medical and medically-necessary transportation to work costs which disabled SSI applicants and recipients pay themselves in order to work and which are disregarded in determining both financial eligibility and  SGA. 

IHS---Indian Health Service, a federal agency that offers free health care at IHS or tribal facilities to Native Americans living on or near reservations; and limited, outpatient care, with sliding scale fees, at  dozens of urban clinics.

Incapacity/incapacitated parent—see caretaker; a state definition of disability, often less strict than SSA’s, once used to qualify second parents for AFDC and often still used to qualify persons for state General Assisitance (GA) or Temporary Disability Assistance (TDA).

Katie Beckett waiver---a waiver allowing a severely disabled child whose parent’s income ordinarily makes her/him “too rich’ for the specialized care that only Medicaid offers while in the family home (even though s/he would be poor enough as a separate “single person” in a medical institution, where parental income is not automatically counted as available) to be fictitiously assumed to be outside the home and in an institution, thus allowing for Medicaid eligibility in spite of otherwise-disqualifying parental income; named for a disabled child---who has since become an adult disability activist---whose plight moved  President Reagan to get Congress to amend the law to allow such waivers. Almost all states have Katie Beckett waivers.  

Life settlements---viatical transactions, sometimes (but not exclusively) based solely on old age (i.e. over 62).

LIHEAP---federally-funded, state-run Low Income Home Energy Assistance Program that pays part of the poor’s heating bills.

Long Term Care (LTC)—medical and related care in SNFs, ICFs, long term medical, mental health  or rehabilitative facilities and, by extension, HCB waiver programs, home health services and even home attendant and SSP-financed supervised group home residential care.

Matching rate---the percentage that the federal government pays to states for certain program expenses---most notably, Medicaid’s; the richest states get 50% and the poorest one gets about 80%, with many in-between depending on their per capita average incomes and economies; states only get matching for paying federally-allowable rates for federally-allowable medical costs of persons whom federal law requires or allows them to cover; states get higher matching for some expenses (100% for family planning & certain computerization costs) but all get only 50% for the personnel & administrative costs of their Medicaid & welfare bureaucracies.

MediCal---California’s name for its Medicaid program.

Medically needy (MN)---in Medicaid eligibility, these are federally-matchable persons who are “categorically-related” by Medicaid law: Aged, blind, disabled, parents & children, etc. who in principle have incomes and/or assets above TANF, SSI or SSP levels—and who, unlike the categorically needy, get to deduct their paid & incurred medical expenses from their gross, originally “excess” income to make it low enough (to become poor enough) to be eligible. States choosing to cover the MN generally use 1, 3 or 6 month MN spend down  eligibility budgeting periods. Originally, states opting to cover the MN had to set uniform family-sized MN income & asset levels for members of all the categories. While states generally continue this practice, CMS  has since let them to vary their MN levels from category to category, especially to avoid inequities. It also let them cover only one or some MN categories (but not all), as Texas once did by covering MN families, but not other MN categories. At first, state MN levels couldn’t exceed 133% of whatever a state’s AFDC (now TANF) program paid to a family of the same size---but now states can, and sometimes do, set their MN levels as high as they want. Most notably, they can raise their MN levels for the aged & disabled from 133% of the TANF level up to the SSI/SSP level to avoid the prior unfair & incongruous result of requiring aged & disabled persons to spend down even past & below the SSI/SSP level to a lower MN level tied to 133% of TANF’s level.  

Medicare and Medicaid---if you don’t know what they are, and the difference between them, you aren’t qualified to even be reading this paper.

MSP---Medicare Savings Programs’ (QMB, SLMB, QI and QDWI) eligibility is determined by local welfare offices; SLMB & QI pay Medicare premiums for those with income under 135% FPL (even if they’re “too rich” for full Medicaid); for QMB eligibles under 100% FPL, they not only pay Pat B (and, if due, Part A) premiums, but all Medicare deductibles & coinsurance too; for QDWI eligibles—those SSDI/Medicare eligibles back at work over 99 months---they pay the Part A premium (in 2006, $393 monthly, but $216 if one paid FICA taxes less than 7.5 years) .

PAPs---Patient Assistance Programs; drug manufacturers’ charities that give free or discounted drugs to the needy under corporate income levels, often by effectively requiring drug salesmen’s access to their doctors. 

Part A---of Title XVIII pays for hospital, limited nursing home, home health & hospice benefits; it is premium-free, except for disabled back at work over 99 months & those over 65 with insufficient work credits.

Part B---of Title XVIII pays doctor and outpatient medical bills; its premium is $88.50 monthly in 2006.

Part C---of Title XVIII lets patients enroll in private HMOs, PPOs & other managed care plans (often with extra coverage & sometimes extra premiums) instead of traditional fee-for-service coverage.

Part D---of Title XVIII, enacted in 2003, offers outpatient prescription drug coverage to Medicare patients, beginning January 1, 2006---through numerous private plans, each with different rules & average, “benchmark” premiums of about $32—but giving much more generous “Extra Help” benefits to those with incomes under 150% FPL.

Participation---Washington State term for the spend down.

Pension---in VA parlance, a welfare-type payment (in 2006, up to $881.58 monthly for single veterans) for  disabled or over-65 veterans of VA-defined “wartime” periods, even if they didn’t serve in a war zone and even if their disability is not service-connected; our almost-constant wars since 1941 qualify most veterans as being “wartime” ones.

Personal care/attendant/aide services---physician-ordered, non-professional, home or even at-work personal aide services for those with ADL deficits paid for by many (but not all) Medicaid programs, up to state-set limits.

Personal needs allowance (PNA)---the state-established amount (at least $25 monthly, but more in most states) of her/his own income which a Medicaid patient in a skilled nursing facility, an intermediate care facility or other long term medical institution is allowed to retain from her/his own income (e.g., Social Security, pension, etc.) for toiletries, snacks, etc., with remaining income being dedicated to helping Medicaid pay the institutional bill; SSA pays up to $25 monthly as a PNA to aged & disabled Medicaid patients in medical institutions with incomes below that amount; but state SSP programs for sub-medical, supervised group home residential-level care of the aged & disabled quite often also utilize the same budgeting practice, with all of a resident’s income (Social Security, pensions, SSI & SSP), except for a small state-set “PNA” amount, being dedicated to paying the facility for room, board and supportive services.    

Pharmacy Plus waivers---waivers once promoted by CMS to allow states to give Medicaid drugs, but not other services, to the aged & disabled, with income over regular Medicaid levels but below 200% FPL; FL, IL, MD, SC, WI and 2 or 3 other states have or once had them. 

PLHIV—person living with HIV; s/he may, or may not, have yet advanced to “full-blown” AIDS and may, or may not, now meet SSA disability rules for getting SSDI or SSI; most PLVIVs are, in fact, still medically “pre-disabled”.

PNA---see Personal needs allowance.

PPOs—“preferred provider” organizations; “loose”, watered-down HMOs with some fee-for-service features; patient cost-sharing is usually much higher for care from “out-of-network” providers than from in-house or “in-network” ones.

Presumptive disability determination---the procedure by which local SSA offices can find needy disability applicants with designated, fairly obvious impairments immediately eligible for up to 3 months of SSI payments (and thus, in almost all states, Medicaid too) while a full-dress disability determination is conducted; presumptive eligibility is also often given for immediate, temporary coverage in the Medicaid & CHIP programs, especially for women and children.

Primary and secondary payers---which health coverage pays first, and which pays any remaining due balance second (or even third or fourth) under CMS & HRSA rules, supplemented by insurance industry standards; Medicare is primary to Medicaid and usually, but not always, to private insurance; Medicaid is secondary to almost everything else (except ADAP & the IHS); and industry rules decide among private payers.

Public Aid---Illinois for welfare, including TANF, GA and SSPs.

PWA---person with AIDS; s/he often, but not always, meets SSA disability rules and is eligible for SSDI and/or SSI, Medicare and/or Medicaid.

QDWI—Qualified Disabled Working Individuals; those SSDI/Medicare eligibles with countable incomes under 200% FPL who are back at work for over 99 months, and whose Part A coverage is no longer free; QDWI pays the Part A premium (in 2006, $393 monthly, but $216 if one paid FICA worker payroll taxes less than 7.5 years) for them.

QI---Qualified Individual; an aged or disabled Medicare patient with countable income between 120% and 135% FPL, and assets under twice the level allowed for SSI, for whom states must pay Medicare Part B premiums--even if  s/he is “too rich” for full Medicaid benefit coverage. 

QMB---Qualified Medicare Beneficiary; an aged or disabled Medicare patient with countable income under 100% FPL, and assets under twice the level allowed for SSI, for whom states must pay not only Medicare Part B premiums but also Part A premiums (if necessary) and deductibles and coinsurance---even if  s/he is “too rich” for full Medicaid benefit coverage.

Ribicoff children—once widely-used term for children who get Medicaid other than through TANF (formerly AFDC) or SSI, usually based on family income and, often, even where their parents don’t qualify for Medicaid.

Ryan White Program—funded by HRSA; offers health and related services (e.g. ADAP) to HIV-positive people through states, localities & non-profits.

Senior settlements---viatical transactions, usually (but not exclusively) based solely on old age (i.e., over 62).

Service-connected---in VA parlance, an illness or injury first incurred while on active military duty—even if on leave, off-duty or off-base-- for which a veteran gets an appropriate percentage (10 to 100%) of disability compensation & high priority for VA medical care.

SGA—Substantial Gainful Activity; in 2006, adjusted gross monthly earnings over $860, not counting “subsidized employment” (wages that aren’t genuinely earned: disguised charity “make-work”) and IRWEs, which disqualify one as “disabled” for purposes of SSDI, SSI and Medicaid---with exceptions for Section 1619 & Ticket to Work Medicaid coverage & for SSDI (but not SSI) receipt during Trial Work Periods & Extended Periods of Eligibility (EPEs).     

Share of cost---California term for the Medicaid spend down.

SLMB---Special Low-income Medicare Beneficiary; an aged or disabled Medicare patient with countable income between 100% and 120% FPL, and assets under twice the level allowed for SSI, for whom states must pay Medicare Part B premiums--even if  s/he is “too rich” for full Medicaid benefit coverage. 

SNFs---skilled nursing facilities offer medical-level nursing care 24/7 to those whose medical conditions & ADLs require such care; paid for by Medicaid, private funds and private long term care insurance; called “extended care” or “custodial care” by Medicare and private insurance, which only partially cover a limited number of days and only after hospitalizations.

SPAPs---State Pharmacy Assistance Programs; 100% state-funded programs that pay for drugs for aged and, in some states, disabled persons who are slightly “too rich” for Medicaid; a few state SPAPs even get federal funds via Medicaid “Pharmacy Plus” waivers.

Spend down---the process by which those with countable incomes above state Medicaid spend down income eligibility levels (which are higher than TANF levels but often lower than SSI levels) must pay or incur medical bills equal to their excess to gain eligibility; called “share-of-cost” in California; states use 1, 3 or 6 month spend down eligibility computation time periods.

SSA---Social Security Administration; pays earned Social Security retirement (age 60 for the widowed; 62 for reduced old age benefits; 65-67 for full benefits); survivors (to children & spouses of deceased workers) [OASDI] and disability [SSDI] benefits (plus auxiliary benefits for children); SSI; and, in most states, SSPs.

SSBG—once known as “title XX”, the federal Social Services Block Grant, supplemented by most states, funds social services for poor families, children, the aged and the disabled (housekeepers, homemakers, child-raising training, budget counseling, respite care, case management, child and adult protective and abuse services, etc.)

SSI---Supplemental Security Income; federal welfare program for the poor aged & disabled that pays up to $603 monthly (2006) and, in almost all states, confers Medicaid eligibility.

State Supplementary Payments (SSPs) are extra state payments added to basic federal SSl by most liberal “blue” states---but few conservative “red” states. SSPs can be, and most commonly are, paid to those living independently. But states can and do offer, or not offer, them--or vary their amounts--by types of living arrangement. Most notably, all but the “reddest”, most conservative states pay an extra-high SSP to frail aged & disabled persons living in supervised, sub-medical-level group homes. SSPs can be paid for states (but at their expense) by SSA as add-ons to the basic federal SSI payment, and most states arrange for that. But others pay the SSP themselves through their welfare offices, thus requiring the aged & disabled to apply duplicatively & unnecessarily at two offices and needlessly adding to their own welfare workloads. Yet almost all states have made the not-unreasonable decision to pay their special, extra-high SSPs for those in supervised group homes only through their own welfare offices so that their aged/disabled social services and adult protective staffs can better monitor resident placements and care and provide them with social services and some case management. 

State-only or General Medical Assistance—Medicaid-like care offered without federal aid by most liberal “blue” states---but few conservative “red” states—to those poor who don’t fit into federal Medicaid categories (those who are not parents, children, aged, blind, disabled, etc.).

Surplus income program---New York term for the Medicaid spend down.

TANF---Temporary Assistance to Needy Families; federally-aided, state-run welfare; formerly Aid to Families with Dependent Children (AFDC); TANF recipients, both children & parents, get automatic Medicaid.

Targeted Case Management (TCM)— at state option, Medicaid-financed medical management of care, treatment and/or social services for designated patients (e.g., HCB waiver patients, the developmentally disabled, etc.); but TCM can also describe to education-centered, but medically-sensitive, supportive/social services to handicapped or learning-disabled students, paid for by local school systems with (quite limited) federal IDEA, sometimes state and similar funding.

Ticket to Work---the 1999 Ticket to Work and Work Incentives Improvement Act (TWWIIA) has federal options letting states give Medicaid to the working disabled, “ex-disabled” & even “pre-disabled” using extra-high income eligibility levels; other program features offer disabled clients continued Medicare after beginning work, enhanced vocational rehabilitation (through state vocational rehabilitation agencies or contracting private “Employment Networks”, or “ENs”) and SSDI & SSI benefit continuance/renewal protections.

Title I---of the Social Security Act created the pre-SSI (1935-1974) Old Age Assistance (OAA) and Aid to the Blind (AB) federally-matched, state-run welfare programs for persons over age 65 and blind persons over 16. Title I, rather than Title II (which is the actual “Social Security” part of the Act that history now celebrates, often with familiar newsreel footage of President Roosevelt’s signing it into law) was--incongruously and quite surprisingly to present-day eyes!--the one part of the Act that 1935’s politicians, media and public almost exclusively then focused on because of the intense need of Depression seniors and the blind for immediate income. 

Title II--is the core “Social Security” part of the original 1935 Act; it created the Old Age and Survivors  Social Security programs, which are paid by SSA from taxed wage-earnings.

Title IV-A--is the welfare part of the original 1935 Act; it created  the federally-matched, state-run Aid to Families with Dependent Children (AFDC) welfare program (later “reformed” as Temporary Assistance to Needy Families, or TANF, in 1996).

Title IV-D---the child support enforcement section of the Act, which helps fund state parent locator, enforcement, collection and paternity determination activities; added in 1974.

Title V---the maternal and child health section of the 1935 Act, which funds the Maternal & Child Health and Special Needs Children (formerly “Crippled Children’s”) health care block grants to states; and the Women’s, Infants’ & Children’s (WIC) program, which offers health screening, immunizations, counseling & referrals---plus vouchers for food purchases—to families with pregnant women or children under 5; most states add their own funding as well; these programs typically have state-set income eligibility levels of about 185/200% FPL.

Title XIV---of the Act created the pre-SSI (1949-1974) Aid to the Permanently and Totally Disabled (APTD) federally-matched, state-run welfare program for disabled adults.

Title XVI states---AK, ID, KS, NE, NV, OR & UT;  they do accept SSI eligibility rules for aged & disabled Medicaid eligibility, but not automatically; they still make them apply separately & duplicatively for Medicaid at welfare offices---causing unnecessary, expensive welfare workloads---due to long-forgotten, no-longer-justified state policy decisions made over 30 years ago; and title XVI of the Act is, of course, the SSI law, added in 1972 and implemented in 1974.

Title XVIII---the Medicare section of the Act; added in 1965 (amended in 1972 to also cover the disabled after 24 months on SSDI and kidney failure patients after 3 months).

Title XIX---the Medicaid section of the Act, also added in 1965, and amended often since then.

Title XX—see SSBG.

Title XXI---the State Child Health Insurance Program (CHIP or SCHIP) section of the Act, added in 1997; it offers states federal matching funds at rates almost 15% above their Medicaid matching rates to give health insurance (or even Medicaid itself) to ordinarily Medicaid-ineligible children of the working poor, using income levels up to 200% FPL or even higher.

Transitional Medical Assistance---Medicaid eligibility extensions of 6 months (and, at state option, 6 or more additional months) given to parents in TANF welfare-to-work programs whose new earnings would otherwise make them (and even their children) “too rich” for Medicaid.

Trial Work Period (TWP)—9 months, not necessarily all in a row, during which SSDI (but not SSI) recipients can earn wages that even may exceed SGA limits, yet still get full SSDI checks.

Tricare—free health insurance (but with premiums for enhanced benefits) for dependents of active duty military & activated Reservists & National Guardsmen; career & disability military retirees; and retirees’ dependents & survivors. Military & health advocates support a Clinton-Graham Senate bill to extend it to un-activated Reservists, Guardsmen & their dependents, but with patients paying part (about 25%) of what the premiums would be if market-priced. 

TrOOP---true out of pocket drug costs; in Part D, drug expenditures that can be counted & credited in calculations to reach the annual $2250 donut hole threshold and its $5100 ceiling, after which patients qualify for catastrophic drug coverage for the rest of that year with very low coinsurance; drug costs paid by Part D, Extra Help, a patient himself, his relatives, SPAPs (but not ADAPs or Medicaid) and some charities count for TrOOP.

Two year waiting period---a 1972 law extended Medicare to the disabled but only after 24 months on SSDI and to those experiencing permanent kidney failure, prolonged dialysis or kidney transplant after only a 3 month wait (they needn’t qualify for SSDI if they themselves, a spouse or a parent is Social Security-insured); and Congress recently made those with amyotrophic lateral sclerosis (ALS; Lou Gehrig’s Disease) immediately eligible for Medicare. 

TWWIIA---see Ticket to Work.

VA—the Veterans’ Administration; now known as the Department of Veterans’ Affairs.

Viatication---the sale of ownership of, or assignment of policy rights to, individual or group life insurance for an actuarially-reduced price below the face death benefit amount to a private investor by an insured person who can document with medical records and physician statements that s/he is terminally ill; requires nursing home or home nursing care; or is simply over age 62. Payments are tax-free, but, unless used for nursing care, are countable by SSI, welfare, Medicaid & VA pensions & medical programs; payouts are typically made in lump sums, but nursing care payments are usually disbursed monthly. 

Waivers—are authorized by Section 1115 of the Social Security Act & similar provisions in CHIP’s & other programs’ laws; given by CMS, HHS & other administering agencies, they let state- or even federally-run programs depart from ordinary eligibility or benefit rules for temporary periods---ostensibly & nominally to test new, innovative policies but often also to expand eligibility, coverage or services or save on budget expenses.