1 January 2006
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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.
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
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
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
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
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”
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.
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
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”
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
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
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
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
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
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
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.
Infants’ and Children’s program; see Title V.