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A federal category of Medicaid eligibility for people who are unable to afford their medical bills but have income and resource levels too high for traditional Medicaid. They may "spend down" their excess income and resources on medical bills to qualify for Medicaid. They must not be currently receiving any public cash assistance benefits, such as SSI or public assistance. Only certain "categories" of individuals are medically needy: DAB category (Disabled/Aged 65+/ Blind), and AFDC category (children under age 21, their parents or other relatives who live with them, and pregnant women).
Medical Insurance and Community Services Administration - A division of New York City's Human Resources Administration that includes Adult Protective Services, the HIV/AIDS Services Administration, the Medical Assistance Program, and the Home Care Services Program. This is the agency that administers the Medicaid, Family Health Plus, and Child Health Plus programs in New York City.
Office of Mental Health - The state agency that provides services for people with mental disabilities.
Office of Mental Retardation and Developmental Disabilities - The state agency that provides services for people with mental retardation and developmental disabilities. This agency also administers the Medicaid Waiver program for people with MR/DD.
New York State Office of Temporary and Disability Assistance - (Pronounced "Oh-ta-Da") This is the New York State agency that administers Temporary Assistance (aka "welfare" or "public assistance"), Food Stamps, HEAP, and other programs. OTDA also conducts all Fair Hearings in New York State, including Medicaid Fair Hearings. See OTDA website.
Ordinarily, when a minor child applies for Medicaid, the income and resources of their parents are counted, because parents are Legally Responsible Relatives for their minor children. However, a child may prevent their parents' income/resources from being counted if the parent signs a statement indicating their refusal to make their income/resources available for the child's medical care. This is called a parental refusal.
When a patient pre-pays their spend-down to the Medicaid agency to activate their Medicaid coverage, instead of incurring medical bills to offset their excess income.
Prenatal Care Assistance Program - A program providing comprehensive prenatal care to low income pregnant women.
Primary Care Physician - The doctor in a managed care plan that provides most of the recipient’s care and is responsible for referring recipient to specialists if needed.
Permanently Residing Under Color of Law - PRUCOL is a category of immigration status used by certain public benefit programs. An immigrant would be considered PRUCOL if they are residing in the United States with the knowledge and permission or acquiescence of the United States Citizenship and Immigration Services, and whose departure that agency does not contemplate enforcing. PRUCOLs are eligible for Medicaid and Safety Net Assistance in New York State.
Qualified Medicare Beneficiary - This is a Medicare Savings Program (MSP) that provides coverage of the out-of-pocket costs associated with Medicare Part A and B. This includes coverage of the Part A hospital deductible and copayments, the Part A copayments for Skilled Nursing Facility (SNF), Part A premium (if applicable), Part B outpatient deductible and coinsurance, and the Part B premium. All those with QMB are also automatically deemed eligible for Full Extra Help with Medicare Part D.
Most public benefits programs require that the recipient show from time to time that they continue to be eligible for that benefit. This is usually called recertification or renewal. Most Medicaid recipients must recertify once a year.
An authorization for a patient in a managed care plan to receive care from a specialist, hospital, or other health care provider. Referrals are usually given, in writing, by a primary care provider.
Resources (aka "assets") are money and property owned by an applicant for public benefits. Different programs have different rules about what types of resources are counted towards the resource limit, and some programs have no resource limit at all. In general, resources include bank accounts, other financial institution accounts, and real property (except the primary residence).
Safety Net Assistance - A cash public assistance (aka welfare) program in New York State that provides benefits to eligible individuals and certain families who do not qualify for Family Assistance or other federal Temporary Assistance programs.
Special Needs Plan - There are two very different programs that go by the name Special Needs Plan:
Supplemental Needs Trust - A legal tool used to help disabled people keep more of their income or assets without losing their public benefits. The technical definition is that they are irrevocable, spendthrift trusts that comply with the provisions of 42 U.S.C. § 1396p(d)(4). There are two types: individual SNTs and pooled SNTs. An SNT can also be a third-party trust, where the money is provided by someone other than the beneficiary. A medical center that focuses on a specific illness.
AKA surplus income or excess income. Some categories of Medicaid applicants can obtain Medicaid in spite of having income above the income limit. Before Medicaid will cover the cost of services for these individuals, they must incur medical expenses that offset their excess income. Medicaid Reference Guide, Income, at 239-242.
Ordinarily, when a married individual applies for Medicaid, the income and resources of their spouse are also counted, because spouses are Legally Responsible Relatives for each other. However, an individual may prevent their spouse's income/resources from being counted if the spouse signs a statement indicating their refusal to make their income/resources available for their spouse's medical care. This is called a spousal refusal.
Social Security Administration - The Federal government agency that administers Social Security benefits, including Retirement and Survivors Insurance, Disability Insurance, and Supplemental Security Income.
A category of Medicaid eligibility in New York State covering those who are aged (65 or over), blind, or disabled (as defined by the Social Security Administration). Also known as Disabled Aged Blind (DAB). This is DIFFERENT than those who receive Medicaid because they receive Supplemental Security Income (SSI) benefits. An individual does NOT need to receive SSI to be eligible for Medicaid under the SSI-related/DAB category.
A referral for a fixed number of visits to a specific health care provider. Unlike a regular referral, it is good for more than one visit.
Temporary Assistance for Needy Families - A federally funded program that provides cash assistance to low income families.
Traumatic Brain Injury Waiver Program - A Medicaid waiver program in New York State which provides services for people diagnosed with a traumatic brain injury, or other related diagnosis, to allow them to remain in their homes. Services covered by this wavier can include service coordination, independent living skills and training, structured day programs, substance abuse programs, intensive behavioral programs, community integration counseling, home and community support services, environmental modifications, respite care, assistive technology, transportation, and community transition services.
An applicant for Medicaid coverage of a nursing home stay will be subject to a transfer penalty if they gave away money or property within a certain period of time (the "look-back period") before applying for Medicaid. If a transfer is found during a look-back period that does not fall under one of the Medicaid exemptions, then a penalty period is calculated based on the amount of money transferred. The penalty is a certain number of months, beginning when the applicant is in the nursing home and applies for Medicaid, during which Medicaid will not pay for the nursing home care.
Income received that is not compensation for work performed by the recipient. It includes Social Security benefits, interest, dividends, pensions, annuities, retirement account distributions, worker's compensation, unemployment insurance, and gifts.
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