- Glossary

• Medically needy
  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).
• MICSA
  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.
  
• OMH
  Office of Mental Health - The state agency that provides services for people with mental disabilities.
• OPWDD
  Office for People With 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.  Formerly known as the Office of Mental Retardation and Developmental Disabilities (OMRDD).
  
• Parental refusal
  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.
  
• Pay-in program
  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.
  
• PCAP
  Prenatal Care Assistance Program - A program providing comprehensive prenatal care to low income pregnant women.
• PCP
  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.
• transfer penalty
  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.
• PRUCOL
  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.
  
• Recertification
  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.
• Referral
  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.
• Resource
  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).
• SNA
  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.
• DOH
  New York State Department of Health - The state agency responsible for public health insurance programs and public health services.
• SSA
  Social Security Administration - The Federal government agency that administers Social Security benefits, including Retirement and Survivors Insurance, Disability Insurance, and Supplemental Security Income.
  
• SNP
  Special Needs Plan - There are two very different programs that go by the name Special Needs Plan:

  • Medicaid SNP - Medicaid managed care plans designed specifically for people with HIV/AIDS. They provide access to medical staff specifically trained to handle HIV/AIDS as well as specialized support services, testing, case management and information on clinical trials.
    
  • Medicare SNP - Medicare Advantage plans that are tailored to serve particular sub-groups of Medicare beneficiaries.  Some are catered to dual eligibles (those with Medicare & Medicaid), some to nursing home residents, and some for people with chronic medical conditions.
• Specialty care center
  A medical center that focuses on a specific illness.
• Spend-down
  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.
• Spousal refusal
  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.
  
• SSI-Related
  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.
  
• Standing referral
  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.
• TBI waiver
  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.
• TANF
  Temporary Assistance for Needy Families - A federally funded program that provides cash assistance to low income families.
• Unearned income
  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.
  
• DAB
  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 SSI-related.  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.
• QMB
  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.
  
• FPL
  Federal Poverty Level.  This is a commonly-used income benchmark used to calculate income eligibility limits for various Federal and State public benefit programs.  The FPL is calculated and published by the U.S. Department of Health and Human Services each year.  In New York, most Medicaid categories are not based upon the FPL.  However, eligibility for many programs is based upon FPL, including the Medicare Savings Programs, Family Health Plus, Child Health Plus, Family Planning Benefit Program, and the Medicaid Buy-In for Working People with Disabilities.  FPL is also used as part of determining eligibility for SNAP (aka Food Stamps).  After the official FPL is determined by the Federal government, New York State must adopt them separately for use in the various State-administered programs.  Updated State program income limits can be found on the Department of Health website.
• MLTC
  Managed Long-Term Care - in the general sense, refers to any type of private managed care organization in New York State whose benefit package includes Medicaid long-term care services (such as home care, adult day care, and nursing home).  Currently, this general category includes Partially-Capitated MLTC plans as well as fully-capitated ones such as MAP and PACE.  The term MLTC is more often used specifically to refer to the partially-capitated type of plan.  These plans do not include any Medicare-covered services, nor do they include all services covered under Medicaid.  Members of these plans must use them to access all types of home care, nursing home care, adult day care, medical transportation, podiatry, audiology, optometry, and dentistry.  All other services are covered either by Medicare or Fee-For-Service Medicaid.  Since 2012, it has been mandatory for dual eligibles needing Community-Based Long-Term Care services to enroll in MLTC, MAP or PACE plans in order to receive them.  See http://www.wnylc.com/health/entry/114/.
• Medicare Advantage
  A voluntary, optional program where Medicare beneficiaries may choose to enroll in a private managed care plan to receive their Medicare health insurance.  These plans must cover all services provided under Medicare Parts A and B (and often D), except for hospice.  Although they must cover the same services to roughly the same extent, there is considerable variation among plans in out-of-pocket costs, and unlike Original Medicare, members are generally limited to providers in the plan's network and subject to utilization management.  Medicare Advantage plans may cover a few extra services not otherwise covered by Medicare (e.g., limited dental, limited vision, gym membership), and they may be a good option for beneficiaries who cannot afford the cost of supplemental Medigap policies, yet whose income is too high for Medicaid (which itself acts as a supplement to Medicare).  To compare Medicare Advantage plans, see http://medicare.gov/find-a-plan.