Obsolete 0124 - Glossary L_R

Effective Date: October 31, 2021 - December 31, 2023

Legal Separation	The couple's rights and duties to each other are set forth in a Decree of Legal Separation, which covers matters such as custody and child support, spousal support, division of property and payment of debts. The parties live separately, but remain legally married to one another.
Liability	Liability is the amount the member must pay toward the cost of medical care. Liability includes the spenddown amount (415), the contribution to cost of care for HCB waiver programs (381, 383, 385, 386, and 389), the contribution to cost of care for services provided by nursing homes, and the MWI premium (314-7).
Mandatory trust	A mandatory trust is a trust that requires the trustee to pay trust earnings or principal to or for the benefit of the beneficiary at certain times. The trust may require disbursement of a specified percentage or dollar amount of the trust earnings or may obligate the trustee to spend income and principal, as necessary, to provide a specified standard of care. The trustee has no discretion as to the amount of the payment or to whom it will be distributed.
Maximum Spousal Needs Standard	The highest amount of money a spouse at home or who does not receive HCB services is allowed to keep when the other spouse is in a nursing home or receives HCB services.
Maximum Spousal Asset Allowance	The maximum amount of assets the community spouse can keep.
Medicaid Qualifying Trust (MQT)	• Is a trust or similar legal device set up other than by a will. • Uses the individual’s or individual spouse’s assets. • Is set up by the individual, the spouse or someone acting for the individual. • Names the individual, and/or spouse, as the beneficiary. • The trustees have discretion with respect to the distribution of payments to the individual. This type of trust does not make the trust unavailable as an asset.
Medical Deduction	A deduction is an allowable medical bill that does not meet all three of the criteria for being an incurred expense It can be paid or unpaid. It must be for medically necessary services: • For a family member who is not eligible for Medicaid, • For services not payable by Medicaid, or • For services received on a date when the person was not eligible for Medicaid, including services received on days in the third month before the application month that are before the Medicaid benefit effective date.
Medicaid Work Incentive program (MWI)	The MWI is a Medicaid program for people with disabilities who work. MWI has a higher income eligibility standard and higher assets standard than other Medicaid programs.
Medical Support Enforcement	A process that establishes the responsibility of a parent to pay for medical care for a Medicaid recipient. The process also includes collection of the medical support.
Medicare	A health insurance program for the aged and disabled that is administered by SSA. Part A Medicare provides hospital coverage, and some short-term nursing home and home-health coverage. Part B Medicare offers outpatient physician and laboratory services.
Medigap	Medigap policies are designed to supplement the individual's Medicare policy, by paying co-payments and deductibles. Some may help with expenses which Medicare does not pay.
Minimum Essential Coverage (MEC)	The requirement that insurance coverage offers ten essential health benefits as mandated by the Affordable Care Act. MEC is defined as a plan that covers: Ambulatory patient services (Outpatient care); Emergency services (Trips to the emergency room); Hospitalization (Inpatient care); Maternity and newborn care; Mental health services and addiction treatment; Prescription drugs; Rehabilitative services and devices; Laboratory services; Preventative services, wellness services and chronic disease; and Pediatric services.
Minimum Spousal Needs Standard	The least amount of money a spouse at home or who does not receive HCB services is allowed to keep when the other spouse is in a nursing home or receives HCB services.
Minimum Spousal Asset Allowance	The least amount of assets the community spouse can keep.
Modified Adjusted Gross Income (MAGI)	The calculation of income used to determine eligibility for federal programs including Medicaid, and premium and cost sharing assistance for tax credits provided to low and moderate income individuals under the health reform law.
Navigator Programs	Special programs that employ experienced and knowledgeable individuals (who may not work for insurers or be paid by insurers for plan enrollments) to assist individuals and small employers evaluate their insurance options within the insurance exchanges.
Negative Action	Any case closure, denial or reduction of benefits, delay or change in the method of issuing benefits. This also includes an increase in the spenddown amount.
Net Lump Sum	The amount of the payment after deducting expenses that are necessary to make the money available, such as lawyer's fees, probate costs, liens including a Medicaid lien, etc. Expenses do not include taxes.
Non-business Day	Saturday, Sunday and state holidays.
Old Age, Survivors, and Disability Insurance (OASDI)	The Social Security programs that provide monthly cash benefits to people and their dependents when they retire, to their surviving dependents, and to disabled worker beneficiaries and their dependents. Also known as Retirement, Survivors, and Disability Insurance (RSDI).
Office of Recovery Services (ORS)	The part of the Department of Health and Human Services responsible for: • Child support enforcement. • Collection of medical payments through third parties and injury suits. · TEFRA liens, · • Estate recoveries.
Overpaid Spenddown	The member paid more for the spenddown than the correct amount. See liability and overstated liability.
Overpayment	A payment for medical services for a member who was not eligible in the month the member received the service. A payment for medical services for a member who was eligible but not for the medical service the member received.
Overstated Liability	The member paid more than the correct liability amount or the member paid the correct spenddown or the contribution to cost of care, but the medical assistance program paid less for the medical services than the amount of the member’s liability.
Ownership of life insurance policy	The owner is the person who owns and controls the policy. Usually the person whose life is insured is the owner. However, the owner could be the person’s spouse, children, or employer. Assignment of ownership includes assignment of a dividends accumulations account unless there is evidence to the contrary. The policy owner has certain important rights to the policy, including the right to: pay the premium(s); name the beneficiaries; determine the various options within the life insurance policy, such as settlement options; change the owners of the policy in the future; borrow from a cash buildup in the policy; and change any other feature in the insurance policy.
Paid Medical Bill	A medical bill that is paid-in-full.
Penalty Period	The amount of time Medicaid restricts services it pays for because of a transfer of assets. It has also been called the sanction period or the period of ineligibility
Per Capita Payments	Per capita payments are payments that are made according to the number of individuals in a specific group and in which each individual shares equally.
Personal Property	Personal property is an item other than real property such as cash, financial accounts, vehicles, tools, merchandise, inventory, livestock, time-shares.
Physical Disabilities Waiver (PDW)	Provides services in the community to members who need a person assistant to help with daily self-care tasks. These members would be in nursing homes without those services.
Pickle Amendment	This amendment (Section 503 of Public Law 94-566) is named after its sponsor, U.S. Representative J. J. Pickle. The amendment protects Medicaid eligibility as described in section 330-3 of this manual.
Premium	The amount of money that a member must pay for insurance coverage. Some premiums must be paid monthly, while others may be paid quarterly, semi-annually, or annually.
Premium Assistance	"Premium Assistance" is an assistance program that provides cash reimbursement for all or part of the insurance premiums paid by an employee for coverage through a qualified employer-sponsored health insurance plan.
Preneed funeral contract	A preneed funeral contract is an agreement whereby the buyer pays in advance for funeral services and/or burial spaces that the seller agrees to furnish upon the death of the buyer or other designated individual.
Principal Place of Residence	An individual's principal place of residence is the dwelling the individual considers his or her established or principal home and to which, if absent, he or she intends to return. It can be real or personal property, fixed or mobile, and located on land or water.
Pooled Trust	1. Trust set up with the assets of a disabled individual. 2. The trust is established and managed by a not for profit organization, AND 3. There is a separate account for each individual, AND 4. The accounts are established solely for the benefit of the individual, AND 5. As the trust allows, any amount remaining in the trust will be paid to the State upon the death of the individual up to the amount of medical services paid by Medicaid.
Proceeds of a life insurance policy	Proceeds of a life insurance policy are the face value of the policy plus any additions payable at maturity of the policy or death of the insured person. Additions include amounts of insurance purchased with dividends that increase the death benefit. The policy may specify other additions that will be payable at death of the insured, such as additional benefits for accidental death. Proceeds do not include dividends or interest left to accumulate. Proceeds do not include the cash surrender value of the policy.
Policy Specialist	Policy Specialists are the State B.E.P. staff responsible for writing and developing new policy. They maintain the policy manuals, and provide clarifications of policy, program oversight, and training on new policy.
Prospective Budgeting	A process of determining countable income for the benefit month based on anticipated income expected to be received during that month.
Protected Period	The twelve months after eligibility is established for nursing home Medicaid during which the institutionalized spouse’s assets may exceed the asset limit pending transfer of assets to the community spouse.
Prudent Person Concept	When a worker uses professional judgment to determine what is acceptable verification.
Public Information	Information that does not identify or describe specific individuals. Public information includes statistical information such as the number of Medicaid recipients or the number of individuals in nursing homes. Public information also includes the policy manuals, brochures and pamphlets, etc.
Qualified Non-citizen	A qualified non-citizen is a non-citizen who is lawfully admitted for permanent residence under various sections of the Immigration and Nationality Act (INA).
Qualified Domestic Relations Order (QDRO)	A QDRO transfers an interest in one individual's pension plan, profit-sharing plan or other retirement investment plan to another individual, usually divorcing spouses.
Qualified Health Plan (QHP)	A health plan offered by a health insurance issuer that meets minimum essential coverage requirements standards in the ACA law and set by the Federally Facilitated Marketplace (FFM).
Real Property	Real property includes items which may be fixed or permanent, such as land, houses, buildings, and trailer homes.
Reasonably Compatible/Reasonable Compatibility	Standard for assessing whether verification can be considered complete, or if additional information is necessary. When data obtained is “reasonably compatible” with an applicant’s attestation, State agencies are prohibited from requiring additional documentation.
Recipient	Any individual who receives medical assistance from any medical assistance program administered by DHHS, DWS or DHCF.
Representative Payee	A person who receives income for a individual.
Restricted Medical Information	Medical, psychiatric, or psychological records that you cannot release directly to the individual because that would harm the individual’s mental health or the safety of any individual or would violate normal professional practice and medical ethics.
Retirement, Survivors, and Disability Insurance (RSDI)	An SSA program that provides cash benefits based on worker contributions. Also known as OASDI.
Retroactive Period	The 3 months immediately before the application month.
Review	The process of checking factors of eligibility to decide if the recipient is still eligible for medical assistance.
Revocable Trust	A revocable trust is a trust that allows the grantor to amend or terminate the trust and regain possession of the property.