Sections 1619(a) and (b) of Title XVI of the Social Security Act define Medicaid eligibility for some SSI clients who have earnings.
A group of health care providers that have entered into a formal arrangement to assume collective responsibility for the care of a specific group of patients and that receive financial incentives to improve the quality and efficiency of health care.
A program to provide home and community based care services to people with acquired brain injury who would otherwise need institutional level care.
Actively engaged in self-employment means the client contributes significant time and talents in the daily activities of a business owned wholly by the individual or in a partnership with others, with the intent to produce a profit.
The expected return on an annuity corresponds to a reasonable estimate of the life expectancy of the beneficiary. The average number of years of expected life remaining for the individual must coincide with the life of the annuity. If the individual is not reasonably expected to live longer than the guarantee period of the annuity, the individual will not receive fair market value for the annuity based on the projected return. In this case, the annuity is not actuarially sound.
The administrative process, civil process, or criminal process that the eligibility agency follows under state law to establish the validity of a medical assistance overpayment or understatement of liability and to establish the reason for the overpayment. The adjudication process also provides a legal basis for enforcing the collection of the overpayment or understated liability error.
Refundable tax credits, paid in advance, that are used for the purchase of health insurance through a state health insurance exchange.
When the agency makes a change that will decrease or stop benefits. An adverse action cannot be taken without advance notice.
Exchanges will provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options (qualified health plans) on the basis of price and quality, and to purchase the coverage.
Provides services in the community to clients age 65 or older who would be in nursing homes without those services.
An informal way to resolve client's complaints or disagreements between workers and clients. The client, the worker, and the worker's supervisor meet to discuss the problem.
A mistake made by DOH or the eligibility agency in determining eligibility or the amount of the client’s liability.
AFDC was the cash assistance program for families with children prior to July 1,1997. It has been replaced by the Temporary Assistance for Needy Families Program(TANF-effective July 1, 1997). Utah’s TANF program is called FEP. We still use AFDCstandards from July 1996 in Family related Medicaid programs.
A deduction for children, parents and spouses. This deduction is used in the Aged, Blind and Disabled programs.
An allowable medical bill is one that meets all of the rules for medical bills as defined in 415-7.
An individual having origins in any of the original peoples of North and South America (including Central America) who maintains tribal affiliation or community attachment. The affiliated tribe must be federally recognized.
Services not included as part of nursing facility coverage. These services must be billed by the supplier and not the long-term care provider.
An investment from which an individual receives regular payments for a period of time or for life.
Any person who has submitted an application for assistance if the application has not yet been approved or denied.
The total value of assets owned by the institutional and community spouse as of the beginning of the first continuous period of institutionalization.
Any real or personal property that has a monetary value.
The maximum value of countable assets a household can own and still be eligible fora program.
Any individual selected by an applicant or recipient to conduct business on his behalf. An authorized representative may make application, provide verifications, completeforms, and be the payee for the client. The authorized representative CANNOT signthe application, review or TPL forms instead of the client, unless the agency determinesthe client is unable to sign forms for himself.
Avenue H is an internet portal for Utah employers and their employees where individuals can find information about available employer-sponsored health plans and enroll on-line.
The BMS is an income standard that is used to determine the spenddown amount for some Medicaid programs.
A file that is produced by SSA. The file contains information about SSA payment status, SSI payment status, and Medicare entitlement dates. BENDEX provides verification of Social Security Numbers. SSA gives us this information only for clients that we identify.
This is a report of client earnings that is based on the employer's report to SSA when FICA is paid on the behalf of the client. Workers may use the report to identify clients who are working and to get basic information about the client's earnings.
The calendar month, or partial month, for which the medical eligibility is approved.
A calculation of the household's anticipated income, deductions and size during the certification period in all benefit months based on the most current information available.
A Medicaid program for people who are blind.
A program to provide home and community based care services to people with acquiredbrain injury who would otherwise need institutional level care.
This is the part of Health Care Financing responsible for Medicaid eligibility policy and disability review.
For the purposes of medical assistance eligibility, business day means any Monday, Tuesday, Wednesday, Thursday or Friday that is not a state holiday.
Automated payment by the state of the Part B Medicare premium for Medicaid, QMB,SLMB and QI-1 recipients. After clients are first identified for BUY-IN, they willbe reimbursed for Part B Medicare premiums which are deducted from their SSA checksafter their approval for medical assistance and before the BUY-IN becomes effective. Then the premiums are no longer deducted from their SSA checks.
Payment by the Medicaid program for a recipient’s private group health insurance. The Medicaid program may choose to pay a recipient’s health insurance if it appears to be cost-effective for the Medicaid program.
The amount of money that an individual can receive from an insurance company forterminating a whole life insurance policy issued by that company.
Child Health Evaluation and Care. This is a special service offered to Medicaidrecipients until the month they turn 21 years old. CHEC services include examinationsand evaluations of the child's general health, growth, development, and nutritionalstatus. CHEC services also include vision and hearing tests, laboratory tests anddental exams.
A payment required by health insurance, Medicaid, CHIP, PCN or Medicare to be paid by the patient to offset some of the cost of care. Also called co-insurance.
Agencies, organizations, or persons other than the customer, from whom information or verification of reported information is obtained.
The spouse who is not living in a medical institution or nursing home, and is not on an HCB Waiver. The other spouse is living in a medical institution, nursing home or is on an HCB Waiver.
The dollar value of the assets that are protected for the community spouse. The allowance will be equal to the greater of:\" the minimum spousal asset allowance at time of application or \" the spousal share not to exceed the maximum spousal asset allowance or\" an amount determined at a fair hearing or\" the amount determined by a court.
The fair hearing or the SSA appeal supported the agency when the client chose to receive continued benefits or chose not to pay the agency’s stated liability amount pending the hearing decision or the eligibility agency decides that the client didn’t take all reasonable actions to make the asset available.
Payments made for medical services issued pending the completion of a fair hearing (125-3) or pending an appeal of an SSA denial of disability (303-7). Payments for medical services issued because of a hardship waiver while the client takes all reasonable actions to make a transferred asset available (371-9) or to make the equity value of home worth more than $500,000 available (371-3, 371-9)
The fair hearing decision supported the client who chose not to receive continued benefits or chose to pay the agency’s stated liability amount pending the hearing decision(125-3, #5) or SSA reversed the denial of disability (303-7) or the eligibility agency decided that the client qualified for a hardship waiver (371-3, 371-9).
Information that identifies clients such as:\" Names, addresses, telephone numbers, and social security numbers.\" Income, assets, medical reports and data, names of persons obligated to provide financial and medical support.\" Clients' benefits, medical conditions, and medical services.
Contiguous property is all property owned by the client that is not separated from the client's residence by property belonging to another person. It is contiguous if the only separation from the home is a river, road, or public right of way. Contiguous property includes lots and the buildings on the lots.
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.
Cost sharing reduction will limit a health plan’s maximum out-of-pocket costs, and for some people will also reduce other cost sharing amounts (i.e., deductibles, coinsurance or copayments) that would otherwise be charged to them by their insurance plan. People who qualify for APTC's will be eligible for cost sharing assistance if they enroll in a silver plan. This assistance will reduce the limit on the out of pocket maximum that can apply to their coverage, with the amount of the reduction depending on income.
Countable income is gross income minus exemptions, allowable disregards, deductions, and earned income expenses. The various programs allow different disregards and deductions. This means \"countable income\" to decide eligibility for one program can be different than the \"countable income\" used to decide eligibility for another program.
CAW is for employed PCN clients who have health insurance provided by their employers. CAW will reimburse PCN clients $50 per month for the cost of health insurance premiums.
The amount of medical expenses that a client is responsible to pay before the health insurance company will begin to pay claims. For example, if the deductible is $200, the client's health insurance will not pay any medical bills until the client has incurred at least $200 in bills.
The amount of the spouse or parent's income that must be considered available to the client because of the financial responsibility of a spouse or parent. Deemed income can also come from an alien sponsor's income.
A child born to a mother who was eligible for and received Medicaid in the month of the child’s birth and the child received Medicaid from the month of birth through the month of their first birthday. Some states may opt to consider children born to a mother who received CHIP during the month of birth as deemed newborns. When the child receives this type of coverage, the child's citizenship is verified and no additional verification is required at any time.
The process of considering a spouse or parent's income and assets to be available to the Medicaid client. Considered the deemed income or assets available to the client whether or not they are actually available to the client.
Salary to be paid later. An amount that has been earned but is not actually paid until a later date, typically through a payment plan, pension or stock option plan.
DHS is the state agency responsible for aging and adult services, child and familyservices, foster care services, substance abuse and mental health services, servicesfor people with disabilities, and child support recovery services.
This is the state agency responsible for job services, unemployment compensation, cash assistance, food stamps and child care assistance. DWS also determines eligibility for medical assistance for people who receive cash or food stamp assistance.
For Aged, Blind or Disabled Medicaid a dependent includes the person's spouse, children under age 18 or children from age 18-22 who are full-time students who live with the client or are temporarily absent
A child under age 18, or age 18 if attending school and expected to graduate beforeturning age 19. An unborn child may be considered a dependent child. For 1931 (oldAFDC criteria) and Family-related Medicaid, a child is still considered dependenteven when the parent has no legal responsibility for the child, but the child isin his parent's home. For example, a child may have been emancipated by marriage,but when the child moves back to the parent's home he becomes a dependent child. When a minor parent lives with her parents, the grandchild is not a dependent childof the grandparents.
Meets the criteria defined by the Social Security Administration (SSA) for blindness or disability. See section 303-1.
A Medicaid Program for people with disabilities.
A person is disabled if the person has a physical or mental impairment that significantly limits the person's ability to do basic work activities for at least 12 months or will result in death. Examples of basic work activities are:\" walking, standing, sitting, lifting, pushing, pulling, reaching, carrying or handling; \" seeing, hearing and speaking; \" understanding, carrying out and remembering simple instructions; Use of judgment, responding appropriately to supervision, co-workers, and usual work situations; and dealing with changes in a routine work setting.
A person who is age 18 or older, disabled or blind before age 22, and receives Childhood Disability Benefits under a parent's or grandparent's claim number with a C and a number at the end. DACs are also called Childhood Disability Beneficiaries.
A discretionary trust is a trust in which the trustee has full discretion as to thetime, purpose and amount of all distributions. The trustee may pay to or for thebenefit of the beneficiary, all or none of the trust as he/she considers appropriate. The beneficiary has no control over the trust.
A lump sum FEP payment that enables the applicant to meet basic needs until other sources of income becomes stable.
A division of DHS that administers child welfare services, foster care, family interventions, subsidized adoptions, and other Human Service functions in Utah communities. DCFS decides Medicaid eligibility for children in foster care and subsidized adoptions.
Determines the customer’s need for the level of care provided by the Technology Dependent Waiver (TDW).
The Utah state agency, in the Utah Department of Health, that is responsible for administering the Medicaid, CHIP and PCN Programs.
A division of DHS that coordinates services to people who have disabilities.
The DSPD Case Manager:\" Determines if the client is medically appropriate for the Physical Disabilities Waiver, the Brain Injury Waiver or the DD/MR Waiver.\" Arranges a client's placement in a group home, sheltered workshop, supported employment project, and other services available to the disabled. \" Helps the client apply for Medicaid.
If 10-day notice cannot be given before deciding eligibility for a new certification period, benefits must extend to the following month. This continued month of eligibility is called the due process month. All of the evidence that is applied in the review month is duplicated for the due process month.
See Medical Support Enforcement.
Compensation in cash or in-kind for which a person performs a service.
An individual's electronic account is an electronic file that includes all information collected and generated by the State regarding each individual’s Medicaid eligibility and enrollment, including all documentation required to determine eligibility. It is transferred between Medicaid/CHIP and the FFE through a secure interface.
An eligible family member is either a spouse of the client, a parent of a minor client, or a spouse of a parent of a minor client, who is also Aged, Blind, or Disabled, whether or not that family member is on, or is applying for, Medicaid.
Emancipated people are no longer the responsibility of their parents. People become emancipated when they turn 18, get married or get a court order that says he is emancipated.
A health benefit plan offered by an employer to employees and dependents.
The difference between the current market value and any amount that the client still owes for that asset.
Electronic Resource Eligibility Product. The name of Utah's computer system used for public assistance case management, benefit calculations and issuance.
The minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide.
Renewals conducted without the involvement of the client. Current electronic data is compared to information in the case file. If both records are compatible, the renewal is updated. If they are not compatible, the agency must contact the client to provide new information to complete the review.
The difference between the community spouse's allowable shelter cost and the shelter standard (see Table II).
The amount of money that an insurance company must pay to the beneficiaries of a person who is insured by the life insurance policy.
A method of resolving a client complaint. The client, local office worker, and their representatives meet with an impartial hearing officer who determines if policy has been applied correctly.
The estimated value of the asset if it was sold at the prevailing price on the open market.
A cash assistance program funded by Utah's Temporary Assistance for Needy Families Program (TANF).
An electronic service through which States may verify certain information with, or obtain such information from, Federal agencies and other data sources, including SSA, the Department of Treasury, and the Department of Homeland Security.
FICA stands for \"Federal Insurance Contributions Act.\" It's the tax withheld from your salary or self-employment income that funds the Social Security and Medicare programs.
The level of income defining poverty by family size published annually in the Federal Register by the United States Department of Health and Human Services (DHHS).
A Federally-facilitated Marketplace will operate on behalf of States electing not to pursue a State-based Exchange. Marketplaces are responsible for calculating premiums and subsidies, enrollment, quality oversight, certification of qualified health plans that can be sold in the exchange, and meant to make the process of selecting health insurance easier and transparent.
Courts decide whether a client committed Fraud. Public assistance fraud is defined in 76-8-1205 of Utah Code. Public Assistance is defined at 35A-1-102 to include “medical assistance provided under Title 26, Chapter 18, Medical Assistance Act.” The penalties for public assistance fraud are in 76-8-1206 of the Utah Code.
Independent island nations which have a legal association with the United States which allows free trade as well as unrestricted travel between the islands and the U.S. They include the islands of Micronesia, Palau, and the Marshall Islands. Citizens of Freely Associated States are not automatically Qualified Aliens for Medicaid purposes.
The individual who creates a trust, sometimes referred to as the \"settlor\" or \"trustor.\"
The total amount of income before any voluntary or involuntary deductions such as, but not limited to, federal and states taxes, FICA, garnishments, insurance premiums (including Medicare), etc.
Also known as exchanges, they are responsible for calculating premiums subsidies, enrollment, quality oversight, certification of qualified health plans that can be sold in the exchange, and meant to make the process of selecting health insurance easier and transparent for individuals and small employer groups (SHOPs).
See health plan.
A group of doctors, clinics, hospitals and other medical experts.
Testimony given that is not based on first-hand knowledge. Hearsay evidence includes rumors and reports of what someone else told you.
HCB Waiver programs allow Medicaid to pay for services in the community that it normally could not pay for. These services allow people, who would otherwise be in a nursing home, to live in their homes or in community settings such as group homes.Utah has six HCB Waiver programs:\" Aged Waver (AW)\" Utah Community Supports Waiver (UCSW)\" Acquired Brain Injury Waiver (ABI)\" Technology Dependent Waiver (TDW)\" Physical Disabilities Waiver (PDW) \"New Choices Waiver (NCW)\" \"Autism Waiver (AUW)\"
The INA is the basic body of immigration law.
See U.S. Citizenship and Immigration Services (USCIS).
An unintentional mistake made by the client or the client's authorized representative.
A computer match system that uses Social Security numbers to get information about clients from DWS, SSA, and IRS.
See IEVS.
Determining self-employment income for an amount of time by using income from a like season, year, or contract period as representative of future income. Income can be annualized over 12 months or less, depending on the circumstances of the individual.
Determining monthly income through a history of past or current knowledge of circumstances and applying those circumstances to future periods. Income that has no history must be anticipated.
Determining monthly income from an average of income over a pre- determined period of time. Income is added together over the number of weeks/months agreed upon with the client and then divided over the number of weeks/months used. If income is paid on a weekly or bi-weekly basis, AFDC related Medicaid averaged income must be factored to a monthly amount (see factoring).
Income received over a specified period of time.
Income that varies in amount or frequency of receipt. This income must be averaged or anticipated.
Income that is paid quarterly, semi-annually, or annually. For example, military summer camp pay, and bonus and incentive income. Received Less Often than Monthly
Income that does not vary either in amount or frequency of receipt. Stable income does not need to be averaged, but is used as it is received.
Medical bills that are for Medicaid-covered services received in a Medicaid benefit month by a person who is covered on the Medicaid card. Incurred expenses may be paid or unpaid.
The first month an application is effective. This is NOT the same as the first month or partial month in the retroactive period. For example, if a client applied for assistance April 5 and is determined eligible for assistance in April, April is the initial month of eligibility. This is true even if that client requested retroactive coverage for March.
The spouse who is either residing in an institution or is eligible for services under a Home and Community Based Waiver. The term \"institutionalized\" will be used to refer to both.
As determined by the adjudication process (820 in the Eligibility Manual), a false or misleading action by a client or client’s representative to obtain, maintain, increase or prevent the decrease or termination of benefits. These actions include but are not limited to:•Misrepresenting, concealing or withholding facts;•Violating program regulations on the use, presentation, acquisition, receipt or possession of medical assistance or the medical card; or•Not reporting the receipt of a medical card or medical service that the individual knows the individual was not eligible to receive;•Posing as someone else;•Not reporting a change within 10 days after the change occurs, and the individual knew the reporting requirements.•Intentionally submitting a signed application or eligibility review containing false or misleading statements in an attempt to obtain public assistance payments, even if the client received no assistance.
A nursing home that furnishes health or rehabilitative services to people with mental retardation or related conditions.
The Internal Revenue Service is the nation's tax collection agency and administers the Internal Revenue Code enacted by Congress.
A trust fund that cannot be changed, controlled, or terminated by the grantor.
A brokerage or bank account that is owned together (jointly) by two or more people.
A holding of property, either real or personal, by two or more persons with each sharing the undivided interest, the entire tenancy passing to the survivor or survivors.
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 is the amount the client 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, the MWI premium (314-7), and the asset co-payment for the Pregnant Woman – Poverty Level program (360-4).
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.
The maximum amount of assets the community spouse can keep.
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.
\" Is a trust or similar legal device set up other than by a will. \" Uses the client's or client spouse's assets.\" Is set up by the client, the spouse or someone acting for the client.\" Names the client as the beneficiary.\" The trustees exercise any discretion with respect to the distribution of payments to the client.
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.
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.
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.
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 policies are designed to supplement the client's Medicare policy, by paying co-payments and deductibles. Some may help with expenses which Medicare does not pay.
The minimum insurance package that fulfills the requirement of the mandate that all individuals carry insurance.
The least amount of assets the community spouse can keep.
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.
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.
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.
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.
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.
Saturday, Sunday and state holidays.
The part of the Department of Human Services responsible for: \" Child support enforcement. \" Collection of medical payments through third parties and injury suits. \" Estate recoveries.
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).
The client paid more for the spenddown than the correct amount. See liability and overstated liability.
A payment for medical services for a client who was not eligible in the month the client received the service. A payment for medical services for a client who was eligible but not for the medical service the client received.
The client paid more than the correct liability amount or the client paid the correct spenddown, contribution to cost of care, or asset co-payment but the medical assistance program paid less for the medical services than the amount of the client’s liability.
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.
Public Assistance Case Management Information System was the computer system used to determine eligibility for public assistance programs before eREP.
A medical bill that is paid-in-full.
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 are payments that are made according to the number of individuals in a specific group and in which each individual shares equally.
Personal property is an item other than real property such as cash, financial accounts, vehicles, tools, merchandise, inventory, livestock, time-shares.
Provides services in the community to clients who need a person assistant to help with daily self-care tasks. These clients would be in nursing homes without those services.
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 336 of this manual.
1. Trust set up with the assets of a disabled individual.2. The trust is established and managed by a not for profit organization, AND3. There is a separate account for each individual, AND4. The accounts are established solely for the benefit of the individual, AND5. 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.
A pre-need 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.
The amount of money that a client must pay for insurance coverage. Some premiums must be paid monthly, while others may be paid quarterly, semi-annually, or annually.
A demonstration program that covers primary care medical services for uninsured adults age 19 through 64 who do not qualify for Medicaid or who owe a spenddown and choose to enroll in PCN instead.
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.
Proceeds of a life insurance policy are the face value of the policy plus any additionspayable at maturity of the policy or death of the insured person. Additions includeamounts of insurance purchased with dividends that increase the death benefit. Thepolicy 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 notinclude the cash surrender value of the policy.
Program Specialists are the State B.E.S. staff responsible for writing and developingnew policy. They maintain the policy manuals, provide clarifications of policy,and provide training on new policy.
A process of determining countable income for the benefit month based on anticipated income expected to be received during that month.
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.
Based on available information the Medicaid eligibility staff uses professional judgment to decide if the information is correct and complete, and whether some other form of verification is required.
Information that does not identify or describe specific clients. Public information includes statistical information such as the number of Medicaid recipients or the number of clients in nursing homes. Public information also includes the policy manuals, brochures and pamphlets, etc.
A qualified alien is an alien who is lawfully admitted for permanent residence under various sections of the Immigration and Nationality Act (INA).
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.
A health plan offered by a health insurance issuer that meets minimum standards in the ACA law and set by an Exchange.
Real property includes items which may be fixed or permanent, such as land, houses, buildings, and trailer homes.
Standard for assessing whether verification can be consideredcomplete, or if additional information is necessary. When data obtained is “reasonablycompatible” with an applicant’s attestation, State agencies are prohibited from requiringadditional documentation.
Any individual who receives medical assistance from any medical assistance program administered by DHS, DWS or DHCF.
A person who receives income for a client.
Medical, psychiatric, or psychological records that you cannot release directly to the client because that would harm the client's mental health or the safety of any individual or would violate normal professional practice and medical ethics.
An SSA program that provides cash benefits based on worker contributions. Also known as OASDI.
The 3 months immediately before the application month.
The process of checking factors of eligibility to decide if the recipient is still eligible for medical assistance. .
A trust that can be terminated or changed by the grantor or a court.
To protect information about clients so that unauthorized people may not see it.
A method of selling property, usually real estate. The seller exchanges the property for a contractual promise of a certain amount of money at specific times.
An individual who actively earns income directly from his own business, trade or profession rather than as wages or salary from an employer.
Substantial Gainful Activity
The state-based insurance exchanges through which small businesses will be able to purchase health insurance for their employees.
The federal agency that administers the RSDI and SSI cash programs and Medicare.
SSDI is authorized by Title II of the Social Security Act. SSDI program provides for payments to individuals because they are disabled. SSDI is the DI part of the RSDI.
1. The trust must be set up for the sole benefit of a disabled individual who is under the age of 65, AND2. The trust contains the assets of that individual, AND3. The trust states that all assets 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.
The difference between a person's countable income and the spenddown limit.
For aged, blind and disabled Medicaid the spenddown limit is 100% of the FPL. For family and child Medicaid the spenddown limit is the BMS. (Table VII)
A deduction from the nursing home or waiver spouse's income to provide income to the spouse at home.
The maximum resource amount, determined at the assessment that the spouse at home may have when eligibility is established.
SCHIP-I is a web-based application enabling state agencies to submit data request to the Social Security Administration (SSA) and receive a citizenship verificatio real-time via the internet.
A file provided to all states by SSA that contains records of all people in the state who are eligible for SSI or a State Supplemental Payment. It also identifies clients who lose SSI status.
Supplemental Security Income. This financial assistance is issued by SSA to disabled individuals who are not eligible for a minimal amount of income from other sources.
SGA is defined as a monthly earned income amount. The amount is increased yearly and is different for clients who are blind and clients who are disabled. SSA uses the SGA as an indicator that the person is not disabled.
A federal supplemental income program funded by general tax revenue (not Social Security taxes). It helps aged, blind, and disabled people, who have little or no income by providing monthly cash payments to meet basic needs for food, clothing, and shelter.
SIPV is the cause of an overpayment or understatement of liability until the adjudication process establishes that the violation was intentional or the client or client’s representative acknowledges the intention in writing.
This is a computerized information exchange system that gives us information from USCIS to verify alien residency status.
Provides services in the community to clients who depend on medical technology for life support and who would be in nursing homes without those services.
The situation where an individual is not in the home or is out-of-State, but intends to return to the home, or to Utah, later. A temporary absence may be for school or training, medical care, military service, temporary religious or other volunteer services such as the Peace Corps, vacation, or any other reason. Institutionalized persons: Periods of institutionalization may be temporary if the client can reasonably be expected to return to the home within a definite period-of-time. An institutionalized aged, blind or disabled person is temporarily absent if he or she expects to and does return home within the month after the absence began.
A type of asset ownership for two or more persons in which, upon the death of one owner, his or her share passes to heirs if a will is left or to the estate if no will is left, rather than to the co-owners.
Life insurance which pays a set amount of money to the named beneficiaries if the insured person dies before reaching a particular age. This kind of insurance usually has no cash value. Many employers offer this kind of insurance coverage to employees.
A trust established by a will or a testamentary trust is a trust established underthe terms of a will and which is only effective upon the death of the individualwho established the will. A trust to which property is transferred during the lifeof the individual who created the will is not a trust established by a will, evenif the will transfers additional property to that trust upon the death of the personwho created the will.
A health insurance program that covers children under age 19 who don't have other insurance and who do not qualify for Medicaid.
An individual, institution, corporation, or agency that may be responsible to pay all or part of a medical cost such as:\" Health, accident, or hospital insurance.\" Liability insurance, such as auto and homeowner's policies.\" Industrial accident claims.\" Court judgments.\" Medical support from an absent parent.
Title IV-E of the Social Security act authorizes payments for foster care or subsidized adoption assistance for children who meet certain eligibility requirements. DCFS is the administering agency for Title IV-E in the state of Utah.
A trust is a right of property held by one person (the trustee) for another (the beneficiary.)
The person for whose benefit the trust is created. Although, this person does not hold legal title, he does have an ownership interest. The beneficiary can receive money from the trust directly or through the trustee.
A trust established by a will or a testamentary trust is a trust established under the terms of a will and which is only effective upon the death of the individual who established the will. A trust to which property is transferred during the life of the individual who created the will is not a trust established by a will, even if the will transfers additional property to that trust upon the death of the person who created the will.
A trust established by an individual. An individual is considered to have establisheda trust if any assets of the individual (or spouse), regardless of how little, weretransferred to a trust other than by a will. This includes situations where someoneacting on behalf of the individual (or spouse) is named as grantor, but the assetsbelonged to, or would have been payable to, the individual or spouse.
Somebody who is given the legal authority to manage money or property on behalf of somebody else.
The USCIS administers immigration and naturalization adjudication functions and establishesimmigration services policies.
The difference between the fair market value of an asset at the time of the transfer less any debts or loans and the amount that a client receives.
The client paid less than the correct spenddown.
A payment for medical services that the agency should have made but didn’t because the client was incorrectly determined to be ineligible or was incorrectly approved for a medical assistance program with a scope of medical services more limited than the program the client was eligible for.
See Underpaid Spenddown.
Income in cash or in-kind derived from a source other than employment.
A medical bill that has a balance at the beginning of a month that the client still owes to the medical provider.
Utah's Premium Partnership for Health Insurance
Provides services in the community to clients with developmental disabilities and who would be in nursing homes without those services.
(UHE) is an internet portal for Utah employers and their employees where individuals can find information about available employer-sponsored health plans on-line.
Numerous programs administered by the Veterans Administration that make payments to veterans and their families. The most common types are: \" Pensions.\" Compensation.\" Educational Benefits.\" Aid and Attendance and Housebound Allowance.\" Clothing Allowance.\" Unusual Medical Expenses.
Somebody, especially a child or young person, who is under the care of a guardian or a court.
A life insurance policy that will pay money to the beneficiaries when the insured person dies. Whole life policies usually have a cash value.
A supplemental food and nutrition education program that helps Utah mothers provide healthy nutrition and education for their families.
This term refers to employees of the Department of Health, the Department of Work Force Services, and the Division of Child and Family Services who accept applications for medical assistance and determine eligibility for medical assistance.