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Actuarially Sound – A promissory note, annuity, mortgage or loan established to pay off the entire asset value over the actual or expected lifetime of the annuitant/lender is actuarially sound. The annuitant/lender is expected to live long enough to receive an amount that is equal to or greater than the amount originally invested. The total amount of proceeds must be designed to be paid out in equal amounts during the term of the agreement, with no deferral and no balloon payments.
Annuitant – An annuitant is the person who receives the income payments of an annuity policy at maturity date for life or for a specified period. The annuitant may or may not be the same as the owner.
Annuitize – Converting the principle of an annuity into a series of payments.
Annuity - An annuity is a type of trust. An individual pays an entity a lump sum of money in return for the right to receive fixed, periodic payments, either for life or a term of years. This includes the investment portion of a single premium pure endowment life insurance policy.
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(III.)
Actual Time Report Card --- A report card that shows individual county/DDS average processing time and the percentage processed timely counting actual days to complete applications in a month. The actual processing time excludes no days and does not adjust the 45th/90th day.
Add-on --- Any individual added to an active case.
Adequate Notice --- A notice that must be received before the effective date of the change that informs the a/r of action taken.
Adjusted Payment --- A payment to the recipient to correct an underpayment and/or other upward adjustments that are needed
Adjusted Application Report Card --- A report card that shows the individual county/DDS average processing time and percentage processed timely excluding days allowable by policy to complete applications.
Adult Care Home --- Licensed group care facility.
Affidavit of Support --- This is a statement of a sponsor’s income, resources, and willingness to support an alien. It is filed with the BCIS by a U.S. resident who sponsors an alien seeking admission to the U.S. as a permanent resident.
Alien --- An alien is an individual who lives in the U.S. but is not a citizen.
Appeal --- An appeal is a request of an applicant/recipient or his representative for a review of the action taken on his case. An SSI Medicaid recipient will appeal through SSA. A non-SSI Medicaid recipient will request an appeal through his county income maintenance caseworker. An appeal of the level of care is requested through the North Carolina Division of Medical Assistance.
Applicant --- A person who signs under penalty of perjury a written application for MA or on whose behalf a written application is made and signed by an authorized representative.
Application --- An application for MA signed by the applicant or his authorized representative.
Application Process --- A series of actions leading to a determination of eligibility or ineligibility for MA.
Approved Amount --- In Medicare claims, the portion of the medical charge that Medicare approves as reasonable. Medicare pays 80% of the approved amount.
Approved Level of Care --- The level of care recommended by the patient's attending physician that meets level of care criteria and is approved by the Prior Approval Unit. See FL-2/MR-2.
Assessment --- The procedure for determining the community spouse's share of resources owned by the couple at the time of institutionalization.
Asset – For purposes of transfer of assets, is resources and income.
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Assignment --- For Medicare, the medical provider's agreement to accept Medicare's approved amount. Medicare pays the provider directly and the provider may charge the patient only the 20% coinsurance. Providers must accept the Medicare assignment if they bill Medicaid for the 20% coinsurance.
Assistance Unit --- The assistance unit (a.u.) consists of the individuals for whom assistance is requested, who are eligible and in the same coverage group and who have the same financially responsible person(s).
Assisted Living --- Group care for a person who cannot remain in his own home and who is placed in a facility licensed by the Department of Health and Human Services as an adult care home.
Authorization Period --- Period for which all factors of eligibility have been established and the recipient is authorized to receive Medicaid.
Authorized Representative --- Any individual who is legally authorized or designated in writing by the applicant/recipient to act on behalf of the applicant/recipient.
Automated Notice --- A notice produced and mailed by EDS to an applicant/recipient based on codes entered by the income maintenance caseworker when action is keyed.
Award Letter --- A statement to an individual from a governmental or private agency indicating benefits for which he/she is eligible.
Base Period --- A designated time for verifying income that is counted in determining the benefit.
Battered Alien --- An immigrant who has been battered or subjected to extreme cruelty by a spouse, parent, or member of the spouse or parent’s family residing in the same household.
Beneficiary of an annuity – The beneficiary is the person who receives any benefit that is paid upon death of the annuitant prior to the maturity date of the annuity.
BENDEX --- Beneficiary Data Exchange System, a computer printout listing the amount of an individual's Social Security benefits.
Benefit Diversion --- Benefit Diversion is a cash payment assistance alternative to traditional Work First Family Assistance (WFFA) for families with a temporary, non-recurring situation associated with employment or other sources of financial stability.
Black Lung --- Payments to a disabled worker, dependents, or survivors resulting from exposure to coal dust.
Boarder --- A person who lives with the a/r and pays a set amount for a room and meals.
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Brown Lung Benefits --- Payments made to persons disabled by lung disease resulting from exposure to raw cotton dust.
Budget Unit --- Persons whose income and resources are considered in the determination of eligibility for an individual or family group.
Caretaker Relative --- The natural or adoptive parent or the specified relative living in the household with the child who is eligible for Medicaid and providing the child's day-to-day care and supervision.
Carolina Access --- A program to link Medicaid recipients with a primary care provider who agrees to provide or arrange most of the enrollee's health care services.
Case ID Number --- A unique computer-assigned identification number.
Case Number --- A number assigned to a case by a county department of social services.
Case Record --- A file containing the application and all documents verifying initial and continuing eligibility for members of the assistance unit.
Casehead/Payee --- The person to whom the benefits are written.
Categorically Needy – SSI Recipient -- Medicaid classification for individuals receiving SSI who are automatically eligible for Medicaid. Classification will always be C or Q (if Medicare). The aid program/category is MAD, MAA, SAA, SAD, AAF payment type 5 or HSF.
Categorically Needy – Non SSI Recipient --- Medicaid classification for Work First coverage groups and for Medicaid cases with caretaker relatives and/or children under 21 who meet the categorically needy income and, if applicable, asset requirements. Classification is C or N. Work First cases must be classified C. Individuals age 19 and 20 who are not caretakers of a child and independently living children under 19 who are not otherwise eligible for MIC must be evaluated for MAF-N. Individuals determined eligible under a poverty coverage group must be N (either MIC or MPW). Caretaker relatives and other children under 19 who meet categorically needy requirements are classified C.
Certification period --- The period of time for which assistance is requested and in which all eligibility factors except need and reserve (when applicable) must be met.
Change in Situation --- A change in a recipient's circumstances that may affect eligibility for assistance.
Child Support --- Money or in-kind goods given for a child by a parent for the child's care.
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Child Tax Credit (CTC) ---Supplement to the earnings of low income taxpayers with earned income. Must be a parent, step-parent, grandparent, or foster parent with a dependent child. The child tax credit may provide a refund to individuals even if they do not owe any tax. There is no advance payment with CTC.
Children’s Health Insurance Program (CHIP) --- The national title for the Health Choice program. (See North Carolina Health Choice.)
Client --- means any applicant for or recipient of Medicaid, or someone who makes inquiries, is interviewed, or has been otherwise served.
Closing Date --- The last day of the month in which the a/r is eligible for benefits.
Collateral --- Any individual, employee, or person representing an agency, firm, organization, etc., whom the Income Maintenance Caseworker approaches to obtain verification of information provided by the budget unit.
Commissions --- Percentage of money made on sales and given in pay, in addition to salary or wages.
Communal Dining Facility --- A public or nonprofit private establishment, approved by FNS, which prepares or serves meals for elderly persons or for Supplemental Security Income recipients and their spouses.
Community Spouse --- The non-institutionalized spouse of an institutionalized spouse.
Community Spouse Resource Allowance --- An amount of countable resources held by the institutionalized spouse, the community spouse or both which is protected for the use of the community spouse. This amount is not considered available to the institutionalized spouse.
Compensation ---- Something received as payment for an asset. Payment is usually considered to be cash, but other forms of payment include in-kind income, real or personal property, support and maintenance, services, or assumption of a legal debt.
Confidentiality --- Safeguarding client information.
Contested Decision --- A tentative State hearing decision with which a county or the a/r disagrees.
Contiguous Property --- Real property with boundaries that touch the homesite property, disregarding the presence of streets, roads, rivers or streams.
Continuous Eligibility --- Once a child under age 19 has qualified for Medicaid he can receive for up to 12 months regardless of financial changes that affect eligibility.
Contribution --- Donation of cash or in-kind made by an individual to or on behalf of a member of the budget unit.
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Cost of Care ---- The amount of money charged to an individual for NF or ICF-MR level of care, a swing bed, or inappropriate level of care bed in a hospital, or waiver services for the Community Alternatives Program (CAP).
County Case Transfer --- The process of referring a case from one county to another based upon the client's new residence. (See County Reassignment)
County Reassignment --- Case action taken when an a/r moves from one county to another.
Court-Ordered Guardianship Fees --- A fee owed to an a/r’s guardian due to a court order and which is deducted from the a/r’s income.
Court-Orders --- Decisions made by judges of courts of competent jurisdiction that specify changes and/or procedures the county DSS's must follow (i.e. Blue v. Craig, child support, custody).
Coverage Group --- The category under which an individual is determined eligible for assistance.
Current Market Value --- The value of an asset if sold on the open market. For real and personal property it is the tax assessed value of the property, unless that value is rebutted and a different value established. Refer to MA-2230, Financial Resources, for instructions on establishing and rebutting the tax value.
Deductible --- An amount for medical expenses that must be paid or incurred by the applicant/recipient or a current budget unit member before Medicaid can be authorized. A deductible results when the countable income of the budget unit members exceeds the established income or maintenance level for the number of persons in the budget unit. (Sometimes called a "spenddown.")
Deductible Balance --- The amount of the deductible remaining to be met on the date Medicaid is authorized and which the applicant/recipient is responsible to pay.
Deduction --- Mandatory and allowable work related expense subtracted from gross earned income for members of the budget unit.
Deemed --- The process of considering income and reserve of persons in the household, or sponsors of lawfully admitted aliens as available to the a/r.
Demonstrated Hardship – The a/r, spouse or personal representative proves through the greater weight of evidence that a denial of institutional services due to excess home equity value will cause the a/r a hardship.
Denial --- Rejection of benefits of the applicant.
Dependent --- An individual who is financially dependent upon another for his well being as defined by financial responsibility regulations for the program.
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Deregistration --- The process by which an individual is removed from work registrant status.
Destitute Households ---- A migrant or seasonal farm worker household whose terminated income was received prior to the date of application and/or no more than $25 will be received from a new source by the 10th day of the month of application. (Applicable to Food Stamp program only.)
Determination of Eligibility --- The process of verifying eligibility factors for applicants/recipients to arrive at a decision on eligibility or ineligibility for programs based on the North Carolina Administrative Code, North Carolina General Statutes, and Federal Regulations.
Diagnosis Related Groupings --- Medicare and Medicaid reimburses general hospitals based on DRG's, a set fee based on the hospital's classification and the patient's diagnosis. The fee paid may be greater or less than the actual charge for the specific procedure provided. The hospital accepts the DRG fee as payment in full. The patient may not be billed if the fee paid is less than the actual charge. Conversely, the patient may not be credited for any excess if the DRG fee paid is greater than the actual charge. He will be responsible only for the Medicare Part A or Medicaid deductible.
Disability --- As defined by the Social Security Administration (SSA), a physical or mental impairment of such severity that it prevents the applicant from engaging in substantial gainful activity (or for a child under 18, an impairment of comparable severity) for at least a year or is expected to result in death. Note: substantial gainful activity is not a consideration for determining disability in HCWD cases.
Disability Determination Services --- The section of the North Carolina Division of Vocational Rehabilitation (VR) that is responsible for making determination of disability for RSDI, SSI, and Medicaid.
Disabled Adult Child --- An individual who is blind or permanently and totally disabled who is unable to become self-supporting after age 18.
Disqualified Individual --- An individual removed from Food Stamps due to an Intentional Program Violation, or for failure or refusal to comply with all program requirements.
Disregard of Earned Income --- Exemption of a portion of earned income for applicants/recipients.
Disregard of Income --- The procedure for exempting certain portions of income when determining benefits.
Division of Medical Assistance --- A division of the North Carolina Department of Health and Human Services responsible for the administration of the Medicaid program.
Division of Services for the Blind --- A division of the North Carolina Department of Health and Human Services responsible for providing financial and medical assistance and services for the blind.
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Division of Social Services --- A division of the North Carolina Department of Health and Human Services responsible for providing financial assistance and services for families with children and aged and disabled individuals.
Documentation --- Record data substantiating all points of eligibility.
Earned Income Tax Credit --- Is a supplement to the earnings of the working poor. An eligible individual can choose to receive the credit in advance payments added to his paycheck or in a lump sum when he files his income tax return.
Effective Date --- The first day of the authorization period for MA.
Eligibility --- The status of an individual qualifying for MA.
Emancipated Minors --- Children who are no longer legally dependent upon their parents/guardians, due to marriage, etc.
Emergency Services Medicaid --- Eligibility for Medicaid by non-qualified aliens is limited to receipt of Medicaid on the days an emergency existed. An emergency is defined as labor and delivery or treatment after the sudden onset of a medical condition manifesting itself by acute systems of sufficient severity, including severe pain, such that absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, or serious impairment to bodily function, or serious dysfunction of any bodily organ or part.
Enumeration --- The process of obtaining a Social Security Account Number.
Equity - The equity of real or personal property is the current market value (see definition above) less any encumbrances (mortgages, liens, or judgments) on the property.
Essential Person --- A person who gives essential service to the a/r and, if in need, is eligible to be included in the assistance unit.
Essential Spouse --- The spouse included in an AABD money payment in 12/73 who continues to be the spouse of and live with the individual who has continued to receive MA since 12/73 without termination.
Estate Recovery --- A claim filed against the estate of a deceased Medicaid recipient when Medicaid has paid for certain medical services. The claim is filed to recover Medicaid dollars paid on behalf of the individual.
Exemption --- Income that is subtracted from an AABD-MA applicant's/recipient's total monthly income, whether earned or unearned.
Ex Parte --- A determination of Medicaid eligibility from an existing record (such as from the SDX, county record, etc.)
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Expedited Services --- A procedure whereby the agency provides certain Food Stamp households an opportunity to receive benefits within a shortened time frame.
Fair Market Value --- For real or personal property, the tax value of the resource at the time of the transfer as verified by the county tax office, and for liquid assets, the current market value of the resource at the time of the transfer as defined in the Financial Resources Section.
Family Allowance --- The amount of income protected from an institutionalized spouse's income for a dependent family member.
Father, Alleged --- The man who is said, without proof, to be the father of the child when the courts have not established paternity.
Father, Legal --- (1) The man who is married to the mother at the time of the child's birth; or (2) A man who has been determined by the courts to be the father; or (3) A man who has legally adopted the child; or (4) A man who has signed affidavits legitimating the child.
Father, Natural --- The biological father of the child.
Father, Putative --- Same as Alleged Father.
Final Decision --- A decision by the State hearings office, after all non-judicial appeal rights have been exhausted.
Financially Responsible Person --- A parent or spouse whose income and resources are considered available to the Medicaid a/r as long as the a/r and the parent or spouse live together in the same household. Applies to PLA living arrangement only. (Same as budget unit.) For aliens admitted due to a sponsor, the sponsor and/or the sponsor’s spouse are financially responsible for the alien by deeming their income to the alien a/r following rules in MA-2262, Sponsor Deeming. They are not considered part of the budget unit and do not need to live with the alien.
FL-2 --- Long-Term Services prior approval form which gives a summary of the patient's medical requirements and which reflects the attending physician's recommendation for the level of care
needed in an institutional setting. An approved FL-2 is required for any Medicaid recipient in a skilled nursing facility (SNF) or an intermediate care facility (ICF).
Forgery --- Signing someone else's name without proper authorization.
Fraud --- A criminal act in which an a/r or authorized representative makes a false statement and/or withholds information willfully, knowingly, and with deceitful intent and, as a result, obtains or attempts to obtain assistance for which he is not eligible.
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(III)
Focused Risk Management Program (FORM) – (formerly Medication Therapy Management) Medicaid recipients participating in FORM may have their prescription overridden at the discretion of the pharmacist. The pharmacists coordinates, integrates and communicates medication regimen discussions with the patients primary care provider and upon consensus, translates the information to the recipient.
Greater Weight of the Evidence – Refers to the quality and convincing force of the evidence rather than to the quantity of the evidence
Guardian --- A person appointed by a court to be legally in charge of the affairs of a minor, or of someone incapable of taking care of his own needs.
Hearing --- A review requested by an a/r to establish whether an adverse action taken by the county department of social services was correct. (See appeal.)
Heir Property --- Ownership of property passed by will or intestate succession.
Homeless --- An individual who lacks a permanent or fixed residence.
Homesite --- Principal place of residence owned by an a/r or a budget unit member.
Identification Card --- A card issued yearly which identifies a person who was authorized for Medicaid when the card was issued. The card does not serve as verification of current eligibility status.
Illegal Alien --- Aliens who entered the U.S. without knowledge of BCIS or were admitted for a limited period of time and did not leave the U.S. when the period of time expired. These aliens may be known or unknown in BCIS but are not in a satisfactory status with BCIS.
Income --- Cash or in-kind resources received for labor, services, government or private benefits, or any money available to members of the budget unit for their maintenance.
Income, Earned --- Money received as a result of employment.
Income, Gross --- Total income before allowable deductions.
Income, Net --- Income after all allowable deductions.
Income, Unearned --- Money received from any source other than employment.
Income Level --- See Maintenance Allowance.
Income Maintenance Caseworker --- Person employed by the county department of social services to determine eligibility for income maintenance programs.
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Incur --- Become liable for, regardless of whether the expense is paid or expected to be paid by insurance, including Medicare, or some other source.
Incurred Medical Expense --- A charge for a medical service provided to an individual regardless of whether it is paid or unpaid. It may be applied to the Medicaid deductible if it will not be reimbursed.
In-Home Health Services and Supplies---Medically necessary services provided to an applicant/recipient (a/r) by a Medicaid certified provider can be sanctioned due to a transfer of assets. These services include the following:
PCS services provided to individuals in an ACH are not subject to this policy. Refer to MA-2240, Transfer of Assets, for an explanation of services.
In-kind Income --- Non-monetary assistance such as food, shelter or something the individual can use or convert to obtain food, or shelter.
Inmate of a Public Institution --- A person who is living in a public institution.
Inquiry --- A request for information regarding assistance or other services.
Institutional Living Arrangement – Institution or establishment that provides food, shelter and some treatment to 4 or more persons who are not related to the owner. This includes nursing facilities, group homes, orphanages, adult care homes, and residential treatment facilities.
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Institutionalized – Long Term Care Budgeting/Community Spouse Resource Allowance and Continuous Period of Institutionalization. This is 30 consecutive days in a medical facility or combination of medical facilities. The facilities are nursing facility, intermediate care facility-mental retardation, (ICF-MR) swing bed, inappropriate level of care in a hospital, or hospital acute level, and psychiatric residential treatment facility (PRTF).
Institutional Services - These services include services provided in a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR), swing bed or inappropriate level of care bed, services provided through the Community Alternatives Program (CAP), or Program of All-Inclusive Care for the Elderly (PACE). These services can be sanctioned due to a transfer of assets. These services do not include acute hospital care regardless of length of stay.
Institutionalized Spouse - An individual who is in SNF, ICF-MR, swing bed or inappropriate level of care bed, state mental hospital, or a general hospital after 30 days, or is approved for CAP/DA or CAP/MR, or PACE, and is married to a spouse who is not institutionalized.
Institutionalized for Transfer of Assets – As defined for a transfer of assets review, institutionalized is an individual receiving institutional services in a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR), swing bed, inappropriate level of care bed in a hospital, services provided through CAP, or services provided through PACE. This is different from the definition of institutionalized for long term care budgeting or institutional living arrangement when determining state/county residency.
Intake --- An initial interview.
Intermediate Care Facility - Mental Retardation Section (ICF-MR) --- An ICF for the mentally retarded that is affiliated with the State's retardation centers or mental hospitals.
Investigation --- A thorough examination of all eligibility factors.
Irrevocable Trust --- A contract in which the terms cannot be altered.
Job Bonus --- A one time 100% exclusion of earned income for 3 consecutive months for each parent/specified relative included in the assistance unit who becomes employed. Job Bonus is applicable ONLY to MAF-C and Work First cases.
Katie Beckett --- (CAP for Children) Medicaid Community Alternatives Program to allow disabled children who are at risk for institutionalization to receive medical care at home. Term used by other states. Katie Beckett is referred to as CAP-C in North Carolina.
Lawful Permanent Resident --- An alien who is legally admitted to the U.S. by the BCIS to live and work on a permanent basis.
Legal Parent --- Natural or adoptive parent after the final order of adoption is issued.
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Legal Representative --- A person acting for and legally authorized to execute a contract for the a/r, such as but not limited to a legal guardian, parent of a minor child, holder of power of attorney, fiduciary (agent), conservator or any trustee managing the a/r’s resources. Legal authorization requires a separate legal document except for parents of minor children.
Legal Temporary Residents --- These are aliens who have applied for legalization and been granted lawful temporary resident status (LTR) and eventually granted lawful permanent residence.
Live-in Attendant --- An individual who resides in a household solely for the purpose of providing medical, housekeeping or childcare services.
Loans --- Money given with the intention of repayment.
Local Conference --- A conference held by the county DSS with a recipient regarding the proposed action on his Food Stamp case.
Local Hearing --- A hearing held by the county department of social services with the recipient following a written notice to the recipient regarding a change in his MA. Additional information may be presented by the recipient who may affect a decision in the case.
Long Term Care (LTC) Budgeting --- Budgeting for individuals who are in an institutional setting rather than in a private home setting. Spousal and parental financial responsibility does not apply in this type of budgeting. The cost of care (room and board) is considered a medical expense and is usually covered along with other medical expenses.
Long Term Care (LTC) Facility --- A skilled nursing facility (SNF), intermediate care facility for the mentally retarded (ICF-MR), state mental hospital, or general hospital after 30 continuous days.
Long Term Care (LTC) Living Arrangement --- Residence in a "nursing home setting" such as skilled nursing facility (SNF), intermediate mentally retarded (ICF-MR), or hospital swing bed/inappropriate level of care bed.
Long Term Care Ombudsman --- An advocacy program mandated by the Older Americans Act and North Carolina General Statutes. LTC Ombudsman assist LTC patients and their families with problems and questions related to LTC.
Lookback Date - The earliest date a transfer can occur and be evaluated for a transfer of assets for less than fair market value. The lookback date varies depending on when an individual applies for Medicaid, is admitted to a NF or ICF/MR or requests CAP waiver services. Sanctions can be determined for transfers that take place on or after the lookback date.
Low Income Subsidy (LIS) --- A program that provides additional assistance for Medicare beneficiaries with income less than 150% of the federal poverty level for the Medicare Part D program.
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Lump Sum Payment --- Money received with no anticipated recurrence.
Maintenance Allowance --- Amount an individual or family group is allowed for basic needs or maintenance.
Manual Notices --- In certain situations the IMC must complete and mail the appropriate notice informing the a/r of changes or adverse actions to be taken in his case.
Mass Revisions (Changes) --- Certain changes that are initiated by the State or Federal government that may affect the entire caseload or significant portions of the caseload.
Means Tested Program --- An assistance program in which an applicant's financial circumstances are considered.
Medicaid Certified --- Enrolled in the North Carolina Medicaid program.
Medicaid Couple --- An MAABD/MQB Medicaid a/r who is married and living with a spouse who is applying for or receiving MAABD/MQB Medicaid.
Medicaid Family Planning Waiver (FPW) --- A program for men age 19 through 60 and women age 19 through 55, with income at or below 185% of the federal poverty level, to receive family planning services.
Medicaid Individual --- A Medicaid a/r who is single or who is married to a WFFA or SSI Recipient.
Medicaid Ineligible Spouse --- An individual not receiving MAABD/MQB Medicaid who is married to and living with a spouse who receives MAABD/MQB Medicaid and who is not an WFFA or SSI recipient.
Medicaid Reimbursement Rate --- The rate at which a given facility is reimbursed for a Medicaid recipient in the approved level of care.
Medical Home -- A primary health care doctor’s office.
Medical Institution --- An institution that provides medical care, including nursing and convalescent care, such as a hospital.
Medicare --- A program of health insurance for aged and disabled individuals who meet the program's eligibility requirements. Title XVIII of the Social Security Act.
Medicare Medical Health Savings Account (Medicare Advantage) (MHSA) -- Yearly Medicare deposits into an interest-bearing account to help the plan member cover their health care costs until the deductible is met. The accounts are linked to high deductible health insurance polices. These plan account funds are a countable resource for Medicaid purposes.
Medicare Part D --- A prescription drug program through Medicare that provides all Medicare beneficiaries with prescription drug assistance. The Low Income Subsidy is a part of this program.
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Migrant Farm Worker --- A person who moves with the migrant stream in order to follow seasonal farm work employment, and does not return to his permanent home each night.
Military Allotments --- Benefits received by dependents of military personnel.
Minimum Medicaid Reimbursement Rate --- The lowest rate at which any facility in the state is reimbursed for a Medicaid patient in the approved level of care.
Minor Mother --- A mother below a certain age as defined by a specific program.
Misrepresentation --- An intentional or unintentional statement giving incomplete, false, or misleading information.
Multiple Household --- A household made up of more than one family unit. This does not include room and board situations, as persons in such living arrangements are considered separate households.
Name --- The name entered in EIS through the Individual ID assignment process or the Name Change (NC) screen. Matches Social Security Records (such as SDX, BENDEX, SOLQ, TPQ, Social Security Card, or Medicare Card.)
Needs Standard --- The amount of money the State determines essential to meet minimal standard of living for a family of a specified size.
Needy Spouse --- The spouse of the a/r whose needs and income are considered in the budget.
Net Profit --- The income received from self-employment, farming, roomers, boarders, or small business, minus allowable expenses.
Newborn Coverage --- Automatic Medicaid coverage for newborns based solely on mother's eligibility status.
Non-assistance Household --- A Food Stamp household in which all family members are not recipients of WFFA, SSI, or a combination of the two.
Non-cooperation --- Failure of a budget unit member to comply with program requirements.
Non-immigrant Aliens (temporary residents) --- Aliens who are not permanently residing in the U.S. These aliens are lawfully admitted but only for a specified period of time, such as foreign students, and are in a satisfactory status with BCIS. These aliens are ineligible for full Medicaid.
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Non-qualified Alien --- An alien who does not meet the alien requirements to receive full Medicaid coverage. Non-qualified aliens potentially are eligible for emergency services only. Non-qualified aliens include illegal aliens, non-immigrants legally admitted to the U.S. but only for a temporary or specified period of time, and/or aliens admitted legally to the U.S. but who do not fall into one of the specified qualified alien categories.
North Carolina Health Choice for Children (NCHC)--- A health insurance program for uninsured children under the age of 19 who do not qualify for Medicaid and have family income under 200% of the Federal Poverty Limit. Funding for this program is capped. This program is known as Children’s Health Insurance Program (CHIP) at the national level.
Nursing Facility --- A nursing facility is a licensed skilled nursing facility (SNF) or intermediate care facility (ICF-MR).
Old Bills --- Outstanding medical bills that were incurred prior to the current certification period that have not been considered in establishing previous authorization.
Overissuance/Overpayment --- Benefits that are in excess of the amount for which the recipient was eligible.
Overstated PML --- Recipient paid too much toward cost of care due to PML being calculated incorrectly.
Partial Payment --- Assistance paid for a portion of the month. (N/A to Medicaid.)
Pass Along --- The disregard of Social Security benefits when determining eligibility for Medical Assistance.
Patient Monthly Liability (PML) --- The portion of his cost of care that a patient in long-term care is expected to pay.
Payee --- The person in whose name the assistance is made.
Payment month --- The month for which a client receives payment. (N/A to Medicaid.)
Payment Schedule --- A list mailed to the county department by the central office showing checks that will be mailed the subsequent month. (N/A to Medicaid.)
Penalty Period --- The period of time in which an a/r could be ineligible for Medicaid payment of nursing home cost of care, CAP, or in-home health services and supplies due to a transfer of resources. The penalty period is also referred to as a sanction period.
Perinatal---The period immediately before and after birth.
Perjury --- The voluntary violation of an oath or vow by swearing to what is untrue or by omission to do what was promised under oath. A signed application is a signed oath.
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Personal Representative --- A substitute payee appointed by the court when the specified relative payee is unwilling or unable to manage the assistance payment in the best interest of the children.
Plan to Achieve Self-Support (PASS) --- The Social Security Act authorizes the exclusion of income and resources of an individual who has a disability or is blind when the individual needs such income and resources to fulfill an approved Plan to Achieve Self-Support (PASS).
Poverty Level --- A Federally established income guideline used to define persons who are economically disadvantaged.
Presumptive Disability or Blindness --- Conditions under which SSI presumes that disability or blindness requirements are met and makes payment for a period of up to six months. If eligibility is not established for full benefits it is not required that repayment of benefits be made.
Presumptive Eligibility --- A determination of limited Medicaid eligibility for pregnant women, completed by qualified medical providers enrolled with and approved by the Division of Medical Assistance.
Primary Heating Source --- The source of heat used most by the household. (N/A to Medicaid.)
Private Disability or Unemployment Benefits --- Includes benefits paid by private insurance plans for persons incapacitated/unemployed.
Private Living Arrangement (PLA) Budgeting --- Evaluation of eligibility for medical charges only when an individual lives in his own home or an adult care home, and spousal and parental financial responsibility applies.
Private Rate --- The rate charged by a facility for a patient who is paying his own cost of care.
Processing Deadline --- The last date in the month the county can take appropriate action on a case.
Program of All-Inclusive Care for the Elderly (PACE) --- A program of all-inclusive care for the elderly. Managed care service delivery for the frail community-dwelling elderly, most of whom are dually eligible for Medicare and Medicaid benefits, and all of whom are certified eligible for nursing home placement according to North Carolina standards.
Program Transfer --- The process of transferring from one category of assistance to another.
Property Tax Value --- The latest tax value of property as ascertained according to Subchapter II of Chapter 105 of the N.C. General Statutes.
Prorated Benefits --- Benefits issued from the date of application. (N/A to Medicaid.)
Prospective Budgeting --- The best estimate of income for a specified period.
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Protective Payee --- A substitute payee appointed when the payee mismanages her money or fails to comply with program regulations.
Prouty (Age 72) Benefits --- Special benefits paid by SSA to persons age 72 or over who have not worked under the Social Security System; payments are minimal.
Psychiatric Residential Treatment Facility (PRTF) --- A facility that provides treatment for children with mental illness or substance abuse/dependency who require services in a non-acute inpatient setting. The child must require supervision and specialized interventions on a 24-hour basis to attain a level of functioning that allows subsequent treatment in a less restrictive setting.
Public Assistance Households --- A Food and Nutrition Services household in which all members receive or are determined eligible to receive SSI, WFFA, or a combination of the two.
Public Charge --- An alien who has become (for deportation purposes) or who is likely to become (for admission/adjustment purposes) solely dependent on government assistance. Government assistance includes Work First, SSI, and Medicaid for Long Term Care only.
Public Institution --- An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
Public Law --- A generic name for statutes passed by Congress.
Pull Check – The procedure used in the State Office to stop delivery of Medicaid cards and Public Assistance checks.
Qualified Alien --- An alien who meets the alien requirements to receive full Medicaid coverage. Qualified aliens potentially are eligible for full Medicaid just like U.S. citizens.
Quality Control (QC) --- A management tool used to determine the accuracy of eligibility and evaluation of needed corrective action.
Quarterly Report --- A form issued quarterly to specified recipients for reporting all income, assets, and other eligibility factors as a requirement for continued benefits.
Reapplication --- A subsequent application when a case has been terminated or suspended.
Rebuttal – The process by which an a/r, the a/r’s spouse or representative proves through a greater weight of evidence factors that eliminate or decrease a sanction period.
Recertification --- A review of all factors of eligibility.
Recipient --- An eligible person whose needs are included in the assistance unit.
Recoupment --- Action to recover overpayments/overissuances made to recipients.
Reenrollment/Redetermination of Eligibility --- A complete review of all eligibility factors.
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Registrant --- An a/r who is required to register with the Employment Security Commission according to program regulations.
Registrant Pool --- The entire group of individuals who are registered with ESC for manpower services.
Regular Employment --- Employment, either full-time or part-time, on a permanent or temporary basis.
Regular Run Register --- A program specific listing mailed to the county indicating client benefits.
Reinstatement --- The reopening of a case without the necessity of a signed application.
Remainder Beneficiary - The person(s) entitled to an annuity's principal, possibly including income that has been accumulated and added to the principal, after the death of the annuitant.
Remainder Interest --- Interest in property over and above life estate holder's share.
Renter --- An individual who pays for separate living quarters.
Replacement of Benefits --- Duplicate benefits issued by the county.
Representative---"Representative" means a person who is acting on behalf of the client.
Reserve --- Cash or its equivalent (liquid assets) and/or real or personal property (non-liquid assets) that are currently available to members of the budget unit.
Residence --- Requirement that a/r’s be living in North Carolina voluntarily with the intent to remain in the state.
Restored Benefits --- Benefits paid to recipients who did not receive them due to an administrative error or change in regulations.
Resulting Trust --- A verbal or written agreement between two or more parties specifying the ownership of an asset.
Retirement, Survivors, Disability Insurance (RSDI) --- A program administered under Title II of the Social Security Act through the Social Security Administration which pays benefits to persons who have contributed enough quarters to the Social Security System, or who are the dependents of one who has contributed to the system, when they are aged or retired, are a surviving spouse or dependent child, or are disabled. NOTE: An individual receiving RSDI as a retired person is not
eligible under M-AD, unless he is actually receiving disability and switches to early retirement benefits at age 62.
Retroactive Period --- The period of 1, 2, or 3 months immediately prior to the month of the Medicaid or WFFA application and in which there is a medical need. (No retro coverage for MQB-Q.) For SSI Medicaid the retro period is 1,2, or 3 months immediately prior to the date of the SSI application.
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Retrospective Budgeting --- Computing income for the benefit month based on actual income in a previous month.
Revocable Trust --- A contract in which terms can be altered.
Right of Recovery --- The responsibility of an individual, institution, corporation, or public or private agency to pay for all or part of medical costs of an a/r.
Roomer --- A person who lives with the a/r and pays a set amount for a room.
SSI Standard of Disability --- A physical or mental impairment which prevents an individual from engaging in any substantial gainful activity (or for a child under 18, an impairment of comparable severity) and which has lasted or is expected to last for at least 12 months or is expected to result in death.
Sanction Period --- The period of time in which an a/r is ineligible for Medicaid payment of institutional services and in-home health services and supplies. In order to sanction in-home health services, the sanction period must have begun during a period the individual received institutional services and continues when the individual goes to private living arrangement. The sanction period is also referred to as a penalty period.
Seasonal Employment --- Employment that is engaged in for a portion of year, at a predictable time each year. The employment may cover a few weeks or several months.
Self-Employment --- Net income of the person from a business enterprise or trade controlled by oneself, i.e., produce sales, farm rental, farming, craft sales, baby-sitting in one's own home.
Self-Supporting --- Maintaining one's self without financial assistance from others.
Skilled Nursing Facility (SNF) --- A long-term care facility which provides twenty-four hour skilled nursing care with a RN or LPN on duty at all times.
Social Security Administration (SSA) --- The agency of the federal government that issues regulations for the RSDI and SSI programs, as well as Medicare and Medicaid, under the Social Security Act.
Specialty Hospitals --- Hospitals providing designated special services (i.e. North Carolina Cancer Institute at Lumberton).
Specified Person --- An individual who (1) is age 60 or over, (2) receives SSI benefits under Title XVI of the Social Security Act or disability or blindness payments under Titles I, II, XIV, XVI of the Social Security Act (such persons include those who have been certified but whose initial payments have not yet been received, or whose checks are entirely recouped to repay a prior overpayment), (3) receives a VA disability payment for a 100% service connected disability, or (4) is a disabled surviving spouse or child of a Veteran.
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Specified Relative --- A relative who provides care and supervision of a child with whom the child lives.
Sponsor --- A person who signed an Affidavit of Support on behalf of an alien as a condition of the alien’s entry or admission to the U.S. An alien may have more than one sponsor. This does not apply to organizations and institutions, such as churches or service clubs.
Sponsored Alien --- An alien admitted lawfully for permanent residence sponsored by an individual who has signed an Affidavit of Support.
Spouse --- An individual who is married to another person, or for Food Stamp purposes, an individual who is holding himself/herself forth to the community as a husband or wife.
Standard Items --- Basic needs allowances used to determine Medicaid classification, measure contributions, establish income from roomers and boarders.
Standard Utility Allowance --- A fixed FS deduction for utilities that the household, if eligible, may choose to use rather than actual utility bills.
State/County Special Assistance for Adults (SC/SA) --- A program of financial and medical assistance for aged and disabled individuals with special needs, such as adult care home placement.
State Data Exchange (SDX) --- A computer file listing the amount of an individual's Supplemental Security Income benefits and which also reflects Social Security amounts for individuals who receive both SSI and Social Security. This file is available as an on-line inquiry.
State Foster Home Funds (SFHF) --- A program of financial assistance for needy children who are placed in foster homes by county departments of social services in accordance with rules and regulations of the Social Services Commission and who are not eligible for IV-E FC.
State Online Query (SOLQ) --- A method of verifying Title II (RSDI) and Title XVI (SSI) benefits for applicants and recipients of Medicaid, Food Stamps, WFFA, etc. When a request is keyed, it is immediately transmitted via a telephone line to the Social Security Administration (SSA), and the response is returned immediately.
Stepparent -- The person who has married a child's natural parent and is not the legal parent of the child.
Straggler Register --- A listing of checks and Medicaid cards issued by the central office for new cases or for cases updated after the regular run cutoff date.
Subsidized Housing --- A Federal subsidy to assist with shelter and utility expenses.
Substantial Gainful Activity --- For disability purposes, gross earnings equal to or exceeding an amount set by Social Security.
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Substantiate --- Verification of information alleged by the applicant/ recipient/representative.
Supplemental Payments/Issuance --- An additional payment/issuance due to increased needs of the budget unit after the regular payment has been authorized.
Supplemental Security Income (SSI) --- A Federal assistance program administered by the Social Security Administration for aged, blind, and disabled persons under Title XVI of the Social Security Act to guarantee a certain level of income. SSI recipients have contributed nothing or not enough to the Social Security System to be able to receive benefits on their own accounts.
Support Payments --- Money paid by an absent parent.
Suspected Fraud --- Basis for belief that an intentional misrepresentation may have occurred.
Tax Value --- The latest tax value of property assessed by the county tax office.
TANF (Temporary Assistance for Needy Families)--- The federal block grant that funds the Work First Family Assistance (WFFA) program.
Tenancy-in-Common --- Ownership of an undivided share of property with two or more owners who were not married to each other at the time the property was gained.
Tenancy by Entirety --- Property owned by a married couple with the rights of survivorship.
Tentative Decision --- A preliminary decision.
Terminated Case --- When assistance has been previously terminated.
Termination --- The ending of specific benefits.
Third Party Liability --- See Right of Recovery.
Third Party Recovery --- Recovery of all or part of a recipient's medical cost from a responsible source such as private insurance.
Thrifty Food Plan --- A USDA determined cost of diet for persons of different ages upon which Food and Nutrition services are determined.
Time Standard --- The requirement to process an action within a specified time.
Timely Notice --- A written notice to inform the recipient of intended action.
Tips --- Gratuities or sums of money in excess of $20 per month given voluntarily for services rendered.
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Trade Readjustment Benefits --- Benefits received as compensation for loss of employment because of foreign imports, when the person is eligible also for unemployment benefits. Benefits are payable through the Employment Security Commission.
Trafficking Victim --- An alien who has been forced into the international sex trade, prostitution, slavery and forced labor through coercion, threats of physical violence, psychological abuse, torture and imprisonment.
Transfer - To change ownership or title from one person(s) to another. A transfer also occurs when an individual takes action to waive or renounce assets or an inheritance to which he is entitled or when an individual takes any action that eliminates his ownership or reduces his control of a asset. For example, changing fee simple property to tenancy-in-common property or adding an additional owner to a savings account is considered a transfer.
Transfer Date for Real Property or Interest in Real Property - The date of transfer for real property is the day the deed is signed by the grantor, delivered, and accepted by the grantee. Unless fraud is suspected, it is presumed this is the date recorded on the front of the deed. The deed does not have to be notarized or registered in order to be a valid title transfer. However, a deed of gift must be registered within 2 years to remain valid.
Transfer Month --- The calendar month in which resources were legally transferred.
Transfer of Assets --- Changing of ownership.
Transitional Benefit Report (TBR) --- The form a family on 12 month Transitional Medicaid is required to complete in order to continue to receive Transitional Medicaid.
Transitional Medicaid ---
a. Four Months Transitional Medicaid --- The up to 4-month period of time that a family may receive Medicaid when they have been determined ineligible for Work First or MAF-C because of new or increased child/spousal support which is collected by IV-D or received by a member of the family and forwarded to IV-D.
b. Twelve Months Transitional Medicaid --- The up to 12-month period of time that a family may receive Medicaid when they have been determined ineligible for Work First or MAF-C because of new or increased earned income.
Uncompensated Value - The difference between the market value less encumbrances (the equity) of the asset at the time of the transfer and any payment or compensation received. The uncompensated value is the amount upon which the sanction is based.
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(III.)
Underissuance --- The amount of food stamps issued to a household that are less than the amount it was eligible to receive.
Underpayment --- A payment that is less than the recipient is eligible to receive in WFFA.
Understated PML --- Recipient paid too little PML toward cost of care and/or received unmet medical needs allowance to which he was not entitled.
Undue Hardship – The application of the sanction period would deprive the individual of medical care, such that the individual’s health or life would be endangered; or of food, clothing, shelter, or other necessities of life.
Undue Hardship Waiver- An individual who incurs a sanction for transfer of assets and is denied or terminated from Medicaid payment of institutional services may request this sanction be waived and can demonstrate the sanction will cause the a/r an undue hardship.
Unemployment Insurance (UI) --- Income received by an individual as compensation for loss of employment due to lay-off, suspension, firing; may include additional amounts paid by unions or employers.
Unmet Medical Needs (UMN) --- Medical expenses such as medical insurance premiums, co-payments, charges made by non-participating providers, and Medicare Part B premiums when the recipient is not on the State Buy-In.
Unpredictable Employment --- Employment which is unplanned and arises only from time to time. Income from such employment is not considered available to the budget unit.
Vendor Payment --- A monetary payment made on behalf of a household/ individual by an outside party.
Verification --- The confirmation of information by direct contact with collateral source or personal review of documented information such as a receipt, ledger, or signed statement.
Verification Date --- The date verifying information is received in the county department of social services.
Violence Against Women Act -- Under the Violence Against Women Act (VAWA) passed by Congress in 1994, the spouses and children of United States citizens or lawful permanent residents (LPR) may self-petition to obtain lawful permanent residency. The immigration provisions of VAWA allow certain battered immigrants to file for immigration relief without the abuser's assistance or knowledge, in order to seek safety and independence from the abuser.
Vulnerability --- A household that is totally or partially subject to the rising cost of energy.
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Wages/Salary --- Compensation paid regularly for services rendered, i.e., baby-sitting in the home of another, sales clerk, EITC.
WFFA (Work First Family Assistance) --- A cash payment and Medicaid for children and parents who meet the income and asset limits for the program. This program is known as TANF at the national level.
Work Programs --- Programs in designated counties that are designated to help an a/r find employment.
Work Release Funds --- Funds to dependents from a prisoner who is employed.
Worker's (Workmen's) Compensation --- Benefits resulting from loss of employment due to injury on the job.
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For questions or clarification on any of the policy contained in these manuals, please contact your local county office. |
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