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PCA
Personal Care Aide - aka "home attendant." A semi-skilled paraprofessional certified under NY law to provide assistance with certain specified activities of daily living for people with disabilities. See 18 NYCRR § 505.14; Personal Care Aide Scope of Practice at http://www.wnylc.com/health/download/46/.
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PCAP
Prenatal Care Assistance Program - A program providing comprehensive prenatal care to low income pregnant women.
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PCP
Primary Care Physician - The doctor in a managed care plan that provides most of the recipient’s care and is responsible for referring recipient to specialists if needed.
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PDN
Private-Duty Nursing - Clients with continuous skilled nursing needs may need a Licensed Practical Nurse (LPN) or Registered Nurse (RN) for up to 24-hours a day. Intravenous or parenteral nutrition, suctioning of tracheostomies, direct administration of medications (putting a pill directly in the client’s mouth), and operating a ventilator are examples of tasks that PCA/HHAs may not perform. PDN is covered (subject to prior approval) by fee-for-service Medicaid and by all types of Medicaid Managed Care plans (MMC, MLTC, etc.) 18 NYCRR § 505.8.
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PRUCOL
Permanently Residing Under Color of Law - PRUCOL is a category of immigration status used by certain public benefit programs. An immigrant would be considered PRUCOL if they are residing in the United States with the knowledge and permission or acquiescence of the United States Citizenship and Immigration Services, and whose departure that agency does not contemplate enforcing. PRUCOLs are eligible for Medicaid and Safety Net Assistance in New York State.
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QMB
Qualified Medicare Beneficiary - This is a Medicare Savings Program (MSP) that provides coverage of the out-of-pocket costs associated with Medicare Part A and B. This includes coverage of the Part A hospital deductible and copayments, the Part A copayments for Skilled Nursing Facility (SNF), Part A premium (if applicable), Part B outpatient deductible and coinsurance, and the Part B premium. All those with QMB are also automatically deemed eligible for Full Extra Help with Medicare Part D.
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Recertification
Most public benefits programs require that the recipient show from time to time that they continue to be eligible for that benefit. This is usually called recertification or renewal. Most Medicaid recipients must recertify once a year.
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Referral
An authorization for a patient in a managed care plan to receive care from a specialist, hospital, or other health care provider. Referrals are usually given, in writing, by a primary care provider.
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Resource
Resources (aka "assets") are money and property owned by an applicant for public benefits. Different programs have different rules about what types of resources are counted towards the resource limit, and some programs have no resource limit at all. In general, resources include bank accounts, other financial institution accounts, and real property (except the primary residence).
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SADC
Social Adult Day Care (aka "social model") - SADC is a structured program designed to support the physical, mental, social and emotional functioning of frail adults or those with a cognitive disorder. Unlike Adult Day Health Care ("medical model"), which is provided in a healthcare facility supervised by doctors, SADC is provided in non-medical settings. It is not covered by fee-for-service Medicaid, but is available under the Lombardi and NHTD waivers, and under Managed Long-Term Care (all flavors).
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SNA
Safety Net Assistance - A cash public assistance (aka welfare) program in New York State that provides benefits to eligible individuals and certain families who do not qualify for Family Assistance or other federal Temporary Assistance programs.
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SNP
Special Needs Plan - There are two very different programs that go by the name Special Needs Plan: - Medicaid SNP - Medicaid managed care plans designed specifically for people with HIV/AIDS. They provide access to medical staff specifically trained to handle HIV/AIDS as well as specialized support services, testing, case management and information on clinical trials.
- Medicare SNP - Medicare Advantage plans that are tailored to serve particular sub-groups of Medicare beneficiaries. Some are catered to dual eligibles (those with Medicare & Medicaid), some to nursing home residents, and some for people with chronic medical conditions.
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SNT
Supplemental Needs Trust - A legal tool used to help disabled people keep more of their income or assets without losing their public benefits. The technical definition is that they are irrevocable, spendthrift trusts that comply with the provisions of 42 U.S.C. § 1396p(d)(4). There are two types: individual SNTs and pooled SNTs. An SNT can also be a third-party trust, where the money is provided by someone other than the beneficiary.
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Specialty care center
A medical center that focuses on a specific illness.
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Spend-down
AKA surplus income or excess income. Some categories of Medicaid applicants can obtain Medicaid in spite of having income above the income limit. Before Medicaid will cover the cost of services for these individuals, they must incur medical expenses that offset their excess income. Medicaid Reference Guide, Income, at 239-242.
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Spousal refusal
Ordinarily, when a married individual applies for Medicaid, the income and resources of their spouse are also counted, because spouses are Legally Responsible Relatives for each other. However, an individual may prevent their spouse's income/resources from being counted if the spouse signs a statement indicating their refusal to make their income/resources available for their spouse's medical care. This is called a spousal refusal.
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SSA
Social Security Administration - The Federal government agency that administers Social Security benefits, including Retirement and Survivors Insurance, Disability Insurance, and Supplemental Security Income.
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SSI-Related
A category of Medicaid eligibility in New York State covering those who are aged (65 or over), blind, or disabled (as defined by the Social Security Administration). Also known as Disabled Aged Blind (DAB). This is DIFFERENT than those who receive Medicaid because they receive Supplemental Security Income (SSI) benefits. An individual does NOT need to receive SSI to be eligible for Medicaid under the SSI-related/DAB category.
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Standing referral
A referral for a fixed number of visits to a specific health care provider. Unlike a regular referral, it is good for more than one visit.
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TANF
Temporary Assistance for Needy Families - A federally funded program that provides cash assistance to low income families.
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TBI Waiver
Traumatic Brain Injury Waiver Program - This is one of New York's four 1915(c) Home and Community Based Services waivers, also called HCBS waivers. The TBI Waiver provides services for people diagnosed with a traumatic brain injury, or other related diagnosis, to allow them to remain in their homes. Services covered by this wavier can include service coordination, independent living skills and training, structured day programs, substance abuse programs, intensive behavioral programs, community integration counseling, home and community support services, environmental modifications, respite care, assistive technology, transportation, and community transition services.
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transfer penalty
An applicant for Medicaid coverage of a nursing home stay will be subject to a transfer penalty if they gave away money or property within a certain period of time (the "look-back period") before applying for Medicaid. If a transfer is found during a look-back period that does not fall under one of the Medicaid exemptions, then a penalty period is calculated based on the amount of money transferred. The penalty is a certain number of months, beginning when the applicant is in the nursing home and applies for Medicaid, during which Medicaid will not pay for the nursing home care.
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Unearned income
Income received that is not compensation for work performed by the recipient. It includes Social Security benefits, interest, dividends, pensions, annuities, retirement account distributions, worker's compensation, unemployment insurance, and gifts.
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Welfare Management System (WMS)
Welfare Management System (WMS), which was built in the 1970s, was the first Medicaid eligibility system in New York. WMS is the eligibility system currently used by the Local Departments of Social Services/Human Resources Administration to manage their cases. Eventually, the goal of New York State is for all cases held in the WMS eligibility system to be eventually moved into the MECM eligibility system.
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Work Requirements for Medicaid Coverage Rule
The Work Requirements for Medicaid Coverage Rule is also known as Work Requirements, Work Reporting Requirements, and Community Engagement Requirements. This is a federal rule, implemented by HR1, and will go into effect on January 1, 2027. According to this rule, in order to keep their health insurance coverage, some people with Medicaid will need to routinely show that they are working, in school, helping out in the community, or participating in job training.
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