NY Health Access - Glossary

• Medicaid

  Medicaid is the public health insurance program for people of limited means. It is jointly funded by the Federal, state, and local governments. However, each state has its own Medicaid program, which completely different rules regarding eligibility and what services are covered. You should assume that any information provided on this website only applies to the New York State Medicaid program (also known as "Medical Assistance").

• 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.

• OTDA
  New York State Office of Temporary and Disability Assistance - (Pronounced "Oh-ta-Da")  This is the New York State agency that administers Temporary Assistance (aka "welfare" or "public assistance"), Food Stamps, HEAP, and other programs.  OTDA also conducts all Fair Hearings in New York State, including Medicaid Fair Hearings.  See OTDA website.
  
• HRA
  New York City Human Resources Administration - This is the City agency that administers the Medical Assistance Program (aka "Medicaid"), as well as Temporary Assistance, Food Stamps, HEAP, and other benefit programs.  Many of these benefits are administered through the Departments of Social Services (DSS) in each county of New York State.  HRA is the DSS for New York City.  See HRA website.
  
• ADAP
  AIDS Drug Assistance Program - A prescription plan that pays for some of the medications needed by low-income people with HIV/AIDS.
• ADM
  Administrative Directive - A type of official memo issued by the New York State Department of Health, instructing local districts how to implement the law and regulations.
  
• AFDC-related
  Medicaid eligibility category for children and their caretaker relatives.
• BFI
  Bureau of Fraud Investigation - A New York City agency that investigates claims of fraud against the HRA’s social service programs, including Medicaid and Family Health Plus.
• Care At Home Waiver
  Medicaid waiver programs that provide medical and related services to severely disabled children so that they do not need to remain institutionalized. This includes case management, respite care and home and vehicle modification services that would not otherwise be covered by Medicaid.
• CASA
  Community Alternative Systems Agency - Division of New York City's HRA that assesses and authorizes Medicaid personal care services for elderly and disabled individuals.
• CHHA
  Certified Home Health Agency - A private home care agency that provides part-time, intermittent health care and support services to individuals who need intermediate and skilled health care.  CHHAs can also provide long-term nursing and home health aide services, physical, occupational, and speech therapy, medical supplies and equipment, and social worker and nutrition services.  Services provided by CHHAs may be reimbursed by Medicare, Medicaid, private payment, and some health insurers.  CHHAs take referrals from physicians, discharge planners, and directly from patients.  There are many CHHAs in New York State, with at least one in each county.  To find CHHAs in your area, go to http://homecare.nyhealth.gov/ in NYS or nationally at http://www.medicare.gov/HHCompare.
  
• Aid Continuing
  Aid Continuing is the right under the due process clause of the U.S. Constitution to have an administrative hearing (fair hearing) held and decided before benefits are reduced or terminated, where the benefits are an entitlement based on financial need.   This right was established by Goldberg v. Kelly, a US Supreme Court decision, and applies to Medicaid eligibility and services. 18 NYCRR Part 358, 360-2.9.  Notice of intent to reduce or terminate benefits must be given 10 days before the effective date of action.  18 NYCRR 358-2.23.  In order to obtain aid continuing, a hearing must be requested before the effective date on the notice.  18 NYCRR 358-2.5.  The recipient has a longer period -- 60 days from the date of the notice -- to request a hearing, but only receives the previous level of benefits unchanged pending the hearing if s/he requests the hearing within 10 days. 

• CHP
  Child Health Plus - A state-subsidized medical insurance program for low-income children up to age 19 who are not eligible for Medicaid.
• Community based long-term care services
  A category of services covered under Medicaid consisting of:

  • Personal Care Services (excluding those who need only housekeeping)
  • Consumer-Directed Personal Assistance Services
  • Certified Home Health Agency
  • Adult Day Health Care (but not social-model adult day care)
  • Private Duty Nursing
  • Long-Term Home Health Care Program (Lombardi waiver)

  An individual must require at least one of those services for at least 120 days per calendar year in order to be eligible to enroll in MLTC.  Furthermore, a dual eligible age 21+ who requires at least one of those services for at least 120 days per calendar year is required to enroll in MLTC.
• Community Spouse
  For purposes of Medicaid eligibility, a community spouse is "[a] person who is the spouse of an institutionalized person [i.e., in a medical institution, nursing facility, or receiving HCBS waiver or PACE services], and who is residing in the community and not expected to receive home and community-based services provided pursuant to a waiver under Section 1915(c) of the Social Security Act for at least 30 consecutive days."  Medicaid Reference Guide, Glossary, at iii.
  
• Earned Income
  For purposes of Medicaid eligibility, "[e]arned income is income received as a result of work activity.  This includes wages, salaries, tips, commissions and income received from self-employment."  Medicaid Reference Guide, Income, at 64.
  
• EPIC
  Elderly Pharmaceutical Insurance Coverage - A program that pays part of the cost of prescription medicine for New York State residents over age 65 with annual income below $35,000 (or $50,000 for couples).  See EPIC website.
  
• Excess Income
  AKA surplus income or spend-down.  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.
  
• Facilitated Enroller
  People or organizations that help complete Medicaid applications and answer questions about public health insurance programs.
• Fair Hearing
  A formal procedure provided by the Office of Administrative Hearings, upon request of a recipient, to determine whether a decision to deny, terminate or reduce services by a local district was correct.
• FHP
  Family Health Plus - A comprehensive New York State health insurance program for low-income adults ages 19 – 64 who have income above the current Medicaid levels, and who do not have other health insurance coverage.  See Family Health Plus website.
  
• Fee-for-service
  A type of health insurance where doctors and other health care providers receive a fee for each service they perform such as tests or office visits.
• HHC
  New York City Health and Hospitals Corporation - The public hospital system in New York City.  HHC serves New Yorkers regardless of immigration status or ability to pay, so it is a good option for many uninsured people.  "HHC provides medical, mental health and substance abuse services through its 11 acute care hospitals, four skilled nursing facilities, six large diagnostic and treatment centers and more than 80 community based clinics. HHC Health and Home Care also provides health services at home for New Yorkers."  See HHC website.
  
• In-kind income
  When a person or organization pays an expense on someone's behalf, rather than giving them cash, this is considered in-kind income.  For example, if a family member pays your phone bill, then it is in-kind income; but if they write you a check so that you can pay your phone bill, it is cash income.  In-kind income is usually not counted for purposes of Medicaid eligibility.  However, see Medicaid Reference Guide, Income, at 106-108.1.
  
• LRR
  Legally Responsible Relative - For purposes of Medicaid eligibility, "[a] relative who, by law, is responsible for the support and care of another person. In New York State, spouses are responsible for each other and parents are responsible for their children under 21."  See Medicaid Reference Guide, Glossary, at xi.
  
• LTHHCP
  Long Term Home Health Care Program - AKA Lombardi waiver or nursing home without walls.  A Medicaid wavier program which provides a nursing home alternative to patients requiring that level of care. It includes coverage of case management by registered nurses, home delivered meals, home improvements, respiratory therapy, medical, social, nutritional and dietary services, and respite care. See DOH website on LTHHCP.
• Look-back period
  The length of the period for which asset documentation is required when applying for Medicaid coverage of nursing home care.  For nursing home Medicaid applications between now and February 2011, the look-back period extends back to February 1, 2006.  From February 2011 onward, the look-back period will be 60 months long.  Medicaid will impose a transfer penalty based on the amount of uncompensated transfers identified within the look-back period.
  
• Managed care
  A type of private health insurance product that typically has the following features:

  • Capitation - the plan is paid a fixed amount per member per month by the payor (e.g., employer, union, Medicare, Medicaid) to provide a defined package of covered services.  The plan's reimbursement does not vary based upon the amount or cost of medical care provided.
  • Network - generally members of a managed care plan can only receive coverage for services provided by medical providers who have agreed in advance to participate in the plan's provider network, and thereby receive a contracted rate of payment.
  • Utilization Management - the plan may impose restrictions on coverage of certain procedures, such as requiring the physician to obtain permission from the plan before performing them, or limiting the number of pills that can be prescribed.  Some plans require members to have a primary care physician (PCP), and require the PCP to give referrals to any specialists before their services will be covered.  Occasionally, managed care plans go further and proactively coordinate care among the member's providers.
• MBI-WPD
  Medicaid Buy-In for Working People with Disabilities - A special Medicaid benefit that has a much higher income limit for people with disabilities who are working.  See DOH MBI-WPD website.
  
• Medical home
  A model of care that gives each patient a more personal and continuous relationship with their physician(s). This can include round the clock access to medical consultations, more comprehensive care coordination, and providing both care and health education in a way that respects the patient’s beliefs and cultural background.