Active Work Requirement |
 |
|
The minimum number of hours per week that an employee is required to work to qualify for and maintain eligibility for benefits.
|
ADAP (AIDS Drug Assistance Program) |
|
|
A program that pays for some or all of the costs associated with HIV/AIDS medications. ADAP only covers Federal Drug Administration (FDA) approved medications on its formulary (list of covered prescriptions).
|
Adjusted Gross Income |
|
|
Gross income minus deductions for certain expenses.
|
Administrative Law Judge |
|
|
|
|
Adult Basic Education |
|
|
Classes offered to CalWORKs recipients that provide basic reading, writing, and math skills.
|
Advance Earned Income Tax Credit (AEITC) |
|
|
|
|
Advanced Pay |
|
|
Money the government sends you to pay for your personal care before you actually receive those services. Then you pay your care provider directly once they provide those services.
|
Affidavit of Support |
|
|
A contract signed by the sponsor that shows that the immigrant applying for a green card is not likely to become dependent on the government for cash welfare or long-term care (nursing homes). There are two types of Affidavits of Support: Old (Traditional) and New (Enforceable). |
Age-18 Redetermination |
|
|
|
|
Aged |
|
|
The Cash Assistance Program for Immigrants considers individuals who are 65 years or older as aged.
|
Ancillary Services |
|
|
Protective shoes, clothing, tools, fees, or other services necessary for work.
|
Annual Election Period |
|
|
The period from November 15 through December 31 when you can enroll in and switch Medicare Part D plans. |
Any Income Deduction |
|
|
|
|
Appeal |
|
|
A process undertaken when an individual disagrees with an insurance carrier's decision to reduce services or deny treatment or payment.
|
Assets |
|
|
Things that are owned, such as a home.
|
Assets for Independence Act (AFIA) |
|
|
Legislation that established IDA programs for non-TANF applicants. The three goals of AFIA include: providing individuals and families with incentives to save earned income, increasing self-sufficiency, and improving the community.
|
Association-Sponsored Group Health Coverage |
|
|
Group coverage offered through an association like a union, guild, or trade organization.
|
Asylees |
|
|
Non-citizens who, while in the United States, are granted permission to remain because of well-founded fear of persecution in their home country.
|
Base Period |
|
|
The yearlong period that SDI uses to determine your regular wages. It starts around 17 months before your disability and ends around 5 months before then. Your base period is divided into 4 quarters, and the quarter with the highest wage is used to determine your benefit amount.
|
Basic Plan |
|
|
|
|
Benchmark Plan |
|
|
|
|
Beneficiary |
|
|
The person who is receiving a benefit.
|
Benefit (California State Disability Insurance - SDI) |
|
|
Weekly income replacement that generally lasts a maximum of 52 weeks. Benefits based on self-employment elective coverage are generally paid for a maximum of 39 weeks. Payments are based on an individual’s income during the SDI program’s base period, which is prior to the onset of disability.
|
Benefit Period |
|
|
The time period that Medicare uses to measure an individual’s use of hospital and skilled nursing facility care. A benefit period begins the day an individual enters a hospital or skilled nursing facility (SNF). The benefit period ends after the individual is released and hasn't received any further hospital care (or skilled care in a SNF) for 60 consecutive days. If an individual goes into the hospital after one benefit period has ended, a new benefit period begins. The inpatient hospital deductible may be charged for each benefit period. There is no limit to the number of benefit periods an individual may have. |
Benefits Planner |
|
|
Someone who can help you understand or apply for benefit programs when you become disabled or turn 65. Their goal is to help you avoid financial complications while developing a sustainable plan for the future. To find a benefits planner in California, use the DB101 Benefits Planner Directory. |
Benefits Planning Query (BPQY) |
|
|
A BPQY is a report that summarizes your current Social Security disability benefits. To order one, visit your local Social Security office or call 800-772-1213 (voice); 800-325-0778 (TTY). Be sure to review your BPQY carefully. If you have questions about it, contact a benefits planner or Social Security. |
Blind |
|
|
Blindness in Social Security disability programs is "statutory blindness," which means:
- You have a central visual acuity of 20/200 or less in your better eye, even while you are wearing a correcting contact lens or glasses in that eye; or
- You have a limitation in the field of vision of your better eye, so that:
- You have a contraction of peripheral visual fields to 10 degrees from the point of fixation, or
- The widest diameter of your visual field subtends an angle no greater than 20 degrees, or
- You have a contraction of peripheral visual fields to 20 percent or less visual field efficiency.
If you have a visual impairment that is not "blindness" as defined above, but your reduced vision (alone or in combination with other disabilities) prevents you from working, you may still be eligible for Supplemental Security Income (SSI) benefits.
|
Blind Work Expenses (BWE) |
|
|
Documented expenses needed in order to work that are reported to Social Security with wage reports. BWEs are for individuals who are awarded Supplemental Security Income because they meet Social Security's rules for being blind.
|
Blue Book (Listing of Impairments) |
|
|
The Social Security publication that provides detailed information about disability programs to physicians and other health care professionals. The Blue Book includes the complete Listing of Impairments, which lists and defines those conditions considered severe enough to prevent a person from doing any gainful activity. The Blue Book can now be accessed online. |
Break-Even Point (BEP) |
|
|
This is the income amount which reduces your Supplemental Security Income payment to zero when Social Security uses the countable income calculation. Your break even point can be determined by your earned and unearned income, living arrangements, and applicable income exclusions. |
California Work Opportunity and Responsibility to Kids (CalWORKs) |
|
|
The state welfare-to-work program that provides income support and access to health coverage on a temporary basis. CalWORKs was formerly Aid to Families with Dependent Children (AFDC).
|
CalWORKs Residency Requirement |
|
|
|
|
CAPI Residency Requirement |
|
|
Living and intending to stay in California. Individuals living in a jail, prison, VA hospital, or other public institution are ineligible for benefits.
|
CARE/HIPP (Comprehensive AIDS Resources Emergency/Health Insurance Premium Payment Program) |
|
|
A program that pays for private health insurance premiums for individuals who are disabled due to HIV or AIDS and who do not qualify for Medi-Cal/HIPP. Enrollment is administered through AIDS organizations authorized by CARE/HIPP. |
Cash Accrual |
|
|
The savings part of a whole life policy, which comes from a portion of the premiums paid by the insured.
|
Cash Value |
|
|
The amount of cash accrual and interest that the insured may be able to borrow money from.
|
Childhood Disability Benefits (CDB) |
|
|
Benefits for disabled adult children of recipients of Social Security disability or retirement benefits. Formerly known as Disabled Adult Child (DAC) benefits.
|
Coinsurance |
|
|
The portion of the payment for medical services that an individual is responsible for. For example, your health coverage may pay for 80% of the costs of a service, while you will have to pay the remaining 20%.
|
Community Service |
|
|
Temporary or transitional work that is performed in the public or private nonprofit sector that provides the Welfare-to-Work participant with job skills that can lead to employment. |
Community Work Incentives Coordinator (CWIC) |
|
|
The federal government pays benefits planners in communities around the country to help people think ahead about work incentives and benefits issues. CWIC'S are benefits planners who are trained by the Social Security Administration to assist beneficiaries with programs including Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) in addition to other related programs.
|
Conditional Permanent Resident |
|
|
U.S. Resident with a I-551 C Card.
|
Consolidated Omnibus Budget Reconciliation Act (COBRA) Administrator |
|
|
An outside company that processes COBRA and/or OBRA premiums. As this company may be located in another state, it may not be familiar with health insurance laws in the state of California.
|
Continuation Coverage |
|
|
|
|
Continuing Disability Review (CDR) |
|
|
A periodic review to determine if there has been any medical improvement in your condition and/or to determine whether you continue to be eligible for Social Security benefits for other reasons. The two types of reviews are called a medical CDR and a work CDR.
|
Copayment |
|
|
A set amount an individual must pay upon receiving medical services. For example, you may have to pay $10 each time you visit the doctor.
|
Countable Earned Income (CEI) |
|
|
|
|
Countable Income Calculation |
|
|
The calculation used to determine how much of your unearned and earned income is counted when determining your SSI benefit and eligibility.
Step 1: If you have unearned income (for example, an SSDI benefit), subtract a $20 "General Income Exclusion" from it to calculate your countable unearned income. If you do not have unearned income, this exclusion is applied to any earned income.
Step 2: If you have earned income (for example, wages), subtract a $65 "Earned Income Exclusion" from it (along with the remainder of the $20 "General Income Exclusion" that you have not applied to Unearned Income), along with any Impairment Related Work Expenses, and divide the resulting figure by two to find your countable earned income. If you have Blind Work Expenses, subtract them after you divide.
Step 3: Add your countable unearned income to your countable earned income to find your total countable income.
|
Countable Income Calculation (CIC) |
|
|
The formula used to determine income and to consider eligibility for SSI-Linked, Medically Needy, and Aged and Disabled Medi-Cal programs.
Step 1: If you have unearned income (for example, an SSDI benefit), subtract a $20 "General Income Exclusion" from it to calculate your countable unearned income. If you do not have unearned income, this exclusion is applied to any earned income.
Step 2: If you have earned income (for example, wages), subtract a $65 "Earned Income Exclusion" from it (along with the remainder of the $20 "General Income Exclusion" that you have not applied to Unearned Income), along with any Impairment Related Work Expenses, and divide the resulting figure by two to find your countable earned income. If you have Blind Work Expenses, subtract them after you divide by two.
Step 3: Add your countable unearned income to your countable earned income to find your total countable income.
Different Medi-Cal programs may include more deductions or exclude certain types of income. See the program descriptions for details.
|
County Organized Health System (COHS) |
|
|
Health-insuring organizations that are organized and operated by a governing board appointed by the county’s Board of Supervisors. All Medi-Cal beneficiaries residing within the county are required to enroll unless they have a voluntary aid code, which allows them to enroll in fee-for-service Medi-Cal. The first plan was implemented in Santa Barbara County in 1983. Five County Organized Health Systems plans operate in eight counties: Monterey, Napa, Orange, San Mateo, Santa Barbara, Santa Cruz, Solano, and Yolo. |
Coverage Effective Date |
|
|
The date an individual is enrolled in coverage. The effective date is usually not the same as the date of hire.
|
Creditable Coverage |
|
|
Coverage that is at least as good as that offered through Medicare Part D. Your health coverage plan can tell you whether or not your coverage is creditable. |
Creditable Coverage |
|
|
Under HIPAA, creditable coverage is prior health coverage that allows you to reduce pre-existing condition exclusionary periods when applying for new coverage. Most forms of health coverage can count as creditable.
|
Critical Access Hospital |
|
|
A hospital facility that provides outpatient and certain inpatient services to people in rural areas. Critical Access Hospitals are given a special status by Medicare.
|
Custodial Parent |
|
|
A parent that lives with the child.
|
Deductible |
|
|
The amount an individual is responsible for paying before Medicare begins to pay. For Part A, the deductible must be paid each benefit period. For Part B, the deductible must be paid each year. |
Deductible |
|
|
The amount an individual is responsible for paying for health care services before the insurer begins to pay.
|
Deemed Income |
|
|
The amount of another person’s income – spouse, sponsor, sponsor’s spouse, parent – that is considered to belong to the individual regardless of whether the person receives this money. |
Deeming Rules |
|
|
Rules used by Social Security and Medi-Cal that determine an individual’s eligibility when living with a non-disabled spouse. If the individual is a minor, deeming rules apply to the parents.
|
Dependent |
|
|
A person, usually a child, who is economically dependent on another person. Different programs have different specific definition of when someone is a dependent.
|
Disability (Definition used by California State Disability Insurance - SDI) |
|
|
Any illness or injury which prevents an individual from doing their regular or customary work. SDI includes disabilities resulting from elective surgery, pregnancy, childbirth, or a related medical condition. The disability must be verifiable by a medical provider. The SDI program may require some applicants to undergo an Independent Medical Examination to determine disability status. |
Disability (Definition used by CalWORKs) |
|
|
A condition that is expected to last at least 30 days and that significantly impairs the individual’s ability to be regularly employed or participate in Welfare-to-Work activities.
To qualify for an exemption from Welfare-to-Work activities due to a disability, a CalWORKs recipient must provide verification from a physician that states the disability, its expected duration, and the extent to which it impairs employment and/or Welfare-to-Work activities. The individual must also actively seek medical treatment to qualify for an exemption. |
Disability (Definition used by private insurers)
|
|
|
Definition of disability may be two-tiered: an inability to participate in the employee's own occupation (regular work) on the first tier, and an inability to participate in any occupation (any work) on the second tier. Refer to policy for definitions of disability.
|
Disability (Definition used by Social Security for Adults) |
|
|
|
The inability to engage in any substantial gainful activity (SGA) due to any medically determinable physical or mental impairment which can be expected to result in death or last for a continuous period of at least 12 months. A person must not only be unable to do his/her previous work but cannot, considering age, education, and work experience, engage in any other kind of SGA which exists in the national economy. It is immaterial whether such work exists in the immediate area, or whether a specific job vacancy exists, or whether the worker would be hired if he/she applied for work. The worker’s impairment(s) must be the primary reason for his/her inability to engage in SGA.
|
Disability (Definition used by Social Security for Children) |
|
|
A child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
|
Disabled Adult Child (DAC) Benefits |
|
|
|
|
Disclosing a Disabling Condition |
|
|
Gernerally, the only time it is required to disclose a disabling condition at the workplace is when requesting a reasonable accommodation. Even then, the requirement is to present the employer with a request that a reasonable accommodation is needed for the person to perform the essential functions of the job. |
Disregard |
|
|
A specified amount of earned or unearned income that is excluded from consideration in the financial eligibility requirements for a Medi-Cal program.
|
Domestic Abuse |
|
|
Assaultive or coercive behavior that includes: physical abuse, sexual abuse, psychological abuse, economic control, isolation, stalking, and threats.
|
Domestic Partner |
|
|
|
• We have a common residence;
• Neither of us is married to someone else, or is a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity;
• We are not related by blood in a way that would prevent us from being married to each other in this state;
• We are both at least 18 years of age;
• We are both members of the same sex or one/or both of us is/are over the age of 62 and meet the eligibility criteria under Title II of the Social Security Act as defined in 42 U.S.C. Section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act as defined in 42 U.S.C Section 1381 for aged individuals;
• We are both capable of consenting to the domestic partnership;
• We consent to the jurisdiction of the Superior Courts of California for the purpose of a proceeding to obtain a judgment of dissolution or nullity of the domestic partnership or for legal separation of partners in the domestic partnership, or for any other proceeding related to the partners’ rights and obligations, even if one or both partners ceases to be a resident of, or to maintain a domicile in, this state.
|
Domestic Violence Survivors |
|
|
|
|
Donut Hole |
|
|
The gap in Medicare Part D coverage when you have between $2,510 and $5,726.25 in total drug costs in a year. Medicare will not help pay for your drug costs during this period unless you qualify for a Low Income Subsidy. |
Dual-Eligibles |
|
|
|
|
Duration of Ticket Services |
|
|
Ticket program services may be used for sixty months (5 calendar years) and sometimes longer. Full use of sixty months of services under current rules is allowed once during each period of a Social Security disability.
|
Earned Income (EI) |
|
|
Salaries, wages, tips, professional fees and other amounts received as pay for physical or mental work actually performed. Funds received from any other source are not included. (Contrast unearned income.) |
Earned Income Deduction |
|
|
Income received from work that is disregarded in the countable income calculation. This calculation evaluates an individual’s financial eligibility for Aged and Disabled Federal Poverty Level (ADFPL), Breast and Cervical Cancer Treatment Program (BCCTP), In Home Supportive Services (IHSS), Medically Needy (MN) and 250% California Working Disabled Program (250% CWD) Medi-Cal. |
Earned Income Tax Credit (EITC) |
|
|
A federal income tax credit for low income working individuals and families. The credit reduces the amount of federal income tax owed and can result in a refund check.
|
Elective Coverage |
|
|
Optional State Disability Insurance (SDI) for the self-employed. Individuals must pay premiums based on self-employment taxes. Unlike SDI for employees, elective coverage generally provides income replacement benefits for a maximum of 39 weeks.
|
Eligibility Category |
|
|
One of several types of health coverage programs that Medi-Cal offers. Each eligibility category has specific requirements, and an individual may be eligible for more than one category.
|
Eligible Non-Citizen |
|
|
Either a:
|
Employer-Sponsored Health Coverage |
|
|
Health coverage offered through an employer.
|
Employment Network |
|
|
An employment services agency that is approved by Social Security. Employment Networks may offer a variety of services such as job readiness services, placement services, vocational rehabilitation, training, job coaches, transportation or other supports.
Employment Network examples:
- Employers
- Employers offering or arranging for job training
- An employer collaborating with a community based organization
- Transportation providers
- Staffing and placement agencies
- Consumer groups
- California Department of Rehabilitation
- Private providers of rehabilitation services
- One Stop Career Centers
- Vocational rehabilitation Service Projects for American Indians with disabilities
- Cottage industries such as benefits planning services combined with other services
- Public or private schools providing transitional education or career development services
- Organizations working with ethnic, disability, or religious faith groups
A current list of Employment Networks can be found on the MAXIMUS site.
|
Empowerment Zone |
|
|
A geographic area, such as a neighborhood, that meets certain population, size, and poverty guidelines. An area must be nominated by the local government and the state to become an Empowerment Zone. The Zone is marked by poverty, unemployment, and general distress. Empowerment Zones receive federal funding for community development. A list of Empowerment Zones can be found on the HUD website. |
Enterprise Community |
|
|
|
|
Exception |
|
|
A request to the plan to either cover a drug that is not on the formulary or to bypass utilization controls. |
Exclusion |
|
|
A service that a health coverage plan won't pay for. Cosmetic surgery, for example, is not covered under most plans.
|
Exempt |
|
|
|
|
Expected Family Contribution (EFC) |
|
|
The amount of money a family is expected to contribute to educational expenses. The Federal Student Aid Commission determines the EFC.
|
Expedited Reinstatement of Benefits |
|
|
Immediate reinstatement of benefits for individuals whose Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI) ended due to employment. This provision is available for up to 5 years after Social Security work incentives have been exhausted.
|
Extended Period of Eligibility (EPE)
|
|
|
The 36 consecutive months that start at the end of the Trial Work Period. During the Extended Period of Eligibility, any month in which gross earnings are or more (for 2008), an individual’s wages are considered Substantial Gainful Activity (SGA). When an individual’s earning first reach SGA, a three month grace period begins, allowing a beneficiary to continue receiving Social Security Disability Insurance (SSDI) payments regardless of wages. After the three month grace period, an individual will not receive SSDI income benefits for months when wages are at or above SGA. If wages fall below SGA, SSDI payments will resume. Beneficiaries who continue to earn SGA income after the EPE will no longer be eligible for SSDI payments. The SGA earnings for blind beneficiaries are different. In 2008, SGA for the blind is $1,570.
|
Fail First Rules |
|
|
A utilization control that requires you to use a cheaper drug before trying more expensive options. |
Federal Adjusted Gross Income |
|
|
Total taxable income. This includes money, goods, property, and services from all sources after any adjustments or deductions that are shown on a federal tax return.
|
Federal Benefit Rate (FBR) |
|
|
The national benefit amount, established by the Social Security Administration (SSA), for Supplemental Security Income (SSI) recipients. The Federal Benefit Rate (FBR) is administered by SSA for all states and Commonwealths annually. For 2008, the FBR is $637 for an individual and $956 for a couple. |
Federal Poverty Level (FPL) |
|
|
A table of income amounts used to determine financial eligibility for federal and state programs. Each year, the Department of Health and Human Services (HHS) issues the Federal Poverty Guidelines in the Federal Register. The Federal Poverty Level for one person is $10,400. For each additional person, add $3,480. For Medi-Cal programs, these figures go into effect in March or April of each year. |
FICA Requirements for Social Security Disability Insurance (SSDI) |
|
|
One of the eligibility requirements for SSDI is to have worked and paid FICA taxes for specified periods of time. If you work and earn at least $1,050 for one quarter (three months), and pay FICA taxes, you earn one SSDI "work credit." You can earn up to four credits within a 12-month period.
The number of work credits needed to qualify for SSDI depends upon how old you were when Social Security determined that you are disabled.
If you were determined disabled before age 24, you need 6 credits within the past 3 years to be eligible for SSDI.
If you were determined disabled between the ages of 24 and 31, you need 12 credits within the past 6 years to be eligible for SSDI.
If you were determined disabled after you turned 31, you need the number of work credits shown in the table below. And unless you are blind, you need to have earned at least 20 of those credits in the 10 years prior to becoming disabled.
Work Credits Required for SSDI Eligibility for those Born After 1929
Became Disabled At Age: |
Number of Credits Needed |
|---|
31 through 42 |
20 |
44 |
22 |
46 |
24 |
48 |
26 |
50 |
28 |
52 |
30 |
54 |
32 |
56 |
34 |
58 |
36 |
60 |
38 |
62 or older |
40 |
|
Five-Year Window |
|
|
The sixty consecutive months during which an individual works nine Trial Work Months.
The Window begins on the onset date of disability, but rolls forward until an individual has worked nine Trial Work Months that all occur within a 60 consecutive month period of time.
|
Food Stamps |
|
|
A federally funded program that helps people with low-income buy food.
|
Foreign Income |
|
|
Income received for services performed in a foreign county by an individual residing in that country.
|
Formulary |
|
|
A list of drugs that a health plan covers.
|
Full-Scope Medi-Cal |
|
|
Complete medical services offered to beneficiaries such as:
Inpatient hospital services (tests, surgeries, procedures) Outpatient hospital services Physician services Medical and surgical dental services Nursing services Home health care Family planning and supplies Rural health clinic and ambulatory services Laboratory and x-ray services Pediatric and family nurse practitioner services Nurse-midwife services Early and periodic screening Diagnosis and treatment (EPSDT) services Prenatal and delivery services Ambulatory services for individuals in an institution Home health services Clinic services Nursing facility services (under 21 years old) Intermediate care facility/mentally retarded services Optometrist services and eyeglasses Prescribed medication TB-related services for TB infected persons Prosthetic devices Dental services Preventative and rehabilitative services Case management Private duty nursing Home respiratory care services Personal care services Home and community based waivers Medical equipment and appliances Diagnostic screening
|
Fully-Insured Plan |
|
|
A plan where an insurance company takes on the risk. In general, health coverage protections specific to California only apply to fully-insured plans, and self-insured plans are regulated by federal laws. Ask your employer or health plan which type of plan you are participating in.
|
General Enrollment Period |
|
|
The period of time between January 1 and March 31 when a Medicare beneficiary can sign up for Part B coverage. Benefits will not begin until July 1 of that year, and a beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare. |
General Income Exclusion (Supplemental Security Income Program) |
|
|
The $20 of earned or unearned income that is not considered when determining the amount for the Supplemental Security Income (SSI) benefit.
|
General Relief/General Assistance (GR/GA) |
|
|
A county program that provides relief to those who are unable to support themselves by their own means, or by friends or relatives, other public funds, or other assistance programs.
|
Grant |
|
|
A monetary reward that does not have to be repaid.
|
Gross Benefit Amount |
|
|
The total benefit amount an insurance company pays before deductions. Deductions are made for an individual’s disability income and for earnings he/she is receiving.
|
Gross Income |
|
|
Income before taxes and other deductions are made.
|
Gross Misconduct |
|
|
A serious violation of company policy or the commission of a crime affecting the workplace that may result in the loss of COBRA benefits. Although "gross misconduct" is not defined in COBRA legislation, past examples include embezzlement, misrepresentation, theft, and non-work related violence.
|
Gross Pre-disability Salary |
|
|
The total pre-tax income paid to an individual by an employer before a disability began and while the individual was covered by disability insurance.
|
Group Coverage |
|
|
Coverage offered to an individual through a group, such as employer-sponsored, association-affiliated or professional group coverage.
|
Group Size |
|
|
Reasonable accommodation protections from the Americans with Disabilities Act (ADA) cover employers with 15 or more employees. California’s Fair Employment and Housing Act (FEHA) covers employers with five or more employees.
|
Guarantee Issue Amount |
|
|
The maximum amount of group coverage available to an individual during the initial enrollment period that does not require medical underwriting. For example, an individual may obtain guaranteed issue amount coverage of two times his or her annual salary, with higher benefit amounts requiring medical underwriting.
|
Guaranteed Issue Period (Medigap) |
|
|
A period of time when an individual can enroll in a Medigap plan without medical underwriting or waiting periods. Medigap providers cannot deny coverage during these periods.
|
Health Screening |
|
|
A process that allows Medigap carriers to refuse coverage based on an individual’s health history. This process is also known as medical underwriting. |
Health Status |
|
|
HIPAA and similar California laws prevent employer-sponsored health coverage plans from denying coverage based on health status. This includes physical and mental health conditions, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
|
High-cost Medical Condition |
|
|
A condition defined by Medi-Cal as one which results in average monthly medical expenses that equal or exceed twice the monthly health insurance premium. For example, if an individual’s monthly health coverage premium is $300, their medical costs must be greater than $600 per month to be considered a high-cost condition. |
HIV/AIDS Disability Form 4814 for Social Security |
|
|
A form for individuals with HIV/AIDS who are applying for Social Security Disability Insurance (SSDI) benefits. The form requires physicians to identify whether an individual has one of the 41 opportunistic infections listed on the form, and to specify any "repeated manifestations" of other symptoms that restrict certain aspects of the individual's life.
|
Home Health Care |
|
|
Services covered by Medicare that include: part-time or periodic skilled nursing care; home health aide services; physical therapy; occupational therapy; speech-language therapy; medical social services; durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers); medical supplies; and other services.
|
Hospice Care |
|
|
Services covered by Medicare Part A for individuals with a terminal illness. Services may include prescriptions for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in an individual’s home; however, Medicare may cover some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
|
Hospital Stays |
|
|
Services covered by Medicare Part A that include a semiprivate room, meals, general nursing, and other hospital services and supplies.
|
Hunt v. Kizer |
|
|
A case law that allows a Medi-Cal recipient to use prior unpaid medical expenses to meet their monthly share of cost.
|
Impairment Related Work Expenses (IRWE) |
|
|
Documented expenses for services or items that are related to one's impairment and needed in order to work. Wheelchairs, physician visits, co-pays for prescriptions, and other medical expenses are some examples of IRWEs. The expenses must be verified by original receipts and canceled checks.
|
In arrears |
|
|
Payment received for the prior month.
|
In Home Supportive Services (IHSS) |
|
|
A program that provides domestic, paramedical, and personal assistance services for people with disabilities so that they can live independently or maintain employment safely. The IHSS program provides an alternative to living in an institution for many people.
|
Income Disregard |
|
|
|
|
Incurring Medical Expenses |
|
|
Being responsible for medical expenses before Medi-Cal coverage begins.
|
Indemnity Plan |
|
|
A type of health insurance plan. You pay monthly premiums and usually have coinsurance and a yearly deductible as well. Also known as fee-for-service. |
Independent living |
|
|
Living on one’s own, in the community, outside of an institution.
|
Independent Review Entity |
|
|
A person outside of a Part D plan who reviews an appeal. This is the first person outside of the plan to review an appeal during the Part D appeals process. |
Indigent Exception |
|
|
A deeming exception for CAPI applicants whose sponsor signed an Old Affidavit of Support. An individual is considered to be indigent if he/she receives less than the federal Supplemental Security Income (SSI) benefit amount - $637 per month in 2008 for an individual ($956 for a couple). |
Individual Coverage |
|
|
Coverage that you buy directly from an insurance company, usually through an agent. You are responsible for paying for the entire premium, and most individual policies require medical underwriting. |
Individual Threshold Amount |
|
|
A personal income limit that enables an individual to retain Supplemental Security Income-Linked Medi-Cal coverage when their earnings go above the state's threshold amount. Social Security will determine an Individual Threshold Amount if the individual has Impairment Related or Blind Work Expenses, a Plan to Achieve Self Support, a publicly funded personal attendant, or medical expenses above the state average amount. |
Individual Work Plan (IWP)
|
|
|
A formal agreement between a ticket holder and an Employment Network that describes how services will achieve an employment goal. The Plan includes specific steps and a time schedule that may span several years.
|
Individualized Education Plan (IEP) |
|
|
An educational plan for a student receiving special education services. The IEP is created with input from parents, teachers, staff, and the student. It includes information on the student’s current performance, goals and evaluation, and on what specific services the student will need.
|
Initial Enrollment Period |
|
|
The first time an individual is eligible to enroll in a group’s benefits programs. During this period, the individual’s medical history is not subject to review. Once enrolled, however, pre-existing condition exclusionary periods may apply. |
Initial Enrollment Period |
|
|
The period when a beneficiary can first sign up for Medicare Part B or Part D. For Social Security Disability Insurance (SSDI) beneficiaries, the initial enrollment period begins the 24 th month of a beneficiary’s Social Security disability payments. In general, it begins three months before you meet Medicare's eligibility requirements and lasts seven months. |
In-Kind Support and Maintenance |
|
|
Food and/or rent only which is supplied or paid for by someone else, not the person receiving a Supplemental Security Income (SSI) cash benefit. Sometimes referred to as ISM. As of March 9, 2005, clothing is no longer considered ISM. |
Inpatient Care |
|
|
Health services received when an individual is admitted to the hospital.
|
Integration |
|
|
The adjustment of payments when an individual is eligible for more than one benefit program.
|
Interval Steps |
|
|
Measurable milestones that show progress towards achieving a vocational goal in a Plan for Achieving Self-Support. For example, if the goal is to obtain a job, the job search would be considered an interval step. |
Investment Income |
|
|
Dividends, capital gains net income, certain rental and royalty income, net passive activity income, and taxable and tax-exempt interest.
|
Lawful Permanent Residents (LPRs) |
|
|
Individuals living within the U.S. with a green card.
|
Legal Adulthood |
|
|
Being able to sign contracts, vote, and enjoy other rights and responsibilities of adulthood. Generally, in the United States, people become legal adults when they turn 18. This is a separate concept from Representative Payee. |
Lifetime Maximum |
|
|
A limit of how much an insurer will spend on you. For example, a plan might cover medical costs until they've spent $100,000, at which point they will no longer help pay for your medical costs.
|
Lifetime Reserve Days |
|
|
The days following a 90-day hospitalization. Medicare allows an individual 60 lifetime reserve days per benefit period that may only be used once during an individual’s lifetime. Medicare will pay for lifetime reserve days, whether used at once or over the individual's lifetime. However, the individual must pay for the daily coinsurance of $512 for 2008. |
Liquid Assets |
|
|
Cash or other property which can be converted to cash within 20 days, excluding non-work days. Liquid assets include: checking and savings accounts, stocks, bonds, mutual fund shares, promissory notes, mortgages, and life insurance policies.
|
Liquid Assets |
|
|
Accessible cash resources that include: individual/joint checking and savings accounts, retirement accounts, stocks, bonds, mining rights and cash value in a life insurance policy.
|
Long-term Care |
|
|
Services that assist individuals with long-term medical and personal needs. Long-term care may include medical services, physical therapy, custodial care, and assistance with activities of daily living (dressing, eating, bathing, etc.). Long-term care may be provided at home, in the community, or in facilities, including nursing homes and assisted living facilities. Medicare will not pay exclusively for custodial care.
|
Look-back Period |
|
|
A window of time prior to enrollment in a new health plan used to define pre-existing conditions. If, for example, your health plan has a “6-month look-back,” any health condition that you received medical advice, diagnosis, care, or treatment for within the six months prior to enrollment would be considered a pre-existing condition. |
Low Income Subsidy |
|
|
Help paying for Medicare Part D costs for those who meet income and asset rules. Also known as "Extra Help".
|
Maintenance Need Level (MNL) |
|
|
The amount of an individual’s income that Medi-Cal determines is used to cover living expenses such as food, clothing and housing.
|
Major Risk Medical Insurance Program (MRMIP) |
|
|
|
|
Match |
|
|
Funds paid by an IDA program when an individual deposits money into the account.
|
Maximum Aid Payment (MAP) |
|
|
Amount of cash aid a CalWORKs applicant is eligible for based on family size. Families who do not have any earned or unearned income are considered exempt and will receive a higher cash payment.
|
MAXIMUS
|
|
|
A private organization authorized by the Social Security Administration (SSA) to manage the Ticket to Work Program. As Program Manager, MAXIMUS provides outreach, recruitment, training, and payment processing to Employment Networks. |
Medicaid |
|
|
A joint Federal and state program that provides assistance with medical costs to some low income individuals with limited resources. Medicaid programs vary from state to state. The federal Medicaid program is called Medi-Cal in California. |
Medicaid Buy-In |
|
|
A program that allows individuals working with a disability to retain Medi-Cal (Medicaid) coverage through premium payments. In California, this program is called the 250% California Working Disabled Program.
|
Medi-Cal Managed Care |
|
|
A Medi-Cal program that requires most recipients to receive services within a network. Recipients are assigned a primary care provider who is responsible for managing their care. Also known as Medi-Cal Prepaid Health Plan.
|
Medi-Cal Prepaid Health Plan |
|
|
|
|
Medical Provider |
|
|
The person who provides a medical certification of a disability. They can be a licensed physician, surgeon, U.S. government medical office, osteopathic physician, chiropractor, podiatrist, optometrist, dentist, designated psychologist, nurse-midwife, nurse practitioner, midwife, or accredited religious practitioner.
|
Medical Treatment/Care |
|
|
Any medical care received by an individual for a medical condition. Examples of medical treatment include being prescribed medication, physician consultations, and therapy for a mental or physical condition.
|
Medical Underwriting |
|
|
The review of an individual’s medical history and/or medical records to determine if the individual is eligible for coverage. Medical underwriting, which may include new medical testing, can be used to deny coverage or determine if a particular pre-existing condition will be covered. |
Medi-Cal/HIPP (Medi-Cal/Health Insurance Premium Payment) |
|
|
A state program that pays for private health insurance premiums. For information on application procedures, call (866) 298-8443.
|
Medically Necessary |
|
|
Services or supplies that are considered by Medicare to be appropriate and needed for treatment. |
Medicare |
|
|
Medicare is a federal program that provides health insurance for people over 65 and many people under 65 who have a disability. If you receive Social Security Disability Insurance benefits you will be eligible to receive Medicare after a two year and five month waiting period.
|
Medicare + Choice Plan |
|
|
|
|
Medicare Advantage |
|
|
|
Formerly known as Medicare + Choice.
|
Medicare Advantage Prescription Drug (MA-PD) Plan |
|
|
|
|
Medicare Appeals Council |
|
|
|
|
Medicare Carrier |
|
|
A private insurance company that contracts with Medicare.
|
Medicare HMOs |
|
|
|
|
Medicare Managed Care Plan |
|
|
A Medicare Advantage option that can have lower co-payments than the Original Medicare Plan, but generally limits individuals to visiting doctors, specialists, or hospitals within the plan's network. Plans must cover all Medicare Part A and Part B services, and some plans cover extras, like prescription drugs. Medicare Managed Care Plans are only available in some areas of the country. Also know as Medicare HMOs.
|
Medicare Modernization Act |
|
|
The 2003 law that created the Medicare Part D program.
|
Medicare Part A |
|
|
|
Medicare Part A is the part of Medicare that helps pay for medical care you get while you’re in a hospital.
|
Medicare Part B |
|
|
Medicare Part B is the part of Medicare that helps pay for medical care you get when you are not staying in a hospital, such as when you go to see a doctor. |
Medicare Part D |
|
|
Medicare Part D is the part of Medicare that helps pay for prescription drugs. |
Medicare Plans |
|
|
|
|
Medicare Preferred Provider Organization (PPO) Plan |
|
|
A Medicare Advantage option that gives an individual the choice of visiting providers within the network or seeing a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician to see a specialist. |
Medicare Private Fee-for-Service Plan |
|
|
A Medicare Advantage option that allows an individual to go to any Medicare-approved doctor or hospital. The insurance plan, rather than the Medicare program, decides what services it will cover and how much it will pay. Although an individual may pay more under this plan, he/she may have extra benefits that the Original Medicare Plan doesn't offer. |
Medicare Savings Programs |
|
|
| Programs that have Medi-Cal pay for Medicare premiums. The types of Medicare costs that Medi-Cal pays for in these programs depends on your income. |
Medicare Special Needs Plan |
|
|
A Medicare Advantage option that provides health care focused on certain health conditions. These plans provide comprehensive Medicare coverage to manage a particular disease or condition, such as congestive heart failure, diabetes, or End-Stage Renal Disease (ESRD). Medicare Special Needs Plans are only available in some areas of the country. |
Medicare Supplement |
|
|
|
|
Medigap |
|
|
A supplemental insurance policy sold by private insurance companies to fill gaps in the Original Medicare Plan. In California, there are 12 Medigap plans labeled Plan A through Plan L. Medigap policies are available only to individuals using the Original Medicare Plan, and it is illegal for an insurance carrier to sell a Medigap policy to an individual who does not have Original Medicare. Also known as Medicare Supplement.
|
Medi-Medi |
|
|
A name used to describe individuals who are eligible for both Medi-Cal and Medicare. |
Milestone |
|
|
|
|
Minimum Basic Standards of Adequate Care (MBSAC) |
|
|
A tool used by California’s Department of Social Services to determine CalWORKs eligibility.
|
Needs Assessment |
|
|
An evaluation that measures an individual's ability to complete activities of daily living (dressing, toileting, bathing, eating, respiration, getting around in the house) and instrumental activities of daily living (housekeeping, shopping, taking medication, meal preparation, managing finances, and getting around out of the house). The needs assessment determines an individual’s level of need for the In Home Supportive Services Program.
|
Net Benefit Amount |
|
|
The benefit amount an insurance company pays after deducting income.
|
Net Countable Earned Income |
|
|
The portion of an individual's earned income that is taken into account when evaluating financial eligibility for Medi-Cal.
|
Network |
|
|
|
|
Notice of Action (NOA) |
|
|
The official name for correspondence between Medi-Cal and beneficiaries.
|
Onset Date (Social Security) |
|
|
The date, after reviewing an individual's medical records, that Social Security determines that a disability began. The date Social Security receives an application does not necessarily establish the onset date.
|
On-the-Job Training (OJT) |
|
|
An employment activity under the Welfare-to-Work Program that provides skills to CalWORKs participants. An employer in the public or private sector can receive compensation for On-the-Job Training of a CalWORKs recipient. |
Open Enrollment Period |
|
|
The annual time period when an individual may add or change coverage in an employer-provided or association-affiliated insurance plan. Changes during most of these annual periods will require medical underwriting to add benefits not elected during the initial enrollment period. The federal government calls this period "open season", and other insurers may use different terms.
|
Original Medicare Plan |
|
|
A pay-per-visit health coverage plan that allows individuals to go to any doctor, hospital, or other health care supplier who accepts Medicare and who is accepting new Medicare patients. The individual is responsible for paying a deductible and copayment. Under the Original Plan, Medicare pays a portion of the Medicare-approved amount, while the individual pays for his/her share (coinsurance). The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). |
Out-Of–Pocket Cost |
|
|
The costs an individual pays without assistance from Medicare, Medi-Cal, or other insurance.
|
Out-of-pocket Maximum |
|
|
The maximum amount of money that you have to spend on health costs in a year. After you reach the out-of-pocket maximum, your policy will pay the entire cost of covered services. The out-of-pocket maximum does not count the premiums you pay and certain other costs may or may not be counted. |
Overpayment |
|
|
Payment that exceeds the approved benefit amount.
|
Paramedical Services |
|
|
Services that are prescribed by a doctor and often administered by in-home care providers. They typically require some level of training or judgment and are essential to the health of the recipient. Common examples include injections, administration of medication, catheter insertion and care, tube feeding, ventilator and oxygen care, treatment of wounds, and other services requiring sterile procedures.
|
Parental Control |
|
|
Social Security uses this as one measure of whether or not a beneficiary should receive an independent living benefit rate. A child is considered to be under "parental control" if their parent has the authority to make decisions on their behalf.
|
Parent-to-Child Deeming |
|
|
Social Security’s process of figuring out how much of parents’ income is used to pay for a child’s basic needs. The amount of deemed income is subtracted from the benefit amount.
|
PASS |
|
|
A Supplemental Security Income (SSI) program that allows you to set aside income and resources for expenses related to a specific work goal. Income that you use for these expenses will not cause your SSI benefit to decrease. Resources that you spend on PASS expenses won't count towards the SSI limit.
|
PASS Cadre |
|
|
|
|
Patient Assistance Program (PAP) |
|
|
A program administered by a pharmaceutical company that provides financial assistance with prescription drug costs. PAPs offer free and discounted prescription drugs to those who qualify.
|
Payer of Last Resort |
|
|
The insurer who pays medical claims last when an individual has multiple sources of health coverage.
|
Permanent Resident |
|
|
U.S. Permanent Resident with either an Alien Registration Card or I-551 Card.
|
Permanently and Totally Disabled |
|
|
Unable to engage in any Substantial Gainful Activity (SGA) due to any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of at least 12 months. |
Permanently Residing in the U.S. Under Color of Law (PRUCOL) |
|
|
Subject to an Order of Supervision On whose behalf an immediate relative petition has been approved and who are entitled to voluntary departure Who have properly filed an application for an adjustment to lawful permanent resident status Granted a stay of deportation Granted voluntary departure and who are awaiting issuance of a visa In deferred action status Who entered and have continually resided in the United States since before January 1, 1972
|
Personal Assistance Services (PAS)
|
|
|
Services designed to assist an individual with a disability perform activities of daily living at home or in the workplace.
|
PhRMA Member |
|
|
|
|
Plan for Achieving Self Support (PASS) |
|
|
A Supplemental Security Income (SSI) program that allows you to set aside income and resources for expenses related to a specific work goal. Income that you use for these expenses will not cause your SSI benefit to decrease. Resources that you spend on PASS expenses won't count towards the SSI limit.
|
Point Of Service (POS) Plan |
|
|
A type of health coverage that allows you to choose between HMO, PPO, and Indemnity coverage. You can choose to pay less and have your care managed by a physician, or pay more to have more choices in the doctors you can see. |
Point-of-Service (POS)
|
|
|
An option offered by some Medicare Managed Care Plans that allows an individual to use doctors and hospitals outside the plan at an additional cost. |
Pre-disability Income |
|
|
|
|
Pre-existing Condition |
|
|
Any condition for which “medical care” was received within six months prior to the effective date of insurance coverage. Medical care includes the use of prescription drugs and physician consultations and services. During a pre-existing condition exclusionary period, coverage for that condition is either not provided or can be limited.
|
Pre-existing Condition Exclusionary Period |
|
|
The period of time from the coverage effective date that the insurer does not cover a pre-existing medical condition. The individual will normally be covered for the condition once the specified time has elapsed. |
Preferred Provider Organization (PPO) |
|
|
A type of health insurance plan. You pay a monthly premium and, when you use medical services, copayments and deductibles. PPOs have networks of physicians. You can see any doctor in the network without getting prior authorization from a primary care physician. Seeing a doctor outside of the network is more expensive. |
Premium |
|
|
A regularly scheduled payment to an insurer or health care plan.
|
Prescription Drug Plan (PDP) |
|
|
A Medicare Part D plan that only offers drug coverage. Also known as a "stand-alone" plan. |
Presumed Maximum Value (PMV) Rule |
|
|
|
|
Presumptive Disability |
|
|
A status granted to Supplemental Security Income (SSI) applicants who have a high chance of being found disabled according to Social Security Administration (SSA) standards. If the SSA finds you presumptively disabled, they will begin benefit payments while your application is still being reviewed.
The SSA may find you presumptively disabled if you meet the medical criteria of the Blue Book Listing of Impairments or if you have HIV/AIDS and meet the criteria of SSA Form 4814. In either case, you must also meet SSI financial requirements to be eligible for presumptive disability benefits.
Repayments of presumptive disability benefits are not required even if SSI benefits are ultimately denied.
|
Preventive Services |
|
|
Health care services aimed at keeping an individual healthy by preventing illness; for example, Pap tests, pelvic exams, yearly mammograms, and flu shots.
|
Prima Facie |
|
|
Evidence that would establish a fact if uncontested.
|
Primary Care Doctor |
|
|
A doctor that provides basic care and acts as an individual’s first point of contact when seeking health services. In many Medicare Managed Care Plans (Medicare HMOs), an individual must see their primary care doctor before going to a specialist. |
Primary Care Provider (PCP) |
|
|
The doctor, nurse practitioner, or other medical service provider who is in charge of your medical care in a Health Maintenance Organizations (HMO). In HMOs, you have to see a PCP in order to get a referral to see a specialist. Other types of health coverage might not have PCPs, or might charge you more if you see a specialist without getting a referral from a PCP. |
Primary Payer |
|
|
The first insurer to pay medical claims when an individual uses multiple sources of health coverage.
|
Prior Authorization |
|
|
A utilization control that requires you to have a drug plan's permission to use a certain drug. |
Private Health Coverage |
|
|
Coverage that is not funded by local, state or federal government. Private health coverage can be paid for by an individual, employer, or association.
|
Private Health Insurance Policy (Med-Cal/HIPP) |
|
|
A health insurance policy from a private insurer, Health Maintenance Organization (HMO), or self-insured trust. |
Proof of Good Health |
|
|
The review of an individual’s medical records, or the performance of medical testing, to determine eligibility for coverage. Individuals who elect coverage through a group during the initial enrollment period for the guarantee issue amount are not normally required to furnish proof of good health. |
Protective Filing Date |
|
|
The date an individual first contacts the Social Security Administration (SSA) to file for Supplemental Security Income (SSI) benefits. The protective filing date establishes the earliest possible date an individual can receive SSI benefits.
|
Protective Supervision |
|
|
Monitoring the activities of a person with cognitive disabilities to assure that they are not a harm to themselves or others.
|
Qualified Alien |
|
|
Individual who is:
- Lawful permanent resident,
- Asylee,
- Refugee,
- Person paroled in the United States for at least 1 year,
- Person who have been granted withholding of deportation or removal,
- Person granted conditional entry,
- Cuban or Haitian entrant, or
- Battered spouse, battered child, or parent of a child who is battered.
|
Qualified Alien |
|
|
According to Social Security, you are considered a qualified alien if the Department of Homeland Security (DHS) says you are in one of these categories:
- Lawfully Admitted for Permanent Residence (LAPR) in the United States, including "Amerasian immigrant" as defined in Section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988, as amended;
- granted conditional entry under Section 203(a)(7) of the Immigration and Nationality Act (INA) as in effect before April 1, 1980;
- paroled into the United States under Section 212(d)(5) of the INA for a period of at least one year;
- refugee admitted to the United States under Section 207 of the INA;
- granted asylum under Section 208 of the INA;
- deportation is being withheld under Section 243(h) of the INA as in effect before April 1, 1997, or removal is withheld under Section 241(b)(3) of the INA; or
- “Cuban or Haitian entrant” under Section 501(e) of the Refugee Education Assistance Act of 1980 or in a status that is to be treated as a “Cuban or Haitian entrant” for SSI purposes.
|
Qualified Disabled Working Individual (QDWI) |
|
|
Be less than 65 years old, Be eligible for Medicare Part A only, Have income at or below 200% of the Federal Poverty Level (until 3/31/2009, $1,734 per month for individuals, $2,333 for couples), Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and Meet all other Medi-Cal eligibility requirements.
|
Qualified Invidiual-1 (QI-1) |
|
|
A Medicare Savings Program that pays for Medicare Part B premiums. To qualify, an individual must:
Be eligible for Medicare Part B Have countable income less than 135% of the Federal Poverty Level (until 3/31/2009, $1,170 per month for individuals, $1,575 for couples), Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and Meet all other Medi-Cal eligibility requirements.
|
Qualified Medicare Beneficiary (QMB) |
|
|
- Be eligible for Medicare Part A and Part B,
- Have countable income at or below 100% of the Federal Poverty Level (until 3/31/2009, $867 per month for individuals, $1,167 for couples),
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
- Meet all other Medi-Cal eligibility requirements.
This program does not apply benefits retroactively.
|
Qualifying Child |
|
|
An IRS classification that may allow a taxpayer to claim the EITC and certain other tax credits. In general, to be a taxpayer’s qualifying child, a person must satisfy four tests:
-
Relationship — the taxpayer’s child or stepchild (whether by blood or adoption), foster child, sibling or stepsibling, or a descendant of one of these.
-
Residence — has the same principal residence as the taxpayer for more than half the tax year. Exceptions apply, in certain cases, for children of divorced or separated parents, kidnapped children, temporary absences, and for children who were born or died during the year.
-
Age — must be under the age of 19 at the end of the tax year, or under the age of 24 if a full-time student for at least five months of the year, or be permanently and totally disabled at any time during the year.
-
Support — did not provide more than one-half of his/her own support for the year.
|
Qualifying Events |
|
|
Events that may end individuals' employer-sponsored group health coverage but qualify them for COBRA or other continuation coverage. See the COBRA Program Description for details. |
Qualifying Family Member |
|
|
A spouse, domestic partner, or parent whose employer-sponsored health plan premiums are paid for by Medi-Cal/HIPP. Medi-Cal/HIPP pays premiums for qualifying family members when it is cost effective to enroll the family member in the employer-sponsored plan.
|
Reasonable Accommodation |
|
|
An adjustment or modification to a job or workplace that enables an employee to successfully perform the essential duties of the job.
|
Reasonable Accommodation Request
|
|
|
A request to an employer to make a modification to a job or workplace that allows an employee to successfully perform the essential duties of a job. The request can come from the employee, or an employee's friend, family member, or medical provider. Reasonable accommodation rules are case-by-case situations, and employers and employees can negotiate the terms under the law.
|
Referral |
|
|
|
|
Refugees |
|
|
Non-citizens who, while outside the U.S. and their home country, were granted permission to enter and live in the U.S. because they had a well-founded fear of persecution in their home country.
|
Regular Attendance (SEIE definition) |
|
|
- Attend a college or university for at least 8 hours a week under a semester or quarter system
- Be in grades 7 - 12 for at least 12 hours a week
- Be in a course of training (with shop practice) to prepare for a paying job for at least 15 hours a week
- Be in a course of training (without shop practice) for 12 hours a week
In some circumstances, like illness or unavailability of transportation, students may be allowed to spend less time than indicated above and still be considered “regularly attending” for the purposes of the SEIE.
|
Renewal Community |
|
|
|
|
Representative Payee |
|
|
An individual who receives benefits on someone else's behalf. Social Security conducts a careful investigation before appointing a relative, friend, or other interested party as the representative payee of individuals who need help managing their benefits.
|
Representative Payee |
|
|
Someone who receives benefits on another person’s behalf. For children under 18, a parent or guardian is usually the representative payee.
|
Resource Exclusions |
|
|
CAPI does not consider the following items when they figure out your countable resources:
-
The home, and any adjoining land
-
Household goods and personal effects that have a total value of $2000 or less
-
One car if it is: necessary for employment, or necessary fro medical treatment, or modified for use by a disabled person, or it provides necessary transportation to perform essential daily activities, or has a current market value less than $4500
-
Property of a trade or business that is essential for self support
-
Non-business property which is essential to self support
-
Resources of a blind or disabled individual necessary to fulfill an approved PASS
-
Certain stocks held by Alaskan natives
-
Life insurance, if the total face value of all policies on one person do not exceed $1500. Otherwise, the cash surrenders values of life insurance policies will count as a resource
-
Restricted allotted Native American lands
-
Payments or benefits paid under other Federal statutes
-
Disaster relief assistance
-
Burial space of any value, and burial funds up to $1500
-
Title XVI (SSI) or Title II (SSDI) retroactive payments for 6 months
-
Housing assistance
-
-
Nine months of payments received as compensation for expenses or losses suffered as a result of a crime
-
Nine months of reallocation assistance
|
Resources |
|
|
Accessible cash resources that include: individual/joint checking and savings accounts, retirement accounts, stocks, bonds, mining rights and cash value in a life insurance policy.
|
Retroactive Payments
|
|
|
Payments made for the period between disability onset and application approval.
|
Sanction |
|
|
|
|
Satisfactory Academic Progress |
|
|
An institution's minimum academic requirements that a student must meet to be eligible for federal student aid.
|
Satisfactory Participation |
|
|
Regular attendance and satisfactory progress in the Welfare-to-Work and Cal-Learn programs. In the Cal-Learn program, satisfactory progress is considered a grade point average of 2.0 |
Secondary Payer |
|
|
A health insurance plan that supplements a primary insurance plan. Health care costs not covered by the primary plan can be submitted to the secondary payer, which often covers some or all of the deductibles, co-payments, and other services not covered by the primary insurance provider. |
Section 301 |
|
|
A rule that allows certain people to keep their Social Security benefits after being found to no longer be medically disabled. For Section 301 to apply, a beneficiary has to be participating in a Social Security approved employment support program, and participation in that program has to increase the likelihood that the beneficiary will not need Social Security benefits after completing the program. Vocational rehabilitation and PASS are two examples of “Social Security approved employment support programs”. |
Self-Initiated Program |
|
|
Full-time vocational training or education that also fulfills the work activity requirements under the Welfare-to-Work Program. The training or program must be expected to be completed within 24 months and take place at an approved school. |
Self-insured Plan |
|
|
A plan that covers an individual’s medical expenses with company funds set aside to pay health claims. In general, self-insured plans are subject to federal, but not state, health coverage laws. Ask your employer or plan to find out if you are in a self-insured plan.
|
Self-Petitioners |
|
|
|
|
Service Wait |
|
|
The period of time an individual is required to be employed by a company or be a member of an association before becoming eligible to enroll for the group’s health coverage. Also known as the minimum service requirements.
|
Share of Cost (SOC) |
|
|
The amount of money an individual pays for health care costs before Medi-Cal coverage begins.
|
Skilled Nursing Facility Care |
|
|
Services that include a semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies. Medicare covers skilled nursing facility care after the individual has been in the hospital for 3 days.
|
Social Security Disability Insurance (SSDI) |
|
|
Social Security Disability Insurance (SSDI) is wage replacement income for individuals who have worked and paid FICA taxes and who now have a disability meeting Social Security disability rules. SSDI provides a variety of benefits to family members when a primary wage earner in the family becomes disabled or dies. SSDI is financed with Social Security taxes paid by workers, employers, and self-employed persons. SSDI benefits are payable to disabled workers, widows, widowers, and children or adults disabled since childhood who are otherwise eligible.
|
Social Security Medical Determination Only |
|
|
A certification that an individual is medically eligible for Social Security disability programs. Individuals can use this medical award document to qualify for OBRA even if they are not eligible for Social Security disability programs for non-medical reasons.
|
Social Security's 1619(b) Provisions |
|
|
Provisions that allow Supplemental Security Income (SSI) beneficiaries to retain Medi-Cal coverage when their combined income is too high to receive any SSI cash benefit. To continue receiving Medi-Cal, an individual must meet all of the following 1619(b) provisions:
- Received an SSI benefit payment in the past twelve months
- Meet medical disability requirements
- Meet non-disability requirements
- Need Medi-Cal health coverage to continue working
- Have wages below the 1619(b) threshold amount of $34,346 annually ($35,906 if blind) as of 2008 in California
|
Special Enrollment Period |
|
|
The period when an individual can apply for Medicare coverage without a late enrollment penalty and can sign up for Medigap without a pre-existing condition waiting period. The special enrollment period typically spans the first eight months following the loss of group health coverage. |
Special Enrollment Rights |
|
|
Rights that allow an individual to qualify for health coverage without having to undergo medical underwriting. Special Enrollment Rights can be requested from an employer within 30 days after previous health coverage is exhausted or terminated. They apply to individuals who do not enroll during the initial enrollment period or have lost their health coverage.
|
Special Need Payment |
|
|
A one-time cash payment to homeless CalWORKs families for temporary or permanent housing.
|
Specified Low-Income Medicare Beneficiary (SLMB) |
|
|
- Be eligible for Medicare Part A and Part B,
- Have countable income less than 120% of the Federal Poverty Level (until 3/31/2009, $1,040 per month for individuals, $1,400 for couples),
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
- Meet all other Medi-Cal eligibility requirements.
|
Sponsor |
|
|
A person who, by signing an affidavit of support, agrees to support an immigrant as a condition of the immigrant’s admission for permanent residence in the U.S. |
Sponsorship |
|
|
The act of legally sponsoring an immigrant to enter the U.S.
|
SSI Resource Exclusions |
|
|
In addition to your home and one car, there are several other resources that may be excluded when determining your SSI countable resource total. Earned Income Tax Credits ( EITC), Child Tax Credits (CTC), Food Stamps, grants, scholarships, fellowships, gifts, property essential to self-support, Individual Development Accounts ( IDAs), and many other items may be excluded. Review your resources and your resource exclusions with your PASS specialist. |
State Employment Security Agencies (SESA) |
|
|
Agencies that collect and develop economic, labor, and employment data at the state and local level.
|
State Health Insurance Assistance Programs (SHIP) |
|
|
|
|
State Medical Review Team (SMRT) |
|
|
A division within Minnesota's Department of Human Services that decides whether or not you meet the state criteria for "blind" or "disabled" status. SMRT uses a standard process to make disability determinations for people with disabilities who either aren't eligible for Social Security benefits (e.g., SSI, SSDI), have an application pending for Social Security benefits, or are in their five-month waiting period for SSDI.
Contact your county human services agency to request a SMRT review.
|
State Supplemental Payment (SSP)
|
|
|
A voluntary state supplement to the Federal Benefit Rate. The SSP in California is $233 for an individual and $568 for a couple. |
Student Earned Income Exclusion (SEIE) |
|
|
|
|
Subsidized Employment (Public & Private) |
|
|
Employment in which the CalWORKs program partially or fully reimburses a Welfare-to-Work participant’s employer for wages and/or training. |
Subsidy and Special Conditions |
|
|
For the purposes of calculating Substantial Gainful Activity (SGA), subsidy and special conditions are support you receive on the job that may result in your receiving more pay than the actual value of the services you perform. Subsidy refers to support you receive from your employer; special conditions are generally provided by someone other than your employer, for example a vocational rehabilitation agency. Social Security considers the existence of subsidy and special conditions when they make an SGA decision. They use only earnings that represent the real value of the work you perform to decide if your work is at the SGA level. This works in your favor - if Social Security decides that subsidy or special conditions exist, you can earn more while continuing to receive beneifts.
Subsidy or special conditions may exist if:
- You receive more supervision than other workers doing the same or a similar job for the same pay;
- You have fewer or simpler tasks to complete than other workers doing the same job for the same pay; or
- You have a job coach or mentor who helps you perform some of your work.
|
Substantial Gainful Activity (SGA) |
|
|
Work that disqualifies an individual from Social Security disability benefits. Social Security uses earning limits to determine whether or not an individual is performing SGA.
For 2008, SGA is $940 ($1,570 for people who are blind).
|
Supplemental Security Income (SSI) |
|
|
|
|
Surrender Charge |
|
|
The penalty assessed when funds are borrowed against the cash value of a whole life policy. The surrender charge decreases the longer the individual is insured.
|
Surrender Value |
|
|
If you were to cancel a life insurance policy prior to death or maturity, you would likely receive some portion of the full value of that policy. The amount you would receive is known as the “surrender value.” The surrender value of your policy should be written into it. If you do not know the surrender value, contact your policy administrator to find out. Not all policies have a surrender value (i.e. - burial insurance and many term insurance policies).
|
Targeted Group |
|
|
|
|
Tax Credit |
|
|
A dollar for dollar reduction in taxes. A tax credit can be used as a deduction from taxes owed.
|
Temporarily Inactive Ticket |
|
|
A Ticket that has been temporarily inactivated because a beneficiary could not make progress on his/her Individual Work Plan due to illness or disability. The clock stops on the timely progress review schedule, and beneficiaries are not penalized for the delay. |
Temporary Aid to Needy Families (TANF) |
|
|
A federal welfare program, formerly known as Aid to Families with Dependent Children (AFDC), that provides income support and access to Medi-Cal for low-income adults with children. In California, TANF is known as CalWORKs.
|
Three Month Grace Period
|
|
|
|
|
Ticket |
|
|
A standard form that indicates eligibility for the Ticket to Work Program.
|
Ticket on Demand |
|
|
A term for requesting a Ticket to Work by calling the Ticket Program Manager: (866) 968-7842.
|
Ticket to Work Program |
|
|
A program of the federal Social Security Administration (SSA) designed to expand access to employment for Social Security beneficiaries with disabilities.
|
Tiered Drug Levels |
|
|
|
|
Timely Progress
|
|
|
Active participation in the Individual Work Plan (IWP) during the first two years of the Ticket program. Thereafter, timely progress is referred to as "increased work activity and earnings" (Year 3, 4, and 5). As long as an individual is making timely progress on the IWP, Social Security will not initiate a medical continuing disability review.
|
Title II child’s benefits |
|
|
Benefits received because a parent is (or was) eligible for Social Security Disability or Social Security retirement insurance. Title II child’s benefits end at 18, unless the child is in high school or another secondary school, in which case they end at 19. |
Trial Work Month |
|
|
Any month when gross income reaches at least $670 (for 2008). Trial Work Month income levels are indexed annually for increases or decreases in the cost of living. Previous Trial Work Month gross income levels were:
|
Trial Work Period (TWP) |
|
|
The nine Trial Work months occurring within a five-year window when an individual can work and continue receiving full Social Security Disability Insurance (SSDI) benefits. These work months can occur one right after the other (consecutive) or one at a time (non-consecutive.) The nine trial work months is the Trial Work Period if the months are used within a five-year window (60 months). |
Underinsured Individual |
|
|
An individual who has insurance that covers only some health care costs.
|
Unearned Income (UI) |
|
|
Funds received from sources for which no paid work activity was performed. (Examples: Disability benefits such as SSDI, SSI, short term disability insurance, and long term disability insurance; VA benefits; Worker's Compensation; income from a trust or investment; spousal support; dividends, profits, or funds received from any source other than work.)
|
Unemployed |
|
|
CalWORKs generally defines unemployed as having worked less than 100 hours in the previous 4 weeks. In a two parent household, one of the parents can work more than 100 per month so long as the family income after deductions (countable income) is below the income limit for the program.
|
Uninhabitable Residence |
|
|
A home that is unfit for living.
|
Uninsured Individual |
|
|
An individual who has no health coverage.
|
Unsubsidized Employment |
|
|
Employment that is not reimbursed to an employer by the CalWORKs Program.
|
Untaxed Income |
|
|
Income that is not subject to state or federal taxes. Income from State Disability Insurance (SDI), Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) are all examples of untaxed income.
|
Utilization Controls |
|
|
Rules that plans use to keep their prescription drug costs down. You may, for example, need prior authorization from the plan to use a particular drug. |
Value Third Reduction (VTR) Rule |
|
|
A rule that decreases the amount of the Supplemental Security Income (SSI) benefit that a person is eligible for by 1/3. The VTR rules apply when someone is receiving both food and shelter from another person. |
Vesting Requirement |
|
|
|
|
Victim of Trafficking |
|
|
An individual who is a victim of sex trafficking; or, a victim of the forced or fraudulent recruitment, harboring, transport, or provision of a person for labor or services that subject the person to involuntary servitude, peonage, debt bondage, or slavery.
|
Victim of Violence/Victim of Abuse/Domestic Violence Survivors |
|
|
An individual who has endured assaultive or coercive behavior that includes: physical abuse, sexual abuse, psychological abuse, economic control, isolation, stalking, and threats.
|
Violence Against Women Act (VAWA) |
|
|
|
|
Vocational Rehabilitation |
|
|
State agencies that provide employment supports for people with disabilities. These supports include things like job training, transportation, and counseling.
|
Waiting Period |
|
|
The amount of time you have to wait between becoming disabled and receiving a benefit. For example, many private disability plans begin paying benefits 7 days after an illness forces you to leave work.
|
Waiting Period (Medigap)
|
|
|
A delay in covering services for an individual with a pre-existing condition. Individuals are exempt from a waiting period if they have had 6 months of previous, continuous coverage. |
Welfare-to-Work Activities |
|
|
Activities that meet the Welfare-to-Work requirement. Most CalWORKs recipients must participate in 20 hours of core activities. Your county may include all or some of the following as acceptible core activities:
Subsidized or unsubsidized employment Work experience On-the-job training Work-study Self-employment Community service Vocational education and training Job search and job readiness assistance
The rest of the Welfare-to-Work requirement can be fulfilled with non-core activities, which may include:
Adult basic education Job skills training directly related to employment Education directly related to employment Secondary school Mental health, substance abuse, and domestic violence services
|
Welfare-to-Work Tax Credit |
|
|
|
|
Work Experience |
|
|
|
|
Work Goal |
|
|
The specific job an individual wishes to have after completing a Plan for Achieving Self-Support. Also known as a vocational or occupational goal.
|
Work Incentives |
|
|
Social Security’s rules that are used to adjust Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits when an individual works.
|
Work Opportunity Tax Credit (WOTC) |
|
|
A federal program that encourages employers to hire job seekers from one of nine targeted groups by offering employers a federal tax credit. The purpose of the WOTC is to help job seekers in the targeted groups overcome barriers to employment. |
Work
|
|
|
Physical or mental activity that is actually performed and results in earned income. |
Workers' Compensation |
|
|
A program that replaces income when you can't work because of on-the-job injuries.
|
Workplace Personal Assistance |
|
|
Services that enable an employee with a disability to perform the essential duties of a job.
|
Youth Transition Demonstration Project |
|
|
|
|
|
