Glossary of Common Terms

A

Activities of Daily Living (ADL). Activities most people perform on a routine basis such as dressing, cleaning, cooking maintaining personal hygiene, taking transportation and paying bills.

Adjusted Gross Income (AGI). Gross income minus allowable deductions.

Administrative Law Judge (ALJ). An official who conducts SSD hearings and makes decisions for an agency. The judge makes decisions regarding Medicare Parts A, B, C, and D appeals that have passed the initial steps of consideration.

Annual Election Period (AEP). The Annual Election Period for Medicare beneficiaries runs from Nov. 15 through Dec. 31 each year. During this time, beneficiaries can change prescription drug or Medicare Advantage, return to original Medicare, or enroll in Medicare Advantage for the first time. Enrollment changes take effect Jan. 1 of the next year.

Appeal. The legal process by which an individual can request his/her denial for benefits be reconsidered.
Appeal Deadline. Last date on which an appeal can be filed to dispute a denial of benefits. You have 60 days from the date on your denial notice to file an appeal.

Assets. Things you own, for example a home, a car, property, bank accounts and retirement funds.

B

Beneficiary. A person who receives a benefit. The benefit may be income or medical insurance such as Medicare or Medicaid.

Benefit Period. A benefit period is the time period used in the hospital insurance program to determine whether covered Part A services can be paid for by the program. Although the days for which the program will make payment are limited by the benefit period, a beneficiary is not limited in the number of benefit periods he may have. An individual may be discharged from and readmitted to a hospital several times during a benefit period and still be in the same benefit period if 60 days have not elapsed between discharge and readmission. The stay need not be for related physical or mental conditions

Benefits Planner. A service provided for Social Security beneficiaries to assist clients in making informed choices and to clarify their understanding of Social Security protection (retirement or disability) while planning their financial future.

Benefits Planning Query (BPQY). A report that can be requested from the Social Security Administration that provides an overview of your current Social Security disability benefits.

C

Cash Value (or Cash Surrender Value). The amount of cash, including interest, a policy owner receives upon terminating (surrendering) a life insurance policy. The owner may also be able to borrow this amount from the policy, decreasing the death benefit.

Catastrophic Coverage. This refers to Medicare’s Part D drug benefit. Once your “true out-of-pocket” (TrOOP) costs reach $4,550 (in 2010), you pay a small coinsurance or co-payment for covered drug costs until the end of the calendar year. Catastrophic coverage also refers to coverage for high-cost medical emergencies or conditions, usually after a large deductible has been met.

Cessation. The discontinuation of benefits for an individual that once received benefits from the Social Security Administration.

Closed Period. A period of benefits awarded with a predetermined end date. The end date is established based on the Social Security Administration’s determination a beneficiary is no longer disabled at the conclusion of the period.

Consultative Examinations. Examinations that Social Security Administration (SSA) sends Social Security Disability (SSD) and/or Supplemental Security Income (SSI) applicants in order to obtain additional information. They are paid for by SSA and may be performed by your own physician or a physician who contracts with SSA.

Continuing Disability Review (CDR). A review scheduled by SSA to determine if you still qualify for continuing disability benefits.

Coinsurance. An amount you may be required to pay as your share of the cost for medical services after you pay any deductibles, usually based on a percentage.

Co-payment. The amount or portion you must pay for medical services, supplies or prescriptions which you receive when you have insurance, including Medicare or Medicaid. A co-payment is usually a set amount, rather than a percentage.

Cost-of-Living Adjustment (COLA). The annual adjustment to benefits based on the increase in the Consumer Price Index.

Coverage Effective Date. The date an individual is enrolled in coverage.

Creditable Prescription Drug Coverage. Prescription drug coverage (from a union or employer, for example) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Critical Access Hospital. A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas.

Custodial Care. Non-skilled personal care, such as help with activities of daily living like bathing, dressing, eating, etc. It may also include the kind of health-related care that most people do themselves, like using eye drops. It most cases, Medicare does not pay for custodial care.

D

Deductible. The amount an individual is responsible for paying for healthcare services before the insurer begins to pay. For Medicare Part A, the deductible is assessed for each benefit period. For Part B, the deductible is assessed January 1st of each year.

Dependent. A person, usually a child, who is physically and/or economically dependent on another person. Different programs have different definitions to determine who is a dependent.

Detailed Earnings Query (DEQY). A report generated by the SSA that lists covered and non-covered earnings, employer names and addresses, and pension data for each year requested. The DEQY is used to verify earnings from self-employment.

Disability. Social Security law defines disability as the “inability to engage in any substantial gainful activity by reason of 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 not less than 12 months.” The definition is more restrictive for children under age 18.

Disability Determination Services (DDS). The agency that, on behalf of SSA, determines whether a Social Security disability claimant meets the criteria for disability as defined under Social Security law.

Donut Hole. Most Medicare drug plans have a coverage gap or “donut hole.” The coverage gap begins after the beneficiary and drug plan have spent a certain amount of money for covered drugs, which results in the beneficiary paying all costs out-of-pocket for prescriptions up to a yearly limit. Starting in 2010, the ACA gradually eliminates the coverage gap in Medicare prescription drug coverage; the gap disappears completely by 2020.

E

Earned Income. Wages or salary received for services performed as an employee or from self-employment.

Exception. A request to the insurer to cover a drug that is not on their formulary.

Exclusion. A service that an insurance plan will not cover based on policy language or its definition of covered services.

Expedited Reinstatement of Benefits (EXR). EXR takes place when an individual who has previously received SSD benefits discontinues their coverage and attempts employment but realizes it is no longer possible for them to perform any gainful activity. EXR allows the former beneficiary of either SSI or SSDI to receive provisional benefits under the same plan as before until Social Security is able to determine whether they will be able to receive the regular benefits again. Once Social Security has made a favorable decision, usually in six months or less, the provisional period ceases. If the decision made is to deny the request for benefits, it is not necessary to repay any benefits that were granted during the provisional period.

Extra Help. A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance

F

Formulary. A list of the drugs covered by a Medicare prescription drug plan (PDP) or Medicare Advantage Prescription Drug plan (MA-PD).

G

Group Health Plan (GHP). A health plan supported by an employee organization or employer that provides medical coverage for employees, former employees and their families. The term GHP refers specifically to a group health plan based on the current employment status of the beneficiary or the beneficiary’s spouse. The GHP can be of any size, however when referring to a GHP for the disabled, the term refers to a plan of any size below 100 employees. A GHP is any plan of, or contributed to by, one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families.

H

Health Maintenance Organization (HMO). A group of doctors, hospitals, and other health care providers. In an HMO (also known as a Medicare Advantage plan) you typically get all your care from the providers who are part of the plan. If you go outside the plan for medical care you are charged more.

Home Health Care. Medicare-covered services including home health aides, skilled nursing care, physical therapy, occupational therapy, speech therapy, some medical equipment, supplies and other services. Home health care services are covered under Medicare Part A and Part B.

Hospice Care. Supportive services covered by Medicare Part A for individuals that are terminally ill.
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I

Impairment Related Work Expenses (IRWE). An IRWE is an expense for an item or service directly related to enabling an individual with a disability to work and is necessarily incurred by that individual because of a physical or mental impairment. Such an expense may involve payment for the purchase, installation, maintenance and repair of an impairment-related item or payment for an impairment-related service. These expenses may be deducted from earnings for the purpose of determining SGA.

Inpatient Rehabilitation Facility. A hospital that provides an intensive rehabilitation program to inpatients.

Institution. A facility that provides short-term or long-term care, such as a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences such as an assisted living facility or group home are not considered institutions for this purpose.

L

Lifetime Reserve Days. The days following a 90-day hospitalization. Medicare allows an individual 60 lifetime reserve days which may only be used once during an individual’s lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

Liquid Assets. Cash or other resources that can be converted to cash such as retirement accounts, insurance cash values, stocks and savings accounts.

Long-Term Care Hospital. Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

M

Medicaid. A medical insurance program funded by federal and state governments to provide low income and limited resource individuals and families with medical care. There may be a requirement for the beneficiary to share in some of the cost.

Medically Determinable Impairment. A physical or mental impairment that results from anatomical, physiological or psychological abnormalities and can be documented by clinical diagnostic techniques and medical test results. In order to have an impairment recognized by SSA, the impairment must be objectively documented.

Medically Necessary. Services or supplies that are considered to be needed for treatment of a medical condition.

Medicare. Health insurance program for eligible disabled individuals and individuals age 65 or older usually consisting of hospital insurance (Part A), supplementary medical insurance (Part B) and voluntary prescription drug coverage with a Prescription Drug Provider, or PDP (Part D).

Medicare Advantage Plan. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. The plan provides all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage, as well as emergency and urgent care. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private insurers a set amount every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B) such as prescription drugs, vision and dental care, and health and wellness programs. Medicare Advantage Plans include Health Maintenance Organization (HMO) Plans, Preferred Provider Organization (PPO) Plans, Private Fee-for-Service (PFFS) Plans, Medical Savings Account (MSA) Plans, Special Needs Plans (SNP), Point of Service (POS) Plans, and Provider Sponsored Organizations (PSOs).

Medicare Appeals Council (MAC). The entity that hears Medicare appeals after they have been denied by an Administrative Law Judge.

Medicare-approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or co-payment that you pay. It may be less than the actual amount a doctor or supplier charges.

Medicare Managed Care Plan. A Medicare Advantage HMO option may have lower co-payments than the Original Medicare Plan. This plan usually limits the services members receive to medical providers who have contracted with the HMO to manage the care of its members. Plans cover all Medicare Part A and Part B services, and some plans may have increased benefits such as prescription drugs. These plans are unavailable in some geographical areas.

Medicare Supplement. See Medigap.

Medigap. Also referred to as the Medicare Supplement. Medigap is a private insurance policy that supplements Original Medicare by paying the Medicare deductibles and coinsurance. Medigap is designed to fill gaps, such as the donut hole, in the Medicare Plan (i.e. If Medicare covers 80% of the approved amount, Medigap insurance will cover the other 20%).

N

Needs Assessment. An evaluation to assess the level of help that is needed for the In Home Supportive Services Program. It includes measurements of the ability to function independently in the home.

Network. A group of doctors or medical service providers who have signed a contract with a health coverage plan to provide care for its members. HMO’s generally require members to see doctors within the network while PPO’s and Point of Service (POS) plans allow you to see doctors outside of the insurance carrier’s network, but you may have to pay more.

O

Office of Disability Adjudication and Review (ODAR). The Hearing Office within SSA’s Office of Disability Adjudication and Review processes claimant appeals. During a hearing an Administrative Law Judge (ALJ) decides whether to reverse a prior denial for benefits.

On-the-Record Decision. A decision made by an administrative law judge prior to a hearing. The decision is made based upon evidence in the file being sufficient to satisfy the judge that a sound decision can be made on the case, usually resulting in a quicker approval for benefits.

Onset Date (Social Security). The date on which Social Security determines that a disability began.

Out-Of–Pocket Cost. The costs an individual pays for medical care which insurance does not cover.

Out-of-Pocket Maximum. The maximum amount of money that you have to spend on health costs in a year before insurance picks up all additional expense for covered benefits.

Overpayment. The amount of lump sum benefits that is due to an entity as a result of the insurer paying for benefits that would have been paid by SSA if a quicker approval for benefits had been possible.

P

Part A. The hospital insurance part of Original Medicare that covers inpatient hospital stays, hospice care, home health care, and care provided in skilled nursing facilities.

Part B. The medical insurance part of Original Medicare that covers doctors’ services and outpatient care. Some of the other services covered include X-rays, medical equipment, and limited ambulance service.

Part C. See Medicare Advantage.

Part D. Prescription drug benefit added to Medicare as part of the 2003 Medicare Modernization Act (MMA). Benefits are offered by private companies through prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PDs). Drug coverage is limited to drugs on a plan’s formulary.

Parent-to-Child Deeming. Social Security formula for the SSI program used in determining how much of parents’ income and resources are available to meet a child’s basic needs. This formula is used to determine the monthly payment and also applies for spouse-to-spouse.

Patient Assistance Program (PAP). A pharmaceutical company program that provides financial assistance with prescription drug costs.

Payer of Last Resort. The insurer who pays medical claims last when there are multiple insurers of health coverage.

Point-of-Service (POS). Option An HMO option that allows you to use doctors and hospitals outside the plan for an additional cost.

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, including seeing specialists without needing a referral from their primary care physician.

Premium. The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Prescription Drug Plan (PDP). A Medicare Part D plan that offers drug coverage only.

Presumptive Disability. A designation given by SSA to disability applicants who are very likely to obtain benefits. Monthly benefits can begin while the case is being reviewed by SSA staff.

Primary Care Provider (PCP). A doctor, nurse practitioner or other medical service provider who is in charge of your medical care. In HMO’s and some other insurance plans you must obtain a referral from the PCP in order to see another physician or a specialist or it may cost substantially more.

Primary Payer. An insurance policy, plan or program that pays first on a claim for medical care.

Private Health Insurance Policy. A health insurance policy which is paid for by the insured.

Prototype Process. A disability redesign model being tested in 10 states that represent about 25 percent of the national disability claims workload. Implementation began on October 1, 1999, in Alabama, Alaska, Colorado, Louisiana, Michigan, Missouri, New Hampshire, Pennsylvania, and in parts of California and New York (expanded to all of New York in April 2001). The Prototype Process eliminates the reconsideration step of the appeal process.

Provider Sponsored Organization (PSO). This is a type of Medicare Advantage plan in which a group of doctors, hospitals, and other health care providers agree to provide health care to people with Medicare for a set amount of money from Medicare every month. These plans are run by the doctors and providers themselves, and not by an insurance company.

Q

Qualified Improvement Organization (QIO). A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to people with Medicare.

Qualified Medicare Beneficiary (QMB). A Medicare Savings Program for people who have low monthly incomes and who qualify for Medicare. QMB pays for Medicare Part A and Part B premiums, and Medicare coinsurance and deductibles amounts for Medicare services provided by Medicare providers.

R

Remand. A claim that has been denied by an Administrative Law Judge, reviewed by the Appeals Council, and returned to the Hearing Office for another decision or hearing.

Representative Payee. An individual who receives benefits on another person’s behalf. For children under 18, it is usually a parent or guardian.

Residual Functional Capacity (RFC). Form A form that rates the physical and mental capacity of a claimant after taking the claimant’s impairments into consideration.

Retroactive Payments. Payments made for the months between the onset of the disability and the approval of benefits. For SSI, this period begins with the latter of the onset of disability or the application date.

S

Secondary Payer. A health insurance plan that pays after the primary insurance plan pays.

Skilled Nursing Facility (SNF). Care Services in an inpatient facility with skilled nurses that include a semiprivate room, meals and rehabilitative services. Medicare covers skilled nursing facility care when the individual is admitted after being hospitalized for at least 3 days.

Social Security Disability Insurance (SSDI). Social Security Disability Insurance (SSDI) is a federal insurance program funded by part of the FICA taxes you pay. SSDI is designed to provide you with income if you are unable to work due to a disability. SSDI is often mistakenly referred to as Social Security Disability Income because it has a monthly cash benefit.

Specified Low-income Medicare Beneficiary (SLMB) Program. A Medicare Savings Program that helps pay for Medicare Part B premiums.

SSI Asset Exclusions. When determining eligibility for Medicaid or SSI, resources that do not count as assets. Resources are cash and any other personal property that an individual (or spouse): owns; has the right, authority, or power to convert to cash; and is not legally restricted from using for his/her support and maintenance.

Subsidy and Special Work Conditions. When calculating Substantial Gainful Activity (SGA), subsidies and supports received that result in earnings which are higher than could be earned in a competitive environment. An example would be a sheltered workshop, where the entity receives government or other grants to employ individuals that are limited in some way. This results in fair treatment for limited individuals and may allow them to earn more while receiving benefits.

Substantial Gainful Activity (SGA). Work that results in a level of earnings that disqualifies an individual from Social Security disability benefits. Social Security uses earning limits to determine whether an individual is performing SGA.

Supplemental Security Income (SSI). A program administered by SSA that provides monthly cash benefits for people with limited income and resources and who are disabled, blind, or age 65 or older. The SSI program is based on financial need.

Special Needs Plan (SNP). A Medicare Advantage option that provides comprehensive medical care to manage certain medical conditions such as diabetes, congestive heart failure (CHF) or End Stage Renal Disease (ESRD). The goal of these plans is to provide health care services to those who can benefit the most from the expertise of the plans’ providers and focused care management. All SNP’s must provide Medicare prescription drug coverage.

T

Trial Work Period (TWP). A period of at least nine months during a 60 month time frame when Social Security Disability Insurance (SSDI) recipients may test his/her ability to work and still receive benefits.

U

Unearned Income (UI). Funds received from any source where no work was performed to receive the funding.

V

Voluntary Enrollee. An individual who does not qualify for Medicare under the main categories (being 65 or older and receiving Social Security or Railroad Retirement benefits or being under 65 and receiving disability benefits for more than 24 months). Voluntary enrollees must be 65 or older and U.S. citizens or immigrants who have been in this country for 5 years (you must be a legal immigrant when you apply). As a voluntary enrollee, you can buy into Medicare Part A and Part B, but you will have to pay a high monthly premium, which increases annually.

W

Waiting Period. The amount of time you have to wait after you are found disabled until receiving a benefit.

Work Incentives. Numerous amendments to the Social Security Act that intend to provide beneficiaries with disabilities incentives to return to work.

Work. Physical or mental activity performed for pay and results in earned income.

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