The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise: (1) §1915(c) waiver program--A home or community-based service authorized for use in Texas by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act. (2) Adverse action--A termination, suspension, or reduction of Medicaid eligibility or covered services. (3) Annual review--The process of redetermining a person's continued eligibility for Medicaid. (4) Appeal--A request for a review of an action or failure to act by the Texas Health and Human Services Commission (HHSC) that may result in a fair hearing. (5) Applicant--A person seeking benefits under a Medicaid-funded program for the elderly and people with disabilities (MEPD) who is not currently receiving MEPD services. (6) Application for assistance--A form prescribed by HHSC that a person uses to apply for MEPD or to have MEPD eligibility redetermined. (7) Assets--All items a person owns that have monetary value. Assets include both income and resources. (8) Authorized representative--An individual: (A) who assists and represents a person in the application or eligibility redetermination process, and who is familiar with that person and that person's financial affairs; or (B) who is a representative payee for an applicant or recipient for another federal benefit. (9) Benefits office--A local HHSC office. (10) Blind--A person who meets Supplemental Security Income (SSI) program requirements for blindness, as defined in 42 U.S.C. §1382c(a)(2). (11) Budgeting--The process of determining a person's financial eligibility for MEPD or for calculating a co-payment. (12) Burial space--A burial plot, grave site, crypt, mausoleum, urn, casket, niche, or other repository customarily and traditionally used for a deceased person's bodily remains. The term also includes necessary and reasonable improvements or additions to these spaces, including vaults, headstones, markers, or plaques; burial containers; arrangements for opening and closing the grave site; and contracts for care and maintenance of the grave site. Contracts for care and maintenance are sometimes referred to as endowment or perpetual care. (13) Certification--HHSC's official authorization of an eligibility determination. (14) CFR--Code of Federal Regulations. (15) Community spouse--See Subchapter C, Division 5, §358.412 of this chapter (relating to Definitions). (16) Co-payment--The amount of personal income a person must pay toward the cost of his or her care. Co-payment was formerly known as applied income. (17) Countable income--The amount of a person's income that is not exempt or excluded. (18) Countable resource--A resource owned by and accessible to a person that is not exempt or excluded. (19) Coverage group--A group of people who are categorically eligible for MEPD under the Texas State Plan for Medical Assistance. (20) Current market value--The amount of money an item would bring if sold in the current local market. (21) Date of application--See §358.520 of this chapter (relating to Date of Application). (22) Deeming--Counting all or part of the income or resources of another person (for example, a parent or spouse) as income or resources available to an applicant or recipient. (23) Disabled--A person who meets SSI program requirements as defined in 42 U.S.C. §1382c(a)(3). (24) Earned income--Income a person receives for services performed as an employee or from self-employment. (25) Earned income tax credit--A special tax credit that reduces the federal tax liability of certain low-income working taxpayers. (26) Eligibility determination--A decision made by HHSC concerning a person's initial eligibility for MEPD. This term does not include any functional or other assessment required for some MEPD services, unless the context clearly indicates otherwise. (27) Eligibility redetermination--A decision made by HHSC concerning a person's continued eligibility for MEPD. This term does not include any functional or other assessment required for some MEPD services, unless the context clearly indicates otherwise. (28) Equity value--The value of a resource based on its fair market value or current market value minus all money owed on the resources and, if sold, any costs usually associated with the sale. (29) Excluded--Income or resources not counted for the purpose of determining eligibility only. (30) Exempt--Income or resources not counted for the purpose of determining eligibility or calculating a co-payment. (31) Fair hearing--An informal proceeding held before an impartial hearings officer in which a person or the person's representative appeals an action taken on the person's case. (32) Fair market value--The current market value of a resource at the time of its sale or transfer. (33) Family member--An applicant's or recipient's spouse, minor child, adult child, stepchild, adopted child, brother, sister, parent, or adoptive parent; or a spouse of the applicant's or recipient's minor child, adult child, stepchild, adopted child, brother, sister, parent, or adoptive parent. (34) Fiduciary agent--A person or organization acting on behalf of or with the authorization of another person under circumstances that involve a high degree of confidence, good faith, and honesty. The term applies to anyone who acts in a financial capacity, whether formal or informal, regardless of title, such as representative payee, guardian, or conservator. (35) Fraud--Deliberate misrepresentation or willful withholding of information for the purpose of obtaining public assistance, either for self or another person. (36) Health Insurance Premium Payment Program--A Medicaid program that pays for the cost of medical premiums. The program reimburses recipients or employers for private health insurance payments for Medicaid-eligible persons when it is cost effective to do so. (37) HHSC--The Texas Health and Human Services Commission. (38) Home--A structure in which a person lives (including a mobile home, a houseboat, and a motor home), other buildings on the home property, and all adjacent land (including land separated by a road, river, or stream), in which the person has an ownership interest and that serves as his or her principal place of residence. (39) Income--Any item a person receives in cash or in kind that can be used to meet his or her need for food or shelter. For purposes of determining MEPD financial eligibility, income includes the receipt of any item that can be applied, either directly or by sale or conversion, to meet the basic needs of food or shelter. (40) Inheritance--Cash, other liquid resources, noncash items, or any right in real or personal property received as the result of someone's death. A person may not have access to his or her inheritance pending legal action or the discovery of the inheritance. (41) Initial eligibility period--The time from a person's certification date to the person's first annual review. (42) In-kind--Consisting of something (such as food, shelter, or replacement of a resource) that is not cash. (43) Institution for mental diseases (IMD)--A hospital, nursing facility, or other institutional setting of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. An IMD includes a state mental health facility operated by the Texas Department of State Health Services. (44) Institutional care--Long-term nursing care, treatment, or services received in a Medicaid-certified long-term care facility. (45) Institutional setting--A living arrangement in which a person applying for or receiving Medicaid lives in a Medicaid-certified long-term care facility or receives services under a §1915(c) waiver program. (46) Insurance--The following terms apply to the definition of insurance: (A) "The insured" means the person named in a life insurance policy whose death affects the proceeds and distribution of the policy. (B) "The beneficiary" means the person or entity named in a contract to receive the proceeds of the policy upon the death of the insured. (C) "The owner" means the person with the right to change the policy as the person sees fit. The owner is the only person who can receive the cash surrender value of the policy. (D) "The insurer" is the company that contracts with the owner. Cont'd... |
