Activities of Daily Living (ADL)
The basic activities that most people must engage in as a requirement of daily living, including personal hygiene, meal preparation, shopping and standard home maintenance.
Adjusted Gross Income
Gross income minus deductions for certain expenses.
Administrative Law Judge (ALJ)
A judge who hears an appeal, typically at a hearing in an agency’s administrative process.
Advance Earned Income Tax Credit (AEITC)
A program that allows individuals with at least one qualifying child to incrementally receive the Earned Income Tax Credit in their paycheck throughout the year.
The process of determining whether a child who is a Supplemental Security Income (SSI) beneficiary will meet the adult definition of disability. The redetermination happens within a year of the 18th birthday.
Annual Election Period
The period from November 15 through December 31 when you can enroll in and switch Medicare Part D plans.
The process experienced when trying to secure Social Security disability benefits upon which a claimant receives an unfavorable decision OR when an individual disagrees with an insurance carrier’s decision to reduce services or deny treatment or payment.
The deadline to file an appeal after a Social Security disability claim has been denied, which is typically 60 days from the date of a claim’s last denial. This date is typically stamped on the first page of the denial letter in the upper right hand corner.
Area Work Incentive Coordinator (AWIC)
Coordinate and/or conduct public outreach on work incentives in their local areas.
Things that are owned, such as a home.
Assets for Independence Act (AFIA)
Federal government-supported Individual Development Accounts demonstration program which selected IDA nonprofit programs for grants.
Association-Sponsored Group Health Coverage
Group coverage offered through an association like a union, guild, or trade organization.
Any Medicare plan that meets just the minimum requirements laid out by the Centers for Medicare Medicaid Services (CMS).
A Medicare Part D plan that follows the guidelines of a basic plan or ends up costing the same amount of money.
The person who is receiving a benefit.
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.
A service provided by Social Security to help you better understand your Social Security protection (retirement or disability) as you plan for your financial future.
Benefits Planning Query (BPQY)
A report that summarizes your current Social Security disability benefits.
Blindness in Social Security 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.
Additionally, if your peripheral vision is so restricted (but not listing level) that it causes you to be a danger to yourself and others, an argument can be made for a finding of disabled. 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) or Social Security Disability Insurance (SSDI) benefits.
Blind Work Expenses (BWE)
A work incentive program for persons who are blind that receive SSI and/or SSDI benefits.
The savings part of a whole life policy, which comes from a portion of the premiums paid by the insured.
Cash Value (or Cash Surrender Value)
The amount of cash accrual and interest that the insured would get upon cashing in a whole life policy or may be able to borrow money from.
Centers for Medicare & Medicaid Services (CMS)
A federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.
The discontinuation of benefits for someone who was once determined to be eligible to receive disability benefits from the Social Security Administation (SSA). This type of decision is usually made at the conclusion of a continuing disability review.
Childhood Disability Benefits (CDB)
There are two types of Social Security benefits for children: benefits that are paid from accumulated credits of a working parent and benefits that are awarded as a result of a disability.
This exists when a disability benefits claimant is determined to be ineligible for ongoing benefits, yet eligible to receive benefits for a period of time in the past.
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 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.
Consolidated Omnibus Budget Reconciliation Act (COBRA) Administrator
An outside company that processes COBRA and/or OBRA premiums.
Medical examinations that Social Security disability and SSI claimants are sometimes sent to during the processing of a claim for disability benefits. The doctors who perform these exams for the SSA are independent physicians who have contracted to perform these services.
Group health coverage through COBRA, or OBRA.
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.
A set amount an individual must pay upon receiving medical services in combination with the amount paid by the insurer. For example, you may have to pay $10 each time you visit the doctor, with the understanding that the health insurance policy covers a large part or the remainder of the balance of the fee owed to the doctor.
Cost-of-Living Adjustment (COLA)
An annual adjustment made based on the increase in the Consumer Price Index. Social Security and Supplemental Security Income (SSI) beneficiaries did not receive COLA in 2010 or 2011.
Coverage Effective Date
The date an individual is enrolled in coverage. The effective date is usually not the same as the date of hire.
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. 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.
The parent who has primary physical custody of a child. Typically the child resides with the custodial parent.
The amount an individual is responsible for paying for healthcare services before the insurer or 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.
Department of Labor (DOL)
Is charged with preparing the American workforce for new and better jobs.
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 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 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.
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.
Disability Determination Services (DDS)
The state-level agency whose main responsibility is determining the eligibility of claimants to receive monetary Social Security disability benefits.
A disability “freeze,” also called a “period of disability,” refers to a period of time you were found to be disabled or blind by Social Security. During the period of disability you may not have any earnings, or your earnings may be very low due to your disability or blindness. You can have more than one period of disability on your record.
In general, SSA does not count your period(s) of disability when they determine whether you have enough work credits to get Social Security disability benefits.
If you are blind or disabled, you can apply to have a period of disability established on your earnings record. Most workers who have a period of disability may also qualify for monthly disability insurance benefits. Even if you do not get disability insurance benefits for your period of disability, a “disability freeze” on your record may help you and your family get future Social Security benefits based on your disability or retirement, or as survivors on your account.
A “period of disability” (i.e., a “disability freeze”) may also affect how SSA computes the monthly benefits amounts payable to you and your family. Usually, if they take your period of disability into account when determining monthly benefit amounts, the benefit amount will be higher.
SSA will ignore your “period(s) of disability” if it is to your advantage to do so. This can happen when you or your family may be entitled or get a higher monthly benefit amount by ignoring your period of disability.
Disability Program Navigator (DPN)
The primary objectives of the Disability Program Navigator (DPN) initiative are to increase the ability of the One-Stop Career Center system to enhance the employability of job seekers with disabilities and increase the number of career advancement opportunities available to them.
The gap in Medicare Part D coverage when you have between $2,830 and $6,440 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.
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.
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.
Employer Assistance Referral Network (EARN)
Is a cost-free national employment referral service sponsored by the U.S. Department of Labor.
Employer-Sponsored Health Coverage
Health coverage offered through an employer.
Employment Network (EN)
An organizational entity (State or local, public or private) that enters into a contract with SSA with the intention of coordinating and delivering employment services, VR services, and/or other support services under the Ticket to Work Program.
A request to the plan to either cover a drug that is not on the formulary or to bypass utilization controls.
A service that a health coverage plan won’t pay for. Cosmetic surgery, for example, is not covered under most plans.
A large file containing copies of everything accumulated during the processing of a claimant’s disability claim. These files are available to the claimant as well as the claimant representative (if applicable) for viewing and copying.
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 month (three years) period that begins the month after the Trial Work Period ends. During the Extended Period of Eligibility, an individual’s wages are considered Substantial Gainful Activity (SGA) if monthly gross earnings are higher than the program allows. When an individual’s earnings 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.
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.
Federal Insurance Contributions Act (FICA)
A U.S. law requiring a deduction from paychecks and income that goes toward the Social Security program and Medicare.
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. Pregnant women count as two people.
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 $1,120 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
|62 or older
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.
A federally funded program that helps people with low income buy food.
Income received for services performed in a foreign county by an individual residing in that country.
A list of drugs that a health plan covers.
A plan where an insurance company takes on the risk. 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.
A monetary award 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.
Income before taxes and other deductions are made.
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.
Coverage offered to an individual through a group, such as employer-sponsored, association-affiliated or professional group coverage.
Guaranteed Issue Period (Medigap)
A period of time when an individual can enroll in a Medigap plan without medical underwriting or waiting periods.
A process that allows Medigap carriers to refuse coverage based on an individual’s health history. This process is also known as medical underwriting.
HIPAA prevents 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.
Hearings on disability cases are conducted by administrative law judges (ALJs), who are appointed by the Social Security Administration (SSA). About 90 percent of all SSDI hearings involved representatives in fiscal year 2007.
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.
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).
Services covered by Medicare Part A that include a semi-private room, meals, general nursing, and other hospital services and supplies.
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.
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.
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.
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.
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 Development Account (IDA)
A matched savings account that helps people with modest means save towards the purchase of a lifelong asset, such as a home.
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 (Medicare)
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 24th 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.
Health services received when an individual is admitted to the hospital.
The adjustment of payments when an individual is eligible for more than one benefit program.
Internal Revenue Service (IRS)
Is the revenue service of the United States federal government.
Dividends, capital gains net income, certain rental and royalty income, net passive activity income, and taxable and tax-exempt interest.
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.
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 $550 for 2011.
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.
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.
Long Term Disability (LTD)
LTD is an income replacement program that protects you and your family in the event you become disabled and are unable to perform the material and substantial duties of your job.
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”.
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 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.
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.
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.
Medically Determinable Impairment
A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms and laboratory findings-not only by the individual’s statement of symptoms.
Services or supplies that are considered by Medicare to be appropriate and needed for treatment.
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 (PDP) under Part D.
Medicare Choice Plan
See Medicare Advantage Plan.
Medicare Advantage Plan
A Medicare program that offers benefits by private insurance companies. These plans can provide more choice and extra benefits. Medicare Advantage Plans include: Managed Care (Medicare HMOs), Private Fee-for-Service, Preferred Provider Organization, and Special Needs Plans. Everyone who has Medicare Parts A and B is eligible to join a plan, except most people with End-Stage Renal Disease (ESRD).
Formerly known as Medicare Choice.
Medicare Advantage Prescription Drug (MA-PD) Plan
Medicare Part D drug coverage that is offered through a Medicare Advantage plan.
Medicare Appeals Council
A group of people within the Centers for Medicare and Medicaid Services (CMS) who hear Medicare appeals after they have gone to an Administrative Law Judge.
A private insurance company that contracts with Medicare.
See Medicare Managed Care Plan.
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 known as Medicare HMOs.
Medicare Modernization Act
The 2003 law that created the Medicare Part D program.
Health coverage options that include: Original Medicare, Medicare Advantage Plans and Medigap.
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 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.
A supplemental insurance policy sold by private insurance companies to fill gaps in the Original Medicare Plan. 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.
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.
A group of doctors or medical service providers who have signed a contract with a health coverage plan. If you have health coverage through a Health Maintenance Organization (HMO), you generally have to see doctors within the network. Preferred Provider Organizations (PPOs) 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.
Office of Hearing Operations (OHO) – formerly known as Office of Disability Adjudication and Review (ODAR)
An SSA Hearing Office that processes either first or second appeals. Medical development by the OHO is frequently conducted through the DDS. However, hearing offices may also contact medical sources directly.
A decision that occurs prior to the hearing when an Administrative Law Judge (ALJ) grants an approval to a disability claimant. These decisions are made because the medical evidence available to an ALJ is strong enough to validate an approval without a formal hearing. On-the-record decisions are generally always approvals.
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
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 healthcare 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).
The costs an individual pays without assistance from Medicare or other insurance.
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.
When an individual is awarded benefits, the SSA sets an onset date for disability. Along with monthly benefits, the individual may be eligible for a lump-sum payment based on that date. This indicates the time period that the SSA should have been providing monthly SSDI benefits to you. Depending on your LTD carrier and its policy stipulations, most or all of this lump sum must be returned to your LTD carrier.
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.
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.
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.
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.
Personal Assistance Services (PAS)
Services designed to assist an individual with a disability perform activities of daily living at home or in the workplace.
Plan for Achieving Self-Support (PASS)
Is a written plan of action for getting a particular kind of job or starting a business.
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.
An option offered by some Medicare Managed Care Plans that allows an individual to use doctors and hospitals outside the network at an additional cost.
See Gross Pre-disability Salary.
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.
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.
A status granted to Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) 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 for SSI benefits, 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.
Healthcare services aimed at keeping an individual healthy by preventing illness; for example, Pap tests, pelvic exams, yearly mammograms, and flu shots.
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.
The first insurer to pay medical claims when an individual uses multiple sources of health coverage.
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
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 insurance 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.
Property Essential for Self-Support (PESS)
Some property that you own and you use to support yourself never counts as a resource.
Protection and Advocacy (P&A)
Monitor, investigate and attempt to remedy adverse conditions in large and small, public and private, facilities that care for people with disabilities.
Protection and Advocacy for Beneficiaries of Social Security (PABSS)
Assist beneficiaries with disabilities in obtaining information and advice about receiving vocational rehabilitation and employment services. Provide advocacy or other related services that beneficiaries with disabilities may need to secure, regain, or maintain gainful employment.
Monitoring the activities of a person with cognitive disabilities to assure that they are not a harm to themselves or others.
Qualified Disabled Working Individual (QDWI) Program
A Medicare Savings Program that pays for Medicare Part A premiums. The QDWI program is for Social Security Disability Insurance (SSDI) beneficiaries who lose their free Medicare Part A due to earnings. To qualify, an individual must:
- Be less than 65 years old,
- Be eligible for Medicare Part A only,
- Have income at or below 200% of the Federal Poverty Level ($3,695 per month for individuals, $4,942 for couples), and
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples).
Qualified Individual-1 (QI-1) Program
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 ($1,239 per month for individuals, $1,660 for couples), and
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples).
Qualified Medicare Beneficiary (QMB) Program
A Medicare Savings Program that pays for Medicare Part A and Part B premiums, coinsurance and deductibles. To qualify, you must:
- Be eligible for Medicare Part A and Part B,
- Have countable income at or below 100% of the Federal Poverty Level ($923 per month for individuals, $1,235 for couples), and
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples).
This program does not apply benefits retroactively.
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.
Events that may end individuals’ employer-sponsored group health coverage, but qualify them for COBRA or other continuation coverage.
A written authorization to visit a specialist from an individual’s primary care doctor. In many Medicare Managed Care Plans (Medicare HMO), an individual must get a referral before receiving care from anyone except the primary care doctor. If an individual fails to get a referral, the plan may refuse to pay for care.
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)
To be considered “regularly attending” school for the Student Earned Income Exclusion (SEIE), a student has to meet one of the following requirements:
- 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.
A disability claim that has been denied by an Administrative Law Judge; reviewed, upon request, by the Appeals Council; and returned to the Hearing Office for a second hearing.
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.
Someone who receives benefits on another person’s behalf. For children under 18, a parent or guardian is usually the representative payee.
Residual Functional Capacity (RFC) Form
A form that rates the residual (left over) functional capacity of a claimant after taking the claimant’s mental or physical disability into consideration. These forms allow a claimant to present an interpretation of the medical evidence rather than simply presenting the medical evidence.
Payments made for the period between disability onset and application approval.
A health insurance plan that supplements a primary insurance plan. Healthcare 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.
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.
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.
Short Term Disability (STD)
Short term disability (STD) pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation insurance). A typical STD policy provides you with a weekly portion of your salary, usually 50, 60, or 66 2/3 percent for 13 to 26 weeks. Most STD policies have a “cap,” meaning you receive a maximum benefit amount per month.
Skilled Nursing Facility Care (SNF)
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 Administration (SSA)
An independent agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors’ benefits.
Social Security Disability Insurance (SSDI)
Social Security Disability Insurance (SSDI) is a payroll tax-funded, federal insurance program. A portion of the FICA taxes you pay are set aside for SSDI (as well as Social Security Retirement and Medicare). SSDI, which was established in 1954, is designed to provide you with income if you are unable to work due to a disability or until your condition improves, and provides income if your condition does not improve.
Specified Low-income Medicare Beneficiary (SLMB) Program
A Medicare Savings Program that helps pay for Medicare Part B premiums that would otherwise be deducted from your Social Security checks. To qualify, you must:
- Be eligible for Medicare Part A and Part B,
- Have countable income less than 120% of the Federal Poverty Level ($1,103 per month for individuals, $1,477 for couples), and
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples).
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.
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 programs that receive money from the federal government to provide free, local health insurance counseling on Medicare.
State Supplemental Payment (SSP)
A voluntary state supplement to the Federal Benefit Rate.
Student (SEIE definition)
For the purposes of the Student Earned Income Exclusion (SEIE), a student is generally someone who is under 22 and regularly attending school.
Student Earned Income Exclusion (SEIE)
An exclusion that allows most students to work without their Supplemental Security Income (SSI) benefit decreasing.
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.
Supplemental Security Income (SSI)
An income benefit program administered by SSA for people with limited income and resources who are disabled, blind, or age 65 or older. The SSI program is based on financial need established by income and assets requirements.
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.
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).
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 Assistance to Needy Families (TANF)
Is a block grant program to help move recipients into work and turn welfare into a program of temporary assistance.
The 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 here.
Three Month Grace Period
The period following the first month when an individual’s wages reach or exceed Substantial Gainful Activity. An individual receives full Social Security Disability Insurance payments regardless of wages during this period.
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
An employment program available to most Social Security beneficiaries with disabilities who meet certain criteria. More information can be found online here.
Tiered Drug Levels
A utilization control that makes some drugs cheaper to use than others.
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
Trial Work Month income levels are indexed annually for increases or decreases in the cost of living.
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).
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, STD and LTD; income from a trust or investment, dividends, profits or funds received from any source other than work are all examples of unearned income.)
An individual who has no health coverage.
Unsuccessful Work Attempt (UWA)
An unsuccessful work attempt is an effort by a disabled individual to do substantial work that either stopped or produced earnings below the Substantial Gainful Activity level after 6 months or less because of:
- The individual’s disabling condition, or
- elimination of the special services or assistance that the individual needed in order to work.
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.
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 one-third. The VTR rules apply when someone is receiving both food and shelter from another person.
See Service Wait.
State agencies that provide employment supports for people with disabilities. These supports include job training, transportation and counseling.
The SSA determines the amount of time you have to wait to receive SSDI benefits, which is 5 full months from the onset date of disability. 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.
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 Incentives Planning and Assistance (WIPA)
Anyone who gets Social Security disability benefits (SSI or SSDI) and wants to work can receive free benefits planning services.
Work Incentives Seminars (WISE)
These are held for beneficiaries with disabilities and their families to learn more about available work incentives through accessible, informal, learning opportunities.
Physical or mental activity that is actually performed and results in earned income.
A program that replaces income when you can’t work because of on-the-job injuries.