D.C. Mun. Regs. tit. 29, r. 29-9599
For the purposes of this chapter, the following terms shall have the meanings ascribed:
Active treatment - A continuous program, which includes consistent implementation of training, therapies, health and related services designed to address the child's social, intellectual, and behavioral deficits and, further, that are directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible.
Activities of Daily Living - Activities including eating, bathing, toileting, grooming, dressing, undressing, mobility, and in place transfers.
Acuity level - The intensity of services required for an applicant or beneficiary. An applicant or beneficiary with a high acuity level requires more care those with lower acuity levels require less care.
Alien - An individual who is not a Citizen or National of the United States pursuant to 8 U.S.C. § 1641 and § 101(a) of the Immigration and Nationality Act, 8 U.S.C. § 1101(a).
AmeriCorps/VISTA income - income given to volunteers in the Volunteers in Service to America (VISTA) program.
Applicant - An individual who is seeking an eligibility determination for Medicaid through an application submission or a transfer from another insurance affordability program.
Application - The single streamlined form that is used by the District of Columbia in accordance with 42 C.F.R. § 435.907(b) or an application described in § 435.907(c)(2) of this chapter submitted on behalf of an individual.
Authorized Representative - Legally authorized individual or entity able to consent on behalf of a prospective applicant.
Beneficiary - An individual who has been determined eligible and is currently receiving Medicaid.
Budget Period - The timeframe over which the individual's income is calculated to determine medically needy Medicaid eligibility.
Carry Over Expense - An unpaid, incurred medical and remedial care expense that may be applied towards a spend down obligation in a future budget period(s) if it was incurred within a previous budget period (or up to three (3) months preceding the month of application) in which spenddown eligibility was established, remains the liability of the individual, and was not fully counted in any previous budget period in which eligibility was met.
Certification Period - Medicaid eligibility is determined for a twelve-month period. This period is called a certification period.
Cost Sharing - When patients pay out-of-pocket for a portion of health care costs not covered by health insurance, including but are not limited to, copays, deductibles, and coinsurance.
Custodial Parent - A court order or binding separation, divorce, or custody agreement establishing physical custody controls; or if there is no such order or agreement or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights pursuant to 42 C.F.R § 435.603(iii)(A)-(B).
Deduction - income that is subtracted from countable earned and unearned income.
Deemed income - the amount of another person's income that is considered to belong to the applicant/recipient.
Deemed Newborn - A child under the age of one (1) who is automatically eligible for Medicaid pursuant to 42 C.F.R. § 435.117.
Deferred Action for Childhood Arrivals (DACA) - Certain individuals who were brought to the U.S. as children are as described pursuant to the Memorandum from Janet Napolitano, Secretary of Homeland Security, to David V. Aguliar, Acting Commissioner, U.S. Customs and Border Protection; Alejandro Mayorkas, Director, U.S., Citizenship and Immigration Services; John Mortan, Director, U.S. Immigration and Customs Enforcement (June 15, 2012) (on file with the U.S. Department of Homeland Security.
Department - For the purposes of this chapter, the term "the Department" shall refer to the Department of Health Care Finance (DHCF) or its designee.
Dependent Child - A natural or biological, adopted or step-child who is under the age of eighteen (18), or is age eighteen (18) and a full-time student in secondary school (or equivalent vocational or technical training).
Earned Income Tax Credit (EITC) - a federal tax credit for working individuals who have low to moderate income.
Eligibility determination - An approval or denial of eligibility in accordance with 42 C.F.R. § 435.911 as well as a renewal or termination of eligibility in accordance with 42 C.F.R. § 435.916.
Emergency medical condition - A medical condition, including emergency labor and delivery, manifesting itself by acute symptoms of sufficient severity including severe pain so that the absence of immediate medical attention could reasonably be expected to result in one of the following:
Exclusion - income that is not counted when determining gross countable income.
Fair Hearings - an administrative procedure that gives applicants and beneficiaries the opportunity to contest adverse decisions regarding eligibility and benefit determinations.
Family - The individuals for whom a tax filer claims a deduction for a personal exemption under § 151 of the Code for the taxable year, which may include the tax filer, the tax filer's spouse, and dependents. 26 U.S.C. § 36B(d)(1) (2012).
Family size - The number of persons counted as members of an individual's household for purposes of MAGI Medicaid eligibility. When counting a household that includes a pregnant woman, the pregnant woman is counted as herself plus the number of children she is expected to deliver.
Federal Benefit Rate - The share of the Supplemental Security Income grant paid by the federal government, which does not include any applicable State supplement.
Federal Poverty Level (FPL) - A measure of income levels updated periodically in the Federal Register by the Secretary of Health and Human Services under the authority of 42 U.S.C. Section 9902(2), as in effect for the applicable budget period used to determine an individual's eligibility in accordance with 42 C.F.R. § 435.603(h).
Home and Community-Based Services Waiver (HCBS Waiver) Programs - Shall be consistent with the definition set forth under 42 CFR § 440.180.
Household Composition - Determined by individuals living together and their relationships to one another. The composition of the household determines an individual's family size.
Household Income - The MAGI-based income of every individual included in an applicant or beneficiary's household.
Incurred expense - An expense for which the individual, the individual's family, or the individual's financially responsible relative is currently financially liable.
Indian - Means any individual who is a member of any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688; 43 U.S.C. §§ 1601 et seq.), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
Institution - Means Institution and Medical institution, as defined in 42 C.F.R. § 435.1010.
Incurred expense - An expense for which the individual, the individual's family, or the individual's financially responsible relative is currently financially liable.
Lawfully Present - Aliens described at 42 C.F.R. Section 152.2(1),(3)-(7); aliens in a valid nonimmigrant status, as defined in 8 U.S.C. § 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. § 1101(a)(17)); aliens granted an administrative stay of removal under 8 C.F.R. Section 241; aliens lawfully present in American Samoa under the immigration laws of American Samoa; and aliens who are victims of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, approved October 28, 2000 ( Pub. L. 106-386, as amended; 22 U.S.C. § 7105(b)) .
Limited or no-English proficiency - As defined by D.C. Official Code § 2-193 (2012 Repl.) as the inability to adequately understand or to express oneself in the spoken or written English language.
Long-term services and supports - Nursing facility services, a level of care in any institution equivalent to nursing facility services; home and community-based services furnished under a waiver or State plan under Sections 1915 or 1115 of the Act; home health services as described in § 1905(a)(7) of the Act and personal care services described in § 1905(a)(24) of the Act.
Lawful Permanent Resident (LPR) - One who was lawfully admitted for permanent residence in accordance with the immigration laws of the United States, such status not having changed since admission. A legalized alien under IRCA whose status has been adjusted from LTR to LPR by INS.
Medicaid - Means the program established under Title XIX and Title XXI of the Social Security Act, 42 U.S.C. §§ 1396 et seq. and Title 29 DCMR, Chapter 9.
Medically Needy - Individuals, as described in 42 U.S.C. § 1396a(a)(10)(A)(ii), who meet non-financial eligibility determination factors but who have incomes over the Medicaid threshold.
Medically Needy Income Level (MNIL) - Fifty percent (50%) of the Federal Poverty Level (FPL) for a household of two (2) or larger; the MNIL for a household of one (1) is ninety-five percent (95%) of that for a household of two, as described in Supplement 8a to Attachment 2.6-A, page 2 of the Medicaid State Plan (also found at: https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach2-6aSup8a.pdf ).
Modified adjusted gross income (MAGI) - Income calculated using the financial methodologies used to determine modified adjusted gross income as defined in 26 U.S.C. § 36B(d)(2)(B) and 42 C.F.R. § 435.603. U.S.
Non-MAGI - Eligibility Groups described at 42 C.F.R. § 435.603 for which MAGI-based methods do not apply.
Nursing assistive personnel - Unlicensed personnel of assigned patient care tasks that do not require professional skill or judgment within a health care, residential, or community support setting; provided, that the patient care tasks are performed under the general supervision of a licensed health care professional.
Parent - A person who has a natural or biological, adopted, or step-child.
Pregnant woman - an individual during pregnancy and the postpartum period, which begins on the date the pregnancy ends, extends twelve (12) months, and ends on the last day of the month in which the twelve (12) month period ends.
Prospective budget period - The timeframe over which an individual's income is calculated that does not include the retroactive months for which an individual requests retroactive Medicaid coverage.
Qualified Alien - An alien described in Section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1641, as amended (PRWORA), and non-citizens required to be eligible by § 402(b) of the PRWORA, as amended, and non-citizens not prohibited by § 403 of PRWORA, as amended including qualified non-citizens subject to the five (5) year bar identified in 8 U.S.C. § 1613.
Qualified Plan - Profit-sharing, money purchase, defined benefit plans, 401K, and other retirement plans that allow a tax-favored way to save for retirement. Employers may deduct contributions made to the plan on behalf of their employees. Earnings on these contributions are generally tax free until distributed at retirement.
Renewal - Annual review to evaluate continued eligibility for Medicaid.
Retroactive budget period - The timeframe of up to three (3) months preceding the month of application for which an individual's income is calculated.
Satisfactory Immigration Status - An immigration status which does not make the alien ineligible for benefits under the applicable program (See § 121(d)(1)(B)(i)(III)) of IRCA, 42 U.S.C.A. § 1320 b-7, note).
Self-employed Simplified Employee Pension (SEP) - A written plan that allows individuals to make contributions toward their own retirement and their employees' retirement without getting involved in a more complex qualified plan.
Sibling - Each of two or more children or offspring having one or both natural, biological, adopted, or step-parents in common.
SIMPLE - An employer sponsored retirement plan offered for small businesses that have one hundred (100) employees or less. State - Includes any of the fifty (50) constituent political entities of the United States and the District of Columbia.
Single Case Agreement - An agreement between a non-enrolled Medicaid provider and the Department for Medicaid reimbursement of covered services that are furnished to an eligible D.C. Medicaid beneficiary.
Skilled Nursing- Medical and educational services that address healthcare needs related to prevention and primary healthcare activities.
Skilled Rehabilitation Services - Services delivered in an inpatient or outpatient setting that assists with retention, regaining, or improving skills and functioning for daily living that are lost or impaired due to a new medical condition, an acute exacerbation of a chronic medical condition, sickness, injury, or disability. Services that require the judgment, knowledge and skill of a qualified therapist and may include, but are not limited to, physical and occupational therapy, speech pathology, and audiology.
Spend Down - Spend down is the process by which an individual may use medical or remedial expenses to reduce countable income to the MNIL to meet financial eligibility requirements for Medicaid coverage.
Spend Down Obligation - The monthly amount of the individual's gross countable income which is over the MNIL multiplied by the number of months in the budget period.
State - Includes any of the fifty (50) constituent political entities of the United States and the District of Columbia.
Streamlined Application for Provider Enrollment - An enrollment application available for providers whose relationship with the Medicaid program is ordering, referring, and/or prescribing services to Medicaid-eligible beneficiaries.
TANF underpayments - TANF payments to a recipient that are lower than the TANF payments the recipient is eligible to receive.
Tax dependent - Tax dependent has the same meaning as the term "dependent" under Section 152 of the Internal Revenue Code, as an individual for whom another individual claims a deduction for a personal exemption under § 151 of the Internal Revenue Code for a taxable year.
TEFRA/Katie Beckett eligibility group - An eligibility group that provides Medicaid benefits for eligible children with disabilities, who would not ordinarily qualify for Medicaid because their income would be above the Medicaid income threshold for children in the District.
U.S. National - A person who is a citizen of the U.S. or a person who, though not a citizen of the U.S., owes permanent allegiance to the U.S.
Verification plan - the plan describing the verification policies and procedures adopted by the Department in accordance with 42 C.F.R. §§ 435.940 - 435.965, and § 457.380.
Well-established religious objections - The applicant is a member of a recognized religious sect or division of the sect and adheres to the tenets or teachings of the sect or division and for that reason is conscientiously opposed to applying for or using a national identification number.
D.C. Mun. Regs. tit. 29, r. 29-9599