Long Term Home Health Care Program
- AKA Lombardi waiver
or nursing home without walls
. A Medicaid wavier program which provides a nursing home alternative to patients requiring that level of care. It includes coverage of case management by registered nurses, home delivered meals, home improvements, respiratory therapy, medical, social, nutritional and dietary services, and respite care. See DOH website on LTHHCP.
A type of private health insurance product that typically has the following features:
- Capitation - the plan is paid a fixed amount per member per month by the payor (e.g., employer, union, Medicare, Medicaid) to provide a defined package of covered services. The plan's reimbursement does not vary based upon the amount or cost of medical care provided.
- Network - generally members of a managed care plan can only receive coverage for services provided by medical providers who have agreed in advance to participate in the plan's provider network, and thereby receive a contracted rate of payment.
- Utilization Management - the plan may impose restrictions on coverage of certain procedures, such as requiring the physician to obtain permission from the plan before performing them, or limiting the number of pills that can be prescribed. Some plans require members to have a primary care physician (PCP), and require the PCP to give referrals to any specialists before their services will be covered. Occasionally, managed care plans go further and proactively coordinate care among the member's providers.
Medicaid Advantage Plus - This is a type of managed care plan that includes virtually all services covered under Medicare and Medicaid. It is like a Medicare Advantage plan merged with a Medicaid managed care plan and an MLTC plan. It covers everything included in Medicaid Advantage, plus all MLTC services. This is one option for dual eligibles who are in need of LTC services and thereby required to enroll in MLTC (the other two are partial-cap MLTC and PACE). Otherwise, it is voluntary.
The acronym MAP is also used to refer to the Medical Assistance Program in New York (in other words, Medicaid).
Medicaid Buy-In for Working People with Disabilities
- A special Medicaid benefit that has a much higher income limit for people with disabilities who are working. See DOH MBI-WPD website.
Medicaid is the public health insurance program for people of limited means. It is jointly funded by the Federal, state, and local governments. However, each state has its own Medicaid program, which completely different rules regarding eligibility and what services are covered. You should assume that any information provided on this website only applies to the New York State Medicaid program (also known as "Medical Assistance").
A type of private managed care plan that is a combination of a Medicare Advantage plan and a Medicaid managed care plan. These plans cover all services under Medicare Parts A, B, & D, as well as almost all services covered under Fee-For-Service Medicaid in New York, with the exception of personal care, CDPAP, mental health, and adult day health care. This type of plan is always optional. It may make sense for dual eligibles who do not require long-term care services.
A model of care that gives each patient a more personal and continuous relationship with their physician(s). This can include round the clock access to medical consultations, more comprehensive care coordination, and providing both care and health education in a way that respects the patient’s beliefs and cultural background.
A federal category of Medicaid eligibility for people who are unable to afford their medical bills but have income and resource levels too high for traditional Medicaid. They may "spend down" their excess income and resources on medical bills to qualify for Medicaid. They must not be currently receiving any public cash assistance benefits, such as SSI or public assistance. Only certain "categories" of individuals are medically needy: DAB category (Disabled/Aged 65+/ Blind), and AFDC category (children under age 21, their parents or other relatives who live with them, and pregnant women).
A voluntary, optional program where Medicare beneficiaries may choose to enroll in a private managed care plan to receive their Medicare health insurance. These plans must cover all services provided under Medicare Parts A and B (and often D), except for hospice. Although they must cover the same services to roughly the same extent, there is considerable variation among plans in out-of-pocket costs, and unlike Original Medicare, members are generally limited to providers in the plan's network and subject to utilization management. Medicare Advantage plans may cover a few extra services not otherwise covered by Medicare (e.g., limited dental, limited vision, gym membership), and they may be a good option for beneficiaries who cannot afford the cost of supplemental Medigap policies, yet whose income is too high for Medicaid (which itself acts as a supplement to Medicare). To compare Medicare Advantage plans, see http://medicare.gov/find-a-plan
Medical Insurance and Community Services Administration - A division of New York City's Human Resources Administration that includes Adult Protective Services, the HIV/AIDS Services Administration, the Medical Assistance Program, and the Home Care Services Program. This is the agency that administers the Medicaid, Family Health Plus, and Child Health Plus programs in New York City.
Managed Long-Term Care
- in the general sense, refers to any type of private managed care organization in New York State whose benefit package includes Medicaid long-term care services (such as home care, adult day care, and nursing home). Currently, this general category includes Partially-Capitated MLTC plans as well as fully-capitated ones such as MAP and PACE. The term MLTC is more often used specifically to refer to the partially-capitated type of plan. These plans do not include any Medicare-covered services, nor do they include all services covered under Medicaid. Members of these plans must use them to access all types of home care, nursing home care, adult day care, medical transportation, podiatry, audiology, optometry, and dentistry. All other services are covered either by Medicare or Fee-For-Service Medicaid. Since 2012, it has been mandatory for dual eligibles needing Community-Based Long-Term Care services to enroll in MLTC, MAP or PACE plans in order to receive them. See http://www.wnylc.com/health/entry/114/
Nursing Home Transition and Diversion Waiver - a Medicaid Home and Community Based Services waiver program in New York which is designed to help transition nursing home residents back to the community, and to divert nursing home-eligible individuals from institutional placement, by providing a comprehensive package of long-term care services in the community. NY Soc. Serv. L. § 366(6-a).
Office of Mental Health - The state agency that provides services for people with mental disabilities.
Office for People With Developmental Disabilities - The state agency that provides services for people with mental retardation and developmental disabilities. This agency also administers the Medicaid Waiver program for people with MR/DD. Formerly known as the Office of Mental Retardation and Developmental Disabilities (OMRDD).
New York State Office of Temporary and Disability Assistance
- (Pronounced "Oh
") This is the New York State agency that administers Temporary Assistance (aka "welfare" or "public assistance"), Food Stamps, HEAP, and other programs. OTDA also conducts all Fair Hearings in New York State, including Medicaid Fair Hearings. See OTDA website.
Program of All-inclusive Care for the Elderly - A PACE is a type of fully-capitated MLTC plan that provides a comprehensive system of health care services for members age 55 and older who are otherwise eligible for nursing home admission. Both Medicare and Medicaid pay for PACE services (on a capitated basis). PACE members are required to use physicians & providers employed by or contracted with their plan. An interdisciplinary team develops care plans and provides on-going care management. The PACE is responsible for directly providing or arranging all primary, inpatient hospital and long-term care services required by a PACE member. Most participants are dually eligible for Medicare and Medicaid, with a small number in only one or the other.
Ordinarily, when a minor child applies for Medicaid, the income and resources of their parents are counted, because parents are Legally Responsible Relatives for their minor children. However, a child may prevent their parents' income/resources from being counted if the parent signs a statement indicating their refusal to make their income/resources available for the child's medical care. This is called a parental refusal.
When a patient pre-pays their spend-down to the Medicaid agency to activate their Medicaid coverage, instead of incurring medical bills to offset their excess income.
Personal Care Aide
- aka "home attendant." A semi-skilled paraprofessional certified under NY law to provide assistance with certain specified activities of daily living for people with disabilities. See 18 NYCRR § 505.14; Personal Care Aide Scope of Practice at http://www.wnylc.com/health/download/46/
Prenatal Care Assistance Program - A program providing comprehensive prenatal care to low income pregnant women.
Primary Care Physician - The doctor in a managed care plan that provides most of the recipient’s care and is responsible for referring recipient to specialists if needed.
Private-Duty Nursing - Clients with continuous skilled nursing needs may need a Licensed Practical Nurse (LPN) or Registered Nurse (RN) for up to 24-hours a day. Intravenous or parenteral nutrition, suctioning of tracheostomies, direct administration of medications (putting a pill directly in the client’s mouth), and operating a ventilator are examples of tasks that PCA/HHAs may not perform. PDN is covered (subject to prior approval) by fee-for-service Medicaid and by all types of Medicaid Managed Care plans (MMC, MLTC, etc.) 18 NYCRR § 505.8.
Permanently Residing Under Color of Law - PRUCOL is a category of immigration status used by certain public benefit programs. An immigrant would be considered PRUCOL if they are residing in the United States with the knowledge and permission or acquiescence of the United States Citizenship and Immigration Services, and whose departure that agency does not contemplate enforcing. PRUCOLs are eligible for Medicaid and Safety Net Assistance in New York State.
Qualified Medicare Beneficiary - This is a Medicare Savings Program (MSP) that provides coverage of the out-of-pocket costs associated with Medicare Part A and B. This includes coverage of the Part A hospital deductible and copayments, the Part A copayments for Skilled Nursing Facility (SNF), Part A premium (if applicable), Part B outpatient deductible and coinsurance, and the Part B premium. All those with QMB are also automatically deemed eligible for Full Extra Help with Medicare Part D.
Most public benefits programs require that the recipient show from time to time that they continue to be eligible for that benefit. This is usually called recertification or renewal. Most Medicaid recipients must recertify once a year.
An authorization for a patient in a managed care plan to receive care from a specialist, hospital, or other health care provider. Referrals are usually given, in writing, by a primary care provider.
Resources (aka "assets") are money and property owned by an applicant for public benefits. Different programs have different rules about what types of resources are counted towards the resource limit, and some programs have no resource limit at all. In general, resources include bank accounts, other financial institution accounts, and real property (except the primary residence).
Social Adult Day Care (aka "social model") - SADC is a structured program designed to support the physical, mental, social and emotional functioning of frail adults or those with a cognitive disorder. Unlike Adult Day Health Care ("medical model"), which is provided in a healthcare facility supervised by doctors, SADC is provided in non-medical settings. It is not covered by fee-for-service Medicaid, but is available under the Lombardi and NHTD waivers, and under Managed Long-Term Care (all flavors).
Safety Net Assistance - A cash public assistance (aka welfare) program in New York State that provides benefits to eligible individuals and certain families who do not qualify for Family Assistance or other federal Temporary Assistance programs.
Special Needs Plan
- There are two very different programs that go by the name Special Needs Plan:
- Medicaid SNP - Medicaid managed care plans designed specifically for people with HIV/AIDS. They provide access to medical staff specifically trained to handle HIV/AIDS as well as specialized support services, testing, case management and information on clinical trials.
- Medicare SNP - Medicare Advantage plans that are tailored to serve particular sub-groups of Medicare beneficiaries. Some are catered to dual eligibles (those with Medicare & Medicaid), some to nursing home residents, and some for people with chronic medical conditions.