Eligibility Online Manual

M200 Definition of Terms

A

A & A - see Aid and Attendance.

AFDC (Aid to Families with Dependent Children) - a program in existence prior to 1/2/97 designed to provide financial assistance to children in need due to absence, unemployment of both parents or incapacity of one or both parents.

ARW - Administrative Rules of Wyoming.

ASVI (Alien Status Verification Index) - the automated database maintained by the INS which may be accessed by State agencies to verify immigration status.

Absence -

A. Continued absence - when the parent is physically away from the home and is not exercising parental care and control, cannot be counted on to help plan the care and control of the child and the return to the home is not expected for at least 30 days (see Care and Control).

B. Temporary absence - When a client leaves the state with the intent to return to Wyoming within three months or meets the conditions specified in M601 or M605

Absent parent - any parent who is not providing care and control of the child(ren) or who cannot be counted on to function in the planning for the physical care, guidance and maintenance of the child(ren).

Access -

A. Ability, or potential ability, to obtain or make use of a resource or income;

B. Access is either restricted (requires the signature of another person or specifies the condition of disposal) or unrestricted (no other signature is required or condition imposed). (see Available)

Achieving a Better Life Experience (ABLE) Account - Type of tax‐advantaged account that an eligible individual can use to save funds for the Qualified Disability Expenses, who was blind or disabled before age 26. An eligible individual can be the designated beneficiary of only one ABLE account, which must be administered by a qualified ABLE program. Wyoming has not approved these accounts to be established in our state. However; this does not exclude Wyoming Medicaid from exempting an ABLE account from a state who has approved ABLE accounts in their state.

A. Qualified Disability Expenses - in general but not limit to education, housing, transportation, employment training and support, assistive technology and related services, health, prevention and wellness, financial management and administrative services, legal fees, expenses for ABLE account oversight and monitoring, funeral and burial; and basic living expenses.

B. Qualified Disability Expense ﴾QDE﴿ for housing - Housing expenses for purposes of an ABLE account are payments for mortgage ﴾including property insurance required by the mortgage holder﴿; real property taxes; rent; Heating fuel; Gas; electricity; water; sewer; or garbage removal.

Adequate notice - see Notice of adverse action.

Administrative hearing/Disqualification Hearing - a formal hearing conducted within established legal proceedings with a duly appointed hearing officer.

Adult - a person age 18 or older or a person under age 18 who meets the Wyoming emancipation laws.

Adverse action - a decision to deny, decrease or terminate the benefits.

Aged - A person 65 years of age or older.

Aged, Blind and Disabled – applies to individuals in need of professional care provided at home, in a nursing home, hospital or intermediate care facility for the mentally retarded. These groups are Nursing Home, HCBS, TB, Hospice, Inpatient Hospital Care, EID, QMB/SLMB, and the SSI Groups.

Agency error (AG) - an incorrect action or failure to take action by the Agency or a contractor of the Agency.

Aid and Attendance (A & A) - optional financial assistance available from the Veteran’s Administration (VA) for an applicant or recipient receiving care in a licensed and certified Medicaid facility as determined by WDH.

Alimony - see Support.

Annuity - An annuity is a contract or agreement where an individual receives fixed, non variable payments on an investment for a lifetime or a specified number of years. A commercial (non-employment related) annuity purchased by or for an individual using that individuals assets will be considered an available resource unless it meets exemption criteria outlined in Table 8.

Applicant - a person, including an authorized representative, who expresses verbally or in writing a desire to make application for benefits and all individuals included in a completed, signed and filed application.

Application - the form on which a person indicates, in writing, the desire to receive assistance, provides information necessary for determining eligibility and informs the client of her/his rights and responsibilities.

Appointment of Conservator - the legal document appointing a conservator to care and manage the affairs of another person.

Appointment of Guardianship - the legal document appointing a guardian to care and manage the affairs of another person.

Assessment -

A. The act of evaluating a person, condition, resources or income.

B. For Medicaid, a determination of the total combined resources available to a married couple when one spouse enters a medical institution and the other spouse continues to live in the community.

Assignment of rights - Any assignment of the rights to support, or any assignment of rights to medical support and to payment for medical care from any third party. This assignment includes child and spousal support and is a condition of eligibility of POWER or Title IV Part E, Foster Care. This allows the state to retain support payments as partial reimbursement of public assistance expenditures made on behalf of the custodial parent and/or the child(ren).

Available - income and resources are considered when actually obtainable and when the applicant/recipient has legal interest in a liquidated sum and has the legal ability to make such sum available for support and maintenance. (see Access)

Average private pay rate - the average statewide cost of care for nursing facility services as determined by WDH.

BENDEX - Social Security Administration's Beneficiary Data Exchange System which provides the amount of RSDI benefits paid to people entered on the system.

BIA (Bureau of Indian Affairs) - an agency within the Department of Interior.

Barrier to sale - there is an inherent legal restriction on the right to sell, convey or transfer the client's share or ownership of a resource.

Beneficiary - an individual having a present or future interest, vested or contingent, in the income from or principal of a trust, also used to designate recipients of Social Security benefits.

Best estimate - the Benefit Specialist's best determination based on knowledge of past, current and future case circumstances which accurately reflects all facts known to the Benefit Specialist at the time.

Blind - an individual receiving benefits for the blind.

Blind work expense exclusion - an amount disregarded for items necessary to enable the blind person to work, including but not limited to, attendant care for transportation, durable medical equipment or prosthetic devices.

Bona fide -

A. For burial, a trust, contract or agreement specified for that express purpose and there cannot be other funds or items designated for burial;

B. An offer made in good faith without fraud or deceit;

C. A bona fide loan is one where there is a written agreement to repay the loan.

Bona fide effort to sell - the act of putting property up for sale at a reasonable price and providing verification of same.

Break-in-aid - a period of one or more months in which a client is not eligible and does not receive assistance.

Burial fund -

A. A resource specifically designated for burial of a specified person;

B. Bank account, life insurance policy or written agreement with a funeral home specifically designated for burial of a specified person and not commingled with funds not set aside for burial.

Burial plot - a grave site, the value of which may include opening and closing costs, a vault, crypt, urn, grave marker, etc. (aka burial space item)

Burial space item - burial containers, burial plot, casket, crypt, gravesite, arrangements for the opening and closing costs, headstone, markers or plaques, mausoleum, urn, niche or other repository customarily and traditionally used for the deceased bodily remains. A contract for care and maintenance of the gravesite, sometimes referred to as endowment or perpetual care, can be excluded as a burial space.

Business expenses - for self-employment, the costs directly related to the production of goods or services provided by the operation which are then subtracted from the gross income to determine the net income.

COLA - cost of living increase.

CPS (Child Protective Services) - child welfare services performed by persons legally responsible for investigating suspected cases of child abuse and neglect and intervening in verified cases.

Care and control - when a parent or caretaker relative can be counted on to function in planning for and/or is giving the child(ren) physical care, guidance and maintenance as follows:

A. Guidance - parental participation in the responsibility for the child's development. Such participation includes, but is not limited to, attending school conferences, disciplining the child, participating in decisions concerning the child's well-being and involvement in the child's extracurricular activities.

B. Maintenance - typically synonymous with "support" as in provision of necessities such as food, clothing and shelter.

C. Physical care - providing continuous care for the child by performing tasks required in the child's daily life such as, but not limited to, bathing, feeding, dressing, assuring medical attention is received by the child, preparing meals, supervising the child's activities and assisting with other physical care needs.

Caretaker - an adult who may or may not be related to the Medicaid client and who is exercising the care and control of the Medicaid client.

Caretaker relative - a person who meets the definition of a relative and is exercising the day-to-day care and control of the child(ren).

Case manager (CM) - the individual designing and implementing the plan of care for Long Term Care or Developmentally Disabled clients who are receiving Home and Community Based Waiver Services.

Case record - includes the applicant's or recipient's case file and the information contained in WES.

Cash surrender value (CSV) - see Value.

Cash value - see Value.

Categorically eligibleapplicants who are receiving assistance from SSI are automatically eligible.

Categorically needy - an individual required by federal law to be provided with medical services.

Change in circumstance - a change which affects the ongoing eligibility/benefit.

Child - a dependent between birth and 18 years of age who is not an emancipated minor or a minor parent.

Children’s Group - children zero through the age of five, six through the age of 18, Newborn and Foster children.

Claim - an eligibility system identification number which is made up of one or more overpayment months.

Claim number - the Social Security number (SSN) plus one or two alpha characters which indicate the primary beneficiary, the type of benefits paid and the designated recipient of the benefits.

Client error (CL) - a misunderstanding or unintended error on the part of the client.

Card management system (CMS) - the computer system used to perform various EBT functions.

Collateral contact - a verbal or interface verification of the circumstances of a Medicaid applicant or client by a knowledgeable person outside the household.

Color of law (aka Permanently Residing Under Color of Law [PRUCOL]) - used by the USCIS and applies to immigrants who are living in the U.S. with the knowledge and permission of the USCIS and whose departure from the U.S. the USCIS does not contemplate enforcing. Immigrant who entered the U.S.:

A. Lawfully in a status other than lawful permanent resident and who are assumed to be here permanently without being granted permanent resident status; or

B. Unlawfully but have resided here continuously since 1/1/72.

Commingled - a financial account in which exempt and nonexempt funds are mixed together.

Common Law Marriage - is one in which the couple lives together for a period of time and holds themselves out to friends, family and the community as "being married," but without ever going through a formal ceremony or getting a marriage license. This is not recognized as a legal marriage in the State of Wyoming. However, Wyoming recognizes common-law marriages when entered into in other states or nations that recognizes common-law marriage. Refer to Table 5B for required documentation to prove common-law marriage.

Community spouse - a spouse who lives in a community, even when s/he is receiving HCBS benefits, whether inside or outside the state of Wyoming, when her/his married partner lives in a swing bed, nursing home facility or receives HCBS or Hospice services. If a spouse is living in a medical institution or nursing facility, they are not considered a community spouse.

Concurrent - occurring simultaneously or at the same time.

Confidentiality - the limitation of the use and disclosure of applicant and recipient information.

Conservator - a person designated by a legal document to take over and protect the interests of an individual whom is unable to manage her/his own affairs.

Continued absence - see Absence.

Continuous period - consecutive days of care in a medical institution.

Contribution - a voluntary or mandatory monetary or in-kind grant or aid provided by another person(s) which is not repayment for goods or services and is not given because of a legal obligation on the giver's part.

Contract for Deed – a contract between a seller and buyer of real property in which the seller provides financing to buy the property for an agreed-upon purchase price and the buyer repays the loan in installments

Cooperate - to comply with child support activities for adults under Family Care. Third party liability cooperation is required for all adults receiving Medicaid.

Cooperation - a client is working with the Child Support Authority (CSA) to establish medical support.

Cost of nursing facility services - the average statewide private pay rate for nursing facility services as of the previous 1/1 as determined by WDH.

Countable income - see Income.

Court of appropriate jurisdiction - a district, county or small claims court as determined by the amount of the overpayment, the circumstances of the case and the advice of legal counsel.

Court order - an order issued by the court and used by CSA to determine necessary enforcement action to collect a support obligation.

Current market value (CMV) - see Value.

Current month - see Month.

Custodian - an individual who has been appointed by the court to care for a person as reflected in a court order.

DAC - Disabled Adult Child age 18 or older who was receiving SSI due to a disability or blindness prior to her/his 22nd birthday.

DDS (Disability Determination Services) - a team composed of physicians/psychologists and disability examiners that determines whether or not an individual is disabled for SSA.

DFS - Department of Family Services

DVR (Division of Vocational Rehabilitation) - a division within the Wyoming Department of Workforce Services that offers services to assist in reaching employment goals agreed to by the agency and their client.

DWS (Department of Workforce Services) - the Department responsible for delivering services through public-private partnerships and a statewide network of job centers.

Date of action - the day the benefit will be issued, increased, reduced, denied or terminated. The date an action will be effective.

Date of application - the date the signed application is received and date stamped in by WDH or designated representative.

Date of discovery – the date the potential overpayment is identified by the eligibility worker.

Date of eligibility - the day benefits are required to begin.

Deem - to consider the income and resources of one person as the income and resources of a second person whether or not they are actually available.

Dependent child - see Child.

Dependent deduction - the difference between the federal SSI rate for the single person standard and the couple standard.

Developmentally disabled (DD) - one who is experiencing significant sub-average physical/emotional/mental functioning as verified by a medical professional or the WDH.

Disabled - A person with a medical determination to receive disability benefits paid through SSA or Railroad Retirement because of a disability considered to be permanent. This determination can also be made by WDH.

Disregard - an allowable deduction from earned or unearned income.

Distribution - a payment, in cash, from a trust to or for the benefit of the beneficiary or a third party.

Documentary evidence error (DE) - an error caused by an applicant or client when at least two written documents are in the case file which substantiate the client willfully and knowingly failed to report or reported incorrectly.

E01 - individuals who are SSI eligible but do not receive a payment as they are in a licensed medical institution.

EID (Employed Individual with Disabilities) - the program allows a low-income, working disabled individual between age 16 up to age 65 to continue to work and purchase medical coverage under the Medicaid work incentives improvement option.

EITC (Earned Income Tax Credit) - an amount of money either deducted from the taxes owed or paid as a refund resulting from filing a Form 1040 or 1040A tax return for a calendar year.

Earned income - see Income.

Edmund's Automobile Valuation Guide - the internet site which provides a used car value guide.

Elderly - a person who is 65 years of age or older (aka Aged).

Eligibility factor - a specified condition a client must meet to qualify or receive benefits.

Emancipation - the condition of being freed from parental care and control resulting from one of the following:

A. Lawfully recognized marriage.

B. Reaching the age of majority (age 18).

C. Military service.

D. Having received a declaration of emancipation pursuant to W.S. 14-1-202 (See Financially Responsible).

Employment - an activity in which an individual works for wages.

Encumbrance - a claim or legal debt(s) against a resource which must be paid when the resource is sold and is supported by a written document.

Equity value - see Value.

Essential person - individual identified as essential to the welfare of the client by the Social Security Administration prior to the implementation of the SSI program in 1974.

Estate - resources and liabilities left by a person at death.

Exempt - a category of income, resources or circumstances not subject to program policy or limits and is not counted for eligibility purposes.

FICA (Federal Insured Contribution Act) - commonly known as the Social Security contribution deducted from wages and used for RSDI payments.

FPL (Federal Poverty Level) - guidelines for poverty level established annually by the Federal Office of Management and Budget.

Face value (FV) - see Value.

Fair market value (FMV) - see Value.

Family care income standard - the maximum income, based on the number of members in a household unit, allowed for medical assistance.

Family care program - medical coverage for adults, including four or twelve month extended coverage.

Fee-simple - An interest in land that, being the broadest property interest allowed by law, endures until the current holder dies without heirs.

Financially responsible - answerable or liable by law for providing the funds to meet the needs of a spouse and/or child(ren) and, for medical assistance, the needs of an unborn (See Emancipation).

Fixed residence - a home or place in which an individual has or intends to live for a specific length of time.

Fluctuating income - see Income.

Foster child - a child who has been placed in a foster care home or an approved/licensed facility by DFS.

Fraud - documented misrepresentation, concealment or nondisclosure of information pertaining to an eligibility factor to obtain a performance payment, remain eligible for payment or to avoid a decrease in payment.

Full-time employment - see Employment.

Garnishment - a legal withholding of a specified sum from wages to satisfy a creditor.

General price list - summary from a mortician itemizing costs of goods and services for a burial or cremation.

Goldberg/Kelly - a Supreme Court decision requiring a client be given written notice prior to reduction, suspension or termination of SSI and allows payments to continue at the previous rate until a decision is made after a timely appeal is filed.

Good cause - a specified reason based on accepted standards supporting the individual's action and thereby eliminates the penalty which normally a sanction is imposed.

Grantor - the person giving the Trustee the legal right to manage a trust.

Gross income - see Income.

Guardian - a person appointed by the court to care for another person as specified in the court.

HCBS (Home and Community-Based Services) - home care services which are Medicaid reimbursable pursuant to a federal waiver.

HHS (Health and Human Services) - the United States Department of Health and Human Services.

HUD (Housing and Urban Development) - a U.S. government department.

HUD escrow account - an account established by HUD under the Family Self-Sufficiency (FSS) Program whereby participating families will have a portion of any rent increase which resulted from increased earnings credited to the account.

Health insurance plan - an individual or group insurance policy or contract or a medical or hospital service agreement or other health care delivery system for the purpose of paying for or reimbursing the cost of hospital and medical care.

Hit - a discrepancy found between WES data and the interface with records of other agencies such as IRS, wages and UIB, RSDI, SSI, State Retirement, Worker's Compensation, etc.

Home - for the purpose of eligibility for Long Term Care Medicaid and Medicare Savings programs, an individual's home is property in which he or she has an ownership interest and that serves as his or her principal place of residence, it can include any of the following:

the shelter in which he or she lives

the land on which the shelter is located

related buildings on such land

Homeless - the condition or lack of a permanent dwelling or lack of a fixed or home address.

Household furnishings - furniture, electric appliances, clothing and personal items owned by the household.

Household Unit - Persons included on a Medicaid application.

ICF/ID - Intermediate Care Facility for the Intellectually Disabled.

IHC - Inpatient Hospital Care.

IIM - Individual Indian Monies.

INA (Immigration and Naturalization Act) - P.L. 99-603.

IRA (Individual Retirement Account) - a pension or plan that permits individuals to set aside savings that are tax free until retirement.

IRS (Internal Revenue Service) - the U.S. government tax collection agency.

Immigrant - a person residing in, and who is not a citizen of the U.S.

Impairment-related work expenses - an amount disregarded for items or services which are directly related to enabling a person with a disability to work and which are necessarily incurred by the individual because of a physical or mental impairment.

Incapacitated - a temporary or permanent condition of blindness, physical disability or mental incompetence determined by WDH.

Income - money received from any source but not any item specified in policy as a resource.

A. Contract income - earnings paid through an agreement with another; considered self-employment if the individual is paying her/his own taxes;

B. Countable income - the amount of income used to determine eligibility.

C. Earned income - payment received in cash or in-kind for wages, salary, tips, commissions as an employee, or net-profit from activities in which the individual is engaged as self-employed.

D. Exempt income - money set aside or free from program policy or limits.

E. Fluctuating income - monthly income that varies in frequency of receipt or amount each month due to working overtime, hourly pay with varying hours, receipt of tips or commissions, changes of hours or pay rate or decrease or increase in hours of work due to vacations, sick leave or seasonal employment.

F. Gross income - the total money the person receives prior to any deductions such as Social Security, withholding tax, garnishments etc.

G. In-kind income - the receipt of goods or services instead of money.

H. Irregular income - income the applicant/recipient cannot reasonably expect to receive.

I. Net income or profit - the gross receipts from self-employment less the current business expenses and/or the allowable income deductions.

J. Nonexempt income - all money received to which the program policy limits are applied.

K. Ongoing income - money received on a regular basis, no less frequently than monthly, and is expected to continue.

L. Self-employment income - earning one's own living directly from one's own profession or business rather than earning a salary or commission from another.

M. Stable income - income received in a set/fixed amount from the same source(s) on a regular basis and there is no additional income that fluctuates.

N. Unearned income - all money received that is not earned by providing goods and services or defined as a resource.

Income producing property - property essential to the production of goods and services, including stock (merchandise), inventory, tools, equipment, trucks, cars, earth moving equipment, etc. This property is used in a trade, business, or other income producing activity.

Incomplete report - any information furnished in writing, in person or by phone which concerns a change in circumstances but is insufficient to verify and/or act upon the change.

Indian land - real property owned jointly by the tribe or where the sale can be made only with the permission of other owners, the tribe or the BIA.

Individual's Immediate Family “Individual” means the applicant or client.- The individual's immediate family includes his or her:

• parents, including adoptive parents;

• minor or adult children, including adoptive and stepchildren;

• siblings (brothers and sisters), including adoptive and stepsiblings.

“Immediate family” also includes the spouse of the above relatives. If the relative's relationship to the recipient is by marriage only, the marriage must be in effect in order for the burial space exclusion to continue to apply. For example, a burial space held for a sister-in-law is no longer excludable if she and the recipient's brother divorce.

Ineligible - not entitled to receive a benefit due to failure to meet one or more of the specified conditions required by the program.

Initial eligibility determination - the act of evaluating each eligibility factor for each person applying for benefits, and finding the case eligible or ineligible during the initial processing period.

Initial month - see Month.

Institution - an establishment that furnishes (in single or multiple facilities) food, shelter and/or some treatment or services to four or more persons unrelated to the proprietor.

Institutionalized individual - an individual who meets one of the following criteria:

A. A patient of a nursing facility.

B. A patient in a hospital receiving swing bed services.

C. A patient receiving home- or community-based services furnished under a waiver.

Institutionalized spouse - a spouse who lives in a swing bed, nursing home facility or receives HCBS or Hospice services.

Insurance settlements - the money received by a person(s) from a company for damage of property or person.

Irrevocable - incapable of being canceled, rescinded, broken or changed by the action of either party.

Irrevocable income trust - a document appointing a person, known as a Trustee, to manage the grantor’s income placed in the trust.

Joint tenancy/Joint tenancy with survivorship - A tenancy with two or more co-owners who take identical interests simultaneously by the same instrument and with the same right of possession. A joint tenancy differs from a tenancy in common because each joint tenant has a right of survivorship to the other’s share (in some states, this right must be clearly expressed in the conveyance – otherwise, the tenancy will be presumed to be a tenancy in common.

Knowledgeable source -

A. A person who has a considerable degree of familiarity of a subject gained through experience with or association with the individual or subject.

B. For evaluation of a resource, a person who is professionally aware of the value of the property in the community.

LIEAP (Low Income Energy Assistance Program) - a 100% federally funded program that exists to partially meet the cost of home heating energy.

Late reporting - information not furnished when the change becomes known to the client or verifications which are not furnished within the allowable time frames.

Law enforcement - persons or agencies that require compliance with the principles and regulations established in a community under the authority of state and/or federal legislation and enforced by judicial decision.

Legal barrier - see Barrier to sale.

Legal encumbrance - a lien or claim on a resource which is recognized by law.

Legal obligation - an obligation, such as a court order, that would be upheld by a judge in a court of law, i.e., a divorce decree, an order issued through an administrative law judge, or a legally enforceable separation agreement.

Legal residents - lawfully residing in the United States.

Life estate - the rights of ownership belonging to an individual and existing until the individual's death but actual title or deed to the property belongs to another individual.

Life insurance - a contract on which the owner pays premiums during his lifetime and:

A. The company pays at least the face amount of the policy to the beneficiary upon the death of the insured.

B. The payment may include a loan or cash surrender value.

C. The payment may include accumulated dividends.

Likely to remain - a determination made by a public health nurse and/or case manager that an institutionalized person is expected to remain in an institution for 30 consecutive days or longer.

Liquid resource - see Resources.

Loan - a debt the borrower has an obligation to repay (See Bona fide).

Lump sum - a payment of earned/unearned money, i.e., payment of retroactive benefits such as, but not limited to, RSDI, lottery winnings, UIB, cash inheritances or workers compensation awards. It is the total amount received minus legal fees required to make the money available and minus the amount designated by the payer or source for medical expenses.

Magi (Modified Adjusted Gross Income) - The figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have.

Mail-In Application - A mail-in application is defined as any application that is mailed in by the individual, representative, or another agency.

Mandatory - refers to a person(s) who is required to meet specified provisions within the law, rules and/or policy.

Marriage or married couple - a contractual relationship recognized by the State of Wyoming with a document, certificate or license or when SSA decides either of the couple is entitled to a Social Security benefit as a spouse.

Mass change - the act of affecting appropriate cases by issuing a new or revised policy caused by a change in state or federal law.

Medicaid - a federal and state funded program that provides health coverage for selected categories of individuals with low income and limited resources established under Title XIX of the Social Security Act.

Medicaid Eligibility Quality Control (MEQC) - a federally mandated process to monitor the administration of eligibility for State Medicaid programs.

Medical professional - a licensed physician, a psychologist or master's level mental health worker. This includes a physician's assistant, public health nurse, registered nurse, or licensed practical nurse.

Medicare Cost Sharing Groups - this includes the Qualified Medicare Beneficiary and Specified Low-Income Medicare Beneficiary Medicaid programs.

Medicare Savings Programs (MSP) - special Medicaid programs for individuals receiving Medicare who have limited income and resources.

A. QMB (Qualified Medicare Beneficiary) - covered under Section 1902(a)(10)(E)(iii) of the Social Security Act. Medicaid pays for Medicare Part A and Part B premiums, deductibles and co-payments.

B. QDWI (Qualified Disabled and Working Individuals ) - covered under Section 1902(a)(10)(E)(ii) of the Social Security Act. Medicaid pays the Medicare Part A premium.

C. SLMB (Specified Low-Income Medicare Beneficiary) – covered under Section 1902(a)(10)(E)(iii) of the Social Security Act. Medicaid pays the Medicare Part B premium.

D. QI (Qualified Individual) - covered under Section 1902(a)(10)(E)(iv) of the Social Security Act. Medicaid pays the Medicare Part B premium.

Medicare Set-Aside (MSA) Account - money from a Workers’ Compensation or personal injury settlement that is set-aside for future medical care must be put into a special account called a Medicare Set-Aside (MSA) Account. When the money in the MSA Account is exhausted, Medicare will begin paying bills for the injury, but only if the money is spent properly. The Center for Medicare and Medicaid Services (CMS) reviews these account every year.

Mental health professional - a licensed psychologist or master's level mental health worker employed by a public or private human services organization or in private practice.

Minor - a person under age 18 who does not meet emancipation criteria in Wyoming laws.

Minor parent - a person who is under the legal age of 18 who is not emancipated and is either the parent of a dependent child living with him/her or is pregnant.

Month -

A. Benefit month - the calendar month for which eligibility will be authorized and benefits issued.

B. Current month - the month in which eligibility is determined.

C. Initial month - the first month for which the client is authorized following any break in aid.

Net income - see Income.

Net profit - the gross receipts, less the current business expenses (See Business expenses and income).

Non-custodial parent - any parent who is not providing care and control of the child(ren) or who cannot be counted on to function in the planning for the physical care, guidance and maintenance of the child(ren).

Nonexempt - (countable) a category of income or resources to be used in budgeting or to which the program policy and limits are to be applied.

Notice of adverse action - a written statement which informs the applicant/recipient of the intended action to be taken, a change in their benefits, or closure of their case. This statement should include the reason and specific regulation(s) supporting the action, the date the action will occur and a statement of the person's right to request a hearing.

A. Adequate notice - a notice of action informing the applicant or client of a decrease or closure in benefits to be received by the household no later than the date the benefits would have been received.

B. Fifteen-day notice period - the fifteen days immediately following the day the notice is mailed per the date on the WES notice.

C. Timely notice - a notice of action mailed at least fifteen days before the date the action would become effective.

Numident - the tape of matched and unmatched Social Security numbers transmitted from the eligibility computer system and run against SSA files.

OBRA 93 - the Omnibus Budget Reconciliation Act of 1993, Pub. L. No. 101-66.

Ongoing eligibility determination - the act of evaluating each open case and finding the case eligible or ineligible based on the reported change in circumstances.

Ongoing income - see Income.

Open case - a client or household authorized in WES for medical benefits.

Out stationing facility - facility designated by WDH to give medical information and/or accept medical applications.

Overpayment/Over-issuance - benefits issued to a client for the benefit month which exceeds the amount for which the client was eligible.

POSSE (Parental Obligation System for Support Enforcement) - the child support enforcement computer system.

Parent - an individual who has established a parent-child relationship under W.S. 14-2-501.

Parental support - see Support.

PASS account - an account set up by an SSI recipient for the specific purpose of fulfillment of a Plan for Achieving Self-Support under Title XVI of the Social Security Act.

Paternity - a legal relationship existing between a child and his natural, legal or adoptive father per W.S. 14-2-501b.

Patient contribution - the monthly amount the Aged, Blind and Disabled individual must pay to the cost of care/services.

Payee - the person in whose name the benefit is issued.

Payment - the act of giving a check or warrant to the grantee or the legal representative.

Payment Error Rate Measurement (PERM) - A federally mandated process to measure improper payments in Medicaid and State Children’s' Health Insurance programs. In addition to reviews of claims data, PERM contains an eligibility portion to measure payment errors as a result of improper eligibility determination and eligibility processing.

Periodic review - a review conducted, as designated in policy, to determine continued eligibility. Documentation should be entered in the case file to acknowledge the review occurred.

Perjury - a willful false statement of a material fact, swearing to what is untrue or omitting to answer all questions under oath.

Personal injury insurance - protection purchased from a company for the payment of cash upon occurrence of an injury or accident and is not for repair, replacement or medical expenses.

Personal needs - a monthly amount of income a Medicaid individual in a nursing home retains to pay for required personal items.

Personal property - all things owned or possessed excluding land and building affixed thereto.

PICKLE Amendment - a federal law requiring Medicaid coverage for an individual who lost SSI for any reason and would remain eligible for SSI if the RSDI cost of living adjustment (COLA) was deducted from her/his income.

Power of Attorney (POA) - a written document a person signs appointing another person to legally act on behalf of or perform duties as if s/he was the person taking the action.

Presumptive eligibility - approval from a qualified provider or qualified hospital for temporary medical services for certain Medicaid programs until an application can be approved or denied by the WDH Customer Service Center.

Primary beneficiary - a person who has worked the specified number of quarters in covered employment and is eligible for retirement or disability benefits from SSA in his/her own right.

Primary evidence - a document or record of an official government agency or public institution accepted in a judicial proceeding as establishing the truth.

Promissory Note - a promissory note is a written, unconditional agreement whereby one party promises to pay a specified sum of money at a specified time (or on demand) to another party. It may be given in return for goods, money loaned, or services rendered.

Property - both real and personal resources owned by the family unit.

Property Agreement - a pledge of security of particular property for the payment of a debt or the performance of some other obligation within a specified period. Property agreements on real estates generally are referred to as mortgages but also may be called real estate or land contract, contracts for deed, deeds or trust.

Prorate - divide or distribute proportionally:

A. Based on days of eligibility for initial months of eligibility.

B. To determine months of ineligibility because of receipt of a lump sum.

C. To average income over intended period of use for self-employment or contractual income.

Prospective budgeting - using the best estimate of the income and circumstances that will exist in the benefit month to determine eligibility and to compute the benefit.

Prospective eligibility - the method of testing income, expenses and circumstances for a future benefit month against specified conditions or factors when eligibility requirements are met.

Public assistance - any program where income and/or resources are tested to determine eligibility, i.e., POWER, SSI, Food Stamps, Child Care and medical assistance, etc.

Public institution - a governmental establishment, or an establishment over which a governmental unit exercises administrative control, that furnishes (in single or multiple facilities) food, shelter and some treatment or services to persons unrelated to the proprietor. The following are public institutions in Wyoming: State Hospital, Wyoming Life Resource Center, State Penitentiary, Women's Center, Honor Farm, Girls' School, Boys' School, and city/county jail facilities.

Pursuit - the act of seeking, obtaining or accomplishing the payment of child support through commonly accepted child support enforcement procedures.

QDWI (Qualified Disabled and Working Individuals) - see Medicare Savings programs.

QMB (Qualified Medicare Beneficiary) - see Medicare Savings programs.

Qualified immigrant - A qualified immigrant means an immigrant who is in one of the following categories as determined by the United Stated Citizenship & Immigration Services (USCIS):

A. Lawfully admitted for permanent residence (LPR) in the United States (holders of green cards). This category includes "American immigrants" as defined under section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988;

B. Granted asylum under section 208 of the Immigration and Nationality Act (INA);

C. Refugee admitted to the United States under section 207 of the INA (the Trafficking Victims Protection Act of 2002 (Public Law 106-386) requires victims of a severe form of trafficking to be treated as refugees for food stamp purposes);

D. A refugee, asylee, one whose deportation is withheld for up to seven years upon entry into the U.S. or a parolee for up to one year after entry into the U.S.

E. Paroled into the United States under section 212(d)(5) of the INA for at least one year;

F. Deportation is being withheld under section 243(h) of the INA as in effect before 4/1/97, or removal is withheld under section 214(b)(3) of the INA;

G. Granted conditional entry under section 203(a)(7) of the INA as in effect before 4/1/80;

H. Cuban or Haitian entrant under section 501(e) of the Refugee Education Assistance Act of 1980; or

I. Under certain circumstances, a battered spouse, battered child or parent or child of a battered person with a petition pending under 204(a)(1)(A) or (B) or 244(a)(3) of the INA.

J. U.S. military connection (veteran, active duty, spouse or unmarried dependent child);

K. Lawfully in the U.S. on 8/22/96 and age 65 or older;

L. Canadian born Indians under 289 of the INA;

M. Afghan or Iraqi Special Immigrants status under section 101 (a)(27) of the Immigration and Nationality Act (INA) shall be available to refugees admitted under section 207 of such Act.

N. Compacts of Free Association (COFA) - Citizens from the Federal States of Micronesia, the Republic of the Marshall Islands and Palau who lawfully reside in the United States.

Qualified Individual (QI) - see Medicare Savings Programs.

Qualified Long-Term Care Partnership Policy - A policy that meets all of the following requirements:

A. The policy covers a beneficiary who was a Wyoming resident or resident of another partnership state when coverage first became effective under the policy;

B. Is a qualified long-term care insurance policy as defined in Section 7702B(b) of the Internal Revenue code of 1986 issued not earlier than the effective date of the State Plan amendment;

C. The Department of insurance has certified that the policy meets the model regulations and requirements of the national Association of Insurance Commissioners model specified in paragraph (5) of the title VI, section 6021 of the federal Deficit Reduction Act of 2005

D. The policy meets the inflation protection federal requirements set forth in section 1917(b)91)(C)(iii)(IV) of the Social Security Act.

E. The policy was issued or amended no earlier than July 1, 2009

Qualifying quarters - quarters of coverage under Title II of the Social Security Act, including quarters worked by the immigrant, a parent while the immigrant was under 18 and quarters worked by a spouse while married to the immigrant, and has not received government benefits.

Quality Assurance (QA) - Evaluating overall performance on a regular basis to provide confidence that the relevant quality measures and standards are satisfied.

Quality Control (QC) - Monitoring specific results to determine if they comply with relevant quality standards and identifying ways to eliminate causes of unsatisfactory performance.

Quarter - three calendar months - January through March, April through June, July through September and October through December.

RSDI (Retirement, Survivors and Disability Insurance) - insurance through the Social Security Administration under Title II of the Social Security Act.

Real property - land and buildings or immovable objects permanently attached thereto; land, and generally whatever is erected, growing upon or affixed to the land.

Reapplication - the completion of an application in writing requesting assistance after being ineligible for benefits for more than one calendar month or, for FS, following a break in participation.

Reasonable appraisal - a value given by a knowledgeable source close in amount to the similar property values in the community or is logical using prudent person judgment.

Reasonably expected - the condition of being in agreement with the belief an event will occur.

Recipient - a person who is eligible for and receiving benefits in her/his own behalf or in behalf of others.

Recover - to collect a payment issued for which the person(s) was not eligible.

Redetermination - to re-verify each factor of eligibility, establish a new best estimate of income, when applicable, make a decision of eligibility and benefit amount based on the verified information and performance standards and enter documentation in the case record when a change in circumstances is reported.

Reinstate - to restore the case to eligible status when a full benefit month has not passed or an administrative hearing request has been requested timely.

Relative -

A. An individual who is through marriage, blood relationship, or court decree, the grandparent, great-grandparent, sibling, aunt or uncle of a child;

B. Any blood relative, including those of half-blood, first cousins, nephews and nieces and persons of preceding generations denoted by prefixes of grand, great or great-great are included in this definition;

C. Stepmother, stepfather, stepbrother and stepsister;

D. Adoptive or natural parents and their adopted or natural children;

E. Siblings, including those related through adoption; and

F. Spouses of any person mentioned above are considered relatives even though the marriage may be terminated by death or divorce.

Rental expenses - costs necessary for the production or collection of rental income, including interest on debts, state and local taxes on real and personal property, general sales taxes, expenses of managing or maintaining the property interest and escrow portions of a mortgage payment, real estate insurance, repairs, lawn care, snow removal and advertising for a tenant.

Resident - a person who lives or dwells in Wyoming for a continued period of time with the intent to reside permanently in the state.

Resource - Any physical property, financial accounts, or other liquid possessions.

Restitution - full payment of assistance paid in error.

Room and/or board income - money received from providing rooms and meals, if a boarder.

SAVE (Systematic Alien Verification for Entitlement) - the USCIS program whereby state agencies may verify the validity of documents provided by immigrants applying for public assistance benefits by obtaining information from a central data file.

SDX (State Data Exchange System) - used to notify the State of the people eligible for SSI.

SHP - State Hospital Placement.

SLMB (Specified Low-Income Medicare Beneficiary) - see Medicare Savings Programs.

SS 5 - an application for a Social Security number and card.

SSA (Social Security Administration) - a division of the U.S. Department of Health and Human Services that administers federal social security programs.

SSI (Supplemental Security Income) - the program funded under Title XVI of the Social Security Act.

SSN (Social Security number) - the account number assigned to all persons who apply and will be used to accumulate work history and contributions for payment of Social Security benefits.

SVES (State Verification and Exchange System) - an automated system which allows rapid access to SSA and SSI information.

Sanction - for Family Care, a restrictive measure or penalty imposed against a recipient for failure to cooperate with the child support authority, or with WDH's third party liability unit.

School - an elementary school, a secondary school or the equivalent to a secondary school or high school.

Secondary evidence - a document or record of a declaration of fact by individuals or entities that have no responsibility to establish the fact and is inferior to primary or best evidence.

Self-employed - when an individual earns her/his living directly from her/his own profession or business AND pays her/his own taxes rather than earning a salary or commission from another.

Sibling - brother, sister, stepbrother, stepsister, half brother, half sister and adopted brother or sister.

1619 Individual - Section 1619 of the Social Security Act provides benefits for disabled or blind individuals who are SSI eligible except for earned income.

Special needs - a child who is less than 18 years old who is developmentally disabled or has a mental or physical incapacity which limits her/his ability to care for herself/himself.

Sponsor - any person or any public or private organization that has executed an "affidavit of support" (USCIS Form I-134) or similar legally binding agreement to support an immigrant as a condition of the immigrant's admission for permanent residence in the U.S. An immigrant may have more than one sponsor.

Sponsored immigrant - an immigrant lawfully admitted for permanent residence into the U.S. and for whom an affidavit of support has been executed.

Spousal maintenance allowance - the amount deducted from the patient contribution for the needs of the community spouse established each January 1 by CMS.

Spousal resource allowance - an amount set by CMS each January 1 as the maximum resources necessary for a community spouse to maintain himself/herself in the community.

Spousal support - see Support.

Stable income - see Income.

Statement - a formal declaration of the circumstance(s) as requested by the agency.

Statute of limitations - the time allowed in the Wyoming statutes in which court action may be initiated and there is no limitation for debts owed to the state of Wyoming.

Stepparent - the spouse of a natural or adoptive parent, who is not a natural or adoptive parent.

Strike - any concerted slowdown, interruption of operations by employees or any stoppage of work by employees, including a stoppage by reason of the expiration of a collective-bargaining agreement.

Support -

A. Alimony/Spousal support - a court or voluntary payment made to an individual by his/her spouse/former spouse;

B. Child support - a court ordered or voluntary payment made by a non-custodial parent for his/her child(ren) to assist with day-to-day maintenance;

C. Military allotment - the military payment allocated as support for a service person's dependents.

D. Parental support - providing to one's child the necessities such as food, clothing, housing, health and medical needs and is usually meant to be provided by expenditure of money or by in-kind unearned income.

Swing bed - a bed in a rural hospital with less than 50 beds that can be used for skilled or intermediate nursing home care and licensed and certified by WDH.

Sworn statement - declaration under penalty of perjury the written information is true and correct.

TPL (Third Party Liability) - an individual, entity or program that is or may be liable to pay all or part of the medical costs of injury, disease or disability of a client.

TPQY (Third Party Query) - an automated system which allows rapid access to SSA and SSI information.

Temporary absence - see Absence.

Tenancy in common - A tenancy by two or more persons, in equal or unequal undivided shares, each person having an equal right to possess the whole property but no right of survivorship.

Terminate - to close a case and/or an individual from a program; to end the certification period before the scheduled time of expiration.

Timely reporting - when information is provided either in writing, in person or by telephone within ten days of the day the client becomes aware of the change in circumstances.

Trafficking -

A. For victims, a commercial sex act is induced by force, fraud or coercion or in which the person induced to perform such an act has not attained 18 years of age and the recruitment, harboring, transportation, provision or obtaining of a person for labor or services through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery;

B. For fraud, illegally trading, buying or selling Food Stamp benefits.

Trust - a property interest held by one person for the benefit of another.

Trustee - any person(s) appointed by the instrument creating the trust, or any person appointed by the court to administer the trust. (AKA grantee)

A. Trustor - the person who sets aside resources by placing them in a trust. Also known as donor, grantor or settler; and

B. Beneficiary - the person(s) who benefits from the trust during the life of the trustor and/or who benefits upon the death of the trustor. Any person(s) appointed by the instrument creating the trust, or any person appointed by the court to administer the trust (aka grantee).

UIB - Unemployment Insurance Benefit.

U.S. (United States) - defined in a geographical sense as the continental United States, Alaska, Hawaii, Puerto Rico, Guam, U.S. Virgin Islands and Northern Mariana Islands.

USCIS (United States Citizenship and Immigration Services) - the U.S. agency responsible for admitting and assigning residence status to people entering the U.S. from other countries.

Unavailable - income and resources

A. Money from a lump sum incapable of being used for day-to-day needs of the household because it was spent or lost as the result of a disaster which was beyond the family's control; or

B. A jointly owned resource the second party refuses to sell and each owner does not have the legal right to sell his/her share; or

C. The resource is inaccessible because a legal barrier or restriction exists; or

D. Income inaccessible to the client because s/he does not have a legal interest in or is tied up in divorce or other legal action.

Uncompensated Value - see Value.

Undocumented Non-Citizen - a foreign national who:

A. Entered the U.S. without appropriate documentation; or

B. After entering legally as a documented non-citizen, remains in the U.S. after documents expired or were revoked.

Undue hardship - when an individual would be forced to go without life sustaining services altogether or as otherwise determined on the basis of criteria.

Unearned Income - see Income.

Unpaid principal - the balance to be paid on an agreement to buy or sell.

VA - the Veterans Administration of the U.S.

VISTA - Volunteers in Service to America.

Value - the monetary worth of a good or service.

A. Cash surrender value (CSV) - the amount the insurer will pay upon cancellation of the policy before death of the insured or before maturity of the policy.

B. Cash value -

1. For resources, the amount that would be paid if the resource were sold or converted to cash;

2. For income, the amount of the income or the value assigned to the service rendered for in-kind income.

C. Current market value (CMV) - the amount for which the property can be expected to sell for on the open market in the community at the time of determination or at the time of transfer or sale.

D. Equity value - the CMV or FMV less any legal debts or encumbrances. For vehicles the equity value is FMV or trade-in value less encumbrances.

E. Face value - the basic death benefit of an insurance policy exclusive of dividend additions or amounts payable due to accidental death or other special provisions.

F. Fair market value (FMV) - the amount of money the sale of property would currently (or at the time of transfer) bring on the open market in the community where the property is located.

G. Trade-in value - for vehicles such as automobiles, trucks, vans and motorcycles, it is the trade-in value according to the Edmund's Automobile Valuation internet site or the lower of two reasonable appraisals of the amount that would be given if the vehicle was exchanged for another or turned in.

H. Uncompensated value - the current market value less the gross sale price.

Vendor - the person or business that provides goods or services to the recipient or on behalf of the recipient.

Vendor payment - the amount paid on behalf of a household which the household cannot convert to cash to meet its needs.

Verification - the act of confirming or proving a fact to be true by obtaining documentation.

WDH - the Wyoming Department of Health.

WES - Wyoming Eligibility System.

WHIPP - Wyoming Health Insurance Premium Payment program.

WIA (Workforce Investment Act) - the federal training act, which replaced the JTPA (Job Training Partnership Act) programs.

WIC (Women, Infants and Children) - supplemental nutritional program administered by the Wyoming Department of Health.

WOLFS - Wyoming On-Line Financial System.

Widow/Widowers - Individual between age of 50 and 64 who was receiving SSI benefits and lost SSI due to receipt of Widow Widowers benefits.

Wyoming Life Resource Center - Formerly Wyoming State Training School.