Common Texas Medicaid Terminology

Activities of Daily Living (ADLs): A set of minimal self-care tasks that typically includes bathing and showering, personal hygiene and grooming, dressing, toilet hygiene, functional mobility, and self-feeding.

Aid & Attendance Benefits: A pension provided by the VA that depends on an individual’s medical condition.

Community Spouse: A husband or wife of a Medicaid applicant who meets two requirements: First, he or she must be married to the “institutionalized spouse,” meaning the one who resides in a medical institution or nursing facility and is likely to remain there for at least 30 consecutive days. Second, the community spouse cannot also be receiving long-term care in a medical institution or nursing facility.

Countable Income: Gross income adjusted for allowable deductions, expenses, and disregards. For someone to qualify for Medicaid, their countable income must be below certain limits.

Countable Resource: Cash, stocks, bonds, investments, credit union, savings, checking accounts, real estate in which one does not reside, etc. For someone to qualify for Medicaid, their countable resources must be below certain limits.

Dual-Eligible: Someone who is eligible for both Medicaid and Medicare.

Estate: “The real and personal property of a decedent, both as such property originally existed and as from time to time changed in form by sale, reinvestment, or otherwise, and as augmented by any accretions and additions and substitutions that are included in the definition of the probate estate found in [the Texas Estate Code]”.^[1]

Exempt Income: Income that is not countable for the purpose of qualifying for Medicaid.^[2]

Exempt Resource: A resource that is not countable for the purpose of qualifying for Medicaid.^[3]

Expanded Spousal Protected Resource Amount (SPRA): The total value of resources that can be protected for the use of the community spouse when the other is institutionalized, expanded to ensure that the community spouse is meeting the MMMNA for income. If the community spouse is not meeting the MMMNA, the expanded SPRA is calculated as the total amount of resources, invested in a certificate of deposit, whose interest income would make up the shortfall. Note that the expanded SPRA may not exceed the couple’s combined countable assets as of the snapshot date.

Medicare Extra Help Program (Part D Low-Income Subsidy): A federal program that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage.

Fee-Only Financial Advisor: An advisor who gets paid a percentage of assets under management.

Home Maintenance Allowance: The amount of money that an individual may deduct from his or her monthly Medicaid copayment in order to cover certain home maintenance expenses. This is only allowed for those who will be institutionalized for a short period of time and whose contributions to the home are deemed necessary.

Housebound Benefits: A pension provided by the VA that applies to those who are substantially confined to the premises because of a permanent disability.

Hybrid Long-Term Care Solution: This is typically a life insurance policy with a death benefit that can be accessed early, either in whole or in part, in the case of an adverse long-term care situation.

Income Limit: The maximum amount of monthly income someone may have and still qualify for Medicaid.

Income Shortfall: For the purposes of the expanded SPRA, the income shortfall is defined as the difference between the MMMNA and community spouse’s monthly countable income. For the purposes of the Modern Half-a-Loaf Strategy, the income shortfall is defined as the difference between an individual’s monthly income and expenses.

Institutionalized Spouse: The spouse who resides in a medical institution or nursing facility and is likely to remain there for at least thirty consecutive days.

Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF-IID): Facilities with a certified designation from Medicaid to provide for individuals with intellectual disabilities.

Lapse Ratio: The percentage of insurance policies that are dropped during a given time period.

Lookback Period: The period of time during which an individual’s total gift amount is monitored in order to determine if there will be a transfer penalty. The current lookback period includes the month in which the Medicaid application is filed, as well as the sixty calendar months that precede it. The length of the lookback period is subject to change.

Medicaid Long-Term Care: The author’s terminology to refer to Texas Medicaid long-term care services and community-based support services. This program is run through the Texas Health and Human Services Commission (HHSC). HHSC oversees three departments:

1. The Department of State Health Service (DSHS)
2. The Department of Family and Protective Services (DFPS)
3. The Department of Aging and Disability Services (DADS): DADS is the department responsible for Medicaid Long-Term Care and for the administration of the Medicaid Estate Recovery Program (“MERP”). The DADS webpage is www.dads.state.tx.us.

Medicaid Minimum Monthly Needs Allowance (MMMNA): The minimum income level for a community spouse set by the Centers for Medicare and Medicaid Services.

Medical Effective Date: “The date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care...but for the application of the penalty period.”^[4]

Medical Necessity: One of the eligibility criteria for Medicaid. Medical necessity, in short, centers on the need for care, the frequency of the care that is required, and the level of skill required to provide the care.

Medicare Part A: The part of Medicare that governs hospital insurance.

Medicare Part B: The part of Medicare that includes medical insurance that is available for purchase; it is not an entitlement.

Medicare Part D: The part of Medicare that governs coverage for prescription drugs.

Name-on-the-Check Rule: Whomever a check is made payable to is the owner of the income

Personal Needs Allowance: The monthly amount that someone on Medicaid may retain from their personal income. Any income above the allowance is applied toward the cost of their care. As of 2020, this is $60.

Qualified Domestic Relation Order (QDRO): An order that can be used to shift income from an institutionalized spouse to a community spouse.

Qualified Medicare Beneficiary (QMB) Program: Covers all Medicare cost-sharing expenses, including Part A and B premiums, deductibles, and coinsurance, for certain low-income individuals.

Resource: A real or potential asset.

Resource Limit: The maximum amount of countable resources that someone can have and qualify for Medicaid.

Snapshot or Snapshot Date: The day and time at which someone’s resources are measured to determine the SPRA or expanded SPRA. This can be found by adding thirty-one days to the date of institutionalization and then finding the next first day of the month, on which the snapshot occurs at 12:01 a.m.

Spousal Protected Resource Amount (SPRA): The total value of resources that can be protected for the use of the community spouse when the other is institutionalized. As of 2020, this is calculated as half of the couple’s combined resources, with a minimum of $25,728 and a maximum of $128,640.

Texas Medicaid Program: The Texas Medicaid Program is run by the Texas Health and Human Services Commission (HHSC).

Transfer Penalty: The delay that an individual experiences in Medicaid qualification as a result of gifting money during the lookback period. As of 2020, qualification is delayed by one day for each $213.71 that is gifted during the lookback period.