Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 477 - MEDICAID ELIGIBILITY › Chapter 1 - GENERAL DEFINITIONS

Current through June 17, 2024
Absent Parent
: A parent who is not living
	 with his/her child(ren).
Adequate Notice
: Notice of case action, which
	 includes a statement of what action(s) are intended, the reason(s) for the
	 intended action(s), and the specific manual reference(s) that supports or the
	 change in federal or state law that requires the action(s).
Affordable Care Act (ACA)
: The Patient
	 Protection and Affordable Care Act of 2010, as amended by the Health Care and
	 Education Reconciliation Act of 2010, as amended by the Three Percent
	 Withholding Repeal and Job Creation Act.
A-Number
: Alien registration number, which is
	 assigned to an alien when s/he enters the United States. Applicant: An
	 individual who is seeking an eligibility determination through submission of an
	 application or a transfer from another agency or insurance affordability
	 program.
Application
: A request for Medicaid benefits
	 submitted by an applicant or his/her authorized representative via a
	 Department-approved format.
Application Date
: For new and reopened cases,
	 the date a properly signed application is received.
Application Signature
: Applications may be
	 signed in writing, by telephonic signature, or by electronic signature.
Application Submission
: Applications may be
	 submitted in person, by mail, by telephone, by fax, or by electronic
	 transmission.
Approval/Denial Date
: The date that a new or
	 reopened case is determined eligible or denied by the Nebraska Department of
	 Health and Human Services.
Assignment
: The transfer of a client's right
	 to third-party resources to the Department, which is accomplished by the
	 submission and approval of an Application.
Authorized Representative
: A person or
	 organization authorized by an applicant, client, or court of competent
	 jurisdiction to represent the applicant or client in any matter(s) with the
	 Department.
Budget Month(s)
: The calendar month(s) for
	 which verification of eligibility factors is used to compute
	 eligibility.
Casualty
: The legal obligation of a third
	 party to indemnify an injured person for damages caused by the third party or
	 for which the third party is otherwise responsible.
Categorical Assistance
: Assistance
	 administered by the Department, including; Assistance to the Aged, Blind, and
	 Disabled (AABD)/MA; and Children's Medical Assistance Program.
Child Support
: Money that is
1. Ordered by a court of competent jurisdiction to be paid by a
	 noncustodial parent on behalf of a minor child, or
2. Paid by a noncustodial parent on behalf of a minor child without a
	 court order.
Client
: An individual who has been determined
	 eligible for and is currently receiving Medicaid.
Court or Tribal Ward
: A child whose custody
	 is committed to a court or other public agency. In order to receive payment
	 from the Department that is otherwise permitted or required, the court or other
	 public agency must be authorized under state law for the placement and
	 supervision of children, and the court or other public agency must have a
	 written agreement with the Department to ensure that Title IV-E requirements
	 are met.
Court Order
: A document signed by a judge and
	 entered into the court record in a court of competent jurisdiction.
Creditable Health Insurance Coverage
: Any
	 current health insurance coverage, except a plan that is limited to a single
	 condition, such as cancer insurance, dental insurance, or long term care
	 insurance. Insurance to which an individual does not have reasonable geographic
	 access is not creditable coverage.
Current Support
: The monthly amount of child
	 support or spousal support ordered by a court of competent jurisdiction.
Deeming
: The process of determining the
	 amount of income and resources of a parent or sponsor that must be considered
	 available to meet the client's needs. Deeming does not apply to pregnant women
	 or children.
Denial
: A case in which an application was
	 completed, signed, and submitted, but the applicant did not meet eligibility
	 requirements.
Department
: The Nebraska Department of Health
	 and Human Services (DHHS), Division of Medicaid and Long-Term Care (MLTC). The
	 Department is the single state agency designated to administer and supervise
	 the administration of the Medicaid program under Title XIX of the federal
	 Social Security Act, as amended.
Dependent Child
: A child from birth through
	 seventeen (17) years old; or who is eighteen (18) years old and a full-time
	 student in secondary school (or equivalent vocational or technical training),
	 if before attaining nineteen (19) years of age the child may reasonably be
	 expected to complete school or training.
Director
: The director of Medicaid.
	 Discharged Ward: An individual who has been discharged as a ward of a court or
	 tribe.
Educational Institution
: A properly licensed
	 or credentialed school, college, university, or vocational or technical
	 training facility.
Effective Income Level
: The income standard
	 applicable under the State Plan for an eligibility group, after taking into
	 consideration any income disregards applied in determining financial
	 eligibility for the group.
Electronic Account
: An electronic file
	 consisting of information collected or generated by the Department regarding
	 client Medicaid/ Children's Health Insurance Program (CHIP) eligibility and
	 enrollment.
Eligibility Determination
: An approval or
	 denial of eligibility, as well as any renewal or termination of
	 eligibility.
Emancipated Minor
: A child eighteen (18)
	 years old or younger who is considered an adult because s/he has
1. Married;
2. Moved away from his/her parent's(s') home and is not receiving
	 support from his/her parent(s); or
3. If a pregnant child, eighteen (18) years old or younger, is denied
	 financial support by her parents, guardians, or custodians due to her refusal
	 to obtain an abortion, the pregnant child shall be deemed emancipated for
	 purposes of eligibility, except that benefits may not be used to obtain an
	 abortion.
Federal Poverty Level (FPL)
: The current
	 federal poverty level in effect for the applicable budget period used to
	 determine an applicant's eligibility or a client's continued
	 eligibility.
Guardian/Conservator
: A person appointed by a
	 court of competent jurisdiction to be in charge of the affairs of another
	 person who cannot effectively manage his/her own affairs because of his/her age
	 or incapacity.
Guardian Ad Litem (GAL)
: A person appointed
	 by a court of competent jurisdiction to protect the best interests of a minor
	 or vulnerable adult in a specific legal action.
Hearing
: An administrative proceeding before
	 the Director or his/her designee. During a hearing, a client, applicant, or
	 his/her authorized representative may present evidence with or without the help
	 of witnesses to show why the action as indicated on the relevant Notice of
	 Action or inaction of the Department should be corrected by the
	 Department.
Incapacity (Physical or Mental)
: As
	 determined by the Social Security Administration (SSA) or the State Review Team
	 (SRT), any physical or mental illness, impairment, or defect, which is expected
	 to last at least thirty (30) days, that is so severe as to reduce substantially
	 or eliminate a parent's ability to provide support or care for a child(ren).
	 Age itself is not considered incapacity.
Inquiry
: Any question received by phone,
	 letter, electronically, or personal contact without any indication that the
	 individual wishes to apply. This may or may not be followed by an application
	 for Medicaid.
Irregular Income
: Income, earned or unearned,
	 that varies in amount from month to month or that is received at irregular
	 intervals. See 477-000-009 for budgeting procedures.
Lawfully Residing
: Qualified alien pregnant
	 women and children who are lawfully present in the United States and who are
	 residents of Nebraska.
Medicaid
: A joint federal and state program
	 under Title XIX of the federal Social Security Act, as amended, that provides
	 medical assistance to eligible low-income individuals.
Medical Need
: A condition of eligibility
	 referring to a medical need.
Medical Payment
: Payment from any health
	 insurance plan, individual, or group or entity for medical expenses, whether
	 for a client or any other member of his/her household.
Medical Support
: The obligation of a
	 noncustodial parent to provide health insurance or pay medical costs.
Minimum Essential Coverage
: Coverage under a
	 specified government-sponsored program, an eligible employer-sponsored plan, a
	 health plan offered in the individual market, a grandfathered health plan, or
	 other health benefits coverage that is recognized by the federal
	 government.
Minor Parent
: An individual eighteen (18)
	 years old or younger, with a child. For treatment of child support when a
	 noncustodial parent pays support for his/her child who is a minor parent, see
	 477 NAC 22-003.02C.
Non-Applicant
: An individual who is not
	 seeking an eligibility determination for him/herself and is included in an
	 applicant's or client's household to determine eligibility for the applicant or
	 client.
Notice of Action (NOA)
: A statement sent by
	 the Department to an applicant, client, or his/her Authorized Representative
	 that includes a reasonably short, plain statement of the action(s) taken by the
	 Department, the factual reason(s) for the action, and reference to the
	 applicable regulatory law(s) or otherwise that authorizes the action(s).
Parent/Caretaker Relative (P/CR)
: A relative
	 of a dependent child by blood, adoption, or marriage, with whom the child is
	 living, who assumes primary responsibility for the child's care, and who is one
	 of the following:
1. The child's father, mother, grandfather, grandmother, brother,
	 sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first
	 cousin, nephew, or niece.
2. The spouse of the parent or relative, even if the marriage is
	 terminated by death or divorce.
3. Another relative of the child based on blood, adoption, or marriage,
	 or an adult with whom the child is living and who has provided sufficient
	 documentation of a court-ordered guardianship/conservatorship of the child.
Pending
: A case in which a complete and
	 signed application has been received and eligibility has not yet been
	 determined by the Department.
Post-Partum Period
: The period following the
	 end of a pregnancy, which begins on the last day of pregnancy, then extends
	 sixty (60) days, and ends on the last day of the month in which the sixty
	 (60)-day period ends.
Power of Attorney (POA)
: A written and
	 notarized authorization allowing one person to act for another person. The
	 powers granted may be general or may be limited to specific circumstances. A
	 POA may be durable, in which case the powers continue to exist even if the
	 appointing individual becomes legally incompetent. A POA ceases to be effective
	 upon the death of the appointing individual.
Pregnant Woman
: A woman during pregnancy and
	 the post-partum period.
Prospective Eligibility for Medical
	 Assistance
: The date of eligibility beginning the first day of the
	 month of the date of application if the client was eligible for Medicaid in
	 that same month.
Reasonably Compatible
: For each eligibility
	 factor (except for SSN, citizenship, and immigration status), reasonable
	 compatibility shall be applied. Electronic data matches shall be used when
	 applicable and compared to an applicant's/client's self-attestation of
	 information. See Appendix 477-000-004 for Verification Plan.
Retroactive Eligibility
: The date of
	 eligibility beginning no earlier than the first day of the third month before
	 the month of application. See 477 NAC 4-001.01.
Secure Electronic Interface
: An interface
	 which allows for the exchange of data between Medicaid and insurance
	 affordability programs.
Sponsor
: A sponsor is an individual
	 who
1. Is a citizen or national of the United States, or an alien who is
	 lawfully admitted to the United States for permanent residence;
2. Is eighteen (18) years of age or older;
3. Lives in any state or the District of Columbia; and
4. Is the person petitioning for the admission of the alien under
	 Section 204 of the Immigration and Nationality Act.
An organization cannot be a sponsor.
Spousal Support
: Alimony or maintenance
	 support for a spouse or former spouse.
Standard of Need
: The maximum standard
	 according to eligible unit size and living arrangement.
State Plan
: The written plan between the
	 Department and the federal government that authorizes and describes how the
	 Department administers Medicaid.
Student
: An individual who is eighteen (18)
	 years old or younger and attending a secondary school (or the equivalent level
	 of vocational or technical training).
Third-Party Resources
: The legal obligation
	 of a third party (including certain individuals, entities, insurers, and
	 programs) to pay for or provide monies or benefits. Medicaid is the payer of
	 last resort. A client must cooperate with the Department to ensure this.
	 Third-Party Resources include Casualty, Child Support, Medical Payment, Medical
	 Support, and Spousal Support.
Timely Notice
: A notice of case action dated
	 and mailed at least ten calendar days before the date the action becomes
	 effective.
Unit
: The number of individuals in a
	 household.
Unsubsidized Employment
: Employment for which
	 the salary is paid wholly by the employer.
Withdrawal
: A voluntary written or verbal
	 retraction of an application.