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Family and Social Services Administration

Medicaid Policy Home > MED Works > Glossary of Terms Glossary of Terms

Browse through the glossary to find some commonly used terms and acronyms pertaining to Medicaid, Social Security and other federal benefits. While this glossary is not all-inclusive, it will help you understand some important terms.

ABC | DEFGHI | JKLMNO | PQR | STUVWXYZ

A

Appeal – The process you can take to ask that a case be heard again when you don’t agree with an agency’s decision. The appeal process can be undertaken if you disagree with a decision made by Medicaid, Social Security, or most government programs.

B

Beneficiary – The person who receives a SSDI benefit.

Blind Work Expense (BWE) – The Blind Work Expense is a work incentive for people receiving SSI because of blindness. Blind Work Expenses are documented expenses that an individual needs in order to work. Transportation costs are an example of a possible BWE. When an individual reports these expenses to Social Security along with their paycheck stubs, the expenses can be deducted from the amount of their earnings that are reviewed by Social Security. This can help the SSI recipient keep more of their SSI check each month that they work.

Break-Even Point – A level of work income that reduces your SSI cash payment to zero when Social Security uses the countable income formula. he Break Even Point can be determined by your earned and unearned income, living arrangements, and applicable income exclusions. When the cash benefit is reduced to zero, you will be placed in 1619(b) status.

Business Plan – When a person has an idea for self-employment, they should have a business plan to explain what they want to do and how they are thinking about doing it. At a minimum, the business plan will show what the business will do, how it will be set up, how it will operate, what it will need to operate, how it will market its service or product, to whom it will sell, how it will be financed, and what the expectations are regarding profit or loss in the near future, etc.

C

Cessation – For both SSI and SSDI, cessation is the point in which Social Security decides that a person no longer qualifies for disability-related benefits because of the amount of their earned income. This decision determines when disability benefits will end.

Continuing Disability Review or CDR – Everyone who receives SSI and/or SSDI has reviews by the Social Security Administration to determine if they are still considered disabled and unable to perform Substantial Gainful Activity. The frequency of these reviews depends on the severity of their impairment and the likelihood of their recovery. There are two types of CDRs: a medical CDR and a work CDR.

Co-pay – The amount an individual must pay out-of-pocket for prescriptions and medical services, along with the amount that is paid by health insurance.

Countable Earned Income – This is the dollar amount of income from a person’s work that is counted by SSA and Medicaid after deductions are made to determine a person’s monthly SSI payment and eligibility for Medicaid.

Countable Income Formula for SSI eligibility – The formula used to figure out what a person’s SSI payment will be. Social Security will not count $20 of a person’s general income in determining eligibility for SSI. If the person is working, Social Security will not count an additional $65 of earned income. Following these deductions, Social Security will count half of the remainder of the person’s earnings in calculating the new SSI payment. Other work incentives may also apply in calculating the SSI payment.

D

Deductible – For health insurance, the amount a person must pay toward medical expenses before insurance plan begins paying.

Deeming – SSI is a financial-needs based program. This means that for SSI eligibility, the income and financial resources of other people who live with, or are responsible for a SSI recipient may taken into consideration. Deeming is the rules used by Social Security and Medicaid to determine their program eligibility when a person lives with a spouse who is not disabled.

Definition of Disability – The Social Security Administration and Indiana Medicaid use similar definitions of disability to determine if a person is eligible for assistance. A brief description of this definition is, “The inability to engage in any Substantial Gainful Activity (SGA) due to a medically determinable mental or physical impairment which can be expected to result in death or last for a continuous period of at last 12 months.” Other special provisions apply to Social Security and Indiana Medicaid in determining disability, although both agencies use similar definitions.

Disability Determination Services (DDS) – The state agency under contract with the Social Security Administration to determine medical eligibility for disability benefits.

Disregard (Indiana Medicaid) – When calculating eligibility for Medicaid, Indiana will disregard (not count) certain amounts of income in the countable income formula. This normally includes a $20 General Income Disregard and a $65 Earned Income Disregard (if the individual is working). Indiana will also disregard some resources (such as a house if you live in it and an automobile if you use it to drive to work or medical appointments.

Dual Eligibles – People who receive benefits from both Medicare and Medicaid are called dual eligibles. There are four categories of dual eligibles: including Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiaries (SLMB), Qualified Working Individual (QWI), and Qualifying Individuals (QI-1). A person may be in one of the four categories, depending on their total monthly income.

E

Earned Income –Earned income may include wages, tips, salaries, or net earnings from self-employment. It may also include other compensation received from performing work activity.

Earned Income Disregard (Indiana Medicaid) – A disregard is an amount of income that is not counted when Medicaid determines eligibility. The earned income disregard is $65 of earnings from a job that is not counted when Medicaid determines its program eligibility.

Earned Income Exclusion (SSI or Supplemental Security Income) – An Earned Income Exclusion is the amount of earnings that are not counted when Social Security figures what your SSI benefit should be. For people receiving SSI, Social Security will exclude $65 of earnings when calculating the countable income formula to determine the amount of a person’s SSI check.

Earned Income Tax Credit or EITC – A federal tax credit for certain low-income working people and their families. The tax credit reduces the amount of money owed in federal taxes, and may result in a refund check from the Internal Revenue Service.

Employment Network or EN –An employment agency or group of agencies that are approved by Social Security to provide a variety of services related to employment, including job readiness services, placement services, vocational rehabilitation, training, job coaches, and other supports. Employment Networks were developed under the Ticket to Work and work Incentives Improvement Act of 1999. Individuals receiving a Ticket to Work in the mail may assign their Ticket to an Employment Network to get assistance in choosing, getting and keeping employment, with a goal of working their way toward self-sufficiency.

Expedited Reinstatement of Benefits or EXR – This is process that allows your cash benefits to be quickly re-started if you have terminated from disability benefits because of work income and then lose your job because of your disability. Persons who have worked their way toward self-sufficiency and no longer receive SSDI or SSI benefits due to high earnings may be eligible for Expedited Reinstatement of Benefits (easy-back-on benefits). This provision is available for up to five years after Social Security work incentives have been terminated.

Extended Medicare Coverage – SSDI beneficiaries may have their Medicare extended for up to 93 months after they return to work.

Extended Period of Eligibility or EPE – This is a work incentive timeline for Social Security Disability beneficiaries that begins immediately following the completion of the 9th Trial Work Period (TWP) month and lasts for 36 consecutive months. During the EPE, if a person earns over Substantial Gainful Activity (SGA), a three month grace period begins, allowing a beneficiary to continue receiving SSDI payments. If earnings continue to be above SGA after the grace period, a beneficiary will not receive a benefit check for additional months during the EPE. However, if earnings fall below SGA the beneficiary does not have to reapply for benefits during the 36 month timeline. After the EPE is completed, if an individual is consistently earning SGA, eligibility for benefits will cease.

F

Federal Benefit Rate or FBR –The FBR is the national benefit amount established by Social Security to determine the basic monthly payment to SSI recipients. As of January 1, 2005, the FBR for a single person is $579 and $869 for a couple. The FBR is reviewed annually and revised based on the cost of living.

Federal Insurance Contribution Act or FICA – FICA is the federal income tax that is withheld from your paycheck. The money from FICA is allocated to the Social Security Trust Fund. FICA contributions are measured in credits. One SSDI credit equals one quarter of a year, or three months. Four SSDI credits are accrued in a twelve month period. Social Security will check the number of credits a person accrues if an individual qualifies for SSDI. Generally, an individual needs 20 credits in the 10 years prior to the onset of their disability to qualify for SSDI. Individuals who are disabled before age 31 need less work to qualify.

Federal Poverty Level or FPL – Every year the department of Health and Human Services issues the Federal Poverty Level guidelines in the Federal Register. The Federal Register is a government publication that includes many federal notices and proposals. The Federal Poverty Guidelines are used to determine eligibility for state and federal programs, including Indiana’s M.E.D. Works (Medicaid for Employees with Disabilities).

G

General Income Disregard (for Indiana Medicaid) - A disregard is an amount of income that is not counted when Medicaid determines eligibility. For Indiana Medicaid, $15.50 is disregarded in the countable income formula.

General Income Exclusion (for SSI or Supplemental Security Income) – The Social Security Administration does not count $20 of income when they use the countable income formula to determine the amount of the SSI check.

Grace Period –If individuals are determined by Social Security to be earning Substantial Gainful Activity following the completion of their Trial Work Period, they will receive their full benefit check for three months before the case benefit may cease.

Gross Earnings – The pay an individual receives for work before the taxes and deductions are withheld from the pay.

H

HUD Earned Income Disregard –Depending on what type of housing subsidy you receive, you may qualify for this HUD work incentive. HUD will not count 100% of your gross earnings when calculating their rental payments for the first year of employment and will not count 50% of their gross earnings the second year of employment if you qualify for this work incentive.

I

Impairment-Related Work Expense or IRWE – This is a work incentive for both SSI and SSDI recipients. The IRWE allows individuals to deduct the amount of documented expenses for services or items related to an impairment that are needed in order to work. IRWE expenses must be paid for by the individual in the months in which they work, and they must be reasonable expenses.

Income – Cash or in-kind services available to an individual that are used to obtain food, shelter, or clothing.

Income averaging – A method used by Social Security to average earnings for SSDI beneficiaries to determine if gross earned income is consistently over the Substantial Gainful Activity levels.

Individual Work Plan or IWP – Under the Ticket to Work program, the IWP is a formal agreement between the Ticket holder and an Employment Network that describes how services will be achieved, what steps will be taken and the time frames to reach an employment goal.

In-kind services – Financial support that is given to the SSI recipient in the form of food and shelter for which the recipient does not pay. For example, an adult SSI recipient living with her parents and pays no room or board may have in-kind services.

J

K

L

Listing of Impairments – The Listing of Impairments is a tool used by Social Security that lists very severe physical and mental illnesses according to the major body systems that they affect, and are identified by several specific medical signs, symptoms and laboratory test results. The impairments prevent an individual’s ability to do any gainful activity. Most of the listed impairments are permanent or expected to result in death. The impairments are expected to last for a continuous period of at least 12 months.

M

MAXIMUS – A private organization authorized by Social Security to manage the Ticket to Work program. MAXIMUS provides training and outreach to Employment Networks, information to Ticket holders, and processes payments to Employment Networks for outcomes under the Ticket to Work.

Medicaid – A program that offers health insurance to certain low-income families, individuals with disabilities, and elderly individuals with limited financial resources. Medicaid is jointly funded by the federal and state government. Medicaid programs vary from state to state though there are some services that are required by the federal government. Optional services can be offered by each state.

Medicaid Buy-In – This is an optional Medicaid program that allows individuals with a disability who work to retain Medicaid coverage. Individuals may pay a premium on a sliding fee scale based on their income. In Indiana, this program is called MED Works.

Medicare – Medicare is medical insurance for elderly (age 65 or older) and/or for individuals with disabilities who receive SSDI. Individuals with disabilities must complete a five month waiting period from their disability onset before their Social Security benefits begin. There is an additional 24 month waiting period (Medicare Qualifying Period) before individuals are entitled to Medicare benefits. Cash benefits will begin before individuals are eligible for Medicare benefits.

There are two parts to Medicare. Medicare Part A pays for hospital in-patient and certain follow-up care. Medicare Part B is an elective coverage and is paid for through monthly premiums. f an individual is also eligible for Medicaid, Medicaid will pay for the Medicare Part B premium (these individuals are also known as ‘dual eligibles.’)

In 2006, a new program called Medicare Part D (The Medicare Prescription Drug Program) will be available for low-income Medicare beneficiaries to help pay for prescription drugs.

M.E.D. Works – An Indiana program to provide Medicaid coverage to working individuals with disabilities who otherwise would lose or be ineligible for Medicaid coverage. It has separate eligibility requirements and a recipient premium structure based on a sliding fee scale for those individuals with disabilities who work.

N

Net Earnings from Self-Employment or NESE – When you are self-employed, the NESE is a formula used by the Internal Revenue Service and Social Security to determine your gross receipts then subtracting your expenses, multiplying by .9235. Individuals who are self-employed are required to pay Social Security and Medicare taxes. The self-employment tax rate is 15.3 percent, with 12.4 percent allocated to the Social Security system and the other 2.9 percent going to Medicare.

O

Occupational Goal or Objective – This is an individual’s work goal in a PASS (Plan for Achieving Self-Support). A work goal is the job or profession that individual plans to achieve.

P

Plan for Achieving Self-Support or PASS – An SSI work incentive which allows an individual to set aside income or resources for a specific work goal or to purchase items, equipment, services or to start up a business, that will lead to increased independence in getting and keeping a job and becoming self- sufficient.

Pre-existing condition – A medical condition in which care (including prescription drugs and doctor’s services) was provided three or more months prior to the effective date of insurance coverage. Insurance companies may have a pre-existing condition exclusionary period in which coverage for the pre-existing condition can be limited or not provided.

Premium – A regularly scheduled payment for health insurance, such as Medicare, M.E.D. Works or other health insurance programs.

Q

Qualified Disabled Working Individual or QDWI – This is a category of Medicaid assistance that can pay the Medicare Part A premium for individuals who lost Medicare Part A coverage because of their work income. Individuals who were eligible for Medicare Part A but have lost it due to earnings from a job may have their Part A premium paid by Indiana Medicaid. This program is for working individuals whose income does not exceed 200% of the Federal Poverty Level, who meet Indiana’s resource guidelines, and who are not otherwise eligible for Medicaid benefits.

Qualified Individual or QI – This is category of Medicaid assistance that can pay the monthly premium for Medicare Part B. Individuals who are entitled to Medicare Part A may be eligible for Indiana Medicaid to pay the monthly premium for their Medicare Part B. These individuals must meet Indiana’s income and resource guidelines.

Qualified Medicare Beneficiary or QMB – This is a category of Medicaid assistance that can pay the monthly premium for Medicare Part B as well as deductibles and co-pays. Individuals who are entitled to Medicare Part A may have their Medicare premiums, deductibles and co-insurance paid by Indiana Medicaid. Individuals eligible under this category must have income below 100% of the Federal Poverty Level and meet the Indiana Medicaid dual eligibility resource limits of $4,000 per individual and $6,000 per couple.

R

Reasonable Accommodation – An adjustment or modification to a job or workplace that enables an employee to perform the essential duties of the job successfully. An example of a reasonable accommodation is putting lifts under a desk to raise it higher so a wheelchair can fit under the desk.

Recipient – An individual who receives SSI or Supplemental Security Income.

Reconsideration – When a claim for Social Security disability benefits is denied at the initial level, the claimant may then request Social Security reconsider the previous decision. The case is then sent to a different disability examiner for a new decision.

Resources – These are goods or items that have a monetary value. Resources can include a checking or savings account, cash on hand, and certain items that you own.

S

Social Security 1619a Provision – For SSI recipients, 1619a helps protect your eligibility for SSI and Medicaid when you go to work and earn a paycheck. 1619a allows individuals who earn above Substantial Gainful Activity to continue to be eligible for a reduced SSI cash benefit up to a “break even” point as long as they meet eligibility, income and resource requirements. 1619a also allows SSI recipients eligible for Medicaid coverage while working. Once individuals reach the break even point, SSI cash payments cease.

Social Security 1619b Provision – For SSI recipients, 1619b helps individuals keep Medicaid eligibility (without a spend-down) after their Social Security eligibility for SSI cash payments stop. This protection continues until annual income reaches the threshold level. For 2005, the Indiana threshold level is $29,194.

Social Security Childhood Disability Benefits (formally called Social Security Disabled Adult Child or SSDAC) – The Childhood Disability Benefit is an SSDI benefit paid based on his/her parent’s contribution to the system, not his/her own. The parent must be disabled, retired or deceased. An individual receiving this benefit must be over the age of 18 with their disability determination before age 22.

Social Security Disability Insurance (SSDI) – Also known as Title II, this entitlement is earned, requires a medical disability, and gross countable earnings below SGA. The cash payment remains the same, regardless of other income, as long as a person does not perform SGA.

Specified Low Income Medicare Beneficiary (SLMB) – This is a category of Medicaid assistance that can pay the monthly premium for Medicare Part B. Individuals who are entitled to Medicare Part A may be eligible for Indiana Medicaid to pay the monthly premium for their Medicare Part B.

Spend down – For Medicaid, if a person’s income is above the Medicaid income standards, he/she may be required to pay out-of-pocket for some of the medical services (the spend-down amount) before receiving Medicaid coverage each month. Each month when the individual’s medical expenses equal or exceed the spend-down amount, Medicaid can help pay the remaining medical expenses. This is similar to a deductible for private insurance.

Subsidy and Special Conditions – A work incentive that applies primarily to Social Security Disability Insurance beneficiaries during the Extended Period of Eligibility. It is considered the support provided by an employer to an employee that may result in an employee receiving more pay than the actual value of the services or work performed by the employee.

The Social Security Administration determines the percentage of support provided to the individual by the employer and applies a dollar amount to this support to determine if the person has reached Substantial Gainful Activity.

Substantial Gainful Activity or SGA – SGA is physical work or mental activities that in work for pay or profit. It applies to the SSDI program during the initial application and on an on-going basis. It applies to the SSI program only in determining where a person is initially eligible for SSI disability payments.

Supplemental Security Income or SSI – Also known as Title XVI, this is an income benefit program for people who are 65 or older, or who are blind, or who have a disability, and who have little or no income and meet resource guidelines. The cash payment varies in amount, depending on earned and unearned income an individual has.

T

Temporary Assistance to Needy Families or TANF – TANF is a welfare program that provides limited income support and access to Medicaid for low income adults with children.

Ticket to Work and Work Incentives Improvement Act or TWIIA – TWIIA is federal legislation that updated many rules about disability benefits and working. It also resulted in special programs that are designed to help people with disabilities who want to work to have access to employment-related services. The TWIIA legislation was designed to remove many of the barriers that affect people’s decisions about going to work because there is often great concern about losing health care coverage and getting support needed to keep a job.

Trial Work Period or TWP – The Trial Work Period is a work incentive for SSDI beneficiaries. It allows you to work without jeopardizing your SSDI benefits. During TWP months, the SSDI person continues to be eligible for their monthly SSDI benefit no matter what they earn.

U

Unearned Income – Disability payments or other funds that an individual receives without any physical or mental work performed. Examples of unearned income may be Social Security Disability Insurance Benefits, income from a trust, investments, support payments or funds received from any other source other than work.

Unsuccessful Work Attempt – Social Security will evaluate an effort to do substantial work, which was stopped or reduced to below SGA level after a short period of time (6 months or less). The Unsuccessful Work Attempt must have resulted because of an individual’s impairment or because special conditions (for example job coaching, or other support) related to an impairment are no longer available to the individual, and the individual is no longer able to perform work at the SGA level.

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