SECTION 358.103. Definitions

The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:

(1) §1915(c) waiver program--A home or community-based service authorized for use in Texas by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act.

(2) Adverse action--A termination, suspension, or reduction of Medicaid eligibility or covered services.

(3) Annual review--The process of redetermining a person's continued eligibility for Medicaid.

(4) Appeal--A request for a review of an action or failure to act by the Texas Health and Human Services Commission (HHSC) that may result in a fair hearing.

(5) Applicant--A person seeking benefits under a Medicaid-funded program for the elderly and people with disabilities (MEPD) who is not currently receiving MEPD services.

(6) Application for assistance--A form prescribed by HHSC that a person uses to apply for MEPD or to have MEPD eligibility redetermined.

(7) Assets--All items a person owns that have monetary value. Assets include both income and resources.

(8) Authorized representative--An individual:

(A) who assists and represents a person in the application or eligibility redetermination process, and who is familiar with that person and that person's financial affairs; or

(B) who is a representative payee for an applicant or recipient for another federal benefit.

(9) Benefits office--A local HHSC office.

(10) Blind--A person who meets Supplemental Security Income (SSI) program requirements for blindness, as defined in 42 U.S.C. §1382c(a)(2).

(11) Budgeting--The process of determining a person's financial eligibility for MEPD or for calculating a co-payment.

(12) Burial space--A burial plot, grave site, crypt, mausoleum, urn, casket, niche, or other repository customarily and traditionally used for a deceased person's bodily remains. The term also includes necessary and reasonable improvements or additions to these spaces, including vaults, headstones, markers, or plaques; burial containers; arrangements for opening and closing the grave site; and contracts for care and maintenance of the grave site. Contracts for care and maintenance are sometimes referred to as endowment or perpetual care.

(13) Certification--HHSC's official authorization of an eligibility determination.

(14) CFR--Code of Federal Regulations.

(15) Community spouse--See Subchapter C, Division 5, §358.412 of this chapter (relating to Definitions).

(16) Co-payment--The amount of personal income a person must pay toward the cost of his or her care. Co-payment was formerly known as applied income.

(17) Countable income--The amount of a person's income that is not exempt or excluded.

(18) Countable resource--A resource owned by and accessible to a person that is not exempt or excluded.

(19) Coverage group--A group of people who are categorically eligible for MEPD under the Texas State Plan for Medical Assistance.

(20) Current market value--The amount of money an item would bring if sold in the current local market.

(21) Date of application--See §358.520 of this chapter (relating to Date of Application).

(22) Deeming--Counting all or part of the income or resources of another person (for example, a parent or spouse) as income or resources available to an applicant or recipient.

(23) Disabled--A person who meets SSI program requirements as defined in 42 U.S.C. §1382c(a)(3).

(24) Earned income--Income a person receives for services performed as an employee or from self-employment.

(25) Earned income tax credit--A special tax credit that reduces the federal tax liability of certain low-income working taxpayers.

(26) Eligibility determination--A decision made by HHSC concerning a person's initial eligibility for MEPD. This term does not include any functional or other assessment required for some MEPD services, unless the context clearly indicates otherwise.

(27) Eligibility redetermination--A decision made by HHSC concerning a person's continued eligibility for MEPD. This term does not include any functional or other assessment required for some MEPD services, unless the context clearly indicates otherwise.

(28) Equity value--The value of a resource based on its fair market value or current market value minus all money owed on the resources and, if sold, any costs usually associated with the sale.

(29) Excluded--Income or resources not counted for the purpose of determining eligibility only.

(30) Exempt--Income or resources not counted for the purpose of determining eligibility or calculating a co-payment.

(31) Fair hearing--An informal proceeding held before an impartial hearings officer in which a person or the person's representative appeals an action taken on the person's case.

(32) Fair market value--The current market value of a resource at the time of its sale or transfer.

(33) Family member--An applicant's or recipient's spouse, minor child, adult child, stepchild, adopted child, brother, sister, parent, or adoptive parent; or a spouse of the applicant's or recipient's minor child, adult child, stepchild, adopted child, brother, sister, parent, or adoptive parent.

(34) Fiduciary agent--A person or organization acting on behalf of or with the authorization of another person under circumstances that involve a high degree of confidence, good faith, and honesty. The term applies to anyone who acts in a financial capacity, whether formal or informal, regardless of title, such as representative payee, guardian, or conservator.

(35) Fraud--Deliberate misrepresentation or willful withholding of information for the purpose of obtaining public assistance, either for self or another person.

(36) Health Insurance Premium Payment Program--A Medicaid program that pays for the cost of medical premiums. The program reimburses recipients or employers for private health insurance payments for Medicaid-eligible persons when it is cost effective to do so.

(37) HHSC--The Texas Health and Human Services Commission.

(38) Home--A structure in which a person lives (including a mobile home, a houseboat, and a motor home), other buildings on the home property, and all adjacent land (including land separated by a road, river, or stream), in which the person has an ownership interest and that serves as his or her principal place of residence.

(39) Income--Any item a person receives in cash or in kind that can be used to meet his or her need for food or shelter. For purposes of determining MEPD financial eligibility, income includes the receipt of any item that can be applied, either directly or by sale or conversion, to meet the basic needs of food or shelter.

(40) Inheritance--Cash, other liquid resources, noncash items, or any right in real or personal property received as the result of someone's death. A person may not have access to his or her inheritance pending legal action or the discovery of the inheritance.

(41) Initial eligibility period--The time from a person's certification date to the person's first annual review.

(42) In-kind--Consisting of something (such as food, shelter, or replacement of a resource) that is not cash.

(43) Institution for mental diseases (IMD)--A hospital, nursing facility, or other institutional setting of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. An IMD includes a state mental health facility operated by the Texas Department of State Health Services.

(44) Institutional care--Long-term nursing care, treatment, or services received in a Medicaid-certified long-term care facility.

(45) Institutional setting--A living arrangement in which a person applying for or receiving Medicaid lives in a Medicaid-certified long-term care facility or receives services under a §1915(c) waiver program.

(46) Insurance--The following terms apply to the definition of insurance:

(A) "The insured" means the person named in a life insurance policy whose death affects the proceeds and distribution of the policy.

(B) "The beneficiary" means the person or entity named in a contract to receive the proceeds of the policy upon the death of the insured.

(C) "The owner" means the person with the right to change the policy as the person sees fit. The owner is the only person who can receive the cash surrender value of the policy.

(D) "The insurer" is the company that contracts with the owner.

(E) "Cash surrender value" means the amount that the insurer pays the owner if the policy is cancelled before death or before it has matured. The cash surrender value usually increases with the age of the policy.

(F) A "participating life insurance policy" is one in which dividends are distributed to the policyholder.

(G) "Term life insurance" means life insurance that has no cash, loan, or dividend value, nor the potential for cash, loan, or dividend value.

(H) "Dividend" means a share of surplus funds allocated to the policyholders of a participating insurance policy. A dividend generally represents a previous overpayment of premiums.

(47) Intermediate care facility for persons with mental retardation or related conditions (ICF/MR)--A Medicaid-certified facility that provides care in a 24-hour specialized residential setting for persons with mental retardation or a related condition. An ICF/MR includes a state supported living center and a state center.

(48) Inter vivos trust--A trust established while the person creating the trust is still living.

(49) Level of care--The type of care a person is eligible to receive in an ICF/MR based upon an assessment of the person's need for care.

(50) Level of care determination--A determination made by the Texas Department of Aging and Disability Services that determines a person's level of care.

(51) Life estate--A right to real property conferred in a legal instrument on a person (beneficiary). The right is conferred for the duration of the beneficiary's lifetime or the lifetime of another person. The beneficiary usually has the right to possess, use, and receive profits from the real property during his or her possession.

(52) Liquid resource--Cash or other property that can be converted to cash within 20 working days.

(53) Long-term care facility--A nursing facility, ICF/MR, or IMD in which medical services are provided.

(54) Look-back period--The period of time HHSC considers to determine if a person transferred, gave away, disposed of, or otherwise reduced his or her countable resources and income without receiving equal value in return and with the intent to give away resources in order to qualify for MEPD.

(55) Medicaid--A state and federal cooperative program, authorized under Title XIX of the Social Security Act and the Texas Human Resources Code, that pays for certain medical and health care costs for people who qualify. Also known as the medical assistance program.

(56) Medical effective date--The date a person's Medicaid coverage begins.

(57) Medical necessity--The determination that a person requires the services of a licensed nurse in an institutional setting to carry out a physician's planned regimen for total care.

(58) Medical services--Services that are directed toward diagnostic, preventive, therapeutic, or palliative treatment of a medical condition and that are performed, directed, or supervised by a state-licensed health professional.

(59) Medicare--Medical coverage available under Title XVIII of the Social Security Act to people 65 years of age or older and to certain disabled people under 65 years of age.

(60) MEPD--A Medicaid-funded program for the elderly and people with disabilities. A public assistance program providing institutional and community-based health-related care for the elderly and people with disabilities. MEPD does not provide cash assistance. Examples of MEPD services and programs are:

(A) primary home care services;

(B) §1915(c) waiver programs, which provide community-based care as an alternative to institutional care;

(C) care in a Medicaid-certified long-term care facility; and

(D) the Program of All-Inclusive Care for the Elderly (PACE).

(61) Mineral rights--Ownership interest in the oil, gas, or minerals beneath the surface of a piece of property.

(62) Month of application--The month in which the date of application falls.

(63) Noninstitutional setting--A living arrangement in which a person applying for or receiving Medicaid does not live in a long-term care facility or receive services under a §1915(c) waiver program.

(64) Nursing facility--An entity that provides organized and structured nursing care and services, and is subject to licensure under Texas Health and Safety Code, Chapter 242.

(65) Parent--A child's natural or adoptive parent or the spouse of the natural or adoptive parent.

(66) Pension funds--Monies held in a retirement fund under a plan administered by an employer or union, or an individual retirement account (IRA) or Keogh account as described in the Internal Revenue Code.

(67) Personal needs allowance--An amount of the recipient's income that a recipient in an institutional setting may retain for personal use.

(68) Primary home care services--Medicaid-funded, in-home attendant services provided to a person with a medical need for specific tasks to delay or prevent the person's need for institutional care.

(69) Principal place of residence--The home where a person resides, occupies, and lives.

(70) Provider--A person, group, or agency contracted to provide a Medicaid-funded service to a person for a fee.

(71) Public institution--An institution defined in 20 CFR §416.201.

(72) Real property--Land and improvements, including buildings and structures. Real property may also include a mine or quarry, standing timber, or minerals.

(73) Recipient--A person receiving benefits under MEPD, including a person whose Medicaid eligibility is being redetermined.

(74) Representative payee--A person or an organization selected to receive benefits on behalf of a recipient, if the recipient is not able to manage or direct the management of benefit payments in his or her own interest.

(75) Resources--Cash, other liquid assets, or any real or personal property, that a person (or spouse or parent, as appropriate):

(A) owns;

(B) has the right, authority, or power to convert to cash (if not already cash); and

(C) is not legally restricted from using for his or her support and maintenance.

(76) Restitution--Securing payment from a recipient when fraud is not indicated or pursued and when the recipient's co-payment has been undercharged because of previously unreported or underreported monthly income or resources.

(77) Retirement, Survivors, and Disability Insurance (RSDI)--Benefits provided under Title II of the Social Security Act.

(78) Retroactive coverage--Payment for Medicaid-reimbursable medical services received up to three months before the month of application.

(79) Social Security--A federal system of retirement and disability insurance for various categories of employed and dependent persons, funded through dedicated payroll taxes.

(80) Social Security Act--The federal statute that provides the authority for various programs referenced in this chapter, including Medicare and Medicaid. See also the definition in this section for certain titles in the Social Security Act.

(81) Social Security Administration (SSA)--The federal agency that issues Social Security numbers, administers Social Security benefit programs, and manages the SSI program.

(82) Social service--A service, other than a medical service, that is intended to assist a person with a physical disability or social disadvantage to function in society on a level comparable to that of a person who does not have such a disability or disadvantage. No in-kind items are expressly identified as social services.

(83) Special income limit--The income limit used to test MEPD eligibility for a person or couple in an institutional setting in accordance with §358.433 of this chapter (relating to Special Income Limit).

(84) Spousal impoverishment--Provision implemented under §1924 of the Social Security Act (42 U.S.C. §1396r-5) designed to prevent the impoverishment of a family, usually a couple, when one spouse needs care in an institutional setting.

(85) State center--A facility operated by the Texas Department of State Health Services with which the Texas Department of Aging and Disability Services contracts to provide services to persons with mental retardation who reside in the facility.

(86) State mental health facility--A facility operated by the Texas Department of State Health Services that provides care for people with mental illness who need the safety, structure, and resources of an in-patient setting.

(87) State supported living center--A facility operated by the Texas Department of Aging and Disability Services that provides residential services and 24-hour supervision and active treatments to assist people with mental retardation.

(88) Supplemental Security Income (SSI) federal benefit rate--Standard payment amount in the SSI program.

(89) Supplemental Security Income (SSI) program--A federal income supplement program, funded by general tax revenues and managed by the SSA, that provides monthly income to people who are aged, blind, or disabled and have limited income and resources.

(90) Support and maintenance--The value of food and shelter that a person receives.

(91) Temporary Assistance for Needy Families--A program that provides temporary benefits (cash assistance) and work opportunities to families with needy dependent children, authorized under Title IV of the Social Security Act.

(92) Testamentary trust--A trust established by a will.

(93) Texas State Plan for Medical Assistance--Document describing the Medicaid-funded services provided in Texas, in accordance with §1902 of the Social Security Act (42 U.S.C. §1396a).

(94) Third-party resource--A source of payment for medical expenses other than Medicaid.

(95) Three months prior--The three calendar months before the month of application.

(96) Titles to Social Security Act--Divisions of the Social Security Act. Titles referenced in this chapter are:

(A) Title II, which governs RSDI benefits;

(B) Title XVI, which governs the SSI program;

(C) Title XVIII, which governs Medicare; and

(D) Title XIX, which governs Medicaid.

(97) Trust--A trust includes any legal instrument, device, or arrangement which may not be called a trust under state law, but which is similar to a trust. That is, it involves a grantor who transfers property to an individual or entity with fiduciary obligations with the intention that it be held, managed, or administered by the individual or entity for the benefit of the grantor or others. This can include (but is not limited to) escrow accounts, investment accounts, pension funds, irrevocable burial trusts, limited partnerships, and other similar entities managed by an individual or entity with the fiduciary obligations.

(98) Unearned income--Income that is not earned.

(99) U.S.C.--United States Code.

(100) Working day--Any day except Saturday, Sunday, a state holiday, or a federal holiday.

Source Note: The provisions of this §358.103 adopted to be effective September 1, 2009, 34 TexReg 5497