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Caretaker Relative: An adult relative living with children under age 19, who is the primary caretaker of the children when neither parent is living in the home.
Catastropic coverage: If beneficiaries have drug expenses that go above the coverage gap, Medicare Part D plans will cover up to 95% of the rest of your prescription costs until the end of the calendar year. There is no limit to this coverage in any one year. It is called “catastrophic” because it is intended to protect individuals against very high drug bills.
Co-insurance: A kind of cost sharing where costs are split on a percentage basis between beneficiaries and the insurance plan. For example, a plan might pay 75% and the beneficiary would pay 25% of the drug costs.
Co-payment: A fixed dollar amount paid by beneficiaries for each prescription drug they receive. For example, a beneficiary might pay $15 for each prescription received and their plan would pay the remaining cost of the drug.
Coverage gap (Doughnut hole): A name for the step in Medicare Part D where beneficiaries who incur more than $2,401 in prescription drug expenditures will reach a coverage gap, known as the “doughnut hole,” with coverage resuming once their expenditures exceed $5,451.25. These amounts may vary by plan. During this coverage gap, beneficiaries must pay out of pocket for all their prescription costs.
COBRA: The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 contains a provision allowing certain employees who lose their jobs, or who lose coverage due to reduced work hours, to temporarily continue to purchase health insurance for themselves and their families at group rates. US Dept. of Labor: (617) 565-9600
Community Health Centers (CHC): Local health centers that provide primary health care services to the insured, underinsured, and uninsured. Free care or sliding-scale fee reduction based on income is available. The services provided and the fees charged vary from center to center.
Community Long-Term Care: Community long-term care helps older people and people who are chronically disabled and require assistance live independently at home. Examples of community long-term care offered to MassHealth members include personal care attendant services, hospice benefits, home health care, durable medical equipment program, and private-duty nursing.
Deductible: The annual amount an individual must pay towards medical services before an insurance plan begins to cover medical costs.
Dual eligibles: Individuals who have both Medicaid and Medicare coverage. Dual eligibles’ prescription drug coverage was shifted from Medicaid to Medicare with the enactment of the new Medicare Part D benefit.
Federal Poverty Level (FPL): The amount of income established by the federal Department of Health and Human Services is used to determine eligibility for a wide variety of federal and state programs. FPL income guidelines are updated annually and vary according to family size and composition. Public assistance programs such as Medicaid define eligibility using some percentage of the FPL as income limits. See the Federal Poverty Level page for an FPL chart with various levels.
Health Safety Net Trust Fund (HSN): The HSN, replaced the Uncompensated Care Pool (UCP) on October 1, 2007, pays acute hospitals and community health centers for services delivered to eligible individuals. The HSN adopted the MassHealth Standard benefit package provided at acute care hospitals and community health centers. Those who are eligible for HSN services include a) Massachusetts residents with household income less than 200% FPL who are otherwise ineligible for MassHealth, for Commonwealth Care, and who do not have access to affordable employer sponsored insurance; b) MassHealth Standard services not covered by primary insurance for those with household income below 200% FPL; and c) those with income between 201-400% of FPL after meeting a deductible equal to 40% of the income in excess of 200% FPL. The HSN includes patient co-pays consistent with Commonwealth Care; but there is no cost sharing for children under 18 years of age or for services provided at community health centers to individuals with income level below 200% FPL. For individuals with significant medical debt, acute hospitals and community health centers will receive reimbursement for unpaid medical expenses exceeding a sliding scale percentage of an individual’s income.
Home- and Community-Based Services Waiver: The Home- and Community-Based Services Waiver allows certain frail people (aged 60 and older) to live at home and get MassHealth Standard. This program allows the person needing the at-home services, if married and living with his or her spouse, to have MassHealth eligibility determined without counting the income and assets of the other spouse.
Long-Term Care Insurance is private insurance designed specifically to pay for long-term care services. Benefits are usually paid for a specific number of days or for a specified dollar amount. These policies typically cover custodial care in a nursing home and/or personal care services in-home.
Long-Term Unemployment: An individual is considered long-term unemployed when he/she has been unemployed for more than one year; or during the past 12 months, he/she has earned less than the minimum amount necessary to qualify for unemployment compensation.
Mass Medline: This program is a public-private partnership between the Massachusetts Office of Elder Affairs and the Massachusetts College of Pharmacy and Health Sciences. It provides information on both public and private prescription assistance programs to people who are having trouble covering their prescription drug costs. Residents can call a toll-free number to speak with an intake specialist who will collect information on the prescriptions needed and provide assistance in finding programs that will cover their costs. Contact: 1-866-633-1617 or complete intake form at their website www.massmedline.com.
Nursing Facility Care: Nursing facilities provide a wide range of services from post-hospital care to rehabilitative care to their more traditional role of providing long-term care to the chronically ill and disabled. MassHealth pays for members to stay in licensed and certified nursing facilities who meet certain clinical criteria, namely the daily need for skilled nursing services or the need for skilled nursing services at least three times per week in addition to daily assistance with two or more Activities of Daily Living.
People with Disabilities: To qualify for MassHealth Standard or CommonHealth, an individual with a disability must be “permanently and totally disabled” as the term is defined by one of three programs: the federal Social Security Administration, the Disability Evaluation Service for MassHealth; or the Massachusetts Commission for the Blind (certification of legal blindness).
Personal Care Attendant (PCA) Services: Personal Care Attendant services help elderly and individuals with disabilities with activities of daily living such as bathing, grooming, eating, getting dressed, and taking medicines. By getting PCA services, some people can live at home instead of having to live in a long-term-care facility.
Premium: A periodic payment, usually monthly, to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.
Serving the Health Information Needs of Elders (SHINE) Counseling Program: This is a free statewide health insurance counseling program for seniors and Medicare beneficiaries in Massachusetts. The SHINE program ensures that individuals have access to unbiased and up-to-date information about their health care options. Contact: 1-800-243-4636 (1-800-AGE-INFO)
Social Security Disability Insurance (SSDI): SSDI is a program that workers, employers, and the self-employed pay for with their Social Security taxes. Benefits are based on work history and earnings. To qualify for SSDI, individuals must have worked long enough and recently enough under Social Security. Social Security pays cash benefits to people who are unable to work for a year or more because of a disability. Family members of disabled workers may be eligible to qualify for benefits based on the disabled worker’s history of working under Social Security.
Spend Down: Persons aged 65 and over and individuals with disabilities may qualify for MassHealth even if their income exceeds certain income standards. “Spend down” refers to the eligibility requirement that they must incur medical expenses equal to a government-determined deductible over a six-month period. Also, non-working individuals with disabilities under age 65 whose household income is greater than 133% FPL must pay a one-time only deductible to qualify for the CommonHealth program. The term “spend down” can also apply to assets in excess of eligibility limits. The elderly who do not qualify for MassHealth because their assets exceed the $2000 per person ($3000 per couple) limit may also qualify for MassHealth by “spending down” their assets until they reach the allowable asset limit. Certain property is not counted towards a person’s total allowable assets.
Supplemental Security Income (SSI): SSI is a cash-assistance program funded and administered by the federal government. The Supplemental Security Income (SSI) program makes cash assistance payments to aged, blind, and disabled individuals (including children under age 18) who have limited income and resources. The federal government funds SSI from general tax revenues. Additionally, a state supplement is included in the payments. Customer Service: 1-800-772-1213
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