Accountable Care Organization

A group of health care providers that have entered into a formal arrangement to assume collective responsibility for the care of a specific group of patients and that receive financial incentives to improve the quality and efficiency of health care.

Advanced Premium Tax Credit

Refundable tax credits, paid in advance, that are used for the purchase of health insurance through a state health insurance exchange.

Adverse Action

When the agency makes a change that will decrease or stop benefits.  An adverse action cannot be taken without advanced notice.

Affordable Insurance Exchange

Exchanges will provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options (qualified health plans) on the basis of price and quality, and to purchase the coverage.

Agency Conference

A meeting held in an attempt to satisfy an individual's complaint.  The individual, local office worker, and the worker's supervisor meet to discuss the problem.  This meeting is held prior to and IN ADDITION TO a Fair Hearing.  A Fair Hearing may be cancelled as a result of an agency conference ONLY at the individual's request.

American Indian and Alaska Native

An individual having origins in any of the original peoples of North and South America (including Central America) who maintains tribal affiliation or community attachment.  The affiliated tribe must be federally recognized.

Annualized Income

Determine income for an amount of time by using income from a like season or year as representative of future income.  Income can be annualized over 12 months or less, depending on the circumstances of the individual.

Applicant

Any person who has submitted a signed application for assistance if the application has not yet been approved or denied.

Authorized Representative

A person other than the child, the child's spouse, or the child's parent, who is applying for benefits on behalf of the child, assisting the child in applying or reapplying for benefits, or is acting on the child's behalf in the case of an agency conference or a hearing.  An authorized representative may file an application, provide verifications and complete forms for the child.

Averaging Income

Determine income from an average of income over a pre-determined period of time.  Income is added together over the number of weeks/months and then divided over the number of weeks/months used.  If income is paid on a weekly or biweekly basis, averaged income must be factored to a monthly amount (see factoring).

O.E.P or OEP

Office of Eligibility Policy -  Part of the Division of Integrated Healthcare that is responsible for setting eligibility policy for Medicaid and Medicare cost sharing programs, CHIP and UPP programs for the State of Utah's Department of Health and Human Services.

BEERS

Beneficiary Earning Exchange Record.  This is a report of earnings that is based on the employer's report to SSA when FICA is paid on the behalf of an individual.  Workers may use the report to identify individuals who are working and to get basic information about their earnings.

BENDEX

Beneficiary Data Exchange.  This is a file on tape that is produced by SSA for all states.  The file contains information about SSA payment status, SSI payment status, and Medicare entitlement dates.  BENDEX provides verification of Social Security Numbers.  SSA gives us this information only for individuals that we identify.

Best Estimate

Calculate your best guess as to a household's income and size during the certification period.  Use this estimate to figure the eligibility for each certification period.  Information reported on the application form should be used to establish a best estimate.

Cafeteria

A dollar amount that some employers allow per employee to A purchase various kinds of benefits, including health insurance.  Sometimes referred to as Plan A Flexible Benefit Plans@

Certification Period

The 12 calendar months for which the CHIP benefits will be received.

Contract Income

Income received over a specified period of time.

Cost Share Reduction

Cost sharing reduction will limit a health plan’s maximum out-of-pocket costs, and for some people will also reduce other cost sharing amounts (i.e., deductibles, coinsurance or copayments) that would otherwise be charged to them by their insurance plan. People who qualify for APTC's will be eligible for cost sharing assistance if they enroll in a silver plan. This assistance will reduce the limit on the out of pocket maximum that can apply to their coverage, with the amount of the reduction depending on income.

D.W.S. or DWS

Department of Workforce Services, the agency responsible for determining eligibility for the CHIP program.  They also determine eligibility for other programs such as Food Stamps, Cash Assistance and Medicaid.

Deferred Payment

The amount of money that an individual receives later than the normal payment date.  The money is held for the individual until a later date.  Payments may be deferred voluntarily or involuntarily.  Self‑employed people sometimes have payments deferred for tax purposes.  Some kinds of deferred payments are:  severance pay, vacation pay, bonuses, and pay delayed by the employer.

Due Process Month  

If 10-day notice cannot be given before deciding eligibility for a new certification period, benefits must extend to the following month.  This continued month of eligibility is called the due process month.  All of the evidence that is applied in the review month is duplicated for the due process month.

Electronic Account

An individual's electronic account is an electronic file that includes all information collected and generated by the State regarding each individual’s Medicaid eligibility and enrollment, including all documentation required to determine eligibility. It is transferred between Medicaid/CHIP and the FFE through a secure interface.

Emancipated

Free to act on your own behalf.  An emancipated person is no longer the responsibility of his parents.  A person becomes emancipated by turning 18 years old, getting married, or getting a court order that says he is emancipated.

Utah Residency is evaluated differently based on whether or not the individual is emancipated.  When determining who to include in the CHIP household, if an emancipated child is living with their parents, the parents must still be included.

Employer Sponsored Insurance

A health benefit plan offered by an employer to employees and dependents.

Employer-Sponsored Insurance/Plan

Health insurance available through an employer or through the Utah Health Exchange. It does not matter how much the employer contributes to the cost of the insurance. If the person has access to the insurance plan because of their status as an employee with the company, it is employer-sponsored insurance.

Energy Employees Occupational Illness Compensation Program

(EEOICP)

The EEOICP makes lump sum payments and reimbursements of medical expenses to employees of the Department of Energy (DOE) or of private companies under contract with DOE, who suffer from specific diseases because of their work in the nuclear weapons industry, and designated beryllium workers.  Survivors of these employees may also receive payments.

Part B - Part B is effective July 31, 2001 and includes compensation of:

• $150,000 for a covered employee or his or her survivors, and

• $50,000 for a covered uranium worker or his or her survivors who previously received $100,000 compensation under the Radiation Exposure Compensation Act.

Part E - Part E is effective October 28, 2004, and includes variable compensation up to $250,000 based on wage loss, medical expenses, impairment, and survivorship.  Eligible individuals may include those exposed to toxic substances such as solvents, chemicals, acids, and metals, in addition to those exposed to radiation.

Enrollee

Any individual who receives CHIP coverage.

ESD

Division for the Department of Workforce Services that performs eligibility functions.

Essential Health Benefits

The minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide.

Ex-Parte Review

Renewals conducted without the involvement of the member.  Current electronic data is compared to information in the case file.  If both records are compatible, the renewal is updated.  If they are not compatible, the agency must contact the member to provide new information to complete the review.

Factoring Income

Convert weekly or every two weeks’ income to a standard 4.3 week month.  Income that is paid weekly or every two weeks must be "converted" to a monthly amount by using the multiplication factor or 4.3 for weekly income or 2.15 for biweekly income.  Income that is paid monthly or twice monthly is not subject to factoring.  Factoring is the last step completed in the best estimate process.  The weekly or every two weeks’ income is first averaged to one amount before factoring

Fair Hearing

One method of resolving an individual complaint.  The individual, local office worker, and other involved persons meet with an impartial authority who determines if policy has been applied correctly.  Any individual may request a Fair Hearing to discuss a negative action.

Federal Data Services Hub

An electronic service through which States may verify certain information with, or obtain such information from, Federal agencies and other data sources, including SSA, the Department of Treasury, and the Department of Homeland Security.

Federally Facilitated Marketplace (FFM)

The FFM will operate on behalf of States.  The FFM is responsible for calculating premiums and subsidies, enrollment, quality oversight, certification of qualified health plans that can be sold in the marketplace.

Flex-Plan

A benefit where an employee has elected to defer some income from their gross pay to be used to reimburse them for out-of-pocket medical expenses.  Sometimes referred to as a Flexible Spending Plan@.

Fluctuating Income

Income that varies in amount or frequency of receipt.  This income must be averaged, and then may need to be factored.

Freely Associated States

Independent island nations which have a legal association with the United States which allows free trade as well as unrestricted travel between the islands and the U.S.  They include the islands of Micronesia, Palau, and the Marshall Islands.  Citizens of Freely Associated States are not automatically Qualified non-citizens for CHIP purposes.

Hearsay Evidence

Testimony given that is not based on first‑hand knowledge.  Hearsay evidence includes rumors and reports of what someone else told you.

IEVS

Income Eligibility Verification System.  This is a computer match system that uses Social Security Numbers to get information about individuals from Job Service, SSA, and IRS.  It is also called Income Match.

Income Match

This is a computer match system that uses Social Security Numbers to get information about individuals from Job Service, SSA, and IRS.

Individual Development Account (IDA)

Matched savings accounts created with TANF block grant funds, or matched by a non-profit organization (these are called Demonstration IDAs).  Their use is restricted to post secondary education and training, business capitalization, and buying a home.

Ineligible

Not meeting the program requirements.

ICE

U.S. Immigration and Customs Enforcement

IRS

Internal Revenue Service.

Modified Adjusted Gross Income (MAGI)

The calculation of income used to determine eligibility for federal programs including Medicaid, and premium and cost sharing assistance for tax credits provided to low and moderate income individuals under the health reform law.

Navigator Programs

Special programs that employ experienced and knowledgeable individuals (who may not work for insurers or be paid by insurers for plan enrollments) to assist individuals and small employers evaluate their insurance options within the insurance exchanges.

ORS

Office of Recovery Services, the part of the Department of Health and Human Services responsible for child support enforcement.  ORS is also responsible for the collection of medical payments through third parties.

Overpayment

A general term which includes benefits issued to ineligible individuals.

PASS Plan

A PASS Plan is a plan for achieving self-support that a disabled or blind person may enter into with Social Security.  The plan allows the person to exclude income and resources for SSI eligibility that are needed to help the person meet the employment goals defined in the plan; (i.e.: education, vocational training, or starting a business).  The SSI recipient must have a feasible occupational objective, a specific savings/spending plan, and must provide clear identification of the funds that are set aside.  A PASS Plan must be in writing and can never exceed 48 months.

Payee

The individual receiving proof of CHIP enrollment, even if that individual is not enrolled himself.  Individuals who have difficulty managing their affairs may have a friend or relative act as their payee.  The CHIP card would then be mailed to that person each month.

A 12 month period of continuous eligibility for an individual who was covered by CHIP while pregnant. The postpartum period begins the month after the member experiences a change in pregnancy status. The postpartum period ends on the last day of the month, that is 12 months after it began.

Premium

The amount of money that a member must pay for insurance coverage.  Some premiums must be paid monthly, while others may be paid quarterly, semi-annually, or annually.

PRUCOL

Permanently Residing Under Color Of Law.  Someone who is not a U.S. citizen may have PRUCOL status if he is in the U.S. with the knowledge and permission of INS and will not be deported.  These non-citizens are not eligible for CHIP enrollment.

Qualified Health Plan

A health plan offered by a health insurance issuer that meets minimum standards in the ACA law and set by an Exchange.

Recurring Income Received Less Often than Monthly

Income that is paid quarterly, semi-annually, or annually.  For military summer camp pay, add bonus and incentive income.

Resident (Utah Resident)

An individual who lives in Utah permanently or indefinitely.  Usually, people who own homes in other states are not Utah residents because their primary place of residence is somewhere else.  If an individual who owns a home in another state claims NOT to be in Utah for a temporary purpose, that individual may be a Utah Resident if he intends to become a Utahan.  Individuals who are employed in another state are usually not Utah residents unless they commute regularly.

Reasonably Compatible

Standard for assessing whether verification can be considered complete, or if additional information is necessary. When data obtained is “reasonably compatible” with an applicant’s attestation, State agencies are prohibited from requiring additional documentation.

Single Streamlined Application

This application will be used to determine eligibility for Medicaid, CHIP, and the premium tax credits available to help consumers purchase insurance in the exchange.

Small Business Health Options Program (SHOP)

The state-based insurance exchanges through which small businesses will be able to purchase health insurance for their employees.

Stable Income

Income that does not vary either in amount or frequency.

SSA

Social Security Administration

State Health Insurance Exchanges

State-based marketplaces for the sale and purchase of health insurance established in federal law and operated in accordance with federal requirements. Health insurers that sell products in the exchanges to small employers and individuals will be required to meet federal standards of coverage, fair practices, and plan administration.

State Supplemental Payment

A small amount of State money issued by SSA to members in Utah who receive SSI.  The money is added to the member's SSI check and Utah reimburses SSA later.

Temporary Absence

The situation existing when an individual is not in the home but intends to return to the home later.  A temporary absence may be for school or training, medical care, vacation, or any other reason.  Usually, periods of institutionalization are temporary only if the individual can reasonably be expected to return to the home within a definite period of time.  The CHIP worker must decide if a child is "temporarily absent" on a case-by-case basis.  It is important to document the decision.

Trust

A right of property held by one person for another.  The person who holds the legal title to the property is the "trustee".  The trustee holds the property for the benefit or use of the beneficiary.

UPP

Utah's Premium Partnership for Health Insurance helps make health insurance more affordable for working individuals and families who do not currently have health insurance.  It reimburses the employee's portion of the monthly premium for their employer sponsored health insurance plan.

VA Benefits

The Veterans Administration (VA) has numerous programs which can make payments to veterans and their families.  The most common types are:

1.      Pensions:  Pensions are paid because of a veteran's service and age, a disability that is not the result of military service, or death of a veteran.  There are three kinds of pensions:  Old Law, Protected 306, and Improved Pensions.  The only pensions that are NOT need-based are those paid because of a special act of Congress or service in the Indian Wars, Civil War, or Spanish-American War.

2.      Compensation:  Compensation payments are made because of a veteran's disability or death.  Compensation includes Death and Indemnity Compensation (DIC), which may be paid to a spouse or child of a veteran even if the death is not a result of military service.  Usually, compensation payments are NOT needs-based.  The only exception is when the compensation is paid to a dependent parent of the veteran.  Then the payment received by the parent is a needs-based payment.

3.      Educational Benefits:  This is not a needs-based payment.  Any portion of a VA educational benefit which is a withdrawal of the veteran's own contribution is not income.

4.      Aid and Attendance and Housebound Allowance:  This is not countable income.        

5.      VA Clothing Allowance:  A lump sum clothing allowance is payable in August each year to a veteran with a service-connected disability who needs a wheelchair or other prosthetic or orthopedic appliance.  This is not countable income.