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