TERMS AND DEFINITIONS

Beneficiary

is the person benefitting from a trust.

Activities of Daily Living - ADLs

are daily, routine skills an individual needs in order to function.  Examples include:  eating, bathing, moving, toileting and grooming.

Day Training & Habilitation Program - DT&H

is a licensed organization that assists individuals with disabilities to develop and maintain life skills, participate in community life, and engage in activities of their own choosing.

Department of Human Resources - DHS

provides health care, economic assistance and other essential services for those who do not have the resources to meet their basic needs and are least able to help themselves.

Developmental Disability - DD

is a mental and/or physical condition that manifests before age 22, substantially affects functioning in several major life activities, and usually lasts through life.

Employment Network - EN

is an entity that contracts with the Social Security Administration (SSA) that provides and coordinates the delivery of necessary services to Social Security disability beneficiaries participating in the Ticket to Work program.

Formal Supports

are community supports for individuals with disabilities that are provided by services and programs.

Global Developmental Delay

is a significant lag in meeting important developmental milestones, including:  physical, cognitive, behavioral and social development.

Informal Supports

are community supports for individuals with disabilities that are provided by family, friends and social network groups.

Instrumental Activities of Daily Living - ADLs

are basic skills an individual needs in order to function.  Examples include:  shopping, managing fnances, essential household chores, planning and preparing meals.

Intermediate Care Facility for Persons with Developmental Disabilities - ICF DD

is a residential facility or licensed health care institution that provides health and rehabilitatiave services for persons with developmental disabilities or related conditinos who require active treatment.

Irrevocable Trust

is a trust that cannot be changed or cancelled after it has been created.

Medical Assistance - MA

is a publicly funded health care program for individuals who meet certain income and other criteria, including persons with disabilities.

Minnesota Department of Health - MDH

is a state agency whose mission is to protect, maintain and improve the health of all Minnesotans.

Nursing Facility - NF

is a facility or part of a facility licensed to provide nursing care for persons who are unable to properly care for themselves.

Parental Fee

is a monthly amount paid by parents of children under 18 accessing TEFRA.  It is based on family income and size.

Personal Care Assistant/Assistance - PCA

provides day-to-day assistance and support to individuals with disablities to help them be more independent in their homes and in the community.

Plan for Achieving Self Support - PASS

is a Supplemental Security Income (SSI) work initiative that lets individuals with disabilities set aside money and other assets for items or services to reach specific work goals.

Related Condition

is a condition closely related to a developmental disability that is severe, chronic, results in impairment of general intellectual functioning or adaptive behavior, requires treatment or services similar to those required for persons with developmental disabilities, manifests before age 22, is likely to continue indefinitely, is not attributable to mental illness, and results in substantial functioning limitations.

Revocable Trust

is a trust that can be changed or cancelled after it has been created.

Social Security Administration - SSA

is a federal agency that administers Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs.  These two major programs provide cash benefits to persons with disabilities.

Social Security Disability Income - SSDI

is a program under Retirement, Survivor and Disablity Insurance (RSDI) that provides cash benefits to individuals who have a disabilty and have worked a certain number of quarters or had a parent or spouse who worked a certain number of quarters and have paid into the Social Security System.  SSDI helps offset the costs of food, clothing and shelter with monthly benefits.

Spenddown

is an amount of money that a person enrolled in a Minnesota Health Care Program (MHCP) is required to pay before they are eligble for Medical Assistance (MA).

State Medical Review Team - SMRT

is a division of the Department of Human Services (DHS) that makes disability determinations using criteria from the Social Security Administration (SSA).

Supplemental Security Income - SSI

is a federal needs-based program for children and adults who have been been able to work or have not worked enough to pay into the Social Security System.  SSI helps to offset the costs of food, clothing and shelter with monthly benefit payments.

Tax Equity Fairness and Responsibility Act - TEFRA

is a component of Medical Assistance (MA) that helps cover health care costs for children with disabiilties.  Only the child's income is used to determine eligibility; however there may be parental fees, depending on family income and size.

Trustee

is the person or entity responsible for the management and distribution of the assets of a trust.

Minnesota Health Care Programs (MHCP)

Definitions of terminology highlighted in Green Italics can be found in the right sidebar.Minnesota Health Care Programs are publicly funded health insurance programs that pay for MA covered services after they have been partially paid or denied by private insurance. (See Medical & Therapy section for more information on private insurance.)

Medical Assistance (MA)

For the purpose of simplicity and clarity, the following information is specific to people with disabilities only.  Some of these programs are also available to individuals without disabilities, but program eligibility and details are not provided here.  Medical Assistance (MA) is a public-funded health care program that pays for medical care for eligible for individuals with disabilities. It is Minnesota’s name for Medicaid. It is a federal program that is jointly funded by federal and state government and is administered by the county.

Eligibility

  • Individuals must be certified as disabled by the State Medical Review Team (SMRT)?.
  • Individuals receiving Supplemental Security Income(SSI) automatically qualify for MA as long as household completes annual review.
  • Income and assets are considered when determining eligibility.  Parents’ income is considered for minors under age 21 years of age.  There is no asset limit for children under age 21. TEFRA- Medical Assistance is an option for children under 19 who do not qualify for MA due to household income and live with at least one of their parents.
  • Every six months, your county financial worker will send you a combined six month review or annual recertification form to update your case and to determine continued eligibility for MA. Information requested may include: checking and savings accounts statements and proof of ownership of assets. Verifications are needed for income and assets for anyone over 21 years of age.

If reviews are not completed, signed and returned, you could lose MA coverage.

Plan for Achieving Self Support (PASS) – Available through the Social Security Administration (SSA), the PASS program allows individuals with disabilities who are 15 years or older to exclude some income and/or assets which would otherwise be counted in determining eligibility for MA.  

Spenddowns - Those who would qualify for MA, except for excess income, may still qualify if they have enough medical bills to meet a spenddown. A spenddown is similar to an insurance deductible. It allows an individual to deduct certain health care expenses from their income, allowing them to meet eligibility requirements. The individual pays for their medical bill up to the spenddown amount, and MA pays the remainder. There are one-month and six-month spenddowns allowing eligibility for shorter or longer periods of time.

Benefits

MA covers a full range of healthcare services payable after private insurance pays their portion or denies coverage. If determined to be medically necessary, services MA will pay for include: medical and dental office visits and hospitalizations; physical, occupational and speech therapy; medications; medical supplies and equipment; nursing facility services; and personal care assistance (PCA).

  Services must be obtained through a medical assistance provider in order for MA to pay for services.

There are no monthly premiums for MA. There are small copays for services.

If you have coverage through private health insurance, MA sometimes reimburses the health insurance premium so you can keep that coverage. You must complete forms, available from your county financial worker, to see if you qualify for this reimbursement. The county would reimburse if taken from an employer, could pay COBRA or an individual policy.

For more information:  The Arc Guide to Medical Assistance

MA will pay for medical bills up to three months prior to the application date, if you would have qualified for MA at that time. (Check box on application.)

TEFRA – Medical Assistance

Tax Equity Fairness and Responsibility Act of 1982 (TEFRA) provides Medical Assistance (MA) benefits for certain children with disabilities without considering their parents’ income in determining eligibility. TEFRA provides coverage after private health insurance has paid part of a claim or has denied coverage.

Applications for TEFRA are completed by a Washington County Developmental Disabilities Social Worker.

DHS Eligibility Criteria – must meet all of the following: 

  • Live with at least one parent
  • Be under age 19
  • Have a disability determination from the State Medical Review Team (SMRT). This is required even if Social Security has certified the child is disabled.  Required documents include a routine physical less than 3 months old, reports from medical specialists, IEP(or IFSP  or IIP’s),  Children’s Disability Worksheet, an IQ score, and an Adaptive Behavior Rating.

  • Need a certain level of care to stay at home which compares to the level of care provided in a hospital, nursing home or Intermediate Care Facility for People with Developmental Disabilities (ICF/DD). 
  • Have home care costs that are less than the cost for care in a medical facility.

If coverage is denied, you can appeal the decision through your county social worker (case manager) or with the State Appeals Office at the  Minnesota Department of Human Services .

If you have coverage through private health insurance, MA sometimes pays a portion of the health insurance premium so you can keep that coverage. You must complete forms, available from your county financial worker, to see if you qualify for this reimbursement.

For more information:  The Arc Guide to Medical Assistance - TEFRA

Parental Fees

Parents’ income is not counted when determining eligibility for TEFRA. However, depending on family size and income, some parents may have to pay a monthly parental fee until their child turns 18.

Parents can request a change in their parental fee if there are changes in family size or living arrangements, changes in family income, or if they qualify for a “Variance for Undue Hardship” if they incur certain out-of-pocket expenses. Appeal requests are made through the Parental Fee Unit. 

Parental fees can sometimes be reimbursed through an employer’s flex spending account. The determination is made by each company’s reimbursement policy.

You can estimate parental fees using the Minnesota DHS Parental Fees Estimator and Parental Fee Worksheet.

Parents receive a statement comparing the costs TEFRA has paid for services with the total parental fee costs for each fiscal year (July 1st – June 30th). If parents have paid more in parental fees than TEFRA has paid for their child’s medical care, the amount is credited to the following year’s parental fees. If the child turns 18 during this time, the excess amount is refunded.

There is only one parental fee for families that have more than one child with a disability. 

If a child with a disability qualifies for both MA and TEFRA, MA may be a better program since the spenddown under MA may be less than the parental fee under TEFRA.

More information on parental fees can be found here.

Mental Health Coverage

Children with mental health issues who do not qualify for TEFRA may be eligible for other county programs under the Children’s Mental Health Act, including: case management, crisis placement, respite care, day treatment and other services.

Reaching Adulthood

When a child turns 18, an application for Supplemental Security Income (SSI) should be made.  If he/she qualifies, insurance coverage will change from MA-TEFRA to standard MA and parental fees will end. If he/she is not found eligible for SSI but still qualifies for TEFRA, coverage continues along with parental fees, if applicable, until age 21.

MinnesotaCare

MinnesotaCare is a health care program for Minnesotans with low incomes.  Enrollees get health care services through a health plan.  You can choose your health plan from those serving MinnesotaCare enrollees in our county.  You can find more information on MinnesotaCare here.

MNsure

If you qualify for Medical Assistance or MinnesotaCare, you do not need to qualify for special enrollment.  You can enroll in one of these programs thorugh MNsure at any time of the year. You can find more information on MNsure here.

Medical Assistance for Employed Persons with Disabilities (MA-EPD)

MA-EPD is a work incentive program for people with disabilities. MA-EPD allows workers with disabilities to qualify for Medical Assistance (MA) under higher income and asset limits than standard MA. The monthly premium is based on monthly income and household size. 

Qualifications

  • Be certified disabled by Social Security Administration (SSA) or the State Medical Review Team (SMRT)?
  • Be between 16 and 65 years old
  • Be employed with taxes withheld or self-employed and file and pay quarterly taxes with the IRS
  • Have monthly income of at least $65.00 (gross income)
  • Have assets of less than $20,000 (excluding your home, vehicle and certain other assets)

Need more information on medical coverage while being employed?

Medical Assistance for Employed Persons with Disabilities – Department of Human Services

Medical assistance while working – Social Security Administration (pages 4-10)