Glossary of Terms
Glossary of Useful Terms
Aid Continuing: Aid Continuing is the right to have an administrative hearing (fair hearing) held and decided before benefits are reduced or terminated.
Community Health Assessment (CHA): The nursing and social assessment conducted by the New York Independent Assessor as the first step in the assessment process.
Consumer: A person who uses Consumer Directed Personal Assistance (CDPA) to receive assistance and support in the community.
Consumer Directed Personal Assistance (CDPA): Defined by New York State Department of Health as a Medicaid program that provides services to chronically ill or physically disabled individuals who have a medical need for help with activities of daily living (ADLs) or skilled nursing services. In plain English, CDPA is a self-directed home care program that allows elderly and disabled New Yorkers to take charge of their own care in the community.
Designated Representative (DR): An Adult who a CDPA consumer has authorized to direct all aspects of their program. This includes but is not limited to communicating with the Fiscal Intermediary and the Managed Long Term Care Organization as well as recruiting, hiring, supervising, scheduling, and firing of Personal Assistants.
Fair Hearing: A formal procedure in which you get to make your case to appeal a decision of either the MLTC or the LDSS responsible for your health care, before an administrative judge from the state Office of Temporary Disability Assistance. After the appeal is made a fair hearing will issue a formal decision on the decision being appealed.
Fiscal Intermediary (FI): A Fiscal Intermediary is an organization that assists consumers using the CDPA program, by providing financial and other services that enable the consumer to otherwise fulfill their responsibilities as an employer.
Fully Integrated Dual Advantage (FIDA):FIDA is a personal health care plan that brings together the resources of Medicare and Medicaid in one place. ReceiveMembers of FIDAs receive full Medicare and Medicaid coverage, long term care services, Part D and Medicaid drugs, and additional benefits from a single, integrated managed care plan.
Fully Integrated Dual Advantage Intellectual & Developmental Disabilities (FIDA-IDD): A FIDA – IDD, like a FIDA is a personal health care plan that brings together the resources of Medicare and Medicaid in one place. Members of FIDAs receive full Medicare and Medicaid coverage, long term care services, Part D and Medicaid drugs, and additional benefits from a single, integrated managed care plan. The primary difference between a FIDA – IDD and a FIDA is that a FIDA – IDD exclusively serves people with intellectual and developmental disabilities.
Grievance: A formal written complaint made about service provided by a managed care organization. Does not pertain to the authorization or denial of services under the plan of care only the way a consumer was treated or their case was handled by the organization or its representatives.
Independent Practitioner Panel: Independent Practitioner Panel (IPP): The regulations replace the requirement for a physician’s order to authorize PCS/CDPA with a requirement that these services are ordered by a qualified, independent practitioner and expand the list of ordering practitioners to include Medical Doctors (MD), Doctors of Osteopathy (DO), Nurse Practitioners (NP) and Physician Assistants (PA) contracted to work for the Independent Practitioner Panel (IPP) under the NYIA. The IPP will issue the Practitioner’s Order (PO) required to authorize PCS and/or CDPAS after reviewing the Community Health Assessment in the Universal Assessment Score – NY, determining if the individual is self-directing or has an appropriate self-directing other, and if the individual can safely receive PCS/CDPAS at home based on their medical stability.
Independent Review Panel (IRP): For new consumers who need 12+ hours of care per day, New York State requires an additional medical review. This review is conducted by the Independent Review Panel (IRP) as part of the New York Independent Assessor evaluation process. The IRP will review the individual’s Community Health Assessment, Physicians Orders and Plan Of Care (POC) and may evaluate other records as needed to recommend whether the proposed POC is reasonable and appropriate to maintain the individual’s health and safety at home. The IRP recommendation to the MCO or LDSS may include suggested changes in scope, type, amount, or duration of services but cannot specify a recommended number of hours.
Internal Appeal: A request for a review of an action taken by a managed care organization. If the plan denies, reduces, or ends services that a consumer believes they should have, they have the right to appeal. For example, the plan reduces personal care services from 12 to 8 hours/day, or denies a request to increase hours due to a change in health. As of March 1, 2018, consumers MUST request this internal appeal first and wait until it is decided by the plan BEFORE they can request a fair hearing.
Health and Recovery Plans (HARPs): A HARP is a managed care plan that manages physical health, mental health, and substance use services in an integrated way for adults with significant behavioral health needs (mental health or substance use).
- HARPs manage the Medicaid services for people who need them
- HARPs also manage an enhanced benefit package of Home and Community-Based Services (HCBS).
- HARPs provide enhanced care management for members to help them coordinate all their physical health, behavioral health and non-Medicaid support needs.
HIV Special Needs Plans (HIV SNPs): HIV SNPs are health plans that cover all the same services covered by other Medicaid health plans, PLUS special services for people living with HIV/AIDS.
Home Care: Home care is a health service provided in a person’s home to assist them with an illness or disability. Services may include nursing care, speech, physical and occupational therapies, home health aide services and personal care services.
Hospice: Hospice is a program that provides care to people with terminal illness. Hospice focuses on comfort and reducing pain, rather than treating disease. The emphasis of the program is to help individuals remain out of hospitals for as long as possible.
Managed Care Organizations (MCOs): Insurance plans contracted to the state to provide a variety of medical coverage to people receiving their healthcare from the state. There are several types of these plans including “Mainstream Managed Care, Managed Long Term Care, HARP, MAP, PACE, FIDAs. All are sometimes referred to as “plans.”
Mainstream Managed Care: Mainstream managed care provides medical services including hospital care, physician services, dental services, pharmacy benefits, and many others. Does not provide Long Term Care Services.
Managed Long Term Care (MLTC): Insurance plans that are paid a monthly premium (“capitation”) by the New York Medicaid program to approve and provide Medicaid home care and other long term care services to people who need long-term care because of a long-lasting health condition or disability.
Medicaid: A federal and state program that provides free health insurance for adults and children who have lower incomes or limited resources. If you want to use CDPA, you will need to enroll in Medicaid. There are options available for people who don’t meet the financial criteria who need to access Medicaid, including special types of trusts, “spend-downs” and the Buy-In Program for working adults with disabilities.
Medicaid Advantage Plus (MAP): Medicaid Advantage Plus (MAP) Program. MAP combines Medicaid and Medicare coverage offered through a managed care organization.. The MAP Program is designed for people who have Medicare and Medicaid and who need health services and Community Based Long Term Services and Supports (CBLTSS) like home care and personal care to stay in their homes and communities as long as possible.
Medicare: A federal program that subsidizes healthcare services for anyone age 65 or older, younger people with disabilities, and patients with end-stage renal disease. Important: Medicare does not cover long-term care for most people.
New York Independent Assessor (NYIA): The organization appointed by New York State to evaluate whether or not a person is eligible for CDPA services. They do not make evaluations about the level of service or how many hours are needed – only about eligibility.
New York State Department of Health (NYSDOH): The state government agency which is responsible for public health, including CDPA and other Medicaid programs.
Nursing Home Transition and Diversion Waiver – a Medicaid Home and Community Based Services waiver program in New York which is designed to help transition nursing home residents back to the community, and to divert nursing home-eligible individuals from institutional placement, by providing a comprehensive package of long-term care services in the community.
Office for People With Developmental Disabilities (OPWDD): This state agency is responsible for coordinating services for New Yorkers with developmental disabilities, including intellectual disabilities, cerebral palsy, Down syndrome, autism spectrum disorders, Prader-Willi syndrome and other neurological conditions.
Office of the Medicaid Inspector General (OMIG): A government entity that operates within the NYS Department of Health to prevent, track and punish acts of fraud, waste or abuse in the Medicaid program in New York State. OMIG maintains a list of Medicaid exclusions, which is a list of providers and individual people who have broken Medicaid law and are banned from participating in Medicaid programs.
Office of Temporary Disability Assistance (OTDA): The Office of Temporary Disability Assistance is a state office responsible for administering fair hearings. It is also responsible for several other programs including providing temporary cash assistance; providing assistance in paying for food; providing heating assistance; overseeing New York State’s child support enforcement program; determining certain aspects of eligibility for Social Security Disability benefits; supervising homeless housing and services programs; and providing assistance to certain immigrant populations.
Personal Assistant (PA): An adult who works for a consumer to assist them with tasks on their plan of care. The consumer is responsible for hiring, supervising, scheduling and firing personal assistants.
Plan of Care: A formal document issued by your managed care organization or local social services district to document the services and supports you are approved to receive through Medicaid. The plan of care outlines which tasks your personal assistants will help you with. Every consumer should make sure to have a copy of their plan of care.
Program for All-Inclusive Care for the Elderly (PACE):A PACE plan provides a comprehensive system of health care services for members age 55 and older who are otherwise eligible for nursing home admission. Both Medicare and Medicaid pay for PACE services
Recertification: Most Medicaid recipients must recertify every year to ensure their continued eligibility for services. Your MLTC or LDSS can facilitate your recertification.
Traumatic Brain Injury Waiver Program – A Medicaid waiver program in New York State which provides services for people diagnosed with a traumatic brain injury (TBI), or other related diagnosis, to allow them to remain in their homes. Services covered by this waiver can include service coordination, independent living skills and training, structured day programs, substance abuse programs, intensive behavioral programs, community integration counseling, home and community support services, environmental modifications, respite care, assistive technology, transportation, and community transition services.