Dictonary and glasses

Helpful Terms

This alphabetical listing of terms and definitions will help you better understand what’s happening as you navigate your way through the Social Security Disability Insurance process. Save a link to this page now, so you can easily revisit and look up terms anytime.

GLOSSARY
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B
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D
E
F
G
H
I
L
M
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P
Q
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U
V
W
Activities of Daily Living (ADL)

The basic activities that most people must engage in as a requirement of daily living, including personal hygiene, meal preparation, shopping and standard home maintenance.

Adjusted Gross Income

Adjusted Gross Income (AGI) is defined as gross income (wages, dividends, retirement distributions) minus adjustments to income, such as student loans or other deductions.

Administrative Law Judge (ALJ)

A judge who hears an appeal, typically at a hearing in an agency’s administrative process.

Age-18 Redetermination

The process of determining whether a child who is a Supplemental Security Income (SSI) beneficiary will meet the adult definition of disability. The redetermination happens within a year of the 18th birthday.

Annual Election Period

The period from October 15 through December 7 each year when you can enroll in, switch or drop a Medicare plan.

Appeal

The process experienced when trying to secure Social Security Disability Insurance benefits when a claimant receives an unfavorable decision OR when an individual disagrees with an insurance carrier’s decision to reduce services or deny treatment or payment.

Appeal Deadline

The deadline to file an appeal after a Social Security Disability Insurance claim has been denied — typically 60 days from the date of a claim’s last denial. This date is typically stamped on the first page of the denial letter in the upper right hand corner.

Area Work Incentives Coordinator (AWIC)

Experienced employment support experts who coordinate and/or conduct public outreach on work incentives in their local areas; provide and/or coordinate and oversee training on Social Security’s employment support programs for all personnel at local Social Security offices; handle sensitive or high profile disability work-issue cases; and monitor the disability work-issue workloads in their areas.

Assets

Things that are owned, such as a home.

Association Health Plans (AHP)

A type of group medical insurance for employers that allows smaller companies (as well as freelancers and the self-employed) to access the health insurance savings associated with large group medical coverage.

Basic Plan

Any Medicare plan that meets just the minimum requirements laid out by the Centers for Medicare Medicaid Services (CMS).

Benchmark Plan

A Medicare Part D plan whose premiums are below the specified amount for each state.

Beneficiary

The person who is receiving a benefit.

Benefit Period

The time period that Medicare uses to measure an individual’s use of hospital and skilled nursing facility care. A benefit period begins the day an individual enters a hospital or skilled nursing facility (SNF). The benefit period ends after the individual is released and hasn’t received any further hospital care (or skilled care in a SNF) for 60 consecutive days. If an individual goes into the hospital after one benefit period has ended, a new benefit period begins. The inpatient hospital deductible may be charged for each benefit period. There is no limit to the number of benefit periods an individual may have.

Benefits Planner

A service provided by Social Security to help you better understand your Social Security protection (retirement or disability) as you plan for your financial future.

Benefits Planning Query (BPQY)

A report that summarizes your current Social Security disability benefits.

Blind

Blindness in Social Security disability programs is defined as having a central visual acuity for distance of 20/200 or less in your better eye with use of a correcting lens; or having a visual field limitation in your better eye, such that the widest diameter of the visual field subtends an angle no greater than 20 degrees.

Blind Work Expenses (BWE)

A work incentive program for persons who are blind that receive SSI and/or SSDI benefits.

Cash Accrual

The savings part of a whole life insurance policy, which comes from a portion of the premiums paid by the insured.

Cash Value (or Cash Surrender Value)

The amount of cash accrual and interest that the insured would get upon cashing in a whole life policy or may be able to borrow money from.

Centers for Medicare & Medicaid Services (CMS)

A federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.

Cessation

The discontinuation of benefits for someone who was once determined to be eligible to receive disability benefits from the Social Security Administation (SSA). This type of decision is usually made at the conclusion of a continuing disability review.

Childhood Disability Benefits (CDB)

There are two types of Social Security benefits for children: benefits that are paid from accumulated credits of a working parent and benefits that are awarded as a result of a disability.

Closed Period

This exists when a disability benefits claimant is determined to be ineligible for ongoing benefits, yet eligible to receive benefits for a period of time in the past.

Coinsurance

The portion of the payment for medical services that an individual is responsible for. For example, your health coverage may pay for 80% of the costs of a service, while you will have to pay the remaining 20%.

Community Work Incentives Coordinator (CWIC)

The federal government pays benefits planners in communities around the country to help people think ahead about work incentives and benefits issues. CWICs, are trained by the Social Security Administration (SSA) to assist beneficiaries with programs including Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) in addition to other related programs. Or suggested shorter definition: CWICs are certified benefits planners who provide beneficiaries information about work, Social Security work incentive programs and rules, and other types of benefits and assistance available in their states.

Consolidated Omnibus Budget Reconciliation Act (COBRA) Administrator

An outside company that processes COBRA and/or OBRA premiums.

Consultative Examinations

Medical examinations that Social Security disability and SSI claimants are sometimes sent to during the processing of a claim for disability benefits. The doctors who perform these exams for the SSA are independent physicians who have contracted to perform these services.

Continuing Disability Review (CDR)

A periodic review to determine if there has been any medical improvement in your condition and/or to determine whether you continue to be eligible for Social Security Disability Insurance benefits for other reasons. The two types of reviews are called a medical CDR and a work CDR.

Co-payment

A set amount an individual must pay upon receiving medical services in combination with the amount paid by the insurer. For example, you may have to pay $10 each time you visit the doctor, with the understanding that the health insurance policy covers a large part or the remainder of the balance of the fee owed to the doctor.

Cost-of-Living Adjustment (COLA)

An annual adjustment made based on the increase in the Consumer Price Index. Your monthly SSDI benefit usually will increase each January with the annual cost-of-living adjustment, which also is applied to Social Security retirement and other federal benefits. COLA increases are intended to help protect your benefits from inflation.

Coverage Effective Date

The date an individual is enrolled in health insurance coverage. The effective date is usually not the same as the date of hire.

Creditable Coverage

Coverage that is at least as good as that offered through Medicare Part D. Your health coverage plan can tell you whether or not your coverage is creditable. Under HIPAA, creditable coverage is prior health coverage that allows you to reduce pre-existing condition exclusionary periods when applying for new coverage. Most forms of health coverage can count as creditable.

Critical Access Hospital

A hospital facility that provides outpatient and certain inpatient services to people in rural areas. Critical Access Hospitals are given a special status by Medicare.

Custodial Parent

The parent who has primary physical custody of a child. Typically the child resides with the custodial parent.

Deductible

The amount an individual is responsible for paying for healthcare services before the insurer or Medicare begins to pay.

Department of Labor (DOL)

A Cabinet-level federal agency to foster, promote, and develop the welfare of US wage earners, job seekers, and retirees; improve working conditions; advance opportunities for profitable employment; and assure work-related benefits and rights.

Dependent

A person, usually a child, who is economically dependent on another person. Different programs have different specific definition of when someone is a dependent.

Disability (Definition used by private insurers)

Definition of disability may be two-tiered: an inability to participate in the employee’s own occupation (regular work) on the first tier, and an inability to participate in any occupation (any work) on the second tier. Refer to policy for definitions of disability.

Disability (Definition used by Social Security for Adults)

By law, Social Security has a very strict definition of disability. To be found disabled, you must be unable to do any substantial work because of your medical condition(s) and your medical condition(s) must have lasted, or be expected to last, at least 1 year, or be expected to result in your death.

Disability (Definition used by Social Security for Children)

Social Security has a strict definition of disability for children under age 18. The child must have a physical or mental condition(s) that very seriously limits his or her activities; and the condition(s) must have lasted, or be expected to last, at least 1 year or result in death. A state agency makes the disablity decision.

Disability Determination Services (DDS)

The state-level agency whose main responsibility is determining the eligibility of claimants to receive monetary Social Security disability benefits.

Disability Freeze

A disability freeze is a period of time in which your earnings information is not considered by the Social Security Administration (SSA) when computing Social Security Disability (SSD) payments. Also called a period of disability, the disability freeze "freezes" an individual's insured status and, in turn, preserves the individual's eligibility for future retirement and disability benefits. The disability freeze can stop your Social Security disability or retirement benefits from being lowered despite years of little or no earnings.

Donut Hole

The Donut Hole, also called coverage gap in Medicare prescription drug coverage (Part D) means there's a temporary limit on what the drug plan will cover for drugs. However, the donut hole closed in 2020 meaning you pay no more than 25% for both brand and generic prescription drugs. Those who qualify for Medicare's low-income subsidy or Medicare Extra Help program can receive financial assistance with prescription drugs.

Earned Income (EI)

Salaries, wages, tips, professional fees and other amounts received as pay for physical or mental work actually performed. Funds received from any other source are not included.

Earned Income Tax Credit (EITC)

A federal income tax credit for low to moderate income working individuals and families. The credit reduces the amount of federal income tax owed and can result in a refund check.

Employer Assistance and Resource Network on Disability Inclusion (EARN)

An agency of the U.S. Department of Labor, EARN helps employers recruit, hire, retain and advance people with disabilities through webinars, events, and a website which provides information on: recruiting and hiring; retention and advancement; laws and regulations; creating an accessible and welcoming workplace; and federal contractor requirements.

Employer-Sponsored Health Coverage

Health coverage offered through an employer.

Employment Network (EN)

A private or state organization that is certified by the SSA to assist SSDI beneficiaries in accessing and using the Ticket to Work Program, a benefit of SSDI.

Exception

A request to Medicare Plan D to either cover a drug that is not on the formulary or to bypass utilization controls.

Exclusion

A service that a health coverage plan won’t pay for. Cosmetic surgery, for example, is not covered under most plans.

Exhibit File

A large file containing copies of everything accumulated during the processing of a claimant’s disability claim. These files are available to the claimant as well as the claimant representative (if applicable) for viewing and copying.

Expedited Reinstatement of Benefits

Immediate reinstatement of benefits for individuals whose Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI) ended due to employment. This provision is available for up to 5 years after Social Security work incentives have been exhausted.

Extended Period of Eligibility (EPE)

An EPE is a feature of the Ticket to Work program. It is a 36-month (three-year) period following the nine-month Trial Work Period. During this time, SSDI benefits will be paid for the months where earnings or work activities are below the Substantial Gainful Activity level.

Federal Adjusted Gross Income

Total taxable income. This includes money, goods, property, and services from all sources after any adjustments or deductions that are shown on a federal tax return.

Federal Benefit Rate (FBR)

The national benefit amount, established by the Social Security Administration (SSA), for Supplemental Security Income (SSI) recipients. The FBR is administered by SSA for all states and commonwealths annually.

Federal Insurance Contributions Act (FICA)

A U.S. law requiring a deduction from paychecks and income that goes toward the Social Security program and Medicare.

Federal Poverty Level (FPL)

Income amounts used to determine financial eligibility for federal and state programs. Each year, the Department of Health and Human Services (HHS) issues the Federal Poverty Guidelines in the Federal Register.

FICA Requirements for Social Security Disability Insurance (SSDI)

One of the eligibility requirements for SSDI is to have worked and paid FICA taxes for specified periods of time. The number of work credits needed to qualify for SSDI depends upon how old you were when Social Security determined that you are disabled. Applicants must have worked and paid FICA taxes five out of the last 10 years.


Foreign Income

Income received for services performed in a foreign county by an individual residing in that country.

Formulary

A list of drugs that a health plan covers.

Fully-Insured Health Plan

In a Fully-Insured Health Plan, the insurance company assumes the risks for claims. In a Self-Funded Health Plan, the employer or individual assumes the risks.

General Enrollment Period

The period of time between January 1 and March 31 when a Medicare beneficiary can sign up for Part B coverage. Benefits will not begin until July 1 of that year, and a beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare.

Gross Benefit Amount

The total benefit amount an insurance company pays before deductions. Deductions are made for an individual’s disability income and for earnings he/she is receiving.

Gross Income

Income before taxes and other deductions are made.

Gross Misconduct

A serious violation of company policy or the commission of a crime affecting the workplace that may result in the loss of COBRA benefits. Although “gross misconduct” is not defined in COBRA legislation, past examples include embezzlement, misrepresentation, theft, and non-work related violence.

Gross Pre-disability Salary

The total pre-tax income paid to an individual by an employer before a disability began and while the individual was covered by disability insurance.

Group Coverage

Coverage offered to an individual through a group, such as employer-sponsored, association-affiliated or professional group coverage.

Guaranteed Issue Period (Medigap)

A period of time when an individual can enroll in a Medigap plan without medical underwriting or waiting periods.

Health Screening

A process that allows Medigap carriers to refuse coverage based on an individual’s health history if they have not signed up for a Medigap plan during the open enrollment period. The insurer may review your medical history and refuse to sell you a policy, or sell you one at a higher cost, if you do not meet its underwriting requirements.This process is also known as medical underwriting.

Health Status

HIPAA prevents employer-sponsored health coverage plans from denying coverage based on health status. This includes physical and mental health conditions, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.

Hearing

Hearings on SSDI cases are conducted by administrative law judges (ALJs), who are appointed by the Social Security Administration (SSA).

HIV/AIDS Disability Form 4814 for Social Security

A form for individuals with HIV/AIDS who are applying for Social Security Disability Insurance (SSDI) benefits. The form asks physicians for details on complications the individual is experiencing and how these may affect activities. This form helps Social Security decide if the individual is eligible for disability benefits.

Home Health Care

Services covered by Medicare that include: part-time or periodic skilled nursing care; home health aide services; physical therapy; occupational therapy; speech-language therapy; medical social services; durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers); medical supplies; and other services.

Hospice Care

Services covered by Medicare Part A for individuals with a terminal illness. Services may include prescriptions for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare.

Hospital Stays

Services covered by Medicare Part A that include a semi-private room, meals, general nursing, and other hospital services and supplies.

Impairment-Related Work Expenses (IRWE)

Expenses for services or items that are related to one’s impairment and needed in order to work. Wheelchairs, physician visits, co-pays for prescriptions, and other medical expenses are some examples. The expenses must be verified by original receipts or canceled checks. IRWE deductions are not allowable if you've been, could be, or will be reimbursed for the cost of the item(s) or service(s).

In Arrears

Social Security makes monthly payments in arrears, which means that when you receive payment, it is for the previous month.

In-Home Supportive Services (IHSS)

State programs that provide domestic, paramedical, and personal assistance services for people with disabilities so that they can live independently or maintain employment safely.

Indemnity Plan

A type of health insurance plan. You pay monthly premiums and usually have coinsurance and a yearly deductible as well. Also known as fee-for-service.

Independent Living

Living on one’s own, in the community, outside of an institution, such as a nursing home.

Independent Review Entity

This is the first person outside of a Part D plan to review an appeal during the Part D appeals process.

Individual Coverage

Individual health insurance is coverage that you purchase on your own, on an individual or family basis, as opposed to obtaining through an employer or from a government-run program like Medicare, Medicaid or CHIP. It can be purchased from a state’s health insurance marketplace/exchange or directly from an insurance company during an annual enrollment period.

Individual Development Account (IDA)

An IDA is a type of savings account usually matched and designed to help low-income individuals build assets and achieve financial stability and long-term self-sufficiency.

Individualized Education Plan (IEP)

An educational plan for a student receiving special education services. The IEP is created with input from parents, teachers, staff, and the student. It includes information on the student’s current performance, goals and evaluation, and on what specific services the student will need.

Initial Enrollment Period (Medicare)

When you're first eligible for Medicare, you have a 7-month Initial Enrollment Period to sign up for Part A and/or Part B. If you're eligible for Medicare when you turn 65, you can sign up during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, or ends 3 months after the month you turn 65. SSDI beneficiaries are eligible for Medicare Part A and Part B starting the 25th month you get the benefits.

In-Kind Support and Maintenance

Food and/or rent only which is supplied or paid for by someone else, not the person receiving a Supplemental Security Income (SSI) cash benefit.

Inpatient Care

Health services received when an individual is admitted to the hospital.

Integration

The adjustment of payments when an individual is eligible for more than one benefit program.

Internal Revenue Service (IRS)

Is the revenue service of the United States federal government.

Investment Income

Investment income is money that someone earns from an increase in the value of investments. It includes dividends paid on stocks, capital gains derived from property sales and interest earned on a savings or money market account.

Legal Adulthood

In the United States, people become legal adults when they turn 18. At this age they can sign contracts, vote and enjoy the rights and responsibilities of adulthood.

Lifetime Reserve Days

The days following a 90-day hospitalization. Medicare allows an individual 60 lifetime reserve days per benefit period that may only be used once during an individual’s lifetime. Medicare will pay for lifetime reserve days, whether used at once or over the individual’s lifetime. However, the individual must pay for the daily coinsurance of $550 for 2011.

Liquid Assets

A liquid asset is an asset that can easily be converted into cash within a short amount of time. Examples include cash, money market funds, stocks, bonds, mutual funds and cash value life insurance policies.

Long-term Care

Services that assist individuals with long-term medical and personal needs. Long-term care may include medical services, physical therapy, custodial care, and assistance with activities of daily living (dressing, eating, bathing, etc.). Long-term care may be provided at home, in the community, or in facilities, including nursing homes and assisted living facilities. Medicare will not pay exclusively for custodial care.

Long Term Disability (LTD)

LTD is an income replacement program that protects you and your family in the event you become disabled and are unable to perform the material and substantial duties of your job.

Low Income Subsidy

Help paying for Medicare Part D costs for those who meet income and asset rules. Also known as “Extra Help”.

Medicaid

A joint Federal and state program that provides assistance with medical costs to some low income individuals with limited resources. Medicaid programs vary from state to state.

Medical Provider

The person who provides a medical certification of a disability. They can be a licensed physician, surgeon, U.S. government medical office, osteopathic physician, chiropractor, podiatrist, optometrist, dentist, designated psychologist, nurse-midwife, nurse practitioner, midwife, or accredited religious practitioner.

Medical Treatment/Care

Any medical care received by an individual for a medical condition. Examples of medical treatment include being prescribed medication, physician consultations, and therapy for a mental or physical condition.

Medical Underwriting

This is a process formerly used by insurance companies to review an individual’s health status when applying for health insurance coverage. It helped to determine whether to offer you coverage, at what price, and with what exclusions or limits. The application of medical underwriting today is rare and can vary depending upon the type of insurance and federal and state regulations.

Medically Determinable Impairment

A medically determinable impairment is defined by the Social Security Administration (SSA) as “an impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.” A statement of symptoms alone is insufficient.

Medically Necessary

Services or supplies that are considered by Medicare to be appropriate and needed for treatment.

Medicare

Medicare is a federal health insurance program for eligible individuals with disabiliites and those age 65 or older. It typically consists of hospital insurance (Part A), medical insurance (Part B), and optional prescription drug coverage (Part D).

Medicare Advantage Plan

Medicare Advantage Plans offer Medicare Part A and Part B benefits through private insurance companies that contract with Medicare. In addition to Part D (prescription drug coverage) they can provide more choices and extra benefits. Medicare Advantage Plan options include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans (PFFS) and Special Needs Plans (SNPs).

Medicare Health Maintenance Organization (HMO) Plan

A Medicare HMO is one type of Medicare Advantage Plan. Services are limited to in-network providers. If you decide to select a provider who is out of network, you may owe a higher cost or the full out-of-pocket amount for those services. HMO plans vary from state and typically offer prescription drug coverage (Medicare Part D), dental, vision, and hearing coverage.

Medicare Managed Care Plan

Medicare Managed Care Plans are offered by private companies that have a contract with Medicare. Medicare managed care plans are often known as Medicare Part C or Medicare Advantage plans. These plans work in place of original Medicare coverage and often offer coverage for services that original Medicare does not. Examples of managed care plans include HMOs, PPOs and HMO-POSs. These vary from state to state.

Medicare Preferred Provider Organization (PPO) Plan

A Medicare Advantage option that gives an individual the choice of visiting providers within the network or seeing a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician to see a specialist.

Medicare Private Fee-for-Service Plan (PFFS) Plan

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Medicare Special Needs Plan

A Medicare Advantage option that provides health care focused on certain health conditions. These plans provide comprehensive Medicare coverage to manage a particular disease or condition, such as congestive heart failure, diabetes, or End-Stage Renal Disease (ESRD). Medicare Special Needs Plans are only available in some areas of the country.

Medicare Supplement

See Medigap.

Medigap

A supplemental insurance policy sold by prviate insurance companies to fill gaps in Original Medicare. A Medigap policy can help pay healthcare costs not covered by Original Medicare such as copayments, coinsurance, and deductibles. A Medigap policy only covers one person. Any standardized Medigap policy is guaranteed renewable even if you have health problems as long as you pay premiums. Also known as Medicare Supplement,

Network

The facilities, providers and suppliers a health insurer or plan has contracted with to provide health care services.

Office of Hearing Operations (OHO)

This is the office in the Social Security Administration (SSA) that oversees SSDI Level 3 Hearings before Administrative Law Judges.

On-the-Record Decision

A decision that occurs prior to the hearing when an Administrative Law Judge (ALJ) grants an approval to a disability claimant. These decisions are made because the medical evidence available to an ALJ is strong enough to validate an approval without a formal hearing. On-the-record decisions are generally always approvals.

Onset Date

The onset date is the day that the SSA determines you were no longer able to work. This is not the date you believe you became disabled or the date that you filed for SSDI benefits. This date is very important and drives the decisions about an SSDI award and benefit amount.

Open Enrollment Period

The yearly period when people can enroll in a health insurance plan.

Original Medicare Plan

Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

Out-Of-Pocket Cost

The costs an individual pays without assistance from Medicare or other insurance.

Out-of-Pocket Maximum

Out-of-pocket maximums generally apply to marketplace or company sponsored plans. It is the maximum amount of money one has to pay for health costs in a year. Once you reach the limit, the policy covers all other costs. Out-of-pocket maximums do not apply to Original Medicare coverage.

Overpayment

Social Security sets an onset date for SSDI payments. Along with monthly benefits, you may be eligible for a lump-sum payment based on that date. If you receive a retroactive SSDI benefit in a lump sum, this could create an overpayment. If you were receiving long term disability (LTD) benefits for a certain period and then receive SSDI benefits for the same period, most or all of this lump sum must be returned to the LTD carrier.

Permanent Resident

A permanent resident is someone who has been granted authorization to live and work in the United States on a permanent basis. As proof of that status, U.S. Citizenship and Immigration Services (USCIS) grants a person a permanent resident card, commonly called a "Green Card."

Permanently and Totally Disabled

Unable to engage in any Substantial Gainful Activity (SGA) due to any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of at least 12 months.

Personal Assistance Services (PAS)

Services designed to assist an individual with a disability perform activities of daily living at home or in the workplace. Such activities might include getting up and ready for work, bathing, dressing, cooking, cleaning, or running errands.

Plan for Achieving Self-Support (PASS)

This is a written plan of action for pursuing and getting a particular type of job or starting a business. A PASS describes the steps you will take, and the items and services you will need to reach your work goal. When you have an approved PASS, Social Security does not count the money you set aside to help you reach your work goal when determining your eligibility for Supplemental Security Income (SSI).

Point Of Service (POS) Plan

A point-of-service plan (POS) is a type of managed-care health insurance plan that provides different benefits depending on whether you use in-network or out-of-network healthcare providers. Typically you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network.

Point-of-Service Option

An option offered by some Medicare Managed Care Plans that allows an individual to use doctors and hospitals outside the network at an additional cost.

Pre-existing Condition

Under current law, health insurance companies cannot refuse to cover you or charge you more just because you have a pre-existing condition or health problem such as asthma, diabetes, or cancer, before the date the new health coverage starts.

Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Premium

The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance.

Prescription Drug Plan (PDP)

A Medicare Part D plan that only offers drug coverage. Also known as a “stand-alone” plan because it is purchased on its own apart from other coverage.

Presumptive Disability

A status granted to Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) applicants who have a high chance of being found disabled. If the SSA finds you presumptively disabled, they will begin benefit payments while your application is being reviewed. Some conditions that qualify as presumptive disabilities include total deafness or blindness, Down syndrome, or a debilitating illness that confines you to bed or a wheelchair.

Preventive Services

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Primary Care Doctor

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.

Primary Care Provider (PCP)

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of healthcare services.

Primary Payer

The first insurer to pay medical claims when an individual uses multiple sources of health coverage.

Property Essential to Self-Support (PESS)

A category of resources that the SSA will not count against your eligibility for SSI. PESS is any resource that is essential to a person’s self-support such as property used in trade or business or personal property that you are required to have as an employee, such as inventory, goods, tools or other equipment.

Protection and Advocacy for Beneficiaries of Social Security (PABSS)

Assist beneficiaries with disabilities in obtaining information and advice about receiving vocational rehabilitation and employment services. Provide advocacy or other related services that beneficiaries with disabilities may need to secure, regain, or maintain gainful employment.

Protective Supervision

Protective supervision is service for people who, due to a mental impairment or mental illness, need to be observed 24 hours per day to protect them from injuries, hazards, or accidents.

Qualified Disabled Working Individual (QDWI) Program

One of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for Part A premiums only if you meet certain eligibility requirements.

Qualified Individual-1 (QI-1) Program

One of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for Part B premiums only if you meet certain eligibility requirements.

Qualified Medicare Beneficiary (QMB) Program

One of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for Part A premiums, Part B premiums, and deductibles, coinsurance, and copayments if you meet certain eligibility requirements.

Qualifying Events

A qualifying event is a change in life circumstances that allows you to alter an existing health insurance policy, or sign up for a new one, outside of open enrollment periods.

Referral

A written authorization to visit a specialist from an individual’s primary care doctor. In many Medicare Managed Care Plans (Medicare HMO), an individual must get a referral before receiving care from anyone except the primary care doctor. If an individual fails to get a referral, the plan may refuse to pay for care.

Remand

A disability claim that has been denied by an Administrative Law Judge; reviewed, upon request, by the Appeals Council; and returned to the Hearing Office for a second hearing.

Representative Payee

An individual who receives benefits on someone else’s behalf. Social Security conducts a careful investigation before appointing a relative, friend, or other interested party as the representative payee of individuals who need help managing their benefits.

Residual Functional Capacity (RFC) Form

A form that rates the residual (left over) functional capacity of a claimant after taking the claimant’s mental or physical disability into consideration. These forms allow a claimant to present an interpretation of the medical evidence rather than simply presenting the medical evidence.

Retroactive Payments

Payments made for the period between disability onset and application approval.

Secondary Payer

A health insurance plan that supplements a primary insurance plan. Healthcare costs not covered by the primary plan can be submitted to the secondary payer, which often covers some or all of the deductibles, co-payments and other services not covered by the primary insurance provider.

Self-insured Plan

With a self-insured (self-funded) plan, an employer reimburses employees for health benefits rather than pay premiums to an insurance company. Employers choose to self-insure because it can allow them to save significantly on premiums. Self-insuring may expose the company to much larger risk in the event that more claims than expected must be paid. The alternative to a self-insured plan is a fully-insured plan.

Short-Term Disability (STD)

Short-term disability (STD) is a type of insurance that provides some compensation or income replacement if you are not able to work for a limited period of time due to sickness or injury (excluding on-the-job injuries, which are typically covered by workers compensation insurance).

Skilled Nursing Facility (SNF) Care

Medicare covers skilled nursing facility care after the person has met the 3-day-consecutive inpatient hospital stay rule. SNF Care can cover semiprivate rooms, meals, skilled nursing and rehabilitative services, and other services and supplies.

SNAP

The Supplemental Nutrition Assistance Program (SNAP) is a federal nutrition program. Known previously as "food stamps," SNAP benefits can provide help for low-income households to buy the food needed for good health.

Social Security Administration (SSA)

An independent agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors’ benefits.

Social Security Disability Insurance (SSDI)

Social Security Disability Insurance (SSDI) is a payroll tax-funded, federal insurance program. A portion of the FICA taxes you pay are set aside for SSDI (as well as Social Security Retirement and Medicare). SSDI, which was established in 1954, is designed to provide you with income if you are unable to work due to a disability or until your condition improves, and provides income if your condition does not improve.

Specified Low-income Medicare Beneficiary (SLMB) Program

One of 4 Medicare Savings Programs, SLMB is a state program that helps pay Part B premiums for people who have Part A and limited income and resources.

State Health Insurance Assistance Programs (SHIP)

The State Health Insurance Assistance Programs (SHIPs) provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers.

State Supplemental Payment (SSP)

This is an additional payment some states provide to supplement Federal Supplemental Security Insurance (SSI) benefits.

Student Earned Income Exclusion (SEIE)

SEIE allows a person who is under age 22 and regularly attending school to exclude earnings from income so as not to affect SSI benefit levels.

Substantial Gainful Activity (SGA)

If a person earns more than a certain amount and is doing productive work, the SSA generally considers that to be engaging in SGA and he or she is not eligible for SSDI. SGA amounts typically change with with changes in the national average wage index.

Supplemental Security Income (SSI)

An income benefit program administered by SSA for people with limited income and resources who are disabled, blind, or age 65 or older. The SSI program is based on financial need established by income and assets requirements.

Tax Credit

A dollar-for-dollar reduction in income tax owed.

The Blue Book (Listing of Impairments)

The Blue Book provides physicians and other health professionals with an understanding of the disability programs administered by the SSA. It explains how programs, such as SSI and SSDI work and the kinds of information a health professional can furnish to help ensure sound and prompt determinations and decisions on disability claims. Updated regularly, it includes complete listings of impairments for both adults and children. The Blue Book can be accessed online.

Ticket to Work Program

A voluntary and free SSA program that helps SSDI beneficiaries return to work and become financially independent, while they keep their Medicare and disability benefits.

Timely Progress

Ticket to Work specifies that you receive free assistance from your service provider or Employment Network to prepare for, find, and keep a job, while you work your way towards financial independence through earned income. Social Security regularly reviews whether you are making timely progress and are actively pursuing your work goals outlined in your Individual Work Plan. As long as you are making timely progress, you are not subject to a Continuing Disability Review (CDR).

Trial Work Period (TWP)

A TWP is a feature of the Ticket to Work program. During this period, one can work for a total of nine months without losing SSDI benefits. Benefits will continue regardless of how much is earned during this time period as long as work activity is reported to the SSA and the beneficiary still has a disabling impairment.

Unearned Income (UI)

Funds received from sources for which no paid work activity was performed. (Examples: Disability benefits such as SSDI, SSI, STD and LTD; income from a trust or investment, dividends, profits or funds received from any source other than work are all examples of unearned income.)

Unsuccessful Work Attempt (UWA)

An UWA is an effort to do substantial work (in employment or self-employment) that you stopped or reduced to below the SGA level after a short time (six months or less) because of your impairment, or the removal of special conditions related to your impairment that were essential to your work.

Vocational Rehabilitation (VR) Agency

A VR is a state-run organization certified by the SSA to provide employment services such as career counseling, training, education and rehabilitation services for people with disabilities.

Waiting Period

The SSA determines the amount of time you have to wait to receive SSDI benefits, which is 5 full months from the onset date of disability.

Work Incentives

Work Incentives are programs, such as SSA’s Ticket to Work, designed to help motivate, support and encourage return-to-work efforts while protecting disability benefits.

Work Incentives Planning and Assistance (WIPA) Projects

WIPA projects provide free benefits counseling to eligible Social Security and Supplemental Security Income beneficiaries who have a disability to help them make informed choices about work, earning more money and how working may affect benefits.

Work Incentives Seminars (WISE)

Free, internet-based seminars that give SSDI beneficiaries information they need to make a decision about going back to work or working for the first time. WISE information may be accessed 24-hours per day at your convenience.