Disability

A physical or mental condition that limits an individual’s ability to perform daily activities. People with disabilities may qualify for Medicare before age 65 or receive coverage through Medicaid.

Dual Eligibility

Refers to individuals who qualify for both Medicare and Medicaid coverage. Dual-eligible beneficiaries often have their Medicare premiums and out-of-pocket costs covered by Medicaid.

Eligibility

The criteria that individuals must meet to qualify for healthcare programs such as Medicare, Medicaid, CHIP, or ACA Marketplace plans. Eligibility is typically based on factors such as age, income, residency, and health status.

Federal Poverty Level (FPL)

A measure of income issued annually by the Department of Health and Human Services (HHS) to determine eligibility for various government assistance programs, including Medicaid, CHIP, and ACA subsidies. The FPL varies based on household size and geographic location.

Gross Income

The total income earned before any deductions, such as taxes or retirement contributions, are taken out. Gross income is used to determine eligibility for programs like Medicaid, CHIP, and ACA Marketplace subsidies.

Income Limits

The maximum income level a household can earn and still qualify for government programs like Medicaid, CHIP, and ACA subsidies. Income limits are typically based on a percentage of the Federal Poverty Level (FPL).

Look-Back Period (Medicaid)

A period of time (usually five years) during which Medicaid reviews an applicant’s financial transactions to determine if assets were transferred to meet Medicaid eligibility. Transferring assets during the look-back period may result in penalties or ineligibility for Medicaid long-term care.

Medically Needy

A category of Medicaid eligibility for individuals whose income is too high to qualify for traditional Medicaid but have significant medical expenses. Medically needy programs allow people to "spend down" their income on medical costs to become eligible.

Pre-Existing Condition

A health condition that existed before the start of an individual's health insurance coverage. Under the ACA, insurers cannot deny coverage or charge higher premiums based on pre-existing conditions.

Resource Limits

The maximum value of assets or resources an individual or household can have and still qualify for programs like Medicaid or the CHIP. Resource limits are typically assessed alongside income limits when determining eligibility.

Spend-Down (Medicaid)

A process by which individuals who have income above their state’s Medicaid eligibility threshold can still qualify for Medicaid by spending their excess income on medical expenses. Once they spend down to the eligibility level, Medicaid covers remaining healthcare costs.

Work Requirements (Medicaid)

Policies that require Medicaid recipients to work, volunteer, or participate in job training as a condition of receiving healthcare benefits. Some states have received federal waivers to implement Medicaid work requirements, though these policies have been challenged in courts.