There are many unfamilar health care terms that you will encounter while you are member of Indiana Medicaid or many of the other Family and Social Services Administration's programs. Below you will find a listing of common terms and their meanings.
Appeal-The process you can utilize to have a decision heard by a third party when you don't agree with an agency's decision. The appeal process can be undertaken if you disagree with a decision made by Medicaid, Social Security, or most government programs. With Medicaid, you must file an appeal stating why you think the denial of your coverage or a specific service is incorrect.
Aid category-A designation under which a person may be eligible for public assistance and medical assistance. Medicaid has many aid categories. Examples of these categories are blind, disabled, and pregnant women.
Aid to Residents in County Homes (ARCH)-A State-funded program that provides medical services to certain residents of county homes.
Americans with Disabilities Act (ADA)-Public Law 101-336. The ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation. It also mandates the establishment of TDD/telephone relay services.
Anthem-A Managed Care Organization (MCO) responsible for state-wide coverage for Hoosier Healthwise participants.
Attending physician-The physician providing specialized or general medical care to a member.
Auto assignment-Process that automatically assigns a managed care member to a managed care provider (or PMP) if the member does not select a provider within the allotted 30 day time frame.
Behavioral health care-Assessment and treatment of mental and psychoactive substance abuse disorders. In Medicaid, many behavioral health services are covered. If you have questions about these services discuss them with your primary medical provider.
Benefit-Health care service coverage that a Medicaid member receives for the treatment of illness, injury, or other conditions allowed by the State.
Benefit level-Limit or amount of services a person is able to receive based on that person's health plan or insurer.
Billed amount-The amount of money requested for payment by a provider for a particular service rendered.
Buy-in-A procedure whereby the State pays a monthly premium to the Social Security Administration on behalf of eligible members to cover Medicare premiums.
Continuing Disability Review (CDR)-Everyone who receives SSI and/or SSDI has reviews by the Social Security Administration to determine if they are still considered disabled and unable to perform Substantial Gainful Activity (SGA). The frequency of these reviews depends on the severity of their impairment and the likelihood of their recovery. There are two types of CDRs: a medical CDR and a work CDR.
Cap-The limit on the number of certain services for which the insurer pays for a given member per calendar year.
Case manager-An experienced professional who works with clients, providers, and insurers to coordinate all necessary services to provide the client with a plan of medically necessary and appropriate health care.
Categorically needy-All individuals receiving financial assistance under the State's approved plan under Titles I, IV-A, X, XIV, and XVI of the Social Security Act or who are in need under the State's standards for financial eligibility in such plan.
Centers for Medicare & Medicaid Services (CMS)-Federal agency overseeing the Medicaid and Medicare programs.
Certificate of Medical Necessity-Form completed by the provider attesting to the eligibility of the member, the medical necessity, the cost-effectiveness, and that the service is part of a prudent course of treatment prescribed by the provider.
Children's Health Insurance Program (CHIP)-A part of the Balanced Budget Act of 1997 that includes an expansion of the Medicaid program that extends coverage to children ages zero to 19 years old whose family income is the Federal Poverty Level (FPL). CHIP is also known as Hoosier Healthwise Package C.
Children's Special Health Care Services (CSHCS)-A State-funded program providing assistance to children with chronic health problems. CSHCS members do not have to be Medicaid eligible. If they are also eligible for the Medicaid, children can be enrolled in both programs.
Co-insurance-The portion of a Medicare-determined allowed charge that a Medicare member is required to pay for a covered medical service after the deductible has been met. The co-insurance or a percentage amount is paid by the Medicaid if the member is eligible for Medicaid.
Community residential facility for the developmentally disabled (CRF/DD)- A residential facility that is operated for the purpose of providing specific services in a residential setting for four to eight persons with developmental disabilities.
Comprehensive outpatient rehabilitation facility (CORF)-A CORF is a nonresidential rehabilitation facility certified under Medicare Part A. Its purpose is to provide (under the supervision of an MD) diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of the injured, disabled, or sick.
Co-payment, co-pay-The amount an individual must pay out-of-pocket for prescriptions and medical services in addition to the amount that is paid by the person's health insurance plan.
Countable Earned Income-This is the dollar amount of income from a person's work that is counted by the Social Security Administration (SSA) and Medicaid after deductions are made to determine a person's monthly Supplementary Security Income payment and eligibility for Medicaid.
County office-County offices of the Division of Family Resources. Offices responsible for determining eligibility for Medicaid using the Indiana Client Eligibility System (ICES).
Covered service-Mandatory medical services required by CMS and optional medical services approved by the State that are paid for by Medicaid. Examples of covered services are prescription drug coverage and physician office visits.
Deductible-For health insurance, the amount a person must pay toward medical expenses before insurance plan begins paying.
Development disability-A severe, chronic disability manifested during the developmental period of childhood that results in impaired intellectual functioning or deficiencies in essential skills.
Disallow-To determine that a service or services are not covered by the Medicaid and will not be paid.
Division of Disability and Rehabilitative Services (DDRS)-A Division of the Family and Social Services Administration. Assists citizens of Indiana, regardless of the severity of the disability, in becoming employed and living in the least restrictive and most appropriate environment possible. For more information, go to: http://www.in.gov/fssa/2328.htm.
Division of Family Resources (DFR)-A Division of the Family and Social Services Administration. The State agency that offers help with job training, public assistance, supplemental nutrition assistance, and other services. For more information, go to: www.in.gov/fssa/2407.htm
Division of Mental Health and Addiction (DMHA)-A Division of the Family and Social Services Administration. The DMHA assists people with mental illness or addiction who are uninsured or underinsured to receive treatment and re-integrate into their community. The Division operates six state hospitals and partners with Indiana's Community Mental Health Centers (CMHC) to provide treatment in communities across Indiana. For more information, go to:www.in.gov/dmha
Drug formulary-List of drugs covered by Medicaid, which includes the drug code, description, strength, and manufacturer.
Dual eligible-A person enrolled in Medicare and Medicaid at the same time, whether due to age or disability.
Durable medical equipment (DME) - Equipment that is necessary for ongoing medical issues. Examples: wheelchairs, hospital beds, and other non-disposable, medically necessary equipment.
Earned Income-Earned income may include wages, tips, salaries, or net earnings from self-employment. It may also include other compensation received from performing work activity. Earned Income is often used in determining a person's eligibility for Medicaid and other social services available through the State.
Eligible member-Person certified by the State as eligible for medical assistance.
Eligible providers-Person, organization, or institution approved by the State as eligible for participation in Medicaid.
Emergency medical condition-A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that one could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or death.
Exclusions-Illnesses, injuries, or other conditions for which there are no covered benefits.
Explanation of Benefits (EOB)-An explanation of services rendered by your provider and any payments made toward those expenses.
Family and Social Services Administration (FSSA)- An umbrella agency responsible for administering most Indiana public assistance programs; includes the Office of Medicaid Policy and Planning, the Division of Aging, the Division of Family Resources, the Division of Mental Health and Addiction, and the Division of Disability & Rehabilitative Services.
Family Planning Service-Any medically approved diagnosis, treatment, counseling, drugs, supplies, or devices prescribed or furnished by a physician to individuals of child-bearing age for purposes of enabling such individuals to determine the number and spacing of their children.
Federal Poverty Level (FPL)-Individual and family income guidelines set by the federal government for the administration of social service benefits. The state-specific guidelines are adjusted for the cost of living in each state. Financial eligibility for social service programs is often based on a percentage of the FPL.
First Steps- Provides early intervention for families who have infants and toddlers (birth to age three) with developmental delays or who show signs of being at risk to have certain delays in the future.
Freedom of choice-A state must ensure that Medicaid beneficiaries are free to obtain services from any qualified provider. Exceptions are possible through waivers of Medicaid and special contract options.
Generic drug-A chemically equivalent copy designed from a brand name whose patent has expired and is typically less expensive.
Health Insurance Portability and Accountability Act (HIPAA)- A set of rules to be followed by health plans, doctors, hospitals, and other health care providers. HIPAA took effect on April 14, 2003. For patients, HIPPA ensures that their medical records are not shared with any outside party that does not need access to them in order to provide further medical treatment.
Home- and Community-Based Services Waiver Programs (HCBS)-Services provided to disabled and aged members for the purpose of allowing them to live in the least restrictive community setting and avoid being placed in an institution.
Hoosier Healthwise-Indiana's health care program for children, low-income families, and pregnant women. Different benefit packages are available to the various populations eligible for Hoosier Healthwise: Package A (Standard), Package B (Pregnancy-related services), and Package C (CHIP).
HoosierRx-A qualified State Pharmaceutical Assistance Program. For more information, go to: https://www.in.gov/medicaid/members/194.htm.
Hospice-An organization that furnishes inpatient, outpatient, and home health care for the terminally ill.
Income-In terms of eligibility, money that you earn through a job, self employment (earned income), or money that is paid to you directly, such as SSI or SSDI (unearned income).
Indiana Client Eligibility System (ICES)-Caseworkers in the local DFR offices use this system to determine an applicant's eligibility for medical assistance, food stamps, and Temporary Assistance for Needy Families (TANF).
Indiana State Department of Health (ISDH)- The State agency responsible for promotion of health and for providing guidance on public health issues. For more information, to go: http://www.state.in.us/isdh/.
Individual Family Service Plan (IFSP)-Documents and guides the early intervention process for children with disabilities and their families. The IFSP is the vehicle through which effective early intervention is implemented in accordance with Part C of the IDEA. It contains information about the services necessary to facilitate a child's development and enhance the family's capacity to facilitate the child's development. Through the IFSP process, family members and service providers work as a team to plan, implement, and evaluate services tailored to the family's unique concerns, priorities, and resources.
Intermediate care facility for individuals with intellectual disabilities (ICF/IID)- An ICF/IID provides residential care treatment for Medicaid-eligible individuals with intellectual disabilities.
Level-of-care (LOC)- Determinations that are rendered by OMPP staff for purposes of determining nursing home or institutional placement of an individual.
Long Term Care Program-A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities.
Managed care-System where the overall care of a patient is overseen by a single provider or organization. Many state Medicaid programs include managed care components as a method of ensuring quality health care to its members in a cost-efficient manner.
Managed care organization (MCO)-Entity that provides or contracts for managed care.
Managed care organization enrollee or member-Any Medicaid or CHIP enrollee participating in Hoosier Healthwise and enrolled in one of the Hoosier Healthwise MCOs.
Managed Health Services (MHS)-An MCO responsible for state-wide coverage for Hoosier Healthwise participants.
Mandated or required services-Services a state is required to offer to categorically needy clients under a state Medicaid plan. (Medically needy clients may be offered a more restrictive service package.) Mandated services include the following: hospital, nursing facility care (21 and over), home health care, family planning, physician, nurse midwives, dental (medical/surgical), rural health clinics, certain nurse practitioners, federally qualified health centers, renal dialysis services, HealthWatch (under age 21), and medical transportation.
MDwise-An MCO responsible for state-wide coverage for Hoosier Healthwise participants.
M.E.D. Works-An Indiana program to provide Medicaid coverage to working individuals with disabilities who otherwise would lose or be ineligible for Medicaid coverage. It has separate eligibility requirements and a recipient premium structure based on a sliding fee scale for those individuals with disabilities who work.
Medicaid-A program that offers health insurance to certain low-income families, individuals with disabilities, and elderly individuals with limited financial resources. Medicaid is jointly funded by the federal and state government. Medicaid programs vary from state to state though there are some services that are required by the federal government. Optional services can be offered by each state.
Medicaid Buy-In-This is an optional Medicaid program that allows individuals with a disability who work to retain Medicaid coverage. Individuals may pay a premium on a sliding fee scale based on their income. In Indiana, this program is called M.E.D. Works.
Medicaid Rehabilitation Option (MRO)-Special program restricted to community mental health centers for persons who are seriously mentally ill or seriously emotionally disturbed.
Medicaid-covered service-A service provided or authorized by an Medicaid provider for an Medicaid enrollee for which payment is available under the Medicaid program. A list of covered services is referenced in IC 12-15-5-1.
Medicaid-Medicare eligible-Member who is eligible for benefits under both Medicaid and Medicare; also called dually eligible. Members in this category are bought-in for Part B coverage of the Medicare Program by the Medicaid Program.
Medical emergency-Defined by the American College of Emergency Physicians as "a medical condition manifesting itself by symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: (1) placing health in jeopardy; (2) serious impairment to bodily function; (3) serious dysfunction of any bodily organ or part; or (4) development or continuance of severe pain."
Medical necessity-The evaluation of health care services to determine if they are medically appropriate and necessary to meet basic health needs; consistent with the diagnosis or condition and rendered in a cost-effective manner; and consistent with national medical practice guidelines regarding type, frequency, and duration of treatment.
Medically needy-Individuals whose income and resources equal or exceed the levels for assistance established under a state or federal plan but are insufficient to meet their costs of health and medical services.
Medicare-The federal medical assistance program described in Title XVIII of the Social Security Act for people over the age of 65, for persons eligible for Social Security disability payments, and for certain workers or their dependents who require kidney dialysis or transplantation.
Mental illness-A single severe mental disorder, excluding mental retardation, or a combination of severe mental disorders as defined in the most current edition of the American Psychiatric Association's DSM.
Network-A grouping of providers that offer an array of medical services.
Nursing facility (NF)-Facility licensed by and approved by the State in which eligible individuals receive nursing care and appropriate rehabilitative and restorative services under the Title XIX (Medicaid) Long Term Care Program.
Optional services or benefits-More than 30 different services that a state can elect to cover under a state Medicaid plan. Examples include personal care, rehabilitative services, prescribed drugs, therapies, diagnostic services, ICF-IID, targeted case managed, and so forth.
Other insurance-Any health insurance benefit(s) that a patient might possess in addition to Medicaid or Medicare.
Outpatient services-Hospital services and supplies furnished in the hospital outpatient department or emergency room and billed by a hospital in connection with the care of a patient who is not a registered bed patient.
Per diem-Daily rate charged by institutional providers.
Personal care-Optional Medicaid benefit that allows a state to provide attendant services to assist functionally impaired individuals in performing the activities of daily living (for example, bathing, dressing, feeding, grooming).
Plan of care (POC)-A formal plan developed to address the specific needs of an individual. It links clients with needed services.
Pre-admission screening (PAS)-A nursing home and community-based services program implemented that is designed to screen a member's potential for remaining in the community and receiving community-based services as an alternative to nursing home placement.
Pre-Admission Screening and Resident Review (PASRR)-A set of federally required long-term care resident screening and evaluation services, payable by the Medicaid program, and authorized by the Omnibus Budget and Reconciliation Act of 1987.
Premium-A regularly scheduled payment for health insurance, such as Medicare, M.E.D. Works or other health insurance programs.
Prescription medication-Drug approved by the FDA that can, under federal or state law, be dispensed only pursuant to a prescription order from a duly licensed physician.
Preventive care-Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization, and well person care.
Primary care physician, primary care provider (PCP)-A physician, the majority of whose practice is devoted to internal medicine, family/general practice, and pediatrics. An obstetrician/gynecologist may be considered a primary care physician.
Prior Authorization (PA)-An authorization required for the delivery of certain services. The Medical Services Contractor and State medical consultants review PAs for medical necessity, reasonableness, and other criteria. The PA must be obtained prior to the service for benefits to be provided within a certain time period, except in certain allowed instances.
Qualified Medicare Benificiary-Also-The QMB-Also program is for people who receive Part A Medicare and whose income is below 100 percent of poverty. This program pays Medicare co-payments and co-insurance amounts for medical services covered by Medicare, including the co-payments for Medicare-approved skilled nursing home care. It also pays the Medicare Part B premiums for eligible clients.
Qualified disabled working individual (QDWI)-A federal category of Medicaid eligibility for disabled individuals whose incomes are less than 200 percent of the federal poverty level. Medicaid benefits cover payment of the Medicare Part A premium only.
Qualified Medicare Beneficiary (QMB)-A federal category of Medicaid eligibility for aged, blind, or disabled individuals entitled to Medicare Part A whose incomes are less than 100 percent of the federal poverty level and assets less than twice the SSI asset limit. Medicaid benefits include payment of Medicare premiums, coinsurance, and deductibles only.
Recipient identification number or member identification number (RID)-The unique number assigned to a member who is eligible for Medicaid services. This number can be found on the front of your Medicaid ID card.
Referring provider-Provider who refers a member to another provider for treatment service.
Resources-These are goods or items that have a monetary value. Resources can include a checking or savings account, cash on hand, and certain items that you own such as a vehicle or property.
Specified low-income Medicare beneficiary (SLMB)-Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization, and well person care.
Supplementary Security Income (SSI)-A federal supplemental security program providing cash assistance to low-income aged, blind, and disabled persons.
Temporary Assistance for Needy Families (TANF)-Needy families with dependent children eligible for benefits under the Medicaid Program, Title IV-A, Social Security Act. A replacement program for AFDC.
Third party liability-A member's medical payment resources, other than Medicaid, available for paying medical claims. These resources generally consist of public and private insurance carriers.
Traditional Medicaid-In the beginning, Medicaid was a Fee For Service (FFS) program. This meant that the government paid providers, like doctors, clinics and hospitals, for each of the services they provided with Medicaid. In most states, Medicaid has been shifting to a managed-care system. In a managed care Medicaid plan, the government pays a health plan a certain dollar amount for each Medicaid beneficiary enrolled, and in return, the plan managed the health care of the beneficiaries.
UnitedHealthcare (UNC)-An MCO responsible for state-wide coverage for Hoosier Care Connect participants.
Unearned Income-Disability payments or other funds that an individual receives without any physical or mental work performed. Examples of unearned income may be Social Security Disability Insurance Benefits, income from a trust, investments, support payments, or funds received from any other source other than work.
Waiver-See Home and Community Based Waiver Programs
Women, Infants, and Children Program (WIC)-A federal program administered by the Indiana State Department of Health that provides nutritional supplements to low-income pregnant or breast-feeding women and to infants and children younger than five years old.