Glossary of Terms
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 Manged Care Organization (MCO)
responsible for state-wide coverage for Hoosier Healthwise
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
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
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
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
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
Centers for Medicare & Medicaid Services
(CMS)-Federal agency overseeing the Medicaid and Medicare
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
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
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
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
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
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
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
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
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
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
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
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
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: www.in.gov/HoosierRX.com.
Hospice-An organization that furnishes
inpatient, outpatient, and home health care for the terminally
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
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
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
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
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
Managed Health Services (MHS)-An MCO
responsible for state-wide coverage for Hoosier Healthwise
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
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
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
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
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
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
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
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
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
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.
Spend-down-Process whereby Medicaid eligibility
may be established if an individual's income is more than that
allowed under the State's income standards and incurred medical
expenses are at least equal to the difference between the income
and the medically needy income standard.
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.
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
Waiver-See Home and Community Based Waiver
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.