Definitions of Terms Used in the Utah Medicaid Program

Following is a list of common terms used in the Medicaid program and a list of common acronyms (abbreviations.)

Assets:  Generally, assets are any type of "property", either in cash or items easily turned into cash, such as bank accounts, cash on hand, land, houses, buildings. Each public assistance program has its own rules about what counts as an asset.  Also, assets which a person reasonably needs for normal living are generally exempt.  For example, the home in which a family lives is an exempt asset.   The value of a vehicle may or may not be counted, depending on the Medicaid program for which a person qualifies.  Some  programs exempt the value of one car that is used four times a year to get to medical appointments, if it is needed for employment, if it is needed for daily living activities due to terrain, or if it has been modified to transport a disabled person.  Other programs exempt only a portion of one car's equity value.

Basic Maintenance Standard (BMS):  This is the income standard, or monthly income limit, used to determine Medicaid eligibility. If a household's income is more than the monthly limit for the household size, after allowable deductions,  the Medically Needy (Spenddown) program may be considered.  See 'Spenddown'.

Child Health Evaluation and Care or "CHEC": The program  to provide comprehensive health care to children from birth to 21 years of age who are eligible for Medicaid.

Client: a person who applies for Medicaid and may be eligible. "Client" is used interchangeably with "recipient" when the person is eligible for Medicaid.

Deductions:  Income deductions allowed from gross monthly income.

Division of Health Care Financing: the government agency in the Utah Department of Health which administers the Medicaid program in Utah.

Fee-for-service :   A fee-for-service Medicaid client is defined as either of the following: (1) a client who is not enrolled in a managed care plan, such as a health maintenance organization (HMO); or (2) a client who is enrolled in a managed care plan, but the service that is needed is covered by Medicaid, not by the plan. For more information, go to Fee for Service.

Federal Poverty Level (FPL): on the Internet at http://aspe.hhs.gov/poverty

Health Maintenance Organization or 'HMO': a managed care plan offering coverage for medical care which may include mental health, pharmacy, and/or dental services.

Income:  All money available to the household counts as income.  For example, wages, child support, interest from investments or bank accounts, Social Security, retirement income.

Medicaid: the medical assistance program authorized under Title XIX of the Social Security Act.

Medicaid Agency: the Utah Department of Health, Division of Health Care Financing.

Medicare: the national health insurance program for aged and disabled persons under Title XVIII of the Social Security Act. Part A includes hospital and skilled nursing facility services. Part B pays professional fees such as physician and outpatient services, physical and occupational therapy, etc. Prescription Drug Coverage was added January 1, 2006, in which beneficiaries choose a drug plan and pay a monthly premium.

Prepaid Mental Health Plan or 'PMHP': a managed care plan offering coverage for mental health care services.

Primary Care Provider:  The primary physician to whom a Medicaid patient may be assigned.  When the Medicaid patient has a Primary Care Provider, this provider must provide an appropriate referral before Medicaid will pay for medical services received from any other provider.

Prior Authorization: approval given by the Division of Health Care Financing before certain medical services being provided.  When Medicaid requires prior authorization, the Medicaid provider is responsible for obtaining the authorization. 

Provider: any individual or entity furnishing medical, mental health, dental or pharmacy services.

Recipient: a person who is eligible for Medicaid.

Restriction Program: This program provides safeguards against inappropriate and excessive use of Medicaid services by assigning a Medicaid client to a Primary Care Provider and a single pharmacy.  For more information, please go to Restriction Program.

Retroactive coverage:  Medicaid eligibility for any of the three months prior to the month of application.  Most Medicaid programs allow an applicant to request coverage for medical services for up to three months prior to the month in which the person filed a Medicaid application.  A person who received medical, dental or mental health services and subsequently qualifies for Medicaid may return to each provider with a Medicaid Identification Card for the month in which service was provided. A provider who has already rendered services may subsequently choose to accept Medicaid as payment in full or refuse to seek Medicaid payment because the patient had not been determined eligible for Medicaid at the time of service.  If the provider accepts Medicaid, Medicaid may pay for the service.  If the provider refuses Medicaid, the patient is responsible for the charges.

Spenddown Program: A Medicaid program which allows applicants to reduce their monthly income to the Medicaid income standard in order to qualify for Medicaid coverage.  This program is also called the Medically Needy program.   An applicant who is otherwise eligible may either (1)  pay "excess" monthly income to the State of Utah or (2)  accept responsibility to pay a portion of their monthly medical bills. Once the household has reduced its income to the Medicaid income standard, Medicaid pays the remainder of the medical bills for eligible persons.

Third Party Liability or 'TPL':  An individual, entity, or program which is or may be liable to pay all or part of the medical cost of injury, disease, or disability of a patient.

Title XIX: the Medicaid Program authorized by the Federal Social Security Act.

Utah Department of Health: the Single State Agency designated to administer or supervise the administration of the Medicaid Program under Title XIX of the federal Social Security Act. All references to "the Medicaid agency" mean the Department of Health. Reference: Utah Code Annotated §26-18-2.1 (1953, as amended) and Utah Administrative Code, Rule R414-1-2.

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 Acronyms

For a list of acronyms commonly used in the administration, policies or procedures of Utah's Medicaid Program click here.