of Terms Used in the Utah Medicaid Program
is a list of common terms used in the Medicaid program and
a list of common acronyms
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.
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.
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
a person who applies for Medicaid and may be eligible. "Client"
is used interchangeably with "recipient" when
the person is eligible for Medicaid.
Income deductions allowed from gross monthly income.
of Medicaid and Health Financing: the government agency
in the Utah Department of Health which administers the Medicaid
program in Utah.
: 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
Poverty Level (FPL): on the Internet at http://aspe.hhs.gov/poverty
All money available to the household counts as income.
For example, wages, child support, interest from investments
or bank accounts, Social Security, retirement income.
Care Plan (MCP): a managed care plan offering coverage
for medical care which may include mental health,
pharmacy, and/or dental services.
the medical assistance program authorized under Title XIX
of the Social Security Act.
Agency: the Utah Department of Health, Division of Medicaid
and Health Financing.
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.
Mental Health Plan or 'PMHP': a managed care
plan offering coverage for mental health care services.
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.
Authorization: approval given by the Division of Medicaid
and Health Financing before certain medical services being
provided. When Medicaid requires prior authorization,
the Medicaid provider is responsible for obtaining
any individual or entity furnishing medical, mental health,
dental or pharmacy services.
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
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
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.
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.
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.
a list of acronyms commonly used in the administration,
policies or procedures of Utah's Medicaid Program click
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