Common Medicaid Terms – Definitions

Medicaid provides more than 66 million Americans with health insurance according to the Kaiser Family Foundation. However, enrolling for the first time can be challenging because you are likely to come across unfamiliar terms. This guide will take you through some of these terms as well as provide a definition for each term.

Beneficiary

The person who benefits from accessing healthcare insurance through Medicaid.

Copayment

A set amount of money that a beneficiary pays for accessing healthcare services such as visiting a doctor’s office or getting prescription drugs.

Hospital Benefit Period

The benefit period starts the moment a beneficiary visits a hospital or healthcare provider’s facility. It ends when a beneficiary goes for 60 straight days without receiving medical care from a hospital.

Credible Coverage

Credible coverage consists of any uninterrupted health insurance that you might have had in the past. This includes group health plan provided by an employer or individual health coverage.

Underwriting

Medical underwriting is a process that insurance companies use to determine whether it makes financial sense to provide health insurance to an applicant. In general, this involves careful scrutiny of one’s medical history.

Deductible

Your share of medical costs that you have to pay out-of-pocket to cover the cost of prescription medications or hospitals visits. The balance is paid by your healthcare plan.

Primary Care Doctor

This is the physician who provides basic medical care. In most cases, a primary care doctor is the medical professional you see first when you have any health problems. Depending on the diagnosis, your doctor may refer you to a specialist or another primary care provider.

Hospice Care

Terminally ill people require specialized care that involves continuous medical treatment as well as emotional, physical, and spiritual support. A hospice facility provides this care to both patients and their families.

Custodial Care

Non-medical and unskilled care provided to patients mostly at home. This includes helping patients cook, take a bath, eat, dress, take their medications, use toilet facilities, or moving around.

Comprehensive outpatient rehabilitation facility (CORF)

Healthcare facility that provides rehabilitation services such as physical therapy to patients recovering from injuries or illnesses. A CORF facility will offer these services on an outpatient basis.

Medicaid Buy-In Program

A program that provides healthcare coverage to people with disabilities in order for them to return to work. Although regulations governing these programs vary from one state to another, criteria such as disability, income level, and age play a big role in determining eligibility.

Preferred Drug List (PDL)

A PDL contains names of drugs that a drug provider can prescribe without requiring prior authorization. To prescribe a drug that is not on the PDL, a drug provider must seek authorization from the local Medicaid agency.

State Children’s Health Insurance Program (SCHIP)

A program run by the federal government that provides children from low-income families with health insurance. Take note that children who are eligible for Medicaid plans cannot enroll in SCHIP.

Managed Care Organization (MCO)

An MCO is an organization that has a contractual agreement with a Medicaid agency to provide certain benefits to Medicaid enrollees. In return, the MCO receives monthly capitation payment (a fixed monthly payment).