To ask for review of a decision that denies or limits a service.
C
Centers for Medicare & Medicaid Services (CMS)
The federal agency that administers Medicare and Medicaid.
Cost-Sharing or Share of cost
Cost-sharing refers to amounts that a member has to pay when services are received. It includes any combination of the following three types of payments: (1) any deductible amount the plan may impose before services are covered; (2) any fixed “copayment” amounts that a plan may require be paid when specific services are received; or (3) any “coinsurance” amount that must be paid as a percentage of the total amount paid for a service. Your Medicaid benefit level determines if you have any share of cost.
Covered Drugs
Prescription durgs covered by UnitedHealthcare Idaho Medicaid Plus. You may find these on the list of covered drugs, also called a formulary or drug list.
Covered Services
Services and supplies covered by UnitedHealthcare Idaho Medicaid Plus.
Custodial Care
Custodial care is personal care provided in a nursing home, hospice or another place when you do not need skilled medical care or skilled nursing care.
D
Disenrollment
The process of ending your membership in the Idaho Medicaid Plus plan. You can request to leave the UnitedHealthcare Idaho Medicaid Plus plan during the open enrollment period. Outside of the open enrollment period, the Idaho Department of Health and Welfare will determine whne your request can be processed.
Dual Eligible
A member that is eligible for both Medicare and Medicaid.
Durable Medical Equipment
Equipment that provides therapeutic benefits; is designed primarily for a medical purpose; is ordered by a physician/provider; is able to withstand repeated use; and is appropriate for use in the home. Equipment, furnished by a supplier or a human health agency that meets the following conditions:
Can withstand repeated use.
Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years.
Is primarily and customarily used to serve a medical purpose.
Generally is not useful to an individual in the absence of an illness or injury.
Is appropriate for use in the home.
E
Emergency Medical Condition
An illness, injury, symptom or condition (including severe pain) that a reasonable person could expect that not getting medical attention right away would:
Put the person's health in danger; or
Put a pregnant woman's baby in danger; or
Cause serious damage to bodily functions; or
Cause serious damage to any body organ or body part.
Emergency Medical Transportation
Taking an ambulance to the hospital for care. This happens if you call 911 and need care right away.
Emergency Services
Services to treat an emergency condition.
F
Family Planning Services
Covered services that include family planning, counselling, and/or prescriptions used to prevent pregancy.
G
Grievance
A complaint that the member communicates to their health plan. It does not include a complaint for a health plan's decision to deny or limit a request for services.
H
Home and community-based care
Supportive services needed to live at home, in a residential assisted living facility (RALF), or certified family home (CFH), instead of living in an institution such as a nursing home or an intermediate care facility (ICF/ID). Consumer-direction or self-direction options are available to members.
Hospital inpatient care
Care in a hospital that usually requires that a patient is admitted to the hospital
I
In-network provider or participating provider
A health care provider that has a contract with your health plan.
M
Medicaid
A state and federal program that helps with health care costs and other social needs like home and community-based services.
Medically Necessary
A service given by a doctor, or licensed health practitioner that helps with a health problem, stops disease, disability, or extends life.
Member or enrollee
A person who is eligible for Medicaid and who is enrolled in the UnitedHealthcare Idaho Medicaid Plus plan.
N
Network
Physicians, health care providers, suppliers and hospitals that contract with a health plan to give care to members.
Non-participating Provider/out of network provider
A health care provider that has a provider agreement with IDHW but does not have a contract with your health plan. You may be responsible for the cost of care for out-of-network providers.
P
Personal Care Services
Provides in-home, hands on services to help people stay in their own homes and communities rather than live in institutional settings, such as nursing homes.
Preventive health care
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Primary Care Provider (PCP)
A person who is responsible for the management of the member's health care. A PCP may be a:
Person licensedas an allopathic or osteopathic physician, or
Practitioner defined as a licensed physician assistant, or
Certified nurse practitioner.
Prior Authorization
Approval from a health plan that may be required before you get a service. This is not a promise that the health plan will cover the cost of the service.
R
Rehabilitation
Services that help a person restore and keep skills and functioning for daily living that have been lost or impaired.
S
Service Plan
A written description of a covered health services, and other supports which may include:
Individual goals
Family support services
Care coordination; and
Share of cost
T
Transition of care
Coordination of care activities including discharge/transition planning, timely follow-up with a provider.
Transportation
If you have a medical appointment, you can request a ride from MTM at 1-877-503-1261. You need to call at least 48 hours before your appointment.
U
Urgent Care
Care for an illness, injury, or condition serious enough to seek immediate care, but not serious enough to require emergency room care.
