Kentucky Medicaid Plan Glossary

Appeal

A request for a fair hearing concerning a proposed agency action, a completed agency action, or failure of the agency to make a timely determination.

Application

A formal request for benefits made to the agency in writing and signed by the applicant or someone acting on behalf of the applicant. Application may be received by mail, phone, fax, in person, or electronically.

Certificate of Coverage

A description of your health care coverage and benefits. Your member handbook serves as your certificate of coverage.

Countable Resource

A resource that is countable when determining resource eligibility.

Decertification

Loss of eligibility to participate as a Medicaid provider, or for a license to operate a Medical facility licensed by DMS.

Department of Community Based Services

The state agency that administers public assistance programs in Kentucky. 

Department of Medicaid Services

The state agency responsible for administering Kentucky Medicaid.

Dependent

An individual who is the financial responsibility of a member of the income unit. Example: This is someone who could be counted as a tax dependent, if income tax is filed.

Drug Formulary

A list of approved prescription drugs developed the health plan.

Emergency

The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.

Fraud

The willful intent to obtain ineligible benefits or payments.

Good Cause

An acceptable reason to defer the requirement to cooperate for certain eligibility factors.

Hearing

A hearing is when you ask your health program to review your case after your plan denied your appeal.

Income

A gain or recurrent benefit measured in money.

Inpatient

A patient who is admitted for an overnight or longer stay at a health care facility and is receiving covered services.

Kentucky Medicaid

Kentucky’s managed care Medicaid program provides comprehensive free or low-cost health care to adults, families, people with disabilities, children under 19, children in foster care and pregnant women who meet income requirements.

Kentucky Resident

A person physically residing and maintaining a residence in the Commonwealth of Kentucky. You must be a Kentucky resident to be eligible for Kentucky Medicaid. To be considered a Kentucky resident, members who are temporarily out of Kentucky for any reason may be required to prove their intent to return to Kentucky.

Dependent children who are attending school out of state may be considered residents if they are out of state during the school year, as long as their primary residence is in Kentucky and they return to Kentucky during breaks. Dependent children attending school out of state may be required to provide proof that they pay out-of-state tuition, vote in Kentucky, and file income taxes using a Kentucky address.

Your residence may be a home you own or are purchasing or renting, a shelter or other physical location where you are staying in lieu of a home, or another person's home.

kynect

It's your way to find, compare and enroll in a Medicaid health plan. For more information about kynect go to kynect.ky.gov  or call 1-844-407-8398.

Legal Guardian

A person who has been granted custody of a minor by court order.

Maternity Benefits Program

The Kentucky Medicaid program includes all Medicaid benefits, including maternity benefits, maternity support services, and maternity case management, and is made available to Kentucky Medicaid members who become pregnant, notify Kentucky Medicaid and UnitedHealthcare Community Plan, and apply for benefits. Eligibility for the program is determined by Kentucky Medicaid.

Medicaid

A state health insurance program for people with low income who meet certain eligibility requirements. Programs can vary from state to state. For information on Kentucky’s Medicaid programs visit https://chfs.ky.gov/agencies/dms/Pages/default.aspx 

Medicare

A federal health insurance program for people who are 65 or older, people with disabilities, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.

Member

An eligible person enrolled in the UnitedHealthcare Health Plan.

Outpatient

A nonhospitalized patient receiving covered services away from a hospital, such as in a physician's office or the patient’s own home, or in a hospital outpatient or hospital emergency department or surgical center.

Primary Care Provider (PCP)

Your PCP is the doctor you see for most of your care provider. Your PCP can be a family or general practitioner, internist, pediatrician, naturopathic physician or other provider approved by UnitedHealthcare Community Plan. 

Provider

A health care professional (such as a doctor, nurse, internist, etc.) or facility (such as a hospital, clinic, etc.).

Recertification

Periodic review of your family’s income and eligibility. During recertification, you must submit current income and residency documentation to verify your eligibility and/or level of premium subsidy. You must recertify for Medicaid every 12 months.

Specialist

A provider of specialized medicine, such as a cardiologist or a neurosurgeon.

Spouse

An individual who is legally married to another or who presents to the community as a husband or wife in a non-legal relationship.

Third Party

An individual, institution, corporation or agency that is responsible for all or part of the medical assistance furnished under the Medicaid State Plan.