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Washington Apple Health (Medicaid) Glossary

Glossary

A

  • 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.

B

  • Behavioral Health Services Only

    This term means those who receive only Behavioral Health benefits based on income requirements.

C

  • 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.

D

  • Decertification

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

  • Department of Social and Health Services (DSHS)

    The state agency that administers public assistance programs in Washington State.

  • 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.

E

  • 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.

F

  • Fraud

    The willful intent to obtain ineligible benefits or payments.

G

  • Good Cause

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

H

  • Health Care Authority (HCA)

    The Washington state agency responsible for administering Washington Apple Health (Medicaid), Apple Health Expansion and other state health programs.

  • Hearing

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

I

  • 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.

L

  • Legal Guardian

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

M

  • Maternity Benefits Program

    Apple Health (Medicaid) benefits include maternity benefits, maternity support services, and maternity case management. Apple Health (Medicaid) and Apple Health Expansion members who become pregnant should notify Washington Health Care Authority (HCA) and UnitedHealthcare Community Plan, to apply for Apple Health for Pregnant Individual coverages.. Eligibility for the program is determined by HCA.

  • 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 Washington’s Apple Health (Medicaid) programs, visit https://www.hca.wa.gov/apple-health

  • 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.

O

  • 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.

P

  • 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.).

R

  • 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.

S

  • Service Area

    The geographic area served by a health plan that provides coverage for Apple Health (Medicaid).

  • 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.

T

  • 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.

W

  • Washington Apple Health (Medicaid)

    Apple Health (Medicaid) provides comprehensive free or low-cost health care to adults, families, individuals with disabilities, children under 19, children in foster care and pregnant individuals who meet income and eligibility requirements.

    Apple Health Expansion provides comprehensive free or low-cost health care to adults 19 and older who meet income requirements and do not qualify for other Apple Health programs based on immigration status.

  • Washington Healthplanfinder

    Washington Healthplanfinder is the website to find, compare and enroll in a health plan that fits your needs and budget. For more information about Apple Health or to enroll, please visit: wahealthplanfinder.org or call 1-855-WAFINDER (1-855-923-4633) TTY/TTD 1-855-627-9604.

  • Washington Resident

    A person physically residing and maintaining a residence in the state of Washington. You must be a Washington resident to be eligible for Washington Apple Health. To be considered a Washington resident, members who are temporarily out of Washington for any reason:

    • May be required to prove their intent to return to Washington State; and
    • May not be out of Washington State for more than three consecutive calendar months.

    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 Washington State and they return to Washington State during breaks. Dependent children attending school out of state may be required to provide proof that they pay out-of-state tuition, vote in Washington, and file income taxes using a Washington 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.

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Disclaimer information

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Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Special Needs plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. Benefits, features and/or devices may vary by plan/area.

Premium disclaimer

Dual Special Needs plans have a $0 premium for members with Extra Help (Low Income Subsidy).

Benefit disclaimer

Benefits, features, and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply.

Nurse Hotline disclaimer

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your provider's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time. Nurse Hotline not for use in emergencies, for informational purposes only. Access to this service is subject to terms of use.

Star ratings disclaimer

Every year, Medicare evaluates plans based on a 5-Star rating system. The 5-Star rating applies to plan year 2026.

Formularies

The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary.

Important provider information

The choice is yours

We will provide you with information to help you make informed choices, such as physicians' and health care professionals' credentials. This information, however, is not an endorsement of a particular physician or health care professional's suitability for your needs.

The providers available through this application may not necessarily reflect the full extent of UnitedHealthcare's network of contracted providers. There may be providers or certain specialties that are not included in this application that are part of our network. If you don't find the provider you are searching for, you may contact the provider directly to verify participation status with UnitedHealthcare's network, or contact Customer Care at the toll-free number shown on your UnitedHealthcare ID card. We also recommend that, prior to seeing any physician, including any specialists, you call the physician's office to verify their participation status and availability.

Some network providers may have been added or removed from our network after this directory was updated. We do not guarantee that each provider is still accepting new members.

Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.

American Disabilities Act notice

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 ("ADA"), UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

Referrals

Network providers help you and your covered family members get the care needed. Access to specialists may be coordinated by your primary care physician.

Paper directory requests

Paper copies of the network provider directory are available at no cost to members by calling the customer service number on the back of your ID card. Non-members may download and print search results from the online directory.

Declaration of disaster or emergency

If you’re affected by a disaster or emergency declaration by the President or a governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.

  • Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare certified facilities);
  • Where applicable, requirements for gatekeeper referrals are waived in full;
  • Plan-approved out-of-network cost-sharing to network cost-sharing amounts are temporarily reduced; and
  • The 30-day notification requirement to members is waived, as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the member.

If CMS hasn’t provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.