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IHMO Ch 13 Key Term
| Question | Answer |
|---|---|
| Categorically needy | Aged, blind, or disabled individuals or families and children who meet financial eligibility requirements for Aid to Families with Dependent Children, Supplemental Security Income, or an optional state supplement. |
| Coinsurance | A cost-sharing requirement under a health insurance policy providing that the insured will assume a percentage of the costs for covered services |
| Copayment (copay) | A patient's payment of a portion of the cost at the time the service is rendered. |
| Covered services | Specific services and supplies for which Medicaid will provide reimbursement; these consist of a combination of mandatory and optional services stated in the plan. |
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) | The program covers screening and diagnostic services to determine physical or mental defects in recipients younger than 21 years of age and health care, treatment, and other measures to correct any defects and chronic conditions discovered. |
| Fiscal agent | An organization under contract to the state to process claims for a state Medicaid program; insurance carrier handling claims from physicians and other suppliers of service for Medicare Part B. |
| Maternal and Child Health Program (MCHP) | A state service organization to assist children younger than 21 years of age who have conditions leading to health problems. |
| Medicaid (MCD) | A federally aided, state-operated, and state-administered program that provides medical benefits for certain low-income persons in need of health and medical care. |
| Medi-Cal | California's version of the nationwide program known as Medicaid. |
| Medically needy (MN) | Persons in need of financial assistance or whose income and resources will not allow them to pay for the costs of medical care; also called medically indigent in some states. |
| Prior approval | The evaluation of a provider request for a specific service to determine the medical necessity and appropriateness of the care requested for a patient. |
| Recipient | A person certified by the local welfare department to receive the benefits of Medicaid under one of the specific aid categories; an individual certified to receive Medicare benefits. |
| Share of cost | The amount the patient must pay each month before he or she can be eligible for Medicaid; also known as liability or spend down. |
| State Children's Health Insurance Program (SCHIP) | A state child health program that operates with federal grant support under Title V of the Social Security Act. |
| Supplemental Security Income (SSI) | A program of income support for low-income aged, blind, and disabled persons established by Title XVI of the Social Security Act. |
| DEFRA | Deficit Reduction Act |
| EPSDT | early, periodic, screening, diagnosis, and treatment |
| FPL | federal poverty level |
| MCD | Medicaid |
| MCHP | Maternal and Child Health Program |
| MN | medically needy |
| MQMB | Medicaid Qualified Medicare Beneficiary |
| OBRA | Omnibus Budget Reconciliation Act |
| OOY | over-one-year claims |
| POS | point-of-service machine |
| QI | qualifying individuals program |
| QMB | qualified Medicare beneficiary |
| RA | remittance advice |
| SCHIP | State Children's Health Insurance Program |
| SLMB | specified low-income Medicare beneficiary |
| SSI | Supplemental Security Income |
| TANF | Temporary Assistance to Needy Families |
| TEFRA | Tax Equity and Fiscal Responsibility Act |
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