Benefit Package or Plan – The group of services that is paid for
Benefits – Services, procedures, and items covered by the West
Virginia Medicaid Program or other third party health insurers.
Beneficiary (aka enrollee, client, member, or recipient) –
A person who gets health benefits through Medicaid.
Bureau for Medical Services (BMS) – The single state agency
within the West Virginia Department of Health and Human Resources (DHHR) responsible
for the Mountain Health Trust program.
Department of Health and Human Resources (DHHR) – The state
Department that oversees the Medicaid Program. County DHHR offices determine if
an individual or family qualifies for Medicaid.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program
– A set of services available for anyone under the age of 21 who gets Medicaid.
EPSDT includes well child visits. It also includes follow-up and/or continued treatment
for issues found. The well child/screening services must be provided at timeframes
that meet reasonable standards of medical practice.
Eligible Medicaid Patient – An individual with a valid identification
card receiving financial and/or medical assistance from DHHR and children in foster
care under Department supervision.
Eligible Person – A person eligible for West Virginia Medicaid
according to Title XIX regulations and who has been determined financially eligible
by the local DHHR office.
Managed Care Organization (MCO) – A MCO is a health care company.
Its doctors and hospitals provide health care services covered by Medicaid. If you
have Medicaid and are in an MCO, you will need to get health care from the doctors
and hospitals that are with your MCO.
Mandatory Medicaid Benefits – Specific types of basic health
services that a State must provide under its Medicaid program. Some of the basic
services are hospital inpatient and outpatient services, physician services, nursing
facility services for individuals aged 21 years or older, home health care for persons
eligible for nursing facility services, family planning services and supplies, laboratory
and x-ray services, and pediatric and family nurse practitioner services.
Medical Identification Card – An identification card sent monthly
to each individual or family that gets Medicaid. This card should be carried at
all times. This card gets shown to a provider’s office when an individual or family
goes for care. The provider uses the information on the card to bill Medicaid for
the services provided.
Medically Appropriate – The most cost-effective service that
best meets the member’s health needs.
Medically Necessary – Services or supplies needed to diagnose
or treat a member.
Medically Needy – An person or family whose income and resources
are above the limits for Medicaid, but whose income and resources are not enough
to meet the costs of his/her family’s health and medical care.
Member – A person enrolled in an MCO.
Medicaid (aka Title XIX, Title 19) – A program that pays for
much or all of the health care services provided to eligible individuals and families.
An individual or family must meet income and other requirements to join. In West
Virginia, Medicaid eligibility is determined by the Department of Health and Human
Medical Home – A medical home is your PCP office or clinic.
This is where you go for check-ups and sick care. All your health care records are
Mountain Health Trust – The name of West Virginia Medicaid’s
Managed Care Program. In Mountain Health Trust, members get to pick their MCO and
Participating Providers – Hospitals, nursing facilities, clinics,
home health agencies and other providers who are in an MCO and/or Medicaid.
Primary Care Provider (PCP) – Your PCP is your family doctor,
nurse of other health care provider at your medical home. The PCP takes care of
you and your family. Your doctor will:
- Take care of you when you are sick or need medical care.
- Give your kids regular check-ups and immunizations (shots) to stay
- Help you manage diseases and other conditions like diabetes, high blood
pressure, and asthma.
- Send you to specialists or other providers when you need
to go. This is called a referral.
- Answer your questions.
- Give you the information
you need to stay healthy.
- Work with you to get the health care you need.
Primary Care – Provides routine medical care and needed referrals
for other care.
Primary Care Case Management (PCCM) – A system of health care
where providers contract directly with the PCCM program. The contract required providers
to provide primary care, make referrals for specialty care, and coordinate the care
of PCCM members. The PAAS is West Virginia’s PCCM Program.
Prior Authorization (PA) – Members need to get PA for some
services. This means approval is needed before some services can be given, billed,
and paid for by Medicaid.
Redetermination Date – The date when a Medicaid member’s eligibility
is reviewed. This review checks to see if the member can stay in Medicaid.
Referral –Your PCP gives you a referral for the care you need
that the PCP cannot provide. You need a referral for most specialty services.
Spend Down –Spend Down is a process to determine Medicaid eligibility
that looks at income and health care costs. Some people make too much money to get
Medicaid, but have very high Medical costs. Spend Down would let some of these people
Third Party Liability – Any other health care payer besides
Medicaid. This could be another insurance or government program (like Medicare)
that pays for all or part of your medical costs. Medicaid is always the payer of
West Virginia Department of Health and Human Resources (WV DHHR)
– The department that provides and oversees health and human services programs in
West Virginia. This includes Medicaid.