Definitions

Benefit Package or Plan – The group of services that is paid for by Medicaid.

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 Resources.

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 kept here.

Mountain Health Trust – The name of West Virginia Medicaid’s Managed Care Program. In Mountain Health Trust, members get to pick their MCO and PCP.

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 well.
  • 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 get Medicaid.

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 last resort.

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.

Want to talk to us about your choices? Have questions? Need help?
Call us at 1-800-449-8466. TTY/TTD: 1-800-449-8466. The call is free!

(Monday-Friday from 8 AM to 8 PM)
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Mountain Health Trust
405 Capitol Street
Suite 406
Charleston, WV 25301
1.800.449.8466