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Affordable Care Act (ACA) - A federal health care reform law enacted in March 2010.
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Aged, Blind, Disabled (ABD) - A Medicaid eligibility category defined as those Ohioans who financially qualify and are 65 or older, blind, or who have disabilities.
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All Services Plan - The service coordination and payment authorization document that identifies goals, objectives and measurable outcomes for health and functioning of an individual on a waiver expected as a result of services provided by both formal and informal caregivers, and that addresses the physical and medical conditions of the individual.
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Authorized Representative - An authorized representative is an individual, age 18 or older, who stands in your place, to help you apply for Medicaid, and/or represent you in a state hearing. You must provide a written statement naming the authorized representative and the duties the authorized representative may perform on your behalf. All notices and correspondence issued by Medicaid must be issued to both you and the authorized representative. An authorized representative is not the same a personal representative who can speak to and work with your managed care plan, on your behalf. If you would like to name someone as your personal representative, you will need to complete and submit paperwork to your managed care plan.
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Beneficiary - A person who is eligible to receive Medicaid coverage.
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Breast and Cervical Cancer Project (BCCP) - Provides full Medicaid coverage to certain women diagnosed with breast or cervical cancer, including pre-cancerous conditions.
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Caretaker Relative - A relative of a dependent child by blood, adoption, or marriage who lives with the child and who assumes primary responsibility for the child's care. Claiming the child as a tax dependent is not required to count as a caretaker relative. A caretaker relative is: (a) the child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, or stepsister. (b) The child’s aunt, uncle, nephew, or niece, including such relatives who start with great, great-great, grand, or great-grand. (c) The child’s first cousin or first cousin once removed. (d) The spouse of such parent or relative, even after the marriage ends by death or divorce.
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Centers for Medicare and Medicaid Services (CMS) - The federal agency with the Department of Health and Human Services that directs the Medicare and Medicaid programs.
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Code of Federal Regulations (CFR) - A collection of general and permanent rules that are published in the Federal Register by agencies and departments in the Federal government. These rules guide the State in its administration of the Medicaid program and its implementation/operation of the Medicaid Information Technology System (MITS).
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Coordination of Benefits (COB) - The process of determining which health plan or insurance policy will pay first when a Medicaid beneficiary is covered by multiple health care insurers.
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Copay - The fee paid by the beneficiary to the provider at the time a service is rendered, unless the beneficiary is exempt from that liability.
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County Department of Job and Family Services (CDJFS) - Offices located in each of Ohio's 88 counties which provide assistance to Ohioans looking to apply for Medicaid and other public assistance.
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Current Procedural Terminology (CPT) - Coding manual used by medical professionals to identify the type of service provided to a beneficiary.
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Date of Service (DOS) - The date that a service or services are rendered to a beneficiary.
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Department of Developmental Disabilities (DODD) - The Ohio Department of Developmental Disabilities (DODD) oversees a statewide system of supports and services for people with developmental disabilities and their families. DODD does this by developing services that ensure an individual’s health and safety, encourage participation in the community, increase opportunities for meaningful employment, and provide residential services and support from early childhood through adulthood.
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Department of Health and Human Services (HHS) - The Federal government's principal agency for protecting the health of all Americans and providing essential human services.
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Department of Rehabilitation and Correction - The Ohio Department of Rehabilitation and Correction (DRC or ODRC) is the administrative department of the Ohio state government that operates state prisons for adults in Ohio.
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Disability Determination Redesign (DDR) - The disability determination redesign is part of a comprehensive strategy to modernize the administration of Ohio’s Medicaid program. As a result of the disability determination redesign, Ohio will join the majority of states in having a single process for the application and determination of disability benefits.
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Dual Eligible - A person who qualifies for two health insurance plans, often referring to a Medicare beneficiary who also qualifies for Medicaid benefits.
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Durable Medical Equipment (DME) - Includes certain types of equipment and supplies for beneficiaries that serve a medical purpose and can stand repeated use. Also known as home medical equipment.
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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) - A comprehensive set of health care services for children younger than 21 who are enrolled in Medicaid. This is called Healthchek in Ohio. In FFS Medicaid, there is a county-level Healthchek coordinator who can help find providers, make referrals to community programs and resources, and aid with lead mitigation. In MCP Medicaid, Healthchek is managed by the MCPs. For individuals under age 21, medical services must be processed for medical necessity, at the lowest cost alternative, even if the services are not normally covered by Medicaid.
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Explanation of Benefits (EOB) - A text description of denial or reduced payment included on the provider's remittance advice.
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Federal Poverty Level (FPL) - The maximum amount of money that a person or family can make and still be considered to be in poverty.
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Federally Qualified Health Center (FQHC) - A health center in a medically under-served area or population that is eligible to receive cost-based Medicaid and Medicare reimbursement and provides direct reimbursement to nurse practitioners, physician assistants, and certified nurse midwives.
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Fee-for-Service (FFS) - A traditional method of paying for medical services under which providers are paid for each service they provide. Bills are either paid by the patient, who then submits them to the insurance company, or the provider, who then submits them to the patient’s insurance carrier for reimbursement.
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Health Insurance Portability and Accountability Act (HIPAA) - A federal law that includes requirements to protect patient privacy, to protect security of electronic medical records, to prescribe methods and formats for exchange of electronic medical information, and to uniformly identify providers.
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Health Insuring Corporation - A corporation licensed in the State of Ohio that enters into a provider agreement with the Ohio Department of Medicaid in the managed health care program.
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Healthchek - A comprehensive set of health care services for children younger than 21 who are enrolled in Medicaid. In FFS Medicaid, there is a county-level Healthchek coordinator who can help find providers, make referrals to community programs and resources, and aid with lead mitigation. In MCP Medicaid, Healthchek is managed by the MCPs. For individuals under age 21, medical services must be processed for medical necessity, at the lowest cost alternative, even if the services are not normally covered by Medicaid.
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Helping Ohioans Move, Expanding Choice (HOME Choice) - Assists older adults and persons with disabilities to move from long-term services and support systems to home and community-based settings.
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Home Health Agency - A provider that specializes in giving skilled nursing, aide, and therapeutic services in the home.
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Home Medical Equipment (HME) - The medical equipment that is paid for by Medicaid and used by beneficiaries in their homes.
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Hospice - A Medicaid benefit that provides palliative medical and social support services needed for the management of an individual's terminal illness.
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Hospital Care Assurance Program (HCAP) - The Ohio Department of Medicaid’s mechanism for meeting the federal requirement to provide additional payments to hospitals which provide a disproportionate share of uncompensated services to the indigent and uninsured.
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Integrated Care Delivery System (ICDS) - A system of managed care plans selected to coordinate the physical, behavioral, and long-term care services for individuals over the age of 18. This system is also called MyCare Ohio.
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Interactive Voice Response System (IVR) - A phone technology that enables individuals to access information related to their eligibility and managed care.
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Intermediate Care Facility for Individuals with Developmental Disabilities (ICF-IDD) - A residential facility for individuals with developmental disabilities that teaches living skills to help people live in less restricted environments.
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Internal Classification of Diseases (ICD) - The standard diagnostic tool for epidemiology, health management, and clinical purposes. Used to classify diseases and other health problems.
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Level One Waiver - A waiver program that allows people who have care needs which require them to live in an Intermediate Care Facility for Individuals with Intellectual Disabilities, to live in the community.
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Long-Term Care (LTC) - A set of health care, personal care, and social services provided to persons who have lost, or never acquired, some degree of functional capacity. Administered at an institution or at home on a long-term basis.
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Managed Care Network - A panel of providers associated with a managed care plan.
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Managed Care Plan (MCP) - Private health insurance companies that are contracted with the State of Ohio and are responsible for arranging and covering all of the health care services offered through traditional Medicaid for their covered beneficiaries.
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Medicaid - The federal medical assistance program that is described in Title XIX of the Social Security Act. Medicaid is administered at the state level and is income or resource-based.
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Medicaid Buy-In for Workers with Disabilities (MBIWD) - Provides health care coverage to working Ohioans who have disabilities and who meet eligibility criteria. Some MBIWD recipients are required to pay monthly premiums based on their incomes.
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Medicaid Premium Assistance Program (MPAP) - Helps people who have limited incomes and assets and are eligible for Medicare pay the costs of Medicare premiums, deductibles, and coinsurance.
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Medicare - The federal health insurance program that is described in Title XVII of the Social Security Act. Medicare is administered at the federal level and is predominantly age-based, only those over age 65 or those with certain disabilities qualify.
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Modified Adjusted Gross Income (MAGI) - “MAGI” stands for “Modified Adjusted Gross Income.” MAGI-Based Eligibility methodology is used to calculate a person’s household size and income. MAGI-Based Eligibility applies to individuals who are considered Covered Families and Children (CFC) Medicaid categories including families, children up to age 19, pregnant women and adults 19 – 64 who are below 138% Federal Poverty Level (FPL).
MAGI rules also apply to time-limited coverage for individuals who were enrolled in Medicaid’s parent category and lost eligibility due to increased earnings or spousal support.
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MyCare Ohio - MyCare Ohio is a way that Medicare, a Federal health care program for disabled people and people aged 65 and older, is working with the Ohio Department of Medicaid to give people with both Medicare and Medicaid a better experience. CMS is the federal agency which oversees Medicaid and Medicare. The MyCare Ohio program offers managed care plans for people with Medicare AND Medicaid that provide all services for both programs, and even some additional services.
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Non-Emergency Transportation (NET) - Medicaid provides transportation to appointments for covered health care services for those who cannot transport themselves.
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Nursing Facility (NF) - Any long-term care facility (excluding Intermediate Care Facilities for Individuals with Intellectual Disabilities), or part of a facility that is currently certified by the Ohio Department of Health as being in compliance with the nursing facility standards and Medicaid conditions of participation.
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Ohio Administrative Code (OAC) - Contains the full text of state agency rules and regulations.
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Ohio Department of Job and Family Services (ODJFS) - Develops and oversees the State’s public assistance, workforce development, unemployment compensation, child and adult protective services, adoption, child care, and child support programs.
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Ohio Department of Medicaid (ODM) - Launched in July 2013, the Ohio Department of Medicaid (ODM) is Ohio's first Executive-level Medicaid agency. With a network of approximately 90,000 active providers, ODM delivers health care coverage to more than 3 million residents of Ohio on a daily basis.
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Ohio Revised Code (ORC) - Contains all acts and laws passed by the Ohio General Assembly and signed by the Governor.
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Personal Representative - A personal representative is a person aged 18 years or older, who stands in the place of the beneficiary to hear information from the managed care plan about the beneficiary’s medical coverage and/or make health care decisions on the beneficiary’s behalf. The managed care plans have forms available on their websites which can be submitted to the plans to name a personal representative, or forms can be requested by calling a managed care plan’s Member Services Department.
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Pre-Admission Screening Resident Review (PASRR) - The system used to determine eligibility for nursing facility placement and/or specialized services.
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Pre-Admission Screening System Providing Options and Resources Today (PASSPORT) - Medicaid waiver program that helps eligible, older Ohioans get the long-term services and support they need to stay in their homes.
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Precertification (Pre-Cert) - The authorization for a specific surgical procedure before it is done or for admission to an institution for care to assure that elective medical and surgical procedures are performed in the appropriate location and are medically necessary. May also be referred to as preadmission certification.
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Pregnancy-Related Services (PRS) - Medical services provided to pregnant women in order to support the life and health of the fetus.
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Prior Authorization (PA) - A requirement that a provider justify the need for delivering a particular service in order to receive reimbursement. Imposed by a health plan or third party administrator.
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Private Duty Nursing (PDN) - The planning of care and care of clients by nurses who work one-on-one with individuals. Care can be provided in the client's home or an institution.
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Program of All-Inclusive Care for the Elderly (PACE) - Integrates the provision of acute and long-term care across settings for frail older adults who have been determined to require at least an intermediate level of care.
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Provider - A person, organization, or institution that provides health care related services and is enrolled in the Ohio Medicaid program.
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Provider Agreement - A contract between the Ohio Department of Medicaid and a provider of Medicaid services in which the provider agrees to comply with the terms of the Department of Medicaid, the State of Ohio, and the Ohio Administrative Code.
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Rural Health Clinic (RHC) - A public or private hospital, clinic, or physician practice designated by the Federal government as in compliance with the Rural Health Clinics Act. Located in areas that are medically underserved or experiencing a shortage of health professionals.
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Service Level Agreement - A formally negotiated agreement between two parties that records the common level of understanding about the level of service.
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State Children's Health Insurance Program (SCHIP) - Provides children and pregnant women with comprehensive health coverage if they meet specific financial criteria.
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Teletype (TTY) - Telephone-based technology developed for those who have a hearing or speech disability that allows Medicaid beneficiaries to type and receive messages instead of talking and listening.
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Waiver (home and community based) Programs - Medicaid home and community-based services waivers allow people with disabilities and chronic conditions to receive care in their homes and communities instead of in long-term care facilities, hospitals or intermediate care facilities. Waivers allow individuals with disabilities and chronic conditions to have more control of their lives and remain active participants in their community.