Terms
Ambulatory Care: See Outpatient Care.
Behavioral Health: A term that includes both mental and substance use disorders.
Board Certified: Doctors or other health professionals who have passed an exam given by a medical specialty board.
Care Coordinator: A healthcare professional who helps members develop a care plan to meet health or long-term support needs.
Copayment: The portion of Medicaid-allowed charges that a member pays directly to the provider for certain services or procedures.
Cost-Sharing: A health plan where the member pays a portion of the cost of care.
Department of Social Services (DSS): Provides benefits and services to children and adults in need. Examples include medical assistance, food assistance, child care, child and adult protective services, and adoption. There are 120 local offices across Virginia.
Disease Management: Coordinating regular treatment and education for members with certain diseases. Examples include diabetes and COPD.
Dual-Eligible: A person who is eligible for both Medicare and Medicaid benefits.
Electronic Medical Record: Computerized patient health records.
Exchange: See Health Insurance Marketplace.
Family Access to Medical Insurance Security (FAMIS): A health insurance program in Virginia for eligible children age 18 and under.
Federal Poverty Level (FPL): A measure of income. It is used to help determine Medicaid and FAMIS eligibility.
Formulary: A list of prescription drugs covered by a health plan. Also called a drug list.
Health Maintenance Organization (HMO): A type of health plan that includes a network of certain doctors and health facilities. It may offer restrictions on seeing non-network providers.
Health Insurance Marketplace: A service that helps people enroll in health insurance plans. It allows people to compare private health plans for themselves and their families. It also helps determine whether a person qualifies for a subsidy to help pay for health insurance. Also known as “Marketplace” or “Exchange.”
Health Insurance Portability and Accountability Act of 1996 (HIPAA): The law that sets standards regarding the security and privacy of personal health information.
Health Risk Assessment (HRA): A survey that evaluates a person’s health risks and quality of life. An HRA may help identify health problems that need immediate assistance.
Home Health Care: Healthcare services a person receives at home.
Managed Care Organization (MCO): A health plan contracted to provide medical services. It also coordinates health care services through a network of providers.
Open Enrollment: The time of year when a Medicaid member may choose to switch to a different health plan. Members will receive a letter in the mail to alert them when it is their time for open enrollment.
Outpatient Care: Medical services that do not require keeping a patient overnight in a healthcare facility.
Physician: A doctor.
Preventive Care: Care to help prevent or detect illness before it occurs. Examples include routine physicals, well-child visits, mammograms, prostate exams, etc.
Primary Care Provider (PCP): The main doctor that provides most personal health care needs. The PCP gives referrals to other health care providers when needed.
Prior Authorization: A requirement for a provider to justify the need for a service. It may include reviewing a person’s eligibility, coverage, and medical needs.
Provider: A supplier of healthcare services like a doctor, hospital, lab, or nursing home.
Specialist: A doctor who practices a certain field of medicine. They diagnose and treat certain conditions and diseases. Some examples of specialties include pediatrics, OB-GYN, cardiology, psychiatry, and urology.
Subsidy: Health plans with reduced copayments, coinsurance, and deductibles. Available to people who purchase a silver-level plan through the Health Insurance Marketplace and have an income between 100 to 250 percent of the Federal Poverty Level. Also known as a Cost-Sharing Reduction.