120 Calendar Day Change Period - After being enrolled in a managed care plan, enrollees have 120 calendar days to change to a new plan, if they wish to do so.
Action - Denial or limited authorization of a requested service or payment to such service; reduction, suspension, or termination of a previously authorized service; or failure of a plan to timely provide services or respond to a grievance or appeal.
Acute Care Services - Short-term medical treatment that may include, but is not limited to, community behavioral health, dental, hearing, home health, independent laboratory and x-ray, inpatient hospital, outpatient hospital/emergency medical, physician, prescribed drug, vision, or hospice services.
Aging and Disability Resource Center (ADRC) - An agency designated by the Department of Elder Affairs (DOEA) to develop and administer a plan for a broad and coordinated system of services for older and disabled persons.
Cause - State-approved reasons that allow enrollees to change their Managed Care Plan outside of their open enrollment period. This is also known as “For Cause.”
Centers for Medicare & Medicaid Services (CMS) - The agency within the United States Department of Health & Human Services that provides administration and funding for Medicare, Medicaid and the Children’s Health Insurance Program under the Social Security Act.
Children's Medical Services Network (CMS Network or CMSN) - A program operated by the Department of Health that provides services for children from birth through age 21 with special health care needs.
Choice Counselor - The AHCA-authorized person who speaks with recipients to help them understand their plan choices and enrolls them into a Medicaid managed care plan.
Complaint - Any oral or written expression of dissatisfaction submitted on behalf of an enrollee submitted to the Managed Care Plan or to a state agency.
Comprehensive Assessment and Review for Long-Term Care Services (CARES) - Florida’s long-term care preadmission screening program for nursing home applicants. CARES helps to identify long-term care needs of individuals and establishes a level of care (medical eligibility) for nursing home and Medicaid waiver applicants.
Department of Children and Families (DCF) - The state agency primarily responsible for deciding Medicaid eligibility. DCF also manages other programs related to abuse and neglect, mental health, substance abuse, homelessness, and other social service programs.
Emergency Dental Services - In accordance with the Medicaid State Plan, medically necessary emergency procedures to relieve pain or infection, limited to emergency oral examinations, necessary x-rays, extractions and the incision and drainage of an abscess
Expanded Benefit - A service or benefit offered to enrollees by a managed care plan that is not available through the Medicaid state plan or fee-for-service Medicaid.
FL Medicaid Member Portal - The FL Medicaid Member Portal allows Medicaid enrollees to check Medicaid eligibility and enrollment status, view and update member addresses, request help using secure messaging, enroll in or change plans, file complaints and see what is happening with your complaint, and receive email or text message alerts instead of mail.
Grievance - Any oral or written expression of dissatisfaction by an enrollee about any matter other than an action, submitted to the Managed Care Plan or to a state agency.
Health Maintenance Organization (HMO) - Corporations that contract with a network of health care providers, such as physicians, hospitals, and laboratories, to provide health care services.
Healthy Behaviors - A program offered by MMA managed care plans that encourages and rewards behaviors that are meant to improve the enrollee’s overall health.
Level of Care (LOC) - The type of long-term care required by a recipient based on medical needs. CARES establishes the level of care for Medicaid recipients.
Long-term Care Assessment - An individualized and comprehensive assessment of an individual’s medical, developmental, behavioral, social, financial and environmental status conducted by a qualified individual for the purpose of determining the need for long-term care services.
Long-term Care Plan (LTC plan) - A managed care plan that provides the services for the Long-term Care part of the Statewide Medicaid Managed Care program.
Managed Care Plan - An eligible plan under contract with the Agency to provide services in the LTC or Managed Medical Assistance (MMA) part of the Statewide Medicaid Managed Care Program.
Managed Medical Assistance Plan (MMA plan) - A managed care plan that provides services for the Managed Medical Assistance part (MMA) of the Statewide Medicaid Managed Care (SMMC) program.
Medicaid - A medical assistance program authorized through the Social Security Act and is available to serve individuals based on financial need and other eligibility criteria.
Medicaid Benefits - Health care and prescription drug assistance available to Medicaid recipients, including those who participate in a managed care plan.
Medicaid Providers - Hospitals, nursing homes, public health units, or other entities enrolled in Medicaid or contracted with a managed care plan to provide services to individuals eligible for Medicaid.
Medicaid Recipient - An individual whom the Department of Children and Families (DCF) or the Social Security Administration (SSA) determines is approved for the Medicaid program.
Medically Needy - Individuals who are not eligible for "full" Medicaid because their income or assets are over the Medicaid program limits may qualify for the Medically Needy program. Individuals enrolled in Medically Needy must have a certain amount of medical bills each month before Medicaid can be approved. This is referred to as a "share of cost" and varies depending on the household's size and income
Medicare - A federal medical assistance program that provides health insurance for Americans of age 65 and older, as well as for persons with disabilities.
Medicare Advantage Plan - A Medicare-approved health plan offered by a private company that covers both hospital and medical services, often includes prescription drug coverage, and may offer extra coverage such as vision, hearing, dental and/or wellness programs. Each plan can charge different out-of-pocket costs and have different rules for how to get services. Such plans can be organized as health maintenance organizations, preferred provider organizations, coordinated care plans, and special needs plans.
Open Enrollment - The 60-day period when enrollees can change managed care plans without a state-approved "cause." Open enrollment occurs yearly for each enrollee.
Patient Responsibility - The cost of Medicaid long-term care services paid by the recipient, or the amount for which the recipient is responsible. This is determined by the Department of Children and Families and is based on the recipient’s income and where he/she lives.
Primary Care Provider (PCP) - A doctor, who monitors your health, treats minor health problems, coordinates your health care, and refers you to a specialist, if needed.
Primary Dental Provider - A Medicaid Prepaid Dental Health Plan staff or subcontracted dentist practicing as a general dentist or pediatric dentist who furnishes primary dental care and patient management services to an enrollee
Provider Service Networks (PSNs) - Health care delivery systems, owned and operated by hospitals, physician groups, or other providers. PSNs have a network of providers and facilities, which provide health care to enrollees.
Qualified Medicare Beneficiaries (QMB) - A Medicaid program that pays the Medicare premium for certain individuals with disability or renal kidney failure.
Routine Dental Care - A well care dental visit for preventive services (e.g. screening, cleaning, check-up, evaluation) or follow up to a previously treated condition and any other routine other than the treatment of a dental illness/condition (e.g. sick care)
Special Low-Income Medicare Beneficiary (SLMB) Program - A Medicaid program to pay the Medicare Part B premium for certain disabled or aged individuals.
Specialized Services - A service or specialized care to include, but not be limited to, personal assistance with bathing, dressing, ambulation, eating, supervision of or assistance with self-administered medications, assistance with securing health care from appropriate sources and transportation to such health care sources and socialization activities.
Straight Medicaid - Refers to Medicaid recipients who are not enrolled in a managed care plan and are receiving medical services on a fee-for-service basis. Also referred to as “regular Medicaid.”
Temporary Loss Period - The period when an enrollee loses eligibility and regains it (no longer than 60 days). During this time, the recipient is able to continue to receive Long-term Care services through their LTC managed care plan.
Third Party - An individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of medical services related to any medical assistance covered by Medicaid. A third party includes a third-party administrator or a pharmacy benefits manager.
