Glossary

  1. 90 Calendar Day Change Period - After being enrolled in a managed care plan, recipients who (1) are newly eligible for Medicaid, or (2), change during the initial 90 days, or (3) change plans during the no change period will have 90 calendar days to “try out” their plan and change to a new plan, if they wish to do so.
  2. Agency for Health Care Administration (AHCA) - Florida department responsible for administering health care programs; DCF determines eligibility for the Agency.
  3. Aging and Disability Resource Center (ADRC) - An agency designed by the Department of Elder Affairs (DOEA) to develop and administer a set of wide-ranging and coordinated services for elderly and or disabled persons.
  4. Appeal - A formal request from a recipient to seek a review for an action taken by the Managed Care Plan.
  5. Benefit - This is a list and schedule of health care services to be delivered to recipients covered under the Managed Care program.
  6. Cause - Also known as "For Cause" or "Good Cause", these are State approved reasons to change care plans during the lock-in period.
  7. 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.
  8. Choice Counseling - This is a free service to help Medicaid recipients pick the managed care plan that is best for them.
  9. Choice Counselor - Choice Counseling is a free service to help Medicaid recipients pick the care plan that is best for them. Picking a plan can be hard. For someone with special care needs or circumstances, the choice can be even more difficult. A Choice Counselor is the person that helps recipients understand their care plan choices and enrolls them into a Medicaid care plan.
  10. Community Outreach - This includes the delivery of information for the benefit, education, or assistance to a community in regards to health-related matters or public awareness. Community outreach includes the delivery of information about health care services, and other information related to social services or social assistance programs offered by the State of Florida, and local communities.
  11. Comprehensive Assessment and Review for Long-Term Care Services (CARES) - A program operated by the Department of Elder Affairs that is Florida’s long-term care preadmission screening program for Medicaid Institutional Care and Medicaid waiver program applicants. An assessment is performed to identify long-term care needs of individuals; to establish level of care (medical eligibility for nursing facility care); and to recommend the least restrictive, most appropriate placement for persons. The emphasis of this program is on enabling persons to remain in their homes through provision of home-based services or with alternative placements such as assisted living facilities.
  12. Co-Payment (Co-pay) - A Co-payment is an amount paid by the recipient for each visit or treatment. Not all visits or treatments require a co-pay. Children and pregnant women are not subject to co-pays for services that are medically necessary.
  13. Department of Children and Families (DCF) - This is the state agency primarily responsible for deciding Medicaid eligibility.
  14. Department of Elder Affairs (DOEA) - The primary state agency responsible for administering human services programs to benefit Florida's elders, for developing policy recommendations for long-term care in addition to overseeing the implementation of federally and state-funded programs and services for Florida's elder population.
  15. Disenrollment - The request to end enrollment in a managed care plan which may require State approval.
  16. Dual Eligible - Persons who are eligible to receive services through the Medicare and Medicaid programs.
  17. Enrollment - The process by which eligible Medicaid recipients enroll in a managed care plan.
  18. Field Choice Counselors - Choice Counseling is a free service to help Medicaid recipients pick the long-term care plan that is best for them. Picking a plan can be hard. For someone with special care needs or circumstances, the choice can be even more difficult. A field choice counselor is the person that meets face to face with the recipients to help them understand their care plan choices and to enroll them into a Medicaid Managed care plan.
  19. Full Medicaid coverage - A person with Full Medicaid coverage is someone who has submitted a Medicaid application to the Department of Children and Families (DCF), and has been found to meet all of the requirements and limits that qualify individuals for this particular program. If you are notified that you have been approved for full Medicaid coverage, this means that full medical coverage exists at the time you choose to start receiving services.
  20. Guardian - A legal representative appointed by the court to act on behalf of a minor or legally incompetent adult.
  21. Health Maintenance Organization (HMO) - HMOs are corporations, licensed under Chapter 627 F.S., that contract with a network of health care providers, such as physicians, hospitals, and laboratories to provide health care services.
  22. Hospice - Facility or program that provides care for terminally ill persons.
  23. Level of Care (LOC) - The type of Long-term care required by a recipient based on medical needs. Department of Elder Affairs CARES staff establish level of care for Medicaid recipients.
  24. Lock-in - It is the period of time where recipients cannot change managed care plans, unless there is a state-approved good cause.
  25. 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.
  26. Long-term Care Plan (LTC plan) - A managed care plan that provides the services for the long-term care component of the Statewide Medicaid Managed Care program.
  27. Managed Care Plan - An eligible plan under contract with the Agency for Health Care Administration to provide services under the Long-term Care or Medical Assistance plan component of the Statewide Medicaid Managed Care program.
  28. Medicaid - It is a state administered federal program of medical assistance that is available to serve individuals based on financial need. Such persons are low-income adults, their families, and persons with certain disabilities. The purpose of Medicaid is to improve the health of people who might otherwise go without medical care for themselves and their children. Medicaid assists qualified persons with the costs of nursing facility care and other medical or health-related expenses. Eligibility for Medicaid is usually based on the family’s or individual’s income and assets.
  29. Medicaid Benefits - Health care and prescription drug assistance available to Medicaid recipients who participate in a managed care plan.
  30. Medicaid Pending - Medicaid Pending is an option for receiving services without having to wait until the DCF completes and approves the Medicaid long-term care application.
  31. Medicaid Providers - Hospitals, nursing homes, public health units, or other entities providing services to individuals eligible for Medicaid.
  32. 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.
  33. Medicare - It is the medical assistance program created to provide health insurance for Americans of age 65 and older, as well as for persons with disabilities so that they could receive health and human services. Eligibility for Medicare is not based on the person’s income or assets. Medicare covers hospitalization, medical care and drugs for aged and disabled individuals.
  34. Nursing Facility - An institutional care facility that furnishes medical or allied inpatient care and services to individuals needing such services.
  35. Open Enrollment - This is the 60 day period when recipients can change managed care plans without a State Approved "Cause" (See definition). Open enrollment occurs yearly on the recipient's anniversary of their first enrollment into a plan.
  36. Optional Services - Services that the state chooses to offer in addition to the federally mandated services.
  37. Patient Responsibility - This is 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.
  38. Power of Attorney - A legal document used for one person to designate another to act on his behalf.
  39. Primary Care Provider (PCP) - A PCP is usually a doctor that monitors your health, treats minor health problems, coordinates your health care, and refers you to a specialist, if needed.
  40. Provider Service Networks (PSNs) - PSNs are health care delivery systems owned and operated by hospitals or physician groups. PSNs have a network of providers and facilities, which provide health care to enrolled recipients.
  41. Qualified Medicare Beneficiaries (QMB) - A Medicaid Program that pays the Medicare premium for certain individuals with disability or renal kidney failure.
  42. Recipient - This is a person eligible for Medicaid who is enrolled in a managed care plan.
  43. Special Low-Income Medicare Beneficiary (SLMB) Program - A Medicaid program to pay the Medicare Part B premium for certain disabled or aged individuals.
  44. Specialized Services - Any 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.
  45. Transportation - An appropriate means of transport provided to an enrollee or recipient to obtain Medicaid authorized/covered services.
  46. Voluntary Enrollment Recipients - Recipients who are not required to enroll in a managed care plan, but can choose to do so.