Affordable Care Act (ACA)
A federal health care reform law enacted in March 2010.
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.
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.
Ambulatory Surgery Center (ASC)
A health care facility that specializes in providing surgery, pain management, and certain diagnostic services in an outpatient setting.
An authorized representative is an individual, age 18 or older, who stands in your place. 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.
A person who is eligible to receive Medicaid coverage.
Breast and Cervical Cancer Project (BCCP)
Provides full Medicaid coverage to certain women diagnosed with breast or cervical cancer, including pre-cancerous conditions.
Bureau of Health Plan Policy (BHPP)
Publishes administrative rules that govern the types of services covered and the methods of provider reimbursement.
Bureau of Long Term Care Facilities (BLTCF)
Oversees the Medicaid policies for nursing homes and intermediate care facilities for individuals with intellectual disabilities.
Bureau of Managed Care (BMC)
Develops, administers, and assesses the Ohio Medicaid Managed Care Program.
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.
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.
Change of Operator/Provider (CHOP)
Refers to when the operator of a long term care facility changes.
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).
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.
The fee paid by the beneficiary to the provider at the time a service is rendered, unless the beneficiary is exempt from that liability.
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.
Covered Families and Children (CFC)
Refers to those who are eligible for the Healthy Families and Healthy Start programs.
Current Procedural Terminology (CPT)
Coding manual used by medical professionals to identify the type of service provided to a beneficiary.
Date of Service (DOS)
The date that a service or services are rendered to a beneficiary.
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.
Diagnosis Related Group (DRG))
A patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources.
A person who qualifies for two health insurance plans, often referring to a Medicare beneficiary who also qualifies for Medicaid benefits.
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.
Electronic Data Interchange (EDI)
The computer-to-computer transfer of business transaction information using standard, industry-accepted document formats.
Electronic Data Management System (EDMS)
The central document repository for provider and/or beneficiary-related documentation.
Electronic Health Record (EHR)
An individual medical record of diagnoses, treatments, and laboratory results that has been stored electronically for use by authorized treatment professionals.
Explanation of Benefits (EOB)
A text description of denial or reduced payment included on the provider's remittance advice.
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.
Family Planning Services (FPS)
Provides services for the prevention of or delay of pregnancy and for the diagnosis and treatment of sexually transmitted infections.
Federal Poverty Level (FPL)
The maximum amount of money that a person or family can make and still be considered to be in poverty.
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.
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 patients insurance carrier for reimbursement.
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A comprehensive set of health care services for children younger than 21 who are enrolled in Medicaid.
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.
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.
Provides children and pregnant women with comprehensive health coverage if they meet specific financial criteria.
Children Families and Women
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.
Home Health Agency
A provider that specializes in giving skilled nursing, aide, and therapeutic services in the home.
Home Medical Equipment (HME)
The medical equipment that is paid for by Medicaid and used by beneficiaries in their homes.
A Medicaid benefit that provides palliative medical and social support services needed for the management of an individual's terminal illness.
Hospital Handbook Transmittal Letters (HHTL)
Letters sent to hospital providers that explain Medicaid rules and regulations, payment revisions, and billing requirements.
Internal Classification of Diseases (ICD)
The standard diagnostic tool for epidemiology, health management, and clinical purposes. Used to classify diseases and other health problems.
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.
Intermediate Care Facility for Persons with Mental Retardation (ICF-MR)
A residential facility for individuals with developmental disabilities that teaches living skills to help people live in less restricted environments
Interactive Voice Response System (IVR)
A phone technology that enables providers to access to information regarding client eligibility, claim and payment status, prior authorization, drug and procedure codes, and provider information.
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.
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.
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.
Managed Care Network
A panel of providers associated with a Managed Care Plan.
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.
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.
Medicaid Buy-In for Workers with Disabilities (MBIWD)
Provides health care coverage to working Ohioans who have disabilities.
Medicaid Eligibility Manual (MEM)
Medicaid Handbook Transmittal Letters (MHTL)
Medicaid Information Technology System (MITS)
The information management system for the Ohio Medicaid program that gives providers, the Department of Medicaid, and other state agencies responsible for administering Medicaid near real time data and decision-making support.
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.
Medicaid Provider Incentive Program (MPIP)
Provides incentive payments to eligible professionals and hospitals that adopt, implement, or upgrade to certified electronic health record technology and use it in a meaningful manner.
Medicaid Handbook Transmittal Letters (MHTLs)
Medical Assistance Letters (MALs)
Non-Emergency Transportation (NET)
Medicaid provides transportation to appointments for covered health care services for those who cannot transport themselves.
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.
Ohio Administrative Code (OAC)
Contains the full text of state agency rules and regulations.
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.
Ohio Department of Medicaid (ODM)
Ohio Revised Code (ORC)
Contains all acts and laws passed by the Ohio General Assembly and signed by the Governor.
Pre-Admission Screening Resident Review
The system used to determine eligibility for nursing facility placement and/or specialized services.
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.
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.
Pregnancy-Related Services (PRS)
Medical services provided to pregnant women in order to support the life and health of the fetus.
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.
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.
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.
A person, organization, or institution that provides health care related services and is enrolled in the Ohio Medicaid program.
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.
Recovery Audit Contractor (RAC)
A vendor used to identify underpayments and overpayments made by the State of Ohio to hospital providers.
Transaction used to explain details needed to perform cash applications directly or via a financial institution. This transaction includes explanation of benefits, identifying claim payments, claim denials and adjustments.
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.
Service Level Agreement
A formally negotiated agreement between two parties that records the common level of understanding about the level of service.
The amount that a beneficiary must pay before Medicaid will start reimbursing them for their claims/services received.
State Children's Health Insurance Program (SCHIP)
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.
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.