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Appendix I: Glossary
- Aid continuing
- A method to continue getting a benefit during a fair hearing
process.
- Appeal
- The process a member uses to ask a plan to reconsider a decision.
- Carved-out
- Services in fee-for-service Medicaid that are not included in
the HIV SNP prepaid benefits package. Carved-out services can
be accessed by SNP enrollees with their regular Medicaid card
without HIV SNP pre-authorization.
- Case manager
- Someone who coordinates medical and social services for SNP
members.
- Chronic illness
- An illness that someone has for a long time like asthma, Parkinson's
Disease, or HIV.
- Complaint
- A concern that a member expresses to a plan. A "complaint" is
also called a "grievance."
- Discharge plan
- A plan for how a member will get care once he or she is disenrolled
from the plan.
- Disenrollment
- Leaving the plan.
- Enrollment confirmation notice
- A letter that tells a new member the starting date of coverage,
the name of the HIV SNP, and all family members who are enrolled.
- Excluded
- Groups that can't join an HIV SNP or another Medicaid health
plan.
- Exempt
- Groups that don't have to join a Medicaid health plan, but can
if they want to.
- Expedited disenrollment
- A process for people who want to leave a plan quickly.
- External appeal
- A process a client can use when a plan says a service is experimental,
investigational, or not medically necessary.
- Fair hearing
- A state process for settling disputes about Medicaid.
- Fee-for-service
- The traditional Medicaid system where the government pays providers
for each service they give patients.
- FFS
- See Fee-for-service.
- Good cause
- A reason that allows a person to switch PCPs at any time.
- Grievance
- Another word for Complaint.
- HIV SNP
- HIV Special Needs Plan
- HIV Special Needs Plan
- A new type of Medicaid health plan specially designed for people
with HIV and their children.
- HIV specialist
- A doctor with a certain amount of training and experience in
treating people with HIV.
- Initial notification letter
- A letter that describes an HIV SNP to someone who has sent in
enrollment materials.
- Mainstream Medicaid health plan
- A managed care plan for people with Medicaid that serves anyone,
whether or not they have HIV.
- Managed care
- A system where the government pays a plan for each member enrolled,
and the plan provides all or most of the person's care.
- Mandatory
- When people have to join a mainstream Medicaid health plan or
an HIV SNP.
- Medicaid
- The government health insurance program for people with low
incomes.
- Member
- Someone who is enrolled in a Medicaid health plan. In this guide,
"enrollee" has the same meaning as "member."
- Network
- The group of doctors, clinics, and hospitals that participate
in a certain plan.
- Notice of denial of enrollment
- A letter that tells people that they cannot enroll in an HIV
SNP.
- Notice of disenrollment
- A letter that tells people when their membership in an HIV SNP
ends.
- PCP
- Primary Care Provider
- Primary care provider
- The doctor who coordinates a person's medical care in an HIV
SNP and provides referrals to specialists.
- Provider
- A doctor, hospital, or clinic.
- Prudent layperson standard
- The rule that HIV SNPs have to pay for medical care if it was
reasonable for the member to think it was an emergency, even if
it turns out not to be.
- Recertification
- The process of showing that you are still eligible for Medicaid.
This process is also called "redetermination."
- Referral
- Permission from the PCP that allows a person in an HIV SNP to
see a specialist.
- Self-refer
- When a person in an HIV SNP can go directly to a service without
getting a referral.
- Spend-down
- A way some people with higher incomes can qualify for Medicaid
if they have high medical expenses.
- Standing referral
- A type of referral that lets someone see a specialist for a
certain number of visits or a certain amount of time.
- Utilization review
- The process a member can use if a plan denies a service and
says it is not medically necessary.
- Voluntary
- When people can choose to join an HIV SNP or "mainstream" managed
care plan, but don't have to.
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