Authorized Representative

A person who is authorized in writing to conduct the personal or financial affairs for an individual.

Appeal

A request for review of adverse action to determine whether the action complied with Medicaid laws, regulations, and/or policy, or a challenge to any DMAS adverse action affecting a provider's reimbursement.

Attending Physician

The physician who has the overall responsibility for the patient’s medical care and treatment.

BabyCare

Prenatal group patient education, nutrition services, and homemaker services for pregnant women and care coordination for high-risk pregnant women and infants up to age two.

Benefits

Services covered under the Virginia Medicaid/FAMIS Program.

CFR

Code of Federal Regulations. Medicaid federal regulations are located at 42 CFR 430 through 42 CFR 505.

CHIP

Virginia’s Child Health Insurance Program for low-income children. The program is funded under Title XXI of the Social Security Act and is known as FAMIS.

Claim

An itemized statement of services rendered by health care providers (such as hospitals, physicians, dentists, etc.), billed electronically or on the CMS 1500 or UB04.

Clinic

A facility for the diagnosis and treatment of outpatients.

CMS

Centers for Medicare and Medicaid Services. The Federal agency of the United States Department of Health and Human Services that is responsible for the administration of Title XIX and Title XXI of the Social Security Act.

Coinsurance

The portion of Medicare- or other insurance- allowed charges for which the patient would be responsible if no other insurance is responsible.

Copayment

The portion of Medicaid/FAMIS-allowed charges which an individual is required to pay directly to the provider for certain services or procedures rendered.

Covered Group

Federal and state laws describe the groups of people who may be eligible for Medicaid/FAMIS. These groups of people are called Medicaid/FAMIS covered groups. The eligibility rules and medical services available are different for certain covered groups. People who meet one of the covered groups' criteria may be eligible for Medicaid/FAMIS coverage if their income and resources are within the required limits of the covered group.

Deductible

The dollar amount that the Medicare/Medicaid member must pay toward the cost of covered benefits before Medicare payment can be made for additional services. Medicaid pays the Medicare Part B deductible for eligible members. Medicare Part A deductible is paid by Medicaid within the Program limits.

Dental

The covered dental services are available to Medicaid/FAMIS eligible children as well as the limited, emergency services available to Medicaid eligible adults.

Dependent

A spouse or child who is entitled to benefits under the Virginia Medicaid/FAMIS Program.

DMAS

Department of Medical Assistance Services. The agency that administers the FAMIS and Medicaid programs in Virginia.

DOS

Date of Service. The date or span of days that services were received by an individual.

DSS

Department of Social Services. The agency responsible for determining eligibility for medical assistance and the provision of related social services. This includes the local Department of Social Services.

EI

Early Intervention. Developmental supports and services that are performed in natural environments to meet the developmental needs of Medicaid or FAMIS eligible children, ages zero to three years of age, who have a 2% or greater delay in one or more developmental areas, atypical development, or diagnosed condition with a high probability of delay.

Eligible Person

An individual satisfying the requirement for Virginia Medicaid/FAMIS in accordance with the State Plan of the Virginia Medical Assistance Program under Title XIX or FAMIS under Title XXI, who has been certified and enrolled as such by a local social services department or FAMIS CPU.

Eligibility Worker

Eligibility worker at the local Department of Social Services who reviews your application for Medicaid, FAMIS or Plan First to determine if you are eligible. This is the person you would contact regarding changes, such as your address or income, or problems, such as not receiving your Medicaid card.

Encounter

Any covered or enhanced service received by a member through a DMAS contractor.

EPSTD

Early and Periodic Screening, Diagnosis, and Treatment. Medicaid's comprehensive and preventive child health program for individuals under the age of 21.

FAMIS

Family Access to Medical Insurance Security. Virginia's CHIP program that operates under Title XXI of the Social Security Act and provides comprehensive health benefits to children through the age of 18, in families with incomes at or below 200 percent of the federal poverty level who do not have any health insurance coverage and are not eligible for Medicaid.

Family Planning Services

Any medically-approved means, including diagnosis, treatment, drugs, supplies, and devices, and related counseling, which are furnished or prescribed by or under the supervision of a physician for individuals of child-bearing age for purposes of enabling such individuals freely to determine the number or spacing of their children.

FAMIS Member

Persons enrolled in DMAS’ FAMIS program are eligible to receive services under the State Child Health Plan under Title XXI of the Social Security Act.

FAMIS Plus Member

Child under the age of 19 who meets “medically indigent” criteria under Medicaid program rules, and who receives the full Medicaid benefit package and have no cost-sharing responsibilities.

FAMIS Moms

Virginia's Health Insurance program for low-income pregnant women whose family income is above Medicaid limits and at or below 200% FPL. It is a Title XXI of the Social Security Act program, known as FAMIS MOMS.

FAMIS Select

Virginia's Child Health Insurance Premium Assistance program for FAMIS eligible children. It is a Title XXI of the Social Security Act program, known as FAMIS Select. Benefits are provided through the private or employer-sponsored plan. There is no wrap-around coverage in FAMIS Select, with the exception of immunizations

FFS

Fee-for-Service. The Department’s traditional health care payment system in which physicians and other providers receive a payment for each unit of service they provide.

Freedom of Choice

The patient's freedom to choose between institutional placement or community-based services, and/or an available program, service, or a participating provider of service.

HIPAA

Health Insurance Portability & Accountability Act. Title II of HIPAA protects the confidentiality and integrity of individually identifiable health information past, present, or future.

HCBS Waiver

Home and Community-Based Services Waiver. The range of community services approved by the Centers for Medicare and Medicaid Services (CMS) pursuant to C1915c of the Social Security Act 420.SC. § 1396 (c) to be offered to individuals as an alternative to institutionalization.

HIPP

Health Insurance Premium Payment Program. Premium assistance program for individuals enrolled in full coverage Medicaid that provides premium assistance subsidy for the employee share of employer-sponsored group health insurance when it is determined to be cost-effective.

HIPP For Kids

Premium assistance program for children under the age of 19 enrolled in full coverage Medicaid that reimburses the employee share of qualified employer-sponsored coverage. The employer must contribute at least 40% to the cost of the premium.

Inpatient

An individual admitted to a hospital, nursing facility, an intermediate care facility, or a residential treatment center.

LOC

Level of Care. The level of service that an individual needs based on their assessment which includes functional activities of daily living, medical and/or nursing, or behavioral needs.

Intensive Care

Constant observation care to critically ill or injured patients in a critical care unit.

MAC

Maximum Allowable Cost. The upper limit allowed by the Virginia Medicaid Program for certain drugs.

Managed Care

Delivery of health care services emphasizing the relationship between a primary care provider (PCP) and the Medicaid member (referred to as a “medical home”). The goal of managed care is to have a central point through which all medical care is coordinated. Managed care has proven to enhance access to care, promote patient compliance and responsibility when seeking medical care and services, provide for continuity of care, encourage preventive care, and produce better medical outcomes. Most Virginia Medicaid members are required to receive their medical care through managed care programs.

MCO

Managed Care Organization. It is an organization that contracts with DMAS to provide, arrange for, deliver, pay for, or reimburse any of the costs of health care services for Medicaid enrollees. 

Medicaid

An assistance program that helps pay for medical care for certain individuals and families with low incomes and resources, if applicable.

Medicaid Member

Any person identified by the Department who is enrolled in Medicaid.

Medicaid Work (Medicaid Buy-In Program)

Medicaid Works allows working people with disabilities whose income is no greater than 80% FPL to pay a premium to participate in the Medicaid program.

Medical Necessity

Those services which are reasonable and necessary for the diagnosis or treatment of an illness, condition, injury, or to improve the function of a disability, consistent with community standards of medical practice and in accordance with Medicaid/FAMIS policy

Medically Indigent

Pregnant women, children, and other individuals who meet certain income and/or age requirements and who are eligible for some or all of the covered Medicaid services.

Medically Needy

Individuals whose income and resources exceed those levels for assistance established under a State or federal plan but are insufficient to meet their costs of health and medical services.

Member

An individual who meets the Virginia Medicaid/FAMIS eligibility requirements and is receiving or has received medical services.

Member Enrollment

The determination by a local department of social services or central processing unit of an individual’s eligibility for Medicaid, FAMIS Plus or FAMIS and subsequent entry into VAMMIS.

NPI

National Provider Identifier. A unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).

NF

Nursing Facility. A nursing facility or a distinct part of another facility which provides, on a regular basis, services to individuals who do not require the degree of care and treatment which a hospital or specialized care unit is designed to provide, but who require care and services which meet the established written criteria.

Open Enrollment

The timeframe in which Members are allowed to change from one MCO to another, without cause, which occurs at least once every 12 months per 42 CFR 438.56 (c)(1) and (f)(1). Open enrollment will occur from October 1st – December 18th for a January 1 effective date. Individuals eligible through Medicaid expansion will have an open enrollment period from November 1st – December 18th for a January 1st effective date. Within sixty (60) calendar days prior to the open enrollment begin date, the Department will inform Members of the opportunity to remain with the current plan or change to another plan without cause. Those Members who do not choose a new health plan during the open enrollment period shall remain in his or her current health plan selection until their next open enrollment period.

Outpatient

A beneficiary who receives medical services but is not admitted to a hospital, hospital, or other institutional settings.

PACE

Program of All-inclusive Care for the Elderly. PACE provides the entire spectrum of health and long-term care services (preventive, primary, acute and long-term care services) to their members on a per member, per month basis.

Participating Provider

A person, organization, or institution with a current valid participation agreement with DMAS who or which will (1) provide the service, (2) submit the claim, and (3) accept as payment in full the amount paid by the Virginia Medicaid/FAMIS Program.

PCP

Primary Care Provider. The doctor or clinic that provides most of your health care needs, gives you referrals to other health care providers when needed, and monitors your health. A PCP may be an internist, a pediatrician (children’s doctor), OB/GYN (women’s doctor), or certain clinics and health departments.

Plan of Care

Plan of  Care is comprised of individual service plans as dictated by the persons' health care and support needs.

Plan First

The limited benefit Medicaid fee-for-service family planning program. Men and women who have income less than or equal to 200 percent of the federal poverty level may be eligible for Plan First if they are not eligible for a full benefit medical assistance program.

Procedure Code

A code used to identify a medical service or procedure performed by a provider.

PHI

Protected Health Information. Individually identifiable patient information, including demographics, which relates to a person's health, health care, or payment for health care.

Provider

An institution, facility, agency, person, corporation, partnership, or association approved by the Department which accepts as payment in full for providing benefits the amounts paid pursuant to a provider agreement with the Department.

Referral

A request by a provider for a participant to be evaluated and/or treated by a different physician, usually a specialist, or to receive specific services.

Residential Treatment Facility

A 24-hour-per-day specialized form of highly organized, intensive, and planned therapeutic interventions, which shall be utilized to treat severe mental, emotional, and behavioral disorders of individuals 21 years old or younger. All services must be provided at the facility as part of the therapeutic milieu.

Retroactive Eligibility

Eligibility in which a person was determined to be eligible for a period of time prior to the month in which the application was initiated. The retroactive period is the three months prior to the application month. Once retroactive eligibility is established, Medicaid/FAMIS coverage begins the first day of the earliest retroactive month in which eligibility exists. Retroactive coverage in FAMIS is only available for newborns.

School Health Services

Any service rendered on the property of a local education agency or public school. Services must be included in an individualized education program (IEP).

Service Authorization

Formerly referred to as prior authorization, the approval necessary for specified services for a specified member by a specified provider before the requested services may be performed and payment made.

State Agency

The Department of Medical Assistance Services is the State Agency designated by the General Assembly of Virginia, under the provision of Title XIX of the Social Security Act, to administer Virginia's Medical Assistance Program.

State Plan

The comprehensive written statement submitted by the Department to the Centers for Medicare and Medicaid Services (CMS) for approval, describing the nature and scope of the Virginia Medicaid program and giving assurance that it will be administered in conformity with the requirements, standards, procedures and conditions for obtaining Federal financial participation.