Medicaid Glossary

Accountable Care Organizations (ACOs) are cooperating groups of doctors, hospitals, and other providers who work together to deliver coordinated care to patients. By centralizing all facets of care into one organization, ACOs are working to streamline health care delivery into a more collected, value-based arrangement.¹

Related Content: Value-based Care in North Carolina

See: Accountable Care Organizations.

Comprised of enrollees, payers, providers, and advocates, advisory boards or groups offer guidance on movements, policy, and initiatives within the health care sector. Advisory boards or groups are typically formed at the local, state, or national level.²

Related Content: UHC Community & State’s National Advisory Board

An advocate is an individual or group of individuals who speak for Medicaid-eligible members in an effort to champion and support legislation, policy, and beneficial care outcomes. Advocates are employed in all sectors of the health care industry and can be part of nonprofit organizations, appointed advisors by private payers, and providers or public government organizations.³

Related Content: UHC Community & State’s National Advisory Board | The importance of consumer engagement

The Affordable Care Act (ACA) is a comprehensive health care reform law to make health care coverage available to more individuals through lower costs and innovative delivery methods. The ACA also initiated an optional Medicaid Expansion, which allows states to further expand coverage eligibility and services individuals. The ACA is sometimes referred to as Obamacare.⁴

Related Content: Expanding Access to Health Care

Aged, Blind, Disabled (ABD) is a full-coverage Medicaid eligibility classification and program for low-income adults who are either 65 and older, blind, or disabled (as determined by Social Security).⁵

Related Content: Member story: Jamie Archer | Managed Long Term Services and Supports (MLTSS) | Improving care for Individuals with I/DD | Member story: Jordan Scott

According to the Health Care Payment Learning and Action Network (HCP-LAN), an alternative payment model (APM) incentivizes providers to deliver higher-quality, cost-effective care though additional, incentive payments. While APMs are designed to incentivize value-based care, they are versatile and can be adapted to work under the more widely used fee-for-service care model.⁶

Related Content: Moving from volume to value: takeaways from the 2019 Annual LAN Summit

Behavioral health is an all-encompassing term describing disorders that have a negative impact on an individual’s mental and physical condition. Examples of behavioral health disorders include substance abuse, addiction, and eating disorders.⁷

Related Content: Importance of Integrating Physical and Behavioral Health | Kansas Peer Driver Program | The importance of integration

A beneficiary is any individual who both qualifies for and utilizes the provided services and supports within Medicaid. Medicaid beneficiaries are often categorized by their eligibility status – financially, categorically, or medically needy. Children eligible for the Children's Health Insurance Program (CHIP) and aged, blind, disabled (ABD) adults are among the most common Medicaid beneficiaries.⁸

Benefits are any and all services and supports provided to an individual through the Medicaid program. From primary care, prescriptions, and emergency services, Medicaid benefits typically offer full coverage of a person’s medical needs. While Medicaid benefits are often seen as exclusive to health care, the program also provides a variety of Home and Community-Based Services (HCBS) through waivers such as personal care, transportation, and homemaking services.⁹

Related Content: https://www.uhccommunityandstate.com/articles/Culture-of-Access.html

A block grant is a predetermined, capped sum of money given annually to a state by the federal government to fund public programs on the state level.¹⁰

Capitation is a monthly advance payment given to a health care provider by an insurance company, determined on a per-patient person count of those enrolled in the health plan, regardless of whether or not care is delivered.¹¹

Care coordination is the combined efforts of payers, health care staff and community-based organizations (CBOs) to organize and effectively collaborate on a patient’s information, health needs, and activity to deliver the best possible care to that patient.¹²

Related Content: SDOH: The next frontier? Part 1: Screening for health related social factors | Part 2: Referring to social services and supports | The importance of consumer engagement 

Care integration is the combination and application of different aspects of health (i.e., physical, behavioral, social) into a single, more unified approach to care. Typically, care integration aims to address the collective health concerns of individuals with complex conditions to improve quality of care and overall individual health.¹³

In Medicaid terms, caregiver refers to individuals, professional or family, who provide day-to-day assistance to people who otherwise, could not easily live on their own due to their age and/or complex health care needs.¹⁴

Related Content: Family Caregiving in the United States | Professional Caregiving in the United States

Categorically needy is one pathway for Medicaid eligibility for people who are either financially needy with children, financially needy and pregnant, or an Aged, Blind or Disabled (ABD) individual. The base for covered services under categorically needy is much wider than for other types of Medicaid eligibility.¹⁵

Related Content: Understanding Medicaid

The Centers for Medicare and Medicaid Services (CMS) is a federal organization that provides services and programs funded under Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). CMS works with payers and providers on the state level to help deliver these programs properly through research, administration, and guidance.¹⁶

Related Content: Highlights from the 2019 National Association of Medicaid Directors Conference | Expanding Access to Health Care

Children’s Health Insurance Program CHIP is an all-encompassing benefit program for nearly 6.7 million uninsured children nationwide. Eligibility for the program is most often determined financially, and is federally required to provide primary care, dental care, behavioral health services, and vaccinations for children from birth to age 19.¹⁷

Related Content: An Introduction to Medicaid with Samantha O’Leary

Within the health care sector, churn refers to a patient’s movement on and off health insurance or their movement between different types of health care coverage, e.g. moving from Medicaid to the Individual Exchange.¹⁸

Under Medicaid, collaborations between entities in the health care sector help advise, fund, and collaborate on projects and improve the quality of life for members. Medicaid collaborations vary greatly from organization to organization, but are often developed between Managed Care Organizations (MCOs), advocacy groups, specialty providers, community-based organizations (CBOs), and state-level influencers. Collaborations are key to the success of Medicaid and provide measurable value to the entire program.¹⁹

Related Content: On Partnerships | Investing in communities for impact | Partnerships and Innovations

Community-Based Organizations (CBOs) are typically nonprofit organizations that work to improve the health and quality of life in the community they represent. CBOs often work beyond the typical parameters of the health care sector by providing housing, healthy food options, outreach programs, and more to the members of their community.²⁰

Related Content: SDOH: The next frontier? Part 2: Referring to social services and supports | Fighting Food Insecurity in Florida | 4H Healthy Living Innovation Spotlight

Complex care refers to services provided to high-need individuals who often require a higher level of care, resulting in higher costs than for an average individual. Complex care individuals often suffer from multiple chronic conditions or disabilities that require more clinically complex attention and care delivery.²¹

Related Content: Working across systems to improve health and well-being 

Often implemented for children through the Children’s Health Insurance Program (CHIP), continuous eligibility refers to an approach to Medicaid enrollment that allows for an individual to continue to receive Medicaid coverage and care – even if financial changes would otherwise change that eligibility.²²

Contract requirements are agreements detailed in contracts between managed care organizations (MCOs) and states to ensure an effective framework for Medicaid benefit delivery to that state’s members. Contract requirements range from rate formularies to required services and can differ greatly on a state-by-state basis.²³

Also commonly referred to as out-of-pocket spending, cost-sharing refers to the payment requirements for individuals under Medicaid who may have a slightly higher income than the federal poverty level. Most children, pregnant women, and severely disabled adults are not subject to cost-sharing payments.²⁴

Related Content: Medicaid as seen through the eyes of Beneficiaries

A disability is defined as a physical or mental impairment that limits an individual from freely participating in a major life activity, such as working, learning, or living independently. States are required to provide coverage under Medicaid to certain disabled individuals – most often disabled children and the severely disabled adults.²⁵

Related Content: Improving care for Individuals with I/DD

Under federal law, state Medicaid programs are required to compensate health care systems – namely, hospitals who serve more of the Medicaid or otherwise uninsured population. These payments, called Disproportionate Share Hospital (DSH) payments, are allotted annually to cover the cost of uncompensated care.²⁶

Dual eligibility refers to an individual’s eligibility to enroll in both Medicaid and Medicare programs. Individuals who are eligible for both programs are commonly referred to as duals or dual eligibles.²⁷

Related Content: Stuck in the middle of the Medicare and Medicaid maze

Dual special needs plan (or DSNPs) are specific Medicare Advantage plans made for duals or dual eligibles. Due to the often-complex nature of social, mental, and physical care needs for duals, DSNPs help centralize the care from the two programs and provide patient-focused care that is easier to navigate.²⁸

Related Content: DSNP 101: Coordinated Care Can Bring Additional Benefits, Convenience to Low-Income Seniors and People With Disabilities | The challenges and opportunities of MedPAC’s recent DSNP policy recommendations (Part 1) | (Part 2)

EPSDT services are the federally required care guidelines for Medicaid-eligible children and people under age 21. EPSDT services help ensure the well-being of low-income youths through primary, dental, and behavioral care, along with additional supports.²⁹

An electronic health record (EHR) is a real-time patient health record that supports the collection of data for clinical care and decision-making as well as billing, quality management, outcome reporting and public health surveillance and reporting. EHRs are a type of health information technology.³⁰

An encounter refers to any engagement, appointment, or delivered care between a Medicaid member and a provider of any kind, and in which a provider submits a claim thereafter. Valuable in shaping future policy, data collected from these encounters is vital for states and managed care organizations (MCOs) to improve care delivery for patients.³¹

Medicaid is considered an entitlement program. Any individual who qualifies for the program has the legal right, or entitlement, to enroll in Medicaid. As an entitlement program, this means states are also legally entitled to federal compensation to implement and run the program.³²

Health equity means all individuals receive the same quality of and access to care – regardless of where they live or socioeconomic demographics. Health advocacy groups often speak for, and work toward, achieving health equity.³³

Related Content: Connecting to address healthy equity in Cleveland

Also commonly referred to as Federal Medical Assistance Percentages (FMAP), Federal Financial Participation (FFP) is the matching funds the federal government provides to states to facilitate and support Medicaid and other social services. Financial percentage rates for the Medicaid program vary from state to state; however, the minimum match required for the federal government is 50%.³⁴

The Federal Fiscal Year (FFY), which runs from October 1 to September 30, is the calendar for the U.S. government budget. Federal Medicaid and all social service funding operates within the FFY, and all grants, budgets, fees, and other financial actions are scheduled to occur within this timeframe.³⁵

See Federal Financial Participation (FFP) above.

The federal poverty level is an annual assessment of an individual’s total yearly income to determine social service coverage and other benefits, such as Medicaid or CHIP eligibility. The FPL can increase or decrease on a year-to-year basis, and eligibility depends on family size as well as total income, with an FPL that grows as an individual’s family size grows.³⁶

Related Content: Expanding Access to Health Care

Federally Qualified Health Centers (FQHCs) are community-based entities that provide comprehensive care to local, often underserved individuals, regardless of coverage. FQHCs offer primary, preventive health services, dental, specialty, and emergency care and more to Medicaid members, homeless, migrants, and other populations regardless of their ability to pay for care.³⁷

Related Content: Value of Partnerships with FQHCs | Partnering with North Carolina Providers.

Different from the fee-for-service (FFS) payment model, a Fee-for-service (FFS) Delivery System is a program model issued by states without a managed care organization (MCO) to deliver care. In a FFS Delivery system, the state serves the “payer” role, directly paying service providers for care and services offered to their members.³⁸

Related Content: Medicaid as seen through the eyes of beneficiaries | Value-based purchasing

The “standard” payment model for most insurance providers and payers, a fee-for-service (FFS) model reimbursement or direct payer payment follows care delivery. Each visit to a health professional under an FFS payment model is billed separately and unlike a value-based payment (VBP), is not dependent on the health outcome of the visit.³⁹

Related Content: Medicaid as seen through the eyes of beneficiaries | Value-based purchasing

Financial need is one pathway to qualifying for Medicaid eligibility. As the name suggests, financial necessity eligibility for Medicaid or Children’s Health Insurance Program (CHIP) is based upon annual earnings against the federal poverty level (FPL). Financially needy individuals are one of the most common types of Medicaid beneficiaries.⁴⁰

Related Content: Understanding Medicaid

Food insecurity is a common social driver of health (SDOH) that describes any limitations on access to consistent, stable nutrition.  While often viewed as a financial hurdle, poor access to food storage and cooking instruments or living a long distance from a grocery store are also types of food insecurity.⁴¹

Related Content: Battling Food Insecurity | Fighting Food Insecurity in Florida | F.E.E.D. (Feeding Everyone with Equity and Dignity)

Also commonly known as a drug list, a formulary is a state-specific list of approved (both preferred and non-preferred) pharmaceuticals covered under Medicaid for its beneficiaries. Formularies tend to change yearly and can greatly differ state to state depending on trends in Medicaid and the needs of the state's population.⁴²

Foster care is a social service system within the United States that works to care for and provide children without available biological parents or guardians a safe, stable home in which to experience childhood. Nearly all ~440,000 foster children in the country today qualify for and use Medicaid for their health care needs.⁴³

Related Content: Unique training offers support to those who care for foster children | Making the foster care system work better for everyone

A fully integrated dual eligible (FIDE) is a specific dually eligible individual who receives fully integrated Medicare and Medicaid benefits from a single managed care organization (MCO) through a fully integrated dual eligible special needs plan, or FIDE-SNP. FIDEs and FIDE-SNPs help streamline and declutter the often hard-to-navigate benefits and requirements that come with being dually eligible.⁴⁴

Related Content: Stuck in the middle of the Medicare and Medicaid maze

See FIDE (above).

Closely related to health equity, health disparities are differences and inequalities in the quality of health and health care services depending on location and demographic. Health disparities are commonly found in low-income neighborhoods and places where access to care is more limited and social determinants of health (SDOH) are more severe.⁴⁵

Related Content: Connecting to address healthy equity in Cleveland

Health information exchange (HIE) is the act of electronic sharing of patient information between legally authorized health care providers or an individual/entity that enables exchange of electronic health information for a limited set of purposes. HIEs are a type of health information technology.⁴⁶

A health information network (HIN) in an entity that oversees or administers policies that define conditions for HIE between multiple unaffiliated entities. The largest HIN in the United States is eHealth Exchange, which currently has participation from 75% of all U.S. hospitals, 70,000 medical groups, more than 8,300 pharmacies and 120 million patients. Many HINs are joint state-private sector endeavors in which participating providers pay a fee to participate.⁴⁷

Health information technology (HIT) involves the exchange of health information in an electronic environment.⁴⁸

The Health Insurance Portability and Accountability Act is a U.S. law designed to protect patients’ medical records and other health information provided to health plans, doctors, hospitals, and other health care providers. These standards give patients access to their medical records and more control over how their personal health information is used.⁴⁹

An individual or group plan provides, or pays the cost of, medical care. A health plan combines health insurance coverage benefits under a product with a specific cost-sharing structure and provider network, within a geographic area. There are various types of health plans.⁵⁰

A health risk assessment (HRA) is a health questionnaire used to provide individuals with an evaluation of their health risks and quality of life. An HRA commonly has three parts—an extended questionnaire, a risk calculation or score, and some form of feedback (e.g., face-to-face consultation with a health advisor or an automatic online report).⁵¹

Holistic health is an approach to health that considers the whole person and how they interact with their environment. This viewpoint emphasizes well-being and all possible influences—social, psychological, environmental—that affect health, such as exercise, food choices and state of mind.⁵²

Related Content: The Importance of Integration

Home- and Community-Based Services (HCBS) provide care for Medicaid beneficiaries in their own home or community (e.g., hospice), rather than institutions or other facility-based settings. HCBS programs help a variety of targeted population groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses. Examples of HCBS are: home-delivered meals, transportation, home repairs and modifications, and financial services.⁵³

Hotspotting is a health care process that uses data to identify high-cost, high-need patients and improve their health outcomes through a coordinated care approach. Hotspotting leads to multidisciplinary care plans that combine physical and behavioral health services, as well as interventions to address non-medical needs that impact health. These could include housing or emotional support.⁵⁴

Related Content: https://newsroom.uhc.com/community/hotspotting.html

Stable housing has a positive, significant impact on individual mental and physical health. Consistent, affordable housing is seen as one of the largest and most consequential social determinants of health (SDOH). Managed care organizations (MCOs), advocacy groups, and public agencies are working to improve housing access and the related health outcomes for homeless individuals across the country.⁵⁵

Related Content: Housing and Policy | UnitedHealthcare surpasses $400 million in investments in affordable housing | The Intersection of Health and Housing

Interagency collaboration is a key factor among MCOs working to improve care delivery in the Medicaid system. By emphasizing interagency collaboration, managed care organizations (MCOs), state agencies, and community-based organizations can better communicate findings, address policy, and work toward improving the services provided to Medicaid beneficiaries.⁵⁶

Long-term care (LTC) includes a variety of both institutional and community-based services that address the medical and non-medical needs of people living with a chronic illness or disability. Long-term care typically includes customized, coordinated services to improve independence and quality of life, while also consistently meeting the needs of patients over time.⁵⁷

Coordinated across providers and settings, long-term services and supports include a range of services that assist individuals with functional limitations on their ability to carry out daily activities. Among the millions of children, adults, and seniors making use of long-term services and supports in the United States, Medicaid is the leading payer.⁵⁸

Related Content: Managed Long Term Services and Supports

A managed care organization (MCO), also known as a managed care entity (MCE), delivers health care benefits in an efficient, streamlined manner that emphasizes improving cost, utilization, and quality of care. Within Medicaid, MCOs establish contractual arrangements with state agencies to deliver health benefits and related services, based on an established rate of payment for those services and a set number of members receiving care within a month.⁵⁹

MLTSS refers to the way that long-term services and supports are delivered in capitated Medicaid managed care programs. More and more, states are shifting to an MLTSS model to help expand home- and community-based services, promote community inclusion, and increase the efficiency of programs. 

Related Content: MLTSS: Helping Those Most In Need | Managed Long Term Services and Supports

Serving more than 64 million Americans, Medicaid is a federal- and state-level program that helps with medical costs for eligible, low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid programs are designed at the state level and most health care costs are covered for a person who qualifies for both Medicare and Medicaid.⁶⁰

As a bipartisan federal agency, the Medicaid and CHIP Payment and Access Commission (MACPAC) leads data research on state Medicaid and Children’s Health Insurance Plans (CHIP) in order to provide fact-based policy recommendations to legislators. MACPAC advises nearly every level of the Medicaid system – from eligibility to care delivery.⁶¹

Medicaid Expansion is an optional eligibility threshold that allows states to adopt to provide coverage to childless adults who earn up to 138% of the federal poverty level (FPL). Initially, federal financing covered 100% of the program, although eligible states received 93% of enhanced federal financing in 2019 and will receive 90% in 2020 and beyond. To date, 36 states and Washington, D.C. have engaged the Medicaid Expansion option.⁶²

Related Content: An Introduction to Medicaid Expansion

Focused on managing cost, utilization, and quality, Medicaid Managed Care enables benefit delivery and related services through contracts between state-level Medicaid agencies and managed care organizations (MCOs). These arrangements leverage an established rate of payment for those services, based on a set number of members receiving care in a month.⁶³

Medically needy is a Medicaid eligibility pathway for individuals who have significant health needs, but may have incomes that are too high to qualify for Medicaid based on financial need. Medically needy individuals have the ability to become eligible by “spending down” the amount of income that’s above a state’s medically needy threshold.⁶⁴

Medicare is the federal health insurance program that covers three main groups of Americans: individuals who are 65 or older, some younger individuals who have disabilities, or individuals with End-Stage Renal Disease – also known as ESRD – and which involves kidney failure that requires dialysis or a transplant. Today, there are more than 40 million Medicare beneficiaries in the country.

Similar to MACPAC, the Medicare Payment Advisory Commission (MedPAC) is an independent, 17-member U.S. federal body headquartered in Washington, D.C., and established by the Balanced Budget Act of 1997. Its main role is to advise the U.S. Congress on issues affecting the administration of the Medicare program.⁶⁵

Medication management aims to create better health outcomes through accurate medical prescriptions. This strategy works with patients, physicians, and pharmacists to create a comprehensive, accessible knowledge base of drug benefits and risks to ensure that a provided prescription is ideal for the patient.⁶⁶

Medication-assisted treatment (MAT) brings together behavioral therapy and medications to help treat substance use disorders (SUDs). Typically used to treat disorders related to opioids or alcohol use, MATs also can be helpful for a person who is working to quit smoking. MAT is one element in multi-pronged approach being taken to treat SUD and opioid use disorders.⁶⁷

Opioid use disorder (OUD) is a diagnosed addiction to an opioid medication. A person who is suffering from OUD will typically take the drug in greater doses or for longer periods of time than recommended. If interrupted, this behavior is often followed by severe withdrawal, which can have significant negative impacts to the person’s mental and/or physical health. Today, more than 2 million Americans suffer from OUD.⁶⁸

Related Content: Medicaid and the Opioid Epidemic

Health outcomes are a measure of the quality of mental and physical health as a result of care delivery – outcomes can be determined on a scale from community-based to the state level. Gauging effective outcomes is a key data point used to influence future policy and care reform.⁶⁹

In the U.S. health care sector, a payer is an organization that handles the financial and operational aspects (which include insurance plans, provider networks) for providing health care to enrolled members. UnitedHealthcare Community Plan is a payer.  

Poverty level groups refer to federal thresholds used to determine federal program eligibility. In terms of Medicaid, the phrase “poverty level groups” is often used to define the different thresholds and groups of individuals based upon Medicaid eligibility.⁷⁰

A primary care physician (PCP) is the main first point of contact for a person with a health concern. A PCP may offer continuing care for various medical conditions, and are not limited by cause, organ system, or diagnosis. PCPs are typically general practice or family physicians.⁷¹

Program design refers to the ins and outs of a state’s Medicaid program. Eligibility, costs, services, and programs within are part of a state’s program design. Although there are many commonalities, program design can vary greatly from state to state and is usually dependent on the health needs of the state’s residents.⁷²

Protected health information (PHI) is the term given to personal health information created, received, stored or transmitted by HIPAA-covered entities and their business associates in relation to the provision of health care, health care operations and payment for health care services.⁷³

Within the U.S. health care sector, a provider is most often defined as an individual or organization—doctor, nurse practitioner, clinical nurse specialist, physician assistant, or health care clinic—that provides and coordinates health care on behalf of a patient. 

A risk-based contract creates a relationship between insurer and provider to expand the financial relationship beyond traditional transactional guidelines. In risk-based contract, outcomes and quality of care measures are related to the receipt of funding.⁷⁴

A rural health clinic (RHC) is typically located in a rural, medically underserved area in the U.S., and uses a separate reimbursement structure from the standards of the Medicare and Medicaid programs. The RHC program helps improve rural health care access through reimbursements that allow clinicians to practice in rural areas, while also increasing the role and use of physician assistants or nurse practitioners.⁷⁵

School-based health centers (SBHCs) are primary care clinics located on primary and secondary school campuses. Most SBHCs offer some combination of primary care, mental health care, substance abuse counseling, case management, dental health, nutrition, and health education. Often times, SBHCs are formed when a school district partners with a community health center, hospital, or local health department.⁷⁶

As defined by the National Institutes of Mental Health, serious mental illness (SMI) includes a mental, behavioral, or emotional disorder that results in serious functional impairment, and can interfere with or limit a person’s major life activities.⁷⁷

Single-payer health care refers to a system of health care where one entity—a single payer—collects all health care fees and pays for all health care costs. In recent years, the potential for a single-payer health care system has been an ongoing topic of debate at the federal level.⁷⁸

Social determinants of health (SDOH) are the economic and social conditions that influence health status. Broadly defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age,” key social determinants of health include employment, housing, and access to transportation. Social determinants are studied and addressed at the individual, community, and population level.⁷⁹

Related Content: SDOH: Improving Health through Integrated Health and Human Services | SDOH: The next frontier? Part 1: Screening for health related social factors | Part 2: Referring to social services and supports | Part 3: Challenges and opportunities to meeting social needs

Social impact investments are those investments made with the intention of delivering a double bottom line: a positive social or environmental impact within the community, and along with it, a financial return.⁸⁰

Social needs are patient-level physical, social, and environmental needs that contribute to an individual’s health. These may include food insecurity, risk of exposure to domestic violence, transportation, housing, and utility needs. Addressing social needs occurs on an individual level through screenings and conversations with health care providers.⁸¹

Related Content: Meeting social needs and addressing social determinants of health

Special Needs Plans are a type of Medicare Advantage Plan that limits its member base to people with specific diseases or characteristics. SNPs are required to cover the same benefits as under traditional Medicare. However, SNPs are also able to customize  benefits and offer supplemental benefits to best serve their specific population along with different provider choices and drug formularies.⁸²

A State Plan Amendment (SPA) is a state and federal agreement detailing how that state will administer its Medicaid and Children’s Health Insurance (CHIP) programs. It ensures a state will follow federal rules and lays out how it will claim federal matching funds for the activities within its program. The state plan identifies groups of individuals to be covered, specific services, as well as methodologies for providers to be reimbursed, and the administrative activities that are underway in the state.⁸³

Substance use disorders are present when the regular or consistent use of alcohol and/or drugs causes clinical impairment, such as health problems, disability, or failure to meet responsibilities at work, school or home. A risk factor for a SUD is often a co-occurring mental health issue.⁸⁴

Supplemental Security Income (SSI) is a federal income supplement program funded through general tax revenues. Designed to help aged, blind and disabled (ABD) people with limited income, SSI provides people with monthly monetary supplements that can be used for basic needs like food, clothing, and shelter.⁸⁵

Temporary Assistance for Needy Families (TANF) is a federal program designed to help needy families become self-sufficient. States receive block grants to design and administer the time-sensitive program to help ensure that dependent individuals are cared for while still being able to be part of their family.⁸⁶

Established through Medicare regulations, the upper payment limit restricts the amount of money a state is allowed to pay for Medicare claims. The Upper Payment Limit (UPL) is determined by the types of providers and the services provided.⁸⁷

Value-based care (VBC) programs offer monetary incentives to health care providers for the quality of care they deliver to people. Value-based care programs are designed to focus on better care for individuals, better health for populations, and lowering costs.⁸⁸

A Medicaid waiver does as its name implies, waiving a Medicaid rule or law in order to deliver a certain benefit or expansion of coverage that isn’t normally covered within a state’s Medicaid plan. Waivers are commonly used to deliver Home- and Community-Based Services (HCBS), such as at-home caretaking, transportation, or medical equipment. Common waivers are: 1115, 1915(b), 1915(c), 1915(i), and 1915 (k).⁸⁹

Related Content: Culture of Access: Waiver Benefit Design Overview and Recommendations

Section 1115 Medicaid Waivers are state-specific waivers that allow a state to better tailor the benefits provided by Children’s Health Insurance Program (CHIP) and Medicaid programs. These waivers often provide states with the ability to provide coverage not normally provided by “standard” Medicaid policies, allowing states to tailor their programs to best serve the needs of their populations.⁹⁰

Related Content: An Introduction to Medicaid with Samantha O’Leary

Section 1915(b) Medicaid Waivers permit a state to modify their Medicaid delivery system by implementing managed care. By implementing these waivers, states can require all of their Medicaid members to receive some or all of their benefits from a managed care organization (MCO).⁹¹

Section 1915(c) Medicaid Waivers allow states to provide federally approved Home- and Community-Based Services (HCBS) to their qualifying members, typically in lieu of institutional care. Nearly every state offers this type of waiver, allowing their members to receive person-centered care in the comfort of their home or other community-based setting.⁹²

Section 1915(i) Medicaid State Plan Options are an authority used by states interested in providing Home- and Community-Based Services (HCBS) to a population with different financial eligibility and disability needs than those served by 1915(c) Waivers. Unlike the 1915(c) Waiver, individuals may qualify under the 1915(i) state plan option even if they don’t meet an institutional level of care.⁹³

Also known as the “Community First Choice Option,” Section 1915(k) Medicaid State Plan Option allows states to provide individual controlled Home- and Community-Based Services (HCBS) and attendant services to eligible members under their state plan, supporting members in their daily life activities as they live in their own homes.⁹⁴