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UnitedHealthcare Community Plan
UnitedHealthcare Community Plan

Healthy Louisiana Plan




Appeal -

1. A request for a fair hearing concerning a proposed agency action, a completed agency action, or failure of the agency to make a timely determination.

2. A legal proceeding in which the applicant/enrollee and BHSF agency representative presents the case being appealed in front of an impartial hearing officer.

Applicant - An individual who is requesting assistance from the agency.

Application - A formal request for benefits made to the agency in writing and signed by the applicant or someone acting on behalf of the applicant. Application may be received by mail, phone, fax, in person, or electronically.

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Category - Classification of applicants/enrollees based upon certain identifying requirements/categories. The federally authorized categories of assistance for which BHSF has responsibility for determining eligibility are Aged (A), Blind (B), LIFC (formerly AFDC-related) (C)& (M), Disabled (D), Qualified Medicare Beneficiaries (Q), Refugee (E) and Tuberculosis Infected (TB).

Certification -

1. The determination that the applicant's circumstances are within the standards for eligibility.

2. The identifying case and eligibility information maintained by the Medicaid Eligibility Data System (MEDS).

Continued Medicaid - the temporary continuation of Medicaid benefits for former LIFC recipients through Transitional Medicaid or Child Support Continuance.

Countable Income - income remaining after all allowable deductions and exclusions specific to the program have been applied.

Countable Resource - A resource that is countable when determining resource eligibility.

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Date of Entry - the date an alien has entered theUnited States according to the Bureau of Citizenship and Immigration Services (BCIS) documentation. BCIS is formerly known as the Immigration and Naturalization Services (INS).

Decertification - loss of eligibility to participate as a Medicaid provider, or for a license to operate a Medical facility licensed by DHH.

Dependent - an individual who is the financial responsibility of a member of the income unit. Example: This is someone who could be counted as a tax dependent, if income tax is filed.

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Earned Income - income in cash or in-kind received in the form of wages, salary, commissions, or profit from activities in which an individual is actively engaged as an employee or from self-employment.

E-MEM - an electronic version of the Medicaid Eligibility Manual (MEM) accessible on the DHH Medicaid Online Manual website. The MEM is written for the Agency Representative as a guide to determine eligibility.

E-MFM - an electronic version of the Medicaid Forms Manual (MFM) that contains all BHSF Medicaid forms, including some for Medicaid providers. The E-MFM is accessible on the DHH Medicaid Online Manual website.

Extended Medicaid - Medicaid coverage for those individuals who lose SSI/MSS eligibility and meet all eligibility requirements for PICKLE, Disabled Adult Children (DAC), Disabled Widows/Widowers (DW/W), Early Widows/Widowers (EW/W), or Disabled Widows/Widowers (DW/w) with no SGA programs.

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Fraud - the willful intent to obtain ineligible benefits or payments.

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Good Cause - an acceptable reason to defer the requirement to cooperate for certain eligibility factors.

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Illegal Alien - an alien who has not been lawfully admitted to theUnited States.

Income - a gain or recurrent benefit measured in money.

Ineligible Alien - an alien admitted to theUnited States for a temporary or specified time who is eligible only for emergency medical services if eligibility requirements are met.

Ineligible Individual - a non-categorically eligible child, parent, or spouse who lives in the home with an SSI-related Medicaid applicant/enrollee.

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Legal Guardian - a person who has been granted custody of a minor by court order.

LaMOMS – a Medicaid program for pregnant women using higher income amounts (up to 200% FPL) that pays for pregnancy related services, dental services, delivery of baby and care up to 60 days after pregnancy ends.

Louisiana Children's Health Insurance Program (LaCHIP) – a Medicaid program that provides health benefits for eligible uninsured children up to age 19.

LouisianaHealth Insurance Premium Payment (LaHIPP) – a program which pays for employer sponsored group health insurance for Medicaid eligible persons when it is determined to be cost effective. “Cost Effective” as applicable to this program means that it would cost less for Medicaid to pay the health insurance premium for the person who receives Medicaid than it would be for Medicaid to pay for the cost of the same person’s medical expenses if they didn’t have insurance.

Louisiana State Health Insurance Information Program (SHIIP) – SHIIP provides education/advocacy through local sponsoring organizations to both retired and pre-retirement age seniors as well as their families. SHIIP offers free and confidential help with Medicare, private health insurance to supplement Medicare, and long term care insurance options. Also, counselors have information on other resources, agencies and organizations that provide services to seniors.

Low Income Families with Children (LIFC) - a program which provides Medicaid to children or families who meet the income limit requirements.

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Medicaid - A state health insurance program for people with low income who meet certain eligibility requirements. Programs can vary from state to state.

Medicare - A federal health insurance program for people who are 65 or older, people with disabilities, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.

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Qualified Alien – an alien entering the United States on or after August 22, 1996, who is eligible only for emergency medical services until the residency requirement for consideration of full Medicaid coverage is met.

Qualified Child – a child who was born before September 30, 1983, is under age 19 and meets AFDC income and resource requirements.

Qualified Medicare Beneficiary Only (formerly Pure QMB - "Only" replaced "Pure") – a QMB only is eligible for Medicaid payment only for Medicare Part A and/or B premiums, Medicare deductibles and Medicare co-insurance for Medicare covered services, not eligible for full Medicaid coverage.

Qualified Medicare Beneficiary Plus (formerly dual QMB - "Plus" replaced "Dual") – a QMB Plus is eligible for the same benefits as QMB Only and full benefit Medicaid in another program.

QI-1 – group one a Medicaid program whereby individuals are eligible for payment of Medicare Part B premiums.

QI-2 – group two a Medicaid program whereby individuals are entitled to partial payment of Medicare Part B premiums. QI-2 program ended December 31, 2002.

Qualified Relative – a child's relative who is within the proper degree of relationship to a child to receive C-related Medicaid coverage.

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Responsible Person – one or more individuals designated by an applicant/enrollee (verbally or by use of a designation form) to act on his/her behalf with respect to a specific Medicaid application or renewal. Same as Authorized Representative.

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Specified Low-Income Medicare Beneficiary (SLMB) Only – a Medicaid program that pays Medicare Part B premiums without full Medicaid benefits.

Specified Low-Income Medicare Beneficiary (SLMB) Plus – a SLMB Plus is eligible for the same benefits as SLMB Only and full benefit Medicaid in another program.

Spouse - an individual who is legally married to another or who presents to the community as a husband or wife in a non-legal relationship.

Stepparent - an individual living in the home who is the legal spouse of the child's parent but is not the child's natural, legal, or adoptive parent.

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Third Party - an individual, institution, corporation or agency that is responsible for all or part of the medical costs for Medicaid enrollees.

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WorkSmart! – formerly the LEPIC project A project developed to enable all Eligibility Field Operation’s Staff to be active participants in improving the eligibility process for the benefit of Medicaid employees and customers. With instruction and practice, staff learns to identify work flow problems, brainstorm possible solutions, test possible solutions on a small scale to find out what works in practice, and implement improvements at the local, regional or state level.

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Young Adult Program - children age 18 to age 21 in the care of the Office of Community Services (OCS) who are entitled to Medicaid.

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