Here you will find helpful definitions that are commonly used when talking about Medicaid, NJ FamilyCare and MLTSS.
ABD – Aged, blind, and disabled people in the NJ FamilyCare Program.
ADDP – AIDS Drug Distribution Program. Drug program for HIV-positive people or people with AIDS.
Affordable Care Act (ACA) – Federal health care reform law.
Alternative Benefit Plan (ABP) – Benefits for people in NJ FamilyCare expansion under the ACA. ABPs cover the 10 essential health benefits in the ACA.
Annual Open Enrollment Period – October 1 to November 15. This is when enrollees can disenroll from one plan and enroll in another one.
Appeal – A request for review of an action such as a denial, a reduction of your benefits or any change in your care.
Authorized Person or Representative – A person who makes decisions for a member.
Beneficiary – A person eligible for NJ FamilyCare.
Benefits Package – Health care services provided by WellCare.
Care Management – Care Management is:
- For the member;
- Goal-oriented; and
- Culturally right for the member.
It makes sure a member gets services:
- On time;
- With support;
- That work; and
- That are cost-effective.
It is for:
- Continuity of care; and
- Coordination of care.
It gets services and supports for members. It must:
- Identify members with special needs;
- Decide a member’s risk;
- Create a care plan;
- Help members get to providers;
- Arrange services;
- Oversee care;
- Make sure there is continuity of care; and
Follow-up and write down care. It makes sure a member:
- Gets better/keeps functioning;
- Gets better/keeps clinical status;
- Has quality of life;
- Is satisfied;
- Follows the care plan;
- Is safe;
- Has cost savings; and
- Is self-directed.
Case Management – Case managers help members get services for episodes of instability.
Case management makes sure a member:
- Gets better/keeps functioning;
- Has quality of life;
- Is satisfied;
- Follows the care plan;
- Is safe; and
- Is self-directed.
Care Plan – A plan for a member’s health needs. The member and/or caregiver, PCP and care manager create it.
The care plan must be:
- Culturally right for the member and/or caregiver;
- Easy to follow by the member and/or caregiver;
- Evaluated often by the care manager; and
- Changed to meet member needs.
Centers for Medicare & Medicaid Services (CMS) – Federal agency that oversees Medicare and Medicaid.
Children with Special Health Care Needs – Children at risk for these long-term conditions: Physical; Developmental; Behavioral; and Emotional. These children need special care.
Chronic Illness – An illness that lasts a long time. A member with this can: Have many hospital stays; Be out of work or school at least 3 months a year; Need care all the time; Have a condition that develops slowly; Have times when it gets worse; and Have times it gets better.
Clinical Peer – A provider in the same/similar specialty as the provider who provided treatment that is under review.
Certified Nurse Midwife (CNM) – A registered nurse approved as a nurse-midwife.
Certified Nurse Practitioner (CNP) – A registered nurse who meets educational/clinical practice rules.
Clinical Nurse Specialist (CNS) – A registered nurse. The CNS may have a license from another state where he/she practices.
Cognitive Rehabilitation Therapy – Activities to meet a member’s needs.
They are to help a member live better by:
- Supporting learned behavior; or
- Creating new activity patterns.
Community Alternative Residential Setting (CARS) – CARS can be:
- Assisted living home;
- Assisted living program;
- Adult family care;
- Community residential services; and
- Comprehensive personal care home.
Complaint – When a member complains about actions of health plan or the plan’s agent.
- Act or failure to act; and
- Anything that causes a member to feel aggrieved.
These are complaints the member has made with the health plan which could have been taken care of in 5 business days.
Complaint Resolution – Actions taken to settle a complaint.
Comprehensive Orthodontic Treatment – Treatment to improve dental deformity or dysfunction.
Continuity of Care – A care plan that continues without interruption.
Co-payment – A fixed amount a member pays for a covered service.
Cultural Competency – This allows people to understand cultural differences. It means using culture to better serve members.
Developmental Disability – A long-term mental or physical disability. It could be mental/physical disabilities combined. It:
- Occurs before a person turns 22;
- Is likely to continue;
- Results in a person having trouble with three or more of these: Self-care, Language, Learning, Moving, Living on their own, Paying for things without help, and/or Needs lifelong or long-term care; Includes disabilities due to: Intellectual disability, Autism, Cerebral palsy, Epilepsy, Spina bifida, and/or Neurological damage
Division of Family Development (DFD) – A state agency offering financial and support programs for certain qualified individuals and families.
Diagnostic Services – Services that help a provider identify illness or injury.
Disability – A physical/mental defect that limits one or more of the major life activities for more than 3 months a year.
Disability in Adults – Adults who are not active because of physical or mental defects. These disabilities may result in death. They may last longer than a year.
Disability in Children – A disabled child under age 18. The disability may be physical or mental. The child may have trouble functioning independently. The disability may result in death. It lasts longer than a year.
Disenrollment – When a member is taken off a particular Health Plan. The member is not taken off of NJ FamilyCare.
Dual Eligible – A person covered by both NJ FamilyCare and Medicare.
Durable Medical Equipment (DME) – Medical equipment which is:
- Used over and over again;
- Used for health or daily living;
- Helps with an illness, injury or disability;
- And Used at home or workplace/school.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) – A federal program for screening/services for members under age 21. It finds physical and mental defects. It decides on care for these defects.
Early and Periodic Screening, Diagnostic and Treatment/Private Duty Nursing (EPSDT/PDN) Services – Private duty nursing services for EPSDT members under age 21. They get this in the community. It is not given in a hospital or facility.
Emergency Medical Condition – An illness, injury or symptom so serious that a person should receive care right away.
Emergency Services – Treatment of an emergency condition to keep it from getting worse. It could be an inpatient or outpatient service.
Enrollee – A person eligible for NJ FamilyCare who lives in a specific area. This person or someone acting for him/her has enrolled in the health plan. They include:
- People in AFDC/TANF;
- AFDC/TANF-Related Pregnant Women and Children;
- SSI-aged, blind and disabled; and People in DCP&P/DCF, NJ FamilyCare, and Division of Developmental Disabilities/Community Care Waiver (DDD/CCW).
Enrollee with Special Needs – An adult who needs special care. It can be an adult with physical, mental/substance abuse, and/or developmental disabilities.
Enrollment – When a person applies to a health plan instead of getting standard Medicaid benefits.
Enrollment Area – Geographic area where NJ FamilyCare-eligible residents may enroll with the health plan.
Enrollment Period – The 12-month period that begins on the effective date of enrollment. It does not guarantee eligibility.
Fair Hearing – The appeal process available for NJ FamilyCare members.
Fee-for-Service (FFS) – Reimbursement of payment for services.
Fraud – An intentional deception or misrepresentation.
Grievance – Written/oral complaint about anything that could not be worked out in 5 business days.
Grievance System – Process for grievances and appeals with the health plan. It allows a member to get a State Fair Hearing.
Health Care Services – These services include:
- And Supplemental.
And are provided to enrollees.
Health Maintenance Organization (HMO) – An HMO contracts with providers and gets prepaid health services for members in a geographic area. It is either:
- A. A Federally Qualified HMO; or
- B. Meets state law including:
- It provides health care;
- It allows members to get the same services that non-enrolled Medicaid-eligible people get in the same area;
- It makes sure members won’t pay debts if it becomes insolvent; and
- It is certified by the state in all or some counties.
HEDIS – Healthcare Effectiveness Data and Information Set
HIPAA – Health Insurance Portability and Accountability Act
Home and Community-Based Services (HCBS) – Services for people living in the community. They are similar to services you get in a facility, and are provided as an alternative to long-term institutional services in a nursing facility.
Managed Care – A comprehensive approach to health care which combines preventive, restorative and emergency services.
Managed Care Covered Service – Any covered services for which the health plan receives payment from the state.
Managed Care Organization (MCO) – An MCO has a risk contract. It is:
- An HMO that meets the advance directives federal law; or
- A public/private HMO that meets the advance directives law.
Members get the same services that non-enrolled Medicaid-eligible people get from the same HMO. It meets solvency standards.
Managed Long Term Services and Supports (MLTSS) – MLTSS is for people who qualify. It includes:
- NJ FamilyCare Plan A benefit package;
- Home and Community Based Services; and
- Long-term care in a nursing or special care facility.
Mandatory Enrollment – When a person eligible for NJ FamilyCare is required to enroll in a health plan. They get services through federal waivers.
Medicaid – A federal/state medical program.
Medicaid Beneficiary – A person who gets NJ FamilyCare.
Medicaid Eligible – A person who qualifies for NJ FamilyCare.
Member – A person enrolled in a NJ FamilyCare plan. It also means enrollee.
MLTSS Case Conferencing – A committee from various DHS divisions and the MCO. It makes sure member services are fully vetted.
MLTSS Electronic Care Management Record – Records with:
- Demographic information;
- Contact information;
- Member ID numbers;
- Assessment information;
- Beginning and end dates;
- Number of units of all services; and
- Case notes.
MLTSS Eligibility – People who qualify for long-term services/supports and have met both the financial and clinical eligibility requirements.
Money Follows the Person or MFP – A federal project to help people to go from facilities to the community. It is for low-income seniors and disabled people. States with MFP get greater federal funding. They get this funding for services for people with Medicaid Waivers or in MLTSS when they move into the community.
Multilingual – English, Spanish and any other language spoken by 200 members or 5 percent of the NJ FamilyCare population of the health plan, whichever is greater.
NCQA – National Committee for Quality Assurance
Non-Covered Medicaid Services – Services not covered by NJ FamilyCare.
Non-Traditional Provider – A provider who gives non-medical care.
Nursing Facility Level of Care (NF LOC) – People eligible for MLTSS services.
Nursing Facility Transitions – A team who helps people go from a facility to the community.
Options Counseling – A process where individuals receive guidance to assist with making choices about their long-term supports. You talk to a counselor about your wants, needs, strengths and choices. They help you with the pros and cons of different services and supports. They also follow up to make sure everything is working for you. Counseling is for people of all income levels, but it is aimed at people with the most immediate concerns.
Plan of Care (PoC) – MLTSS – A written plan of member needs and care.
Preventive Services – Services by a provider to:
- Prevent disease and disability;
- Treat secondary conditions before they happen or early on;
- Prolong life; and
- Promote physical/mental health.
Primary Care – Care/laboratory services given by:
- A general practitioner;
- Family physician;
- Physician assistant; and
- CNMs, CNPs/CNSs.
Primary Care Provider (PCP) – A medical doctor, doctor of osteopathy or other medical provider. The PCP provides:
- Preventive care;
- Illness/injury diagnosis and treatment;
- Coordination of care;
- Record keeping; and
- Specialist referrals.
Prior Authorization – Permission for a service authorized in advance of the requested service.
Provider – Any physician, hospital, facility or health provider of enrollee services who is authorized or licensed to provide services.
Qualified Individual with a Disability– A disabled person who gets public services/programs.
Reassignment– When services from a PCP or dentist end and the member is switched to another PCP or dentist.
Referral Services – Services given by a provider other than the PCP. The PCP or the health plan ordered these services.
- Exception A: It isn’t needed for a family planning provider.
- Exception B: It isn’t needed for a member getting services at a Federally Qualified Health Center.
This happens when the health plan has a contract with the FQHC. These services are paid by Medicaid fee-for-service.
Residential Treatment Center (RTC) – A live-in facility for:
- Substance abuse;
- Mental illness; and
- Behavioral problems.
Routine Care – Treatment at a doctor’s office or other less formal setting. It is given when there wouldn’t be health effects if it wasn’t done within 24 hours.
Screening Services – When a provider examines a member or uses tests to find diseases or conditions.
Service Delivery Verification – This is how the MCO makes sure a member gets services.
Special Medicaid Programs – These are for:
- AFDC/TANF-related family members who do not qualify for cash help; and
- SSI-related aged, blind and disabled (ABD) people whose incomes/resources go over SSI standards.
For AFDC/TANF, they are:
- Medicaid Special: covers children ages 19–21 using AFDC standards;
- NJ Family Care: covers pregnant women and children up to age 1 with incomes at or below 185 percent of the federal poverty level (FPL); Children up to age 6 at 133 percent of FPL; and Children up to age 13 (age range goes up every year until children up to age 18 are covered) at 100 percent of FPL.
For SSI-related, they are:
- Community Medicaid Only: [NAME_NJ] benefits for ABD who meet SSI age and disability criteria. They do not get cash help. They include former SSI recipients whose Medicaid is continued; and
- NJ Care: NJ FamilyCare benefits for all SSI-related ABD people with incomes below 100 percent of the FPL and resources at or below 200 percent of SSI standards.
SSI – Supplemental Security Income Program. Cash help and NJ FamilyCare benefits for ABD people and those who meet SSI financial needs criteria.
TANF – Temporary Assistance for Needy Families
Uncontested Claim – A claim that can be processed without more information from the provider of the service or third party.
Urgent Care – Care for an illness or injury within 24 hours. The condition is serious enough that a person needs care right away. It is not serious enough for the emergency room.
Utilization – The rate of service use or types of service within a period of time.
Utilization Review – Makes sure health care is needed. This includes:
- Ambulatory review;
- Prospective review;
- Concurrent review;
- Second opinions;
- Care management;
- Discharge planning; and
- Retrospective review.
Verbal/Psychological Abuse/Mistreatment – Any verbal or nonverbal acts or omissions by an employee, volunteer or intern to a member that results in:
- Emotional harm;
- Fear; and
Examples include, but are not limited to:
- Ignoring need;
- Playing favorites;
- Racial slurs; and
- Threatening actions.
Voluntary Enrollment – When a Medicaid-eligible person enrolls by choice in a NJ FamilyCare plan.
WIC – A special supplemental food program for Women, Infants, and Children.