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.
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.
C
Certificate of Coverage
A description of your health care coverage and benefits. Your member
handbook serves as your certificate of coverage.
Countable Resource
A resource that is countable when determining resource eligibility.
D
Decertification
Loss of eligibility to participate as a Medicaid provider, or for a
license to operate a Medical facility licensed by DMS.
Department of Community Based Services
The state agency that administers public assistance programs in Kentucky.
Department of Medicaid Services
The state agency responsible for administering Kentucky Medicaid.
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.
Drug Formulary
A list of approved prescription drugs developed the health plan.
E
Emergency
The emergent and acute onset of a symptom or symptoms, including
severe pain, that would lead a prudent layperson acting reasonably to
believe that a health condition exists that requires immediate medical
attention, if failure to provide medical attention would result in
serious impairment to bodily functions or serious dysfunction of a
bodily organ or part, or would place the person’s health in serious jeopardy.
F
Fraud
The willful intent to obtain ineligible benefits or payments.
G
Good Cause
An acceptable reason to defer the requirement to cooperate for
certain eligibility factors.
H
Hearing
A hearing is when you ask your health program to review your case
after your plan denied your appeal.
I
Income
A gain or recurrent benefit measured in money.
Inpatient
A patient who is admitted for an overnight or longer stay at a health
care facility and is receiving covered services.
K
Kentucky Medicaid
Kentucky’s managed care Medicaid program provides comprehensive free
or low-cost health care to adults, families, people with disabilities,
children under 19, children in foster care and pregnant women who meet
income requirements.
Kentucky Resident
A person physically residing and maintaining a residence in the
Commonwealth of Kentucky. You must be a Kentucky resident to be
eligible for Kentucky Medicaid. To be considered a Kentucky resident,
members who are temporarily out of Kentucky for any reason may be
required to prove their intent to return to Kentucky.
Dependent children who are attending school out of state may be
considered residents if they are out of state during the school year,
as long as their primary residence is in Kentucky and they return to
Kentucky during breaks. Dependent children attending school out of
state may be required to provide proof that they pay out-of-state
tuition, vote in Kentucky, and file income taxes using a Kentucky address.
Your residence may be a home you own or are purchasing or renting, a
shelter or other physical location where you are staying in lieu of a
home, or another person's home.
kynect
It's your way to find, compare and enroll in a Medicaid health plan.
For more information about kynect go to kynect.ky.gov or
call 1-844-407-8398.
L
Legal Guardian
A person who has been granted custody of a minor by court order.
M
Maternity Benefits Program
The Kentucky Medicaid program includes all Medicaid benefits,
including maternity benefits, maternity support services, and
maternity case management, and is made available to Kentucky Medicaid
members who become pregnant, notify Kentucky Medicaid and
UnitedHealthcare Community Plan, and apply for benefits. Eligibility
for the program is determined by Kentucky Medicaid.
Medicaid
A state health insurance program for people with low income who meet
certain eligibility requirements. Programs can vary from state to
state. For information on Kentucky’s Medicaid programs visit https://chfs.ky.gov/agencies/dms/Pages/default.aspx
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.
Member
An eligible person enrolled in the UnitedHealthcare Health Plan.
O
Outpatient
A nonhospitalized patient receiving covered services away from a
hospital, such as in a physician's office or the patient’s own home,
or in a hospital outpatient or hospital emergency department or
surgical center.
P
Primary Care Provider (PCP)
Your PCP is the doctor you see for most of your care provider. Your
PCP can be a family or general practitioner, internist, pediatrician,
naturopathic physician or other provider approved by UnitedHealthcare
Community Plan.
Provider
A health care professional (such as a doctor, nurse, internist, etc.)
or facility (such as a hospital, clinic, etc.).
R
Recertification
Periodic review of your family’s income and eligibility. During
recertification, you must submit current income and residency
documentation to verify your eligibility and/or level of premium
subsidy. You must recertify for Medicaid every 12 months.
S
Specialist
A provider of specialized medicine, such as a cardiologist or a neurosurgeon.
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.
T
Third Party
An individual, institution, corporation or agency that is responsible
for all or part of the medical assistance furnished under the Medicaid
State Plan.
