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.
B
Behavioral Health Services Only
This term means those who receive only Behavioral Health benefits based on income requirements.
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 DHH.
Department of Social and Health Services (DSHS)
The state agency that administers public assistance programs in Washington State.
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
Health Care Authority (HCA)
The Washington state agency responsible for administering Washington Apple Health (Medicaid), Apple Health Expansion and other state health programs.
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.
L
Legal Guardian
A person who has been granted custody of a minor by court order.
M
Maternity Benefits Program
Apple Health (Medicaid) benefits include maternity benefits, maternity support services, and maternity case management. Apple Health (Medicaid) and Apple Health Expansion members who become pregnant should notify Washington Health Care Authority (HCA) and UnitedHealthcare Community Plan, to apply for Apple Health for Pregnant Individual coverages.. Eligibility for the program is determined by HCA.
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 Washington’s Apple Health (Medicaid) programs, visit https://www.hca.wa.gov/apple-health
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.
S
Service Area
The geographic area served by a health plan that provides coverage for Apple Health (Medicaid).
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.
W
Washington Apple Health (Medicaid)
Apple Health (Medicaid) provides comprehensive free or low-cost health care to adults, families, individuals with disabilities, children under 19, children in foster care and pregnant individuals who meet income and eligibility requirements.
Apple Health Expansion provides comprehensive free or low-cost health care to adults 19 and older who meet income requirements and do not qualify for other Apple Health programs based on immigration status.
Washington Apple Health (Medicaid) – Integrated Managed Care
Washington's integrated managed care Apple Health (Medicaid) program provides comprehensive free or low-cost health care and behavioral health services to adults, families, people with disabilities, children under 19, children in foster care and pregnant women who meet income requirements.
Washington Healthplanfinder
Washington Healthplanfinder is the website to find, compare and enroll in a health plan that fits your needs and budget. For more information about Apple Health or to enroll, please visit: wahealthplanfinder.org or call 1-855-WAFINDER (1-855-923-4633) TTY/TTD 1-855-627-9604.
Washington Resident
A person physically residing and maintaining a residence in the state of Washington. You must be a Washington resident to be eligible for Washington Apple Health. To be considered a Washington resident, members who are temporarily out of Washington for any reason:
May be required to prove their intent to return to Washington State; and
May not be out of Washington State for more than three consecutive calendar months.
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 Washington State and they return to Washington State during breaks. Dependent children attending school out of state may be required to provide proof that they pay out-of-state tuition, vote in Washington, and file income taxes using a Washington 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.
