Appeal

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.

Behavioral Health Services Only

This term means those who receive only Behavioral Health benefits based on income requirements.

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.

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.

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.

Fraud

The willful intent to obtain ineligible benefits or payments.

Good Cause

An acceptable reason to defer the requirement to cooperate for certain eligibility factors.

Health Care Authority (HCA)

The state agency responsible for administering Washington Apple Health (Medicaid) 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.

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.

Legal Guardian

A person who has been granted custody of a minor by court order.

Maternity Benefits Program

This Health Care Authority (HCA) program includes all Apple Health (Medicaid) benefits, including maternity benefits, maternity support services, and maternity case management, and is made available to Apple Health (Medicaid) members who become pregnant, notify HCA and UnitedHealthcare Community Plan, and apply for benefits. 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.

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.

Primary Care Provider (PCP)

Your personal health care provider. Your primary care provider can be a family or general practitioner, internist, pediatrician, or other provider approved by UnitedHealthcare Community Plan. To receive benefits, your primary care provider must provide or coordinate your care. If you need to see a specialist, your primary care provider will refer you.

Provider

A health care professional (such as a doctor, nurse, internist, etc.) or facility (such as a hospital, clinic, etc.).

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.

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.

Third Party

An individual, institution, corporation or agency that is responsible for all or part of the medical costs for Medicaid.

Washington Apple Health (Medicaid)

Washington's Medicaid program, called Washington 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.

Washington Healthplanfinder

It's your new way to find, compare and enroll in a health plan that fits your needs and budget. For more information about Apple Health (Medicaid) 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 (Medicaid). 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.