Products for complex populations

Aged, Blind, Disabled (ABD) is a full-coverage Medicaid eligibility classification and program for low-income adults who are either 65 and older, blind, or disabled (as determined by Social Security).¹

Behavioral health is an all-encompassing term describing disorders that have a negative impact on an individual’s mental and physical condition. Examples of behavioral health conditions include substance use and eating disorders.²

Care integration is the combination and application of different aspects of health (physical, behavioral, social) into a single, more unified approach to care. Typically, care integration aims to address the collective health concerns of individuals with complex conditions to improve quality of care and overall individual health.³

Dual eligibility refers to an individual’s eligibility to enroll in both Medicaid and Medicare programs. Individuals who are eligible for both programs are commonly referred to as duals or dual eligibles.⁴

Dual Special Needs Plans (DSNPs) are specific Medicare Advantage plans made for duals or dually eligible individuals. Due to the often-complex nature of social, mental and physical care needs for duals, DSNPs help centralize care from the two programs and provide patient-focused care that is easier to navigate.⁵

Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) fully integrate the benefits of both Medicare and Medicaid under one managed care organization into a unified care plan. FIDE-SNPs help streamline and declutter the often hard-to-navigate benefits and requirements that come with being dually eligible.⁶

Foster care is a social service system within the United States that works to care for and provide a safe, stable home to children without available biological parents or guardians. Nearly all ~440,000 foster children in the country today qualify for and use Medicaid for their health care needs.⁷

Home- and Community-Based Services (HCBS) provide care for Medicaid beneficiaries in their own home or community (e.g., hospice), rather than institutions or other facility-based settings. HCBS programs help a variety of targeted population groups, such as people with intellectual or developmental disabilities, physical disabilities and/or mental illnesses. Examples of HCBS include home-delivered meals, transportation, home repairs and modifications, and financial services.⁸

A Highly Integrated Dual Special Needs Plan (HIDE-SNP) is an integrated care plan that combines the benefits of Medicare and Medicaid from a managed care organization into a more unified care plan. Although less integrated than FIDE-SNPs, HIDE-SNPs still incorporate both behavioral health and Managed Long Term Services and Supports benefits into their plans.⁹

Medicaid Expansion is an optional eligibility threshold that allows states to provide coverage to childless adults who earn up to 138% of the federal poverty level (FPL). Initially, federal financing covered 100% of the program, although eligible states received 93% of enhanced federal financing in 2019 and will receive 90% in 2020 and beyond. To date, 36 states and Washington, D.C. have engaged the Medicaid Expansion option.¹⁰

Managed Long Term Services and Supports (MLTSS) refers to the way that long-term services and supports are delivered in capitated Medicaid managed care programs. More and more states are shifting to an MLTSS model to help expand home- and community-based services, promote community inclusion and increase the efficiency of programs.¹¹

Special Needs Plans (SNPs) are a type of Medicare Advantage Plan that limits its member base to people with specific diseases or characteristics. SNPs are required to cover the same benefits as traditional Medicare. However, SNPs are able to customize benefits and offer supplemental benefits to best serve their specific population, including different provider choices and drug formularies.¹²

This glossary is intended to be informational only and relates to terms used commonly in Medicaid programs and design. In most cases, terms are derived from publicly available sources. Terms covered in this glossary are subject to change and may have alternate definitions when used in relation to other programs or products, or by other sources or companies.