Products and populations terms

Serving more than 72 million Americans, Medicaid is a federal- and state-level program that provides medical coverage to eligible, low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid programs are designed at the state level, and most health care costs are covered for a person who qualifies for both Medicare and Medicaid.¹

A Medicaid beneficiary is any individual who both qualifies for and utilizes the provided services and supports within the program. Medicaid beneficiaries are often categorized by their eligibility status: financially, categorically or medically needy. Children eligible for the Children's Health Insurance Program (CHIP) and aged, blind, disabled (ABD) adults are among the most common Medicaid beneficiaries.²

The Children’s Health Insurance Program (CHIP) is an all-encompassing benefit program for nearly 6.7 million uninsured children nationwide. Eligibility for the program is most often determined financially. CHIP is federally required to provide primary care, dental care, behavioral health services and vaccinations for children from birth to age 19.³

Supplemental Security Income (SSI) is a federal income supplement program funded through general tax revenues. Designed to help aged, blind and disabled (ABD) people with limited income, SSI provides people with monthly monetary supplements that can be used for basic needs like food, clothing and shelter.⁴

Temporary Assistance for Needy Families (TANF) is a federal program designed to help needy families become self-sufficient. States receive block grants to design and administer this time-sensitive program to help ensure that dependent individuals are cared for in their own homes.⁵

Medicaid benefits are any and all services and supports provided to an individual through the program, including primary care, prescriptions and emergency services. Medicaid benefits typically offer full coverage of a person’s medical needs. While Medicaid benefits are often seen as exclusive to health care, the program also provides a variety of Home and Community-Based Services (HCBS) through waivers, such as personal care, transportation and homemaking services.⁶

A Medicaid waiver does as its name implies: waives a Medicaid rule or law in order to deliver a certain benefit or expansion of coverage that isn’t normally covered within a state’s Medicaid plan. Waivers are commonly used to deliver Home and Community-Based Services (HCBS), such as at-home caretaking, transportation or providing medical equipment. Common waivers are: 1115, 1915(b), 1915(c), 1915(i), and 1915 (k).⁷

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services are the federally-required care guidelines for Medicaid-eligible children and people under age 21. EPSDT services help ensure the well-being of low-income youths through primary, dental and behavioral care, along with additional supports.⁸

An individual or group health plan provides, or pays the cost of, medical care. Typically, a health plan combines health insurance coverage benefits within a provider network for cost-saving opportunities, usually within one geographic area. There are various types of health plans.⁹

A managed care organization (MCO), also known as a managed care entity (MCE), delivers health care benefits in an efficient, streamlined manner that emphasizes improving cost, utilization and quality of care. Within Medicaid, MCOs establish contractual arrangements with state agencies to deliver health benefits and related services. These are based on an established rate of payment for those services and a set number of members receiving care within a month.¹⁰

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.