Medical assistance program established in 1965 by Title XIX of the Social Security Act that is jointly funded by the federal government and the states. It provides medical benefits for certain low-income persons in need of health and medical care. Recipients’ benefits, data for claims processing, and payments vary from state to state. Medicaid is jointly funded by the federal and state governments to assist states in providing long-term care assistance to people who meet certain eligibility criteria. California’s Medicaid program is known as Medi-Cal .

Lets providers electronically access the state’s eligibility file using a point-of-sale device, computer software, and automated voice response system. Also called recipient eligibility verification system (REVS) .

Any federal or state health insurance program that receives funds via the Medicaid legislation with the intent to provide additional health services to Medicaid recipients.

Organization under contract to the state to process claims for a state Medicaid program.

Federal program created by the Deficit Reduction Act of 2005 to track and prevent Medicaid fraud. Government contractors will review the actions of those seeking payment from Medicaid, conduct audits, identify overpayments, and educate providers and others on program integrity and quality of care.

Prepaid health plan that provides comprehensive services to Medicaid beneficiaries but not to commercial or Medicare enrollees. Also called Medicaid-only managed care organization (MCO) .

System approved by the Centers for Medicare and Medicaid Services (CMS) that supports the operation of the Medicaid program. It includes the following types of subsystems or files: recipient eligibility, Medicaid provider, claims processing, pricing, Surveillance and Utilization Review System (SURS), Management and Administrative Reporting Subsystem (MARS), and potentially encounter processing. The objectives of this system and its enhancements include the Title XIX program control and administrative costs, service to recipients and providers, answers to inquiries, operations of claims control and computer capabilities, and management reporting for planning and control.

State division that is responsible for administering federal and state policies and overseeing the state’s Medicaid program.