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UnitedHealthcare Community Plan and Healthy Michigan - Helpful definitions

Glossary

A

  • Appeal

    An appeal is the action you can take if you do not agree with a coverage or payment decision made by your Medicaid Health Plan. You can appeal if your plan:

    Denies your request for:

    • A healthcare service
    • A supply or item
    • A prescription drug that you think you should be able to get

     

    Reduces, limits, or denies coverage of:

    • A healthcare service
    • A supply or item
    • A prescription drug you already got

     

    Your plan stops providing or paying for all or part of:

    • A service
    • A supply or item
    • A prescription drug you think you still need

     

    Does not provide timely medical services.

C

  • Co-payment

    A set amount you may be required to pay as your share of the cost for a medical service or supply. This may include:

    • A doctor’s visit
    • Hospital outpatient visit
    • Prescription drug

D

  • Durable Medical Equipment

    Equipment and supplies ordered by a healthcare provider for everyday or extended use. This may include:

    • Oxygen equipment
    • Wheelchairs
    • Crutches
    • Blood testing strips for diabetics

E

  • Emergency Medical Condition

    An illness, injury, or condition so serious that you would seek care right away to avoid harm.

  • Emergency Medical Transportation

    Ambulance services for an emergency medical condition.

  • Emergency Room Care

    Care given for a medical emergency when you think that your health is in danger.

  • Emergency Services

    Review of an emergency medical condition and treatment to keep the condition from getting worse.

  • Excluded Services

    Medical services that your plan doesn’t pay for or cover.

G

  • Grievance

    A complaint that you let your plan know about. You may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person or provider treated you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered or denied (see Appeal).

H

  • Habilitation Services and Devices

    Health care services that help a person keep, learn, or improve skills and functioning for daily living. These services can be done inpatient or outpatient and may include:

    • Physical and occupational therapy
    • Speech-language pathology
    • Services for people with disabilities

  • Health Insurance

    Health insurance is a type of coverage that pays for medical and/or drug costs for people. It can pay the person back for costs from illness or injury. It can also pay the provider directly. Health insurance requires the payment of premiums (see premium) by the person getting the insurance.

  • Home Health Care

    Healthcare services that a healthcare provider decides you need in your home for treatment of an illness or injury. Home health care helps you regain independence and become as self-sufficient as you can.

  • Hospice Services

    Hospice is a special way of caring for people who are terminally ill and provide support to the person’s family.

  • Hospital Outpatient Care

    Care in a hospital that usually does not need an overnight stay.

  • Hospitalization

    Care in a hospital that needs admission as an inpatient and could require an overnight stay. An overnight stay for you to be looked after could be outpatient care.

M

  • Medical Health Plan

    A plan that offers healthcare services to members who meet State eligibility rules. The State contracts with certain Health Maintenance Organizations (HMO) to provide health services for those who are eligible. The State pays the premium on behalf of the member.

  • Medically Necessary

    Healthcare services or supplies that meet accepted standards of medicine needed to diagnose or treat:

    • An illness
    • Injury
    • Condition
    • Disease, or
    • Symptom

N

  • Network

    Health care providers contracted by your plan to provide health services. This includes:

    • Doctors
    • Hospitals
    • Pharmacies

  • Non-Participating Provider

    A healthcare provider that does not have a contract with the Medicaid Health Plan as a provider of care.

P

  • Participating Provider/Network Provider

    A healthcare provider that has a contract with the plan as a provider of care.

  • PCP

    A licensed physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides and manages your health care services. This can also be called a Primary Care Physician. Your primary care provider is the person you see first for most health problems. They make sure that you get the care you need to keep you healthy. They also may talk with other doctors and healthcare providers about your care and refer you to them.

  • Physician Services

    Healthcare services provided by a person licensed under state law to practice medicine.

  • Plan

    A plan that offers health care services to members that pay a premium.

  • Pre-authorization

    Approval from a plan that is required before the plan pays for certain:

    • Services
    • Medical equipment, or
    • Prescriptions

    This is also called prior authorization, prior approval, or precertification. Your plan may require preauthorization for certain services before you receive them. This excludes an emergency.

  • Premium

    The amount paid for health care benefits every month. Medicaid Health Plan premiums are paid by the State on behalf of eligible members.

  • Prescription Drug Coverage

    Health insurance or plan that helps pay for prescription drugs and medications.

  • Prescription Drugs

    Drugs and medications that require a prescription by law by a licensed Provider.

  • Primary Care Physician (PCP)

    A licensed physician who provides and manages your health care services. (See Primary Care Provider.)

  • Provider

    A person, place or group that’s licensed to provide health care like doctors, nurses, and hospitals.

R

  • Referral

    When your Primary Care Provider sends you to a Specialist for a covered service.

  • Rehabilitation Services and Devices

    Rehabilitative services and/or equipment ordered by your doctor to help you recover from an illness or injury. These services can be done inpatient or outpatient and may include:

    • Physical and occupational therapy
    • Speech-language pathology
    • Psychiatric rehabilitation services

S

  • Skilled Nursing Care

    Services in your own home or in a nursing home provided by trained:

    • Nurses
    • Technicians
    • Therapists

  • Specialist

    A licensed physician specialist that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

U

  • Urgent Care

    Care for an illness, injury, or condition bad enough to seek care right away but not bad enough that it needs emergency room care.

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Disclaimer information

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Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Complete plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

Premium disclaimer

Dual Special Needs plans have a $0 premium for members with Extra Help (Low Income Subsidy).

Benefit disclaimer

Benefits, features, and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply.

Nurse Hotline disclaimer

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your provider's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time. Nurse Hotline not for use in emergencies, for informational purposes only. Access to this service is subject to terms of use.

Star ratings disclaimer

Every year, Medicare evaluates plans based on a 5-Star rating system. The 5-Star rating applies to plan year 2026.

Formularies

The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary.

Important provider information

The choice is yours

We will provide you with information to help you make informed choices, such as physicians' and health care professionals' credentials. This information, however, is not an endorsement of a particular physician or health care professional's suitability for your needs.

The providers available through this application may not necessarily reflect the full extent of UnitedHealthcare's network of contracted providers. There may be providers or certain specialties that are not included in this application that are part of our network. If you don't find the provider you are searching for, you may contact the provider directly to verify participation status with UnitedHealthcare's network, or contact Customer Care at the toll-free number shown on your UnitedHealthcare ID card. We also recommend that, prior to seeing any physician, including any specialists, you call the physician's office to verify their participation status and availability.

Some network providers may have been added or removed from our network after this directory was updated. We do not guarantee that each provider is still accepting new members.

Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.

American Disabilities Act notice

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 ("ADA"), UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

Referrals

Network providers help you and your covered family members get the care needed. Access to specialists may be coordinated by your primary care physician.

Paper directory requests

Paper copies of the network provider directory are available at no cost to members by calling the customer service number on the back of your ID card. Non-members may download and print search results from the online directory.

Declaration of disaster or emergency

If you’re affected by a disaster or emergency declaration by the President or a governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.

  • Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare certified facilities);
  • Where applicable, requirements for gatekeeper referrals are waived in full;
  • Plan-approved out-of-network cost-sharing to network cost-sharing amounts are temporarily reduced; and
  • The 30-day notification requirement to members is waived, as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the member.

If CMS hasn’t provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.