A 
ACCESS
The extent to which an individual who needs care and services is able to receive them. Access is more than having insurance coverage or the ability to pay for services. It is also determined by the availability of services, acceptability of services, cultural appropriateness, location, hours of operation, transportation needs, and cost.
ACCESSIBLE SERVICES
Services that are affordable, located nearby, and open during evenings and weekends. Staff is sensitive to and incorporates individual and cultural values. Staff is also sensitive to barriers that may keep a person from getting help. For example, an adolescent may be more willing to attend a support group meeting in a church or club near home than to travel to a mental health center. An accessible service can handle consumer demand without placing people on a long waiting list.
ACCREDITATION
An official decision made by a recognized organization that a health care plan, network, or other delivery system complies with applicable standards.
ACTIVITY THERAPY
Includes art, dance, music, recreational and occupational therapies, and psychodrama.
ADDITION
The number of persons admitted, readmitted, or transferred to a specified service during the reporting period.
ADMINISTRATIVE COSTS
Costs not linked directly to the provision of medical care. Includes marketing, claims processing, billing, and medical record keeping, among others.
ADVERSE SELECTION
Occurs when plan enrollees include a higher percentage of high-risk individuals than are in the average population, resulting in the potential for greater health care utilization and, therefore, increased costs.
ALTERNATIVE THERAPY
An alternative approach to mental health care is one that emphasizes the interrelationship between mind, body, and spirit. Although some alternative approaches have a long history, many remain controversial.
ANOREXIA NERVOSA
Anorexia nervosa is an eating disorder characterized by unusual eating habits such as avoiding food and meals, picking out a few foods and eating them in small amounts, weighing food, and counting the calories of all foods. Individuals with anorexia nervosa may also exercise excessively.
ANXIETY DISORDERS
Anxiety disorders range from feelings of uneasiness to immobilizing bouts of terror. Most people experience anxiety at some point in their lives and some nervousness in anticipation of a real situation. However if a person cannot shake unwarranted worries, or if the feelings are jarring to the point of avoiding everyday activities, he or she most likely has an anxiety disorder.
ANY WILLING PROVIDER
A requirement that a health plan contract for the delivery of health care services with any provider in the area who would like to provide such services to the plan's enrollees.
APPROPRIATENESS
The extent to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient's or member's needs. (See also, medically necessary)
APPROPRIATE SERVICES
Designed to meet the specific needs of each individual child and family. For example, one family may need day treatment, while another may need home-based services. Appropriate services for one child and family may not be appropriate for another. Appropriate services usually are provided in the child's community.
ASSERTIVE COMMUNITY TREATMENT
A multi-disciplinary clinical team approach of providing 24-hour, intensive community services in the individual's natural setting that help individuals with serious mental illness live in the community.
ASSESSMENT
A professional review of child and family needs that is done when services are first sought from a caregiver. The assessment of the child includes a review of physical and mental health, intelligence, school performance, family situation, and behavior in the community. The assessment identifies the strengths of the child and family. Together, the caregiver and family decide what kind of treatment and supports, if any, are needed.
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)
ADHD is a chronic condition and is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD may have trouble paying attention or controlling impulsive behaviors. They may be overly active and have difficulty controlling their behavior in school and social settings.
AUTISM
Autism, also known as autism spectrum disorder, is a complex developmental disability that appears in early childhood, usually before age 3. Autism prevents children and adolescents from interacting normally with other people and affects almost every aspect of their social and psychological development.
AUTO-ENROLLMENT
The automatic assignment of a person to a health insurance plan (typically done under Medicaid plans).
AVERAGE LENGTH OF STAY
This represents the average time a client receives a specified service during a specified time period. This is generally computed by counting all the days that clients received the service during the time period and dividing by the number of clients that received the service during the same period. (Days a person was on furlough or not receiving are not counted.)
B
BEHAVIORAL HEALTHCARE
Continuum of services for individuals at risk of, or suffering from, mental, addictive, or other behavioral health disorders.
BEHAVIORAL HEATH CARE FIRM
Specialized (for-profit) managed care organizations focusing on mental health and substance abuse benefits, which they term "behavioral healthcare." These firms offer employers and public agencies a managed mental health and substance abuse benefit.
BEHAVIORAL THERAPY
As the name implies, behavioral therapy focuses on behavior-changing unwanted behaviors through rewards, reinforcements, and desensitization. Desensitization, or Exposure Therapy, is a process of confronting something that arouses anxiety, discomfort, or fear and overcoming the unwanted responses. Behavioral therapy often involves the cooperation of others, especially family and close friends, to reinforce a desired behavior.
BENCHMARK
The industry measure of best performance for a particular indicator or performance goal. The benchmarking process identifies the best performance in the industry (health care or non-health care) for a particular process or outcome, determines how that performance is achieved, and applies the lessons learned to improve performance.
BENEFICIARY
A person certified as eligible for health care services. A beneficiary may be a dependent or a subscriber.
BENEFIT PACKAGE
Services covered by a health insurance plan and the financial terms of such coverage. These include cost, limitation on the amounts of services, and annual or lifetime spending limits.
BINGE-EATING DISORDER
Binge-eating is an eating disorder characterized by frequent episodes of compulsive overeating, but unlike bulimia, the eating is not followed by purging. During food binges, individuals with this disorder often eat alone and very quickly, regardless of whether they feel hungry or full.
BIOFEEDBACK
Biofeedback is learning to control muscle tension and "involuntary" body functioning, such as heart rate and skin temperature; it can be a path to mastering one's fears. It is used in combination with, or as an alternative to, medication to treat disorders such as anxiety, panic, and phobias.
BIOMEDICAL TREATMENT
Medication alone, or in combination with psychotherapy, has proven to be an effective treatment for a number of emotional, behavioral, and mental disorders. Any treatment involving medicine is a biomedical treatment. The kind of medication a psychiatrist prescribes varies with the disorder and the individual being treated.
BIPOLAR DISORDER
Extreme mood swings punctuated by periods of generally even-keeled behavior characterize this disorder. Bipolar disorder tends to run in families. This disorder typically begins in the mid-twenties and continues throughout life. Without treatment, people who have bipolar disorder often go through devastating life events such as marital breakups, job loss, substance abuse, and suicide.
BORDERLINE PERSONALITY DISORDER
Symptoms of borderline personality disorder, a serious mental illness, include pervasive instability in moods, interpersonal relationships, self-image, and behavior. The instability can affect family and work life, long-term planning, and the individual's sense of self-identity.
BULIMIA NERVOSA
Bulimia nervosa is an eating disorder characterized by excessive eating. People who have bulimia will eat an excessive amount of food in a single episode and almost immediately make themselves vomit or use laxatives or diuretics (water pills) to get rid of the food in their bodies. This behavior often is referred to as the "binge/purge" cycle. Like people with anorexia, people with bulimia have an intense fear of gaining weight.
C
CAPITATION
A fixed amount of money paid per person for covered services for a specific time; usually expressed in units of per member per month (pmpm).
CAREGIVER
A person who has special training to help people with mental health problems. Examples include social workers, teachers, psychologists, psychiatrists, and mentors.
CARVE-IN
A generic term that refers to any of a continuum of joint efforts between clinicians and service providers; also used specifically to refer to health care delivery and financing arrangements in which all covered benefits (e.g., behavioral and general health care) are administered and funded by an integrated system.
CARVE-OUT
A health care delivery and financing arrangement in which certain specific health care services that are covered benefits (e.g., behavioral health care) are administered and funded separately from general health care services. The carve-out is typically done through separate contracting or sub-contracting for services to the special population.
CASE MANAGER
An individual who organizes and coordinates services and supports for children with mental health problems and their families. (Alternate terms: service coordinator, advocate, and facilitator.)
CASE MANAGEMENT
A service that helps people arrange for appropriate services and supports. A case manager coordinates mental health, social work, educational, health, vocational, transportation, advocacy, respite care, and recreational services, as needed. The case manager makes sure that the changing needs of the child and family are met. (This definition does not apply to managed care.) Managed care definition: A system requiring that a single individual in the provider organization is responsible for arranging and approving all devices needed under the contract embraced by employers, mental health authorities, and insurance companies to ensure that individuals receive appropriate, reasonable health care services.
CHILD PROTECTIVE SERVICES
Designed to safeguard the child when abuse, neglect, or abandonment is suspected, or when there is no family to take care of the child. Examples of help delivered in the home include financial assistance, vocational training, homemaker services, and daycare. If in-home supports are insufficient, the child may be removed from the home on a temporary or permanent basis. Ideally, the goal is to keep the child with the family whenever possible.
CHILDREN AND ADOLESCENTS AT RISK FOR MENTAL HEALTH PROBLEMS
Children are at greater risk for developing mental health problems when certain factors occur in their lives or environments. Factors include physical abuse, emotional abuse or neglect, harmful stress, discrimination, poverty, loss of a loved one, frequent relocation, alcohol and other drug use, trauma, and exposure to violence.
CLAIM
A request by an individual (or his or her provider) to that individual's insurance company to pay for services obtained from a health care professional.
CLINICAL PSYCHOLOGIST
A clinical psychologist is a professional with a doctoral degree in psychology who specializes in therapy.
CLINICAL SOCIAL WORKER
Clinical social workers are health professionals trained in counseling and psychotherapy and in client-centered advocacy that assist clients with information, referral, and direct help in dealing with local, State, or Federal government agencies. As a result, they often serve as case managers to help people "navigate the system." Clinical social workers cannot write prescriptions.
COGNITIVE THERAPY
Cognitive therapy aims to identify and correct distorted thinking patterns that can lead to feelings and behaviors that may be troublesome, self-defeating, or even self-destructive. The goal is to replace such thinking with a more balanced view that, in turn, leads to more fulfilling and productive behavior.
COGNITIVE-BEHAVIORAL THERAPY
A combination of cognitive and behavioral therapies, this approach helps people change negative thought patterns, beliefs, and behaviors so they can manage symptoms and enjoy more productive, less stressful lives.
COLLATERAL SERVICES
Services that include contacts with significant others involved in the client's/patient's life for the purpose of discussing the client's/patient's emotional or behavioral problems or the collateral's relationship with the client/patient.
COMMUNITY SERVICES
Services that are provided in a community setting. Community services refer to all services not provided in an inpatient setting.
CONDUCT DISORDERS
Children with conduct disorder repeatedly violate the personal or property rights of others and the basic expectations of society. A diagnosis of conduct disorder is likely when these symptoms continue for 6 months or longer. Conduct disorder is known as a "disruptive behavior disorder" because of its impact on children and their families, neighbors, and schools.
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)
An act that allows workers and their families to continue their employer-sponsored health insurance for a certain amount of time after terminating employment. COBRA imposes different restrictions on individuals who leave their jobs voluntarily versus involuntarily.
CONSUMER
Any individual who does or could receive health care or services. Includes other more specialized terms, such as beneficiary, client, customer, eligible member, recipient, or patient.
CONSUMER RUN SERVICES
Mental health treatment or support services that are provided by current or former mental health consumers. Includes social clubs, peer-support groups, and other peer-organized or consumer-run activities.
CONTINUOUS QUALITY IMPROVEMENT (CQI)
An approach to health care quality management borrowed from the manufacturing sector. It builds on traditional quality assurance methods by putting in place a management structure that continuously gathers and assesses data that are then used to improve performance and design more efficient systems of care. Also known as total quality management (TQM).
CONTINUUM OF CARE
A term that implies a progression of services that a child moves through, usually one service at a time. More recently, it has come to mean comprehensive services. Also see system of care and wraparound services.
COORDINATED SERVICES
Child-serving organizations talk with the family and agree upon a plan of care that meets the child's needs. These organizations can include mental health, education, juvenile justice, and child welfare. Case management is necessary to coordinate services. Also see family-centered services and wraparound services.
COUPLES COUNSELING AND FAMILY THERAPY
These two similar approaches to therapy involve discussions and problem-solving sessions facilitated by a therapist-sometimes with the couple or entire family group, sometimes with individuals. Such therapy can help couples and family members improve their understanding of, and the way they respond to, one another. This type of therapy can resolve patterns of behavior that might lead to more severe mental illness. Family therapy can help educate the individuals about the nature of mental disorders and teach them skills to cope better with the effects of having a family member with a mental illness-such as how to deal with feelings of anger or guilt.
COST-SHARING
A health insurance policy provision that requires the insured party to pay a portion of the costs of covered services. Deductibles, coinsurance, and co-payment are types of cost sharing.
CREDITABLE COVERAGE
Any prior health insurance coverage that a person has received. Creditable coverage is used to decrease exclusion periods for pre-existing conditions when an individual switches insurance plans. Insurers cannot exclude coverage of pre-existing conditions, but may impose an exclusion period (no more than 12 months) before covering such conditions. (See also, Health Insurance Portability and Accountability Act)
CRISIS RESIDENTIAL TREATMENT SERVICES
Short-term, round-the-clock help provided in a nonhospital setting during a crisis. For example, when a child becomes aggressive and uncontrollable, despite in-home supports, a parent can temporarily place the child in a crisis residential treatment service. The purposes of this care are to avoid inpatient hospitalization, help stabilize the child, and determine the next appropriate step.
CULTURAL COMPETENCE
Help that is sensitive and responsive to cultural differences. Caregivers are aware of the impact of culture and possess skills to help provide services that respond appropriately to a person's unique cultural differences, including race and ethnicity, national origin, religion, age, gender, sexual orientation, or physical disability. They also adapt their skills to fit a family's values and customs.
D
DSM-5 (DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION)
An official manual of mental health problems developed by the American Psychiatric Association. Psychiatrists, psychologists, social workers, and other health and mental health care providers use this reference book to understand and diagnose mental health problems. Insurance companies and health care providers also use the terms and explanations in this book when discussing mental health problems.
DAY TREATMENT
Day treatment includes special education, counseling, parent training, vocational training, skill building, crisis intervention, and recreational therapy. It lasts at least 4 hours a day. Day treatment programs work in conjunction with mental health, recreation, and education organizations and may even be provided by them.
DEDUCTIBLE
The amount an individual must pay for health care expenses before insurance (or a self-insured company) begins to pay its contract share. Often insurance plans are based on yearly deductible amounts.
DELUSIONS
Delusions are bizarre thoughts that have no basis in reality.
DEMENTIA
Dementia is a problem in the brain that makes it hard for a person to remember, learn and communicate; eventually is becomes difficult for a person to take care of himself or herself. This disorder can also affect a person's mood and personality.
DEPRESSION
Depression is a mood disorder characterized by intense feelings of sadness that persist beyond a few weeks. Two neurotransmitters-natural substances that allow brain cells to communicate with one another-are implicated in depression: serotonin and norepinephrine.
DIAGNOSTIC EVALUATION
The aims of a general psychiatric evaluation are 1) to establish a psychiatric diagnosis, 2) to collect data sufficient to permit a case formulation, and 3) to develop an initial treatment plan, with particular consideration of any immediate interventions that may be needed to ensure the patient's safety, or, if the evaluation is a reassessment of a patient in long-term treatment, to revise the plan of treatment in accord with new perspectives gained from the evaluation.
DISCHARGE
A discharge is the formal termination of service, generally when treatment has been completed or through administrative authority.
DROP-IN CENTER
A social club offering peer support and flexible schedule of activities: may operate on evenings and/ weekends.
DRUG FORMULARY
The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either "closed," including only certain drugs or "open," including all drugs. Both types of formularies typically impose a cost scale requiring consumers to pay more for certain brands or types of drugs.
DUALLY DIAGNOSED
A person who has both an alcohol or drug problem and an emotional/psychiatric problem is said to have a dual diagnosis.
E
EARLY INTERVENTION
A process used to recognize warning signs for mental health problems and to take early action against factors that put individuals at risk. Early intervention can help children get better in less time and can prevent problems from becoming worse.
EDUCATION SERVICES
Locating or providing a full range of educational services from basic literacy through the General Equivalency Diploma and college courses. Includes special education at the pre-primary, primary, secondary, and adult levels.
EMERGENCY
A planned program to provide psychiatric care in emergency situations with staff specifically assigned for this purpose. Includes crisis intervention, which enables the individual, family members and friends to cope with the emergency while maintaining the individual's status as a functioning community member to the greatest extent possible.
EMERGENCY AND CRISIS SERVICES
A group of services that is available 24 hours a day, 7 days a week, to help during a mental health emergency. Examples include telephone crisis hotlines, suicide hotlines, crisis counseling, crisis residential treatment services, crisis outreach teams, and crisis respite care.
EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA), also referred to as the FEDERAL ANTI-PATIENT DUMPING LAW
An act pertaining to emergency medical situations. EMTALA requires hospitals to provide emergency treatment to individuals, regardless of insurance status and ability to pay (EMTALA, 2002).
EMPLOYED
This is a broad category of employment that includes competitive, supported, and sheltered employment.
EMPLOYEE ASSISTANCE PLAN (EAP)
Resources provided by employers either as part of, or separate from, employer-sponsored health plans. EAPs typically provide preventive care measures, various health care screenings, and/or wellness activities.
EMPLOYMENT RETIREMENT INCOME SECURITY ACT (ERISA)
Health plans that are self-insured are exempt from state regulation under this 1974 act.
EMPLOYMENT/VOCATIONAL REHABILITATION SERVICES
A broad range of services designed to address skills necessary for participation in job-related activities.
ENROLLEE
A person eligible for services from a managed care plan.
ENROLLMENT
The total number of covered persons in a health plan. Also refers to the process by which a health plan enrolls groups and individuals for membership or the number of enrollees who sign up in any one group.
F
FAMILY-CENTERED SERVICES
Help designed to meet the specific needs of each individual child and family. Children and families should not be expected to fit into services that do not meet their needs. Also see appropriate services, coordinated services, wraparound services, and cultural competence.
FAMILY-LIKE ARRANGEMENTS
A broad range of living arrangements that simulate a family situation. This includes foster care and small group homes.
FAMILY SUPPORT SERVICES
Help designed to keep the family together, while coping with mental health problems that affect them. These services may include consumer information workshops, in-home supports, family therapy, parenting training, crisis services, and respite care.
FEE FOR SERVICE
A type of health care plan under which health care providers are paid for individual medical services rendered.
FOSTER CARE
Provision of a living arrangement in a household other than that of the client's/patient's family.
G
GATEKEEPER
Primary care physician or local agency responsible for coordinating and managing the health care needs of members. Generally, in order for specialty services such as mental health and hospital care to be covered, the gatekeeper must first approve the referral.
GENERAL HOSPITAL
A hospital that provides mental health services in at least one separate psychiatric unit with specially allocated staff and space for the treatment of persons with mental illness.
GENERAL SUPPORT
Includes transportation, childcare, homemaker services, day care, and other general services for clients/patients.
GROUP-MODEL HEALTH MAINTENANCE ORGANIZATION (HMO)
A health care model involving contracts with physicians organized as a partnership, professional corporation, or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for care of their patients.
GROUP THERAPY
This form of therapy involves groups of usually 4 to 12 people who have similar problems and who meet regularly with a therapist. The therapist uses the emotional interactions of the group's members to help them get relief from distress and possibly modify their behavior.
H
HALLUCINATIONS
Hallucinations are experiences of sensations that have no source. Some examples of hallucinations include hearing nonexistent voices, seeing nonexistent things, and experiencing burning or pain sensations with no physical cause.
HEALTH EMPLOYER DATA AND INFORMATION SET (HEDIS)
A set of HMO performance measures that are maintained by the National Committee for Quality Assurance. HEDIS data is collected annually and provides an informational resource for the public on issues of health plan quality.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
This 1996 act provides protections for consumers in group health insurance plans. HIPAA prevents health plans from excluding health coverage of pre-existing conditions and discriminating on the basis of health status.
HEALTH MAINTENANCE ORGANIZATION (HMO)
A type of managed care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Services are furnished through a network of providers.
HOME-BASED SERVICES
Help provided in a family's home either for a defined period of time or for as long as it takes to deal with a mental health problem. Examples include parent training, counseling, and working with family members to identify, find, or provide other necessary help. The goal is to prevent the child from being placed outside of the home. (Alternate term: in-home supports.)
HORIZONTAL CONSOLIDATION
When local health plans (or local hospitals) merge. This practice was popular in the late 1990s and was used to expand regional business presence.
HOUSING SERVICES
Assistance to clients/patients in finding and maintaining appropriate housing arrangements.
I
INDEMNITY PLAN
Indemnity insurance plans are an alternative to managed care plans. These plans charge consumers a set amount for coverage and reimburse (fully or partially) consumers for most medical services.
INDEPENDENT LIVING SERVICES
Support for a young person living on his or her own. These services include therapeutic group homes, supervised apartment living, and job placement. Services teach youth how to handle financial, medical, housing, transportation, and other daily living needs, as well as how to get along with others.
INDIVIDUALIZED SERVICES
Services designed to meet the unique needs of each child and family. Services are individualized when the caregivers pay attention to the needs and strengths, ages, and stages of development of the child and individual family members. Also see appropriate services and family-centered services.
INDIVIDUAL THERAPY
Therapy tailored for a patient/client that is administered one-on-one.
INFORMATION AND REFERRAL SERVICES
Information services are those designed to impart information on the availability of clinical resources and how to access them. Referral services are those that direct, guide, or a client/patient with appropriate services provided outside of your organization.
IN HOME FAMILY SERVICES
Mental health treatment and support services offered to children and adolescents with mental illness and to their family members in their own homes or apartments.
INPATIENT HOSPITALIZATION
Mental health treatment provided in a hospital setting 24 hours a day. Inpatient hospitalization provides: (1) short-term treatment in cases where a child is in crisis and possibly a danger to his/herself or others, and (2) diagnosis and treatment when the patient cannot be evaluated or treated appropriately in an outpatient setting.
INTAKE/ SCREENING
Services designed to briefly assess the type and degree of a client's/patient's mental health condition to determine whether services are needed and to link him/her to the most appropriate and available service. Services may include interviews, psychological testing, physical examinations including speech/hearing, and laboratory studies.
INTENSIVE CASE MANAGEMENT
Intensive community services for individuals with severe and persistent mental illness that are designed to improve planning for their service needs. Services include outreach, evaluation, and support.
INTENSIVE RESIDENTIAL SERVICES
Intensively staffed housing arrangements for clients/patients. May include medical, psychosocial, vocational, recreational or other support services.
INTERPERSONAL PSYCHOTHERAPY
Through one-on-one conversations, this approach focuses on the patient's current life and relationships within the family, social, and work environments. The goal is to identify and resolve problems with insight, as well as build on strengths.
L
LEGAL ADVOCACY
Legal services provided to ensure the protection and maintenance of a client's/patient's rights.
LENGTH OF STAY
The duration of an episode of care for a covered person. The number of days an individual stays in a hospital or inpatient facility.
LIVING INDEPENDENTLY
A client who lives in a private residence and requires no assistance in activities of daily living.
LOCAL MENTAL HEALTH AUTHORITY
Local organizational entity (usually with some statutory authority) that centrally maintains administrative, clinical, and fiscal authority for a geographically specific and organized system of health care.
M
MANAGED CARE
An organized system for delivering comprehensive mental health services that allows the managed care entity to determine what services will be provided to an individual in return for a prearranged financial payment. Generally, managed care controls health care costs and discourages unnecessary hospitalization and overuse of specialists, and the health plan operates under contract to a payer.
MEDICAID
Medicaid is a health insurance assistance program funded by Federal, State, and local monies. It is run by State guidelines and assists low-income persons by paying for most medical expenses.
MEDICAID CLIENT
Mental health clients to whom some services were reimbursable through Medicaid.
MEDICAL GROUP PRACTICE
A number of physicians working in a systematic association with the joint use of equipment and technical personnel and with centralized administration and financial organization.
MEDICAL REVIEW CRITERIA
Screening criteria used by third-party payers and review organizations as the underlying basis for reviewing the quality and appropriateness of care provided to selected cases.
MEDICALLY NECESSARY
Health insurers often specify that, in order to be covered, a treatment or drug must be medically necessary for the consumer. Anything that falls outside of the realm of medical necessity is usually not covered. The plan will use prior authorization and utilization management procedures to determine whether or not the term "medically necessary" is applicable.
MEDICARE
Medicare is a Federal insurance program serving the disabled and persons over the age of 65. Most costs are paid via trust funds that beneficiaries have paid into throughout the courses of their lives; small deductibles and some co-payments are required.
MEDICATION THERAPY
Prescription, administration, assessment of drug effectiveness, and monitoring of potential side effects of psycho-tropic medications.
MEDIGAP
MediGap plans are supplements to Medicare insurance. MediGap plans vary from State to State; standardized MediGap plans also may be known as Medicare Select plans.
MEMBER
Used synonymously with the terms enrollee and insured. A member is any individual or dependent who is enrolled in and covered by a managed health care plan.
MENTAL HEALTH
How a person thinks, feels, and acts when faced with life's situations. Mental health is how people look at themselves, their lives, and the other people in their lives; evaluate their challenges and problems; and explore choices. This includes handling stress, relating to other people, and making decisions.
MENTAL HEALTH PARITY (ACT)
Mental health parity refers to providing the same insurance coverage for mental health treatment as that offered for medical and surgical treatments. The Mental Health Parity Act was passed in 1996 and established parity in lifetime benefit limits and annual limits. These protections were broadened in the current law, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
MENTAL HEALTH PROBLEMS
Mental health problems are real. They affect one's thoughts, body, feelings, and behavior. Mental health problems are not just a passing phase. They can be severe, seriously interfere with a person's life, and even cause a person to become disabled. Mental health problems include depression, bipolar disorder (manic-depressive illness), attention-deficit/ hyperactivity disorder, anxiety disorders, eating disorders, schizophrenia, and conduct disorder.
MENTAL DISORDERS
Another term used for mental health problems.
MENTAL ILLNESSES
This term is usually used to refer to severe mental health problems in adults.
MOBILE TREATMENT TEAM
Provides assertive outreach, crisis intervention, and independent-living assistance with linkage to necessary support services in the client's/patient's own environment.
N
NETWORK
The system of participating providers and institutions in a managed care plan.
NETWORK ADEQUACY
Many States have laws defining network adequacy, the number and distribution of health care providers required to operate a health plan. Also known as provider adequacy of a network.
NEW GENERATION MEDICATIONS
Anti-psychotic medications which are new and atypical.
NON-INSTITUTIONAL SERVICES
A facility that provides mental health services, but not on a residential basis, other than an inpatient facility or nursing home.
NON-MEDICAID SERVICES
Services other than those funded by Medicaid.
NURSE PRACTITIONER (NP)
A nurse practitioner is a registered nurse who works in an expanded role and manages patients' medical conditions.
NURSING HOME
An establishment that provides living quarters and care for the elderly and the chronically ill. This includes assisted living outside a nursing home.
O
OBSESSIVE COMPULSIVE DISORDER
Obsessive Compulsive Disorder is a chronic, relapsing illness. People who have it suffer from recurrent and unwanted thoughts or rituals. The obsessions and the need to perform rituals can take over a person's life if left untreated. They feel they cannot control these thoughts or rituals.
OUTCOMES
The results of a specific health care service or benefit package.
OUTCOMES MEASURE
A tool to assess the impact of health services in terms of improved quality and/or longevity of life and functioning.
OUTCOMES RESEARCH
Studies that measure the effects of care or services.
P
PANIC DISORDERS
People with panic disorder experience heart-pounding terror that strikes suddenly and without warning. Since they cannot predict when a panic attack will seize them, many people live in persistent worry that another one could overcome them at any moment.
PARANOIA AND PARANOID DISORDERS
Symptoms of paranoia include feelings of persecution and an exaggerated sense of self-importance. The disorder is present in many mental disorders and it is rare as an isolated mental illness. A person with paranoia can usually work and function in everyday life since the delusions involve only one area. However, their lives can be isolated and limited.
PASTORAL COUNSELING
Pastoral counselors are counselors working within traditional faith communities to incorporate psychotherapy, and/or medication, with prayer and spirituality to effectively help some people with mental disorders. Some people prefer to seek help for mental health problems from their pastor, rabbi, or priest, rather than from therapists who are not affiliated with a religious community.
PAYER
The public or private organization that is responsible for payment for health care expenses.
PERFORMANCE MEASURE
A measure that describes the health care being provided. Current performance measures indicate whether a health plan or provider has appropriately provided certain services expected to lead to desirable outcomes.
PHARMACY BENEFIT MANAGER (PBM)
PBMs are third party administrators of prescription drug benefits.
PHOBIAS
Phobias are irrational fears that lead people to altogether avoid specific things or situations that trigger intense anxiety. Phobias occur in several forms, for example, agoraphobia is the fear of being in any situation that might trigger a panic attack and from which escape might be difficult; social phobia is a fear of being extremely embarrassed in front of other people.
PHYSICIAN ASSISTANT
A physician assistant is a trained professional who provides health care services under the supervision of a licensed physician.
PLAN OF CARE
A treatment plan especially designed for each child and family, based on individual strengths and needs. The caregiver(s) develop(s) the plan with input from the family. The plan establishes goals and details appropriate treatment and services to meet the special needs of the child and family.
PLAY THERAPY
Geared toward young children, play therapy uses a variety of activities-such as painting, puppets, and dioramas-to establish communication with the therapist and resolve problems. Play allows the child to express emotions and problems that would be too difficult to discuss with another person.
POINT-OF-SERVICE PLAN (POS)
A modified managed care plan under which members do not have to choose how to receive services until they need them. Members receive coverage at a reduced level if they choose to use a non-network provider.
POSTTRAUMATIC STRESS DISORDER (PTSD)
Posttraumatic Stress Disorder is an anxiety disorder that develops as a result of witnessing or experiencing a traumatic occurrence, especially life threatening events. PTSD can cause can interfere with a person's ability to hold a job or to develop intimate relationships with others.
PRACTICE GUIDELINES
Systematically developed statements to standardize care and to assist in practitioner and patient decisions about the appropriate health care for specific circumstances. Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion. Practice guidelines are also referred to as clinical criteria, protocols, algorithms, review criteria, and guidelines.
PRE-EXISTING CONDITION
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can't refuse to cover treatment for your pre-existing condition or charge you more.
PREFERRED PROVIDER ORGANIZATION (PPO)
A health plan in which consumers may use any health care provider on a fee-for-service basis. Consumers will be charged more for visiting providers outside of the PPO network than for visiting providers in the network (American Association of Preferred Provider Organizations).
PRIMARY CARE PHYSICIAN (PCP)
Physicians with the following specialties: group practice, family practice, internal medicine, obstetrics/gynecology, and pediatrics. The PCP is usually responsible for monitoring an individual's overall medical care and referring the individual to more specialized physicians for additional care.
PRIOR AUTHORIZATION
The approval a provider must obtain from an insurer or other entity before furnishing certain health services, particularly inpatient hospital care, in order for the service to be covered under the plan.
PSYCHIATRIC EMERGENCY WALK-IN
A planned program to provide psychiatric care in emergency situations with staff specifically assigned for this purpose. Includes crisis intervention, which enables the individual, family members and friends to cope with the emergency while maintaining the individual's status as a functioning community member to the greatest extent possible and is open for a patient to walk-in.
PSYCHIATRIST
A psychiatrist is a professional who completed both medical school and training in psychiatry and is a specialist in diagnosing and treating mental illness.
PSYCHOANALYSIS
Psychoanalysis focuses on past conflicts as the underpinnings to current emotional and behavioral problems. In this long-term and intensive therapy, an individual meets with a psychoanalyst three to five times a week, using "free association" to explore unconscious motivations and earlier, unproductive patterns of resolving issues.
PSYCHODYNAMIC PSYCHOTHERAPY
Based on the principles of psychoanalysis, this therapy is less intense, tends to occur once or twice a week, and spans a shorter time. It is based on the premise that human behavior is determined by one's past experiences, genetic factors, and current situation. This approach recognizes the significant influence that emotions and unconscious motivation can have on human behavior.
PSYCHOSOCIAL REHABILITATION
Therapeutic activities or interventions provided individually or in groups that may include development and maintenance of daily and community-living skills, self-care, skills training includes grooming, bodily care, feeding, social skills training, and development of basic language skills.
Q
QUALITY ASSURANCE
An approach to improving the quality and appropriateness of medical care and other services. Includes a formal set of activities to review, assess, and monitor care to ensure that identified problems are addressed.
R
REGISTERED NURSE (RN)
A registered nurse is a trained professional with a nursing degree who provides patient care and administers medicine.
REPORT CARD
An accounting of the quality of services, compared among providers over time. The report card grades providers on predetermined, measurable quality and outcome indicators. Generally, consumers use report cards to choose a health plan or provider, while policy makers may use report card results to determine overall program effectiveness, efficiency, and financial stability.
RESIDENTIAL SERVICES
Services provided over a 24-hour period or any portion of the day which a patient resided, on an on-going basis, in a State facility or other facility and received treatment.
RESIDENTIAL TREATMENT CENTERS
Facilities that provide treatment 24 hours a day and can usually serve more than 12 young people at a time. Children with serious emotional disturbances receive constant supervision and care. Treatment may include individual, group, and family therapy; behavior therapy; special education; recreation therapy; and medical services. Residential treatment is usually more long-term than inpatient hospitalization. Centers are also known as therapeutic group homes.
RESPITE RESIDENTIAL SERVICES
Provision of periodic relief to the usual family members and friends who care for the clients/patients.
RESPITE CARE
A service that provides a break for parents who have a child with a serious emotional disturbance. Trained parents or counselors take care of the child for a brief period of time to give families relief from the strain of caring for the child. This type of care can be provided in the home or in another location. Some parents may need this help every week.
RETIRED
Clients who are of legal age, stopped working and have withdrawn from one's occupation.
RISK
Possibility that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contractual services. A managed care provider is at risk if actual expenses exceed the payment amount.
RISK ADJUSTMENT
The adjustment of premiums to compensate health plans for the risks associated with individuals who are more likely to require costly treatment. Risk adjustment takes into account the health status and risk profile of patients.
RISK SHARING
Situation in which the managed care entity assumes responsibility for services for a specific group but is protected against unexpected high costs by a pre-arranged agreement for higher payments for those individuals who need significantly more costly services. Risk is usually shared by the managed care entity and the State.
S
SCHIZOPHRENIA
Schizophrenia is a mental disorder characterized by "positive" and "negative" symptoms. Psychotic, or positive, symptoms include delusions, hallucinations, and disordered thinking (apparent from a person's fragmented, disconnected and sometimes nonsensical speech). Negative symptoms include social withdrawal, extreme apathy, diminished motivation, and blunted emotional expression.
SCHOOL ATTENDANCE
Physical presence of a child in a school setting during scheduled class hours. "Regular" school attendance is attendance at least 75% of scheduled hours.
SCHOOL BASED SERVICES
School-based treatment and support interventions designed to identify emotional disturbances and/or assist parents, teachers, and counselors in developing comprehensive strategies for addressing these disturbances. School-based services also include counseling or other school-based programs for emotionally disturbed children, adolescents, and their families within the school, home and community environment.
SEASONAL AFFECTIVE DISORDER (SAD)
Seasonal affective disorder (SAD) is a form of depression that appears related to fluctuations in the exposure to natural light. It usually strikes during autumn and often continues through the winter when natural light is reduced. Researchers have found that people who have SAD can be helped with the symptoms of their illness if they spend blocks of time bathed in light from a special full-spectrum light source, called a "light box."
SECTION 1115 WAIVER
A statutory provision that allows a State to operate its system of care for Medicaid enrollees in a manner different from that proscribed by the Centers for Medicare and Medicaid Services (CMS), in an attempt to demonstrate the efficacy and cost-effectiveness of an alternative delivery system through research and evaluation.
SECTION 1915(B) WAIVER
A statutory provision that allows a State to partially limit the choice of providers for Medicaid enrollees; for example, under the waiver, a State can limit the number of times per year that enrollees can choose to drop out of an HMO.
SELF-HELP
Self-help generally refers to groups or meetings that: involve people who have similar needs; are facilitated by a consumer, survivor, or other layperson; assist people to deal with a "life-disrupting" event, such as a death, abuse, serious accident, addiction, or diagnosis of a physical, emotional, or mental disability, for oneself or a relative; are operated on an informal, free-of-charge, and nonprofit basis; provide support and education; and are voluntary, anonymous, and confidential. Many people with mental illnesses find that self-help groups are an invaluable resource for recovery and for empowerment.
SERIOUS EMOTIONAL DISTURBANCE (SED)
Diagnosable mental, behavioral, or emotional disorder affecting a child that exists or has existed within the past year for a period of time sufficient to meet diagnostic criteria specified in the most recent Diagnostic and Statistical Manual of Mental Disorders
published by the American Psychiatric Association and that has resulted in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities. SED includes disorders such as major depression,
attention-deficit/hyperactivity disorder, anxiety disorders, conduct disorder, and eating disorders.
SERIOUS MENTAL ILLNESS (SMI)
Diagnosable mental, behavioral, or emotional disorder affecting an adult that exists or has existed within the past year for a period of time sufficient to meet diagnostic criteria specified in the most recent Diagnostic and Statistical Manual of Mental Disorders
published by the American Psychiatric Association and that has resulted in functional impairment that substantially interferes with or limits one or more major life activities. SMI includes disorders such as major depression, schizophrenia, bipolar disorder,
obsessive compulsive disorder (OCD), panic disorder, post traumatic stress (PTSD) and borderline personality disorder. In 2020, there were an estimated 14.2 million adults aged 18 or older (or 5.6% of all U.S. adults) in the United States with SMI
(NIMH).
SERVICE
A type of support or clinical intervention designed to address the specific mental health needs of a child and his or her family. A service could be provided only one time or repeated over a course of time, as determined by the child, family, and service provider.
SINGLE-STREAM FUNDING
The consolidation of multiple sources of funding into a single stream. This is a key approach used in progressive mental health systems to ensure that "funds follow consumers."
STAFF-MODEL HMO
An HMO that directly employs, on a salaried basis, the doctors and other providers who furnish care.
STATE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP)
The Children's Health Insurance Program (CHIP) is a partnership between the federal and state governments that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program. CHIP benefits are different in each state. But all states provide comprehensive coverage, like routine check-ups, immunizations, doctor visits, and prescriptions.
STATE COVERAGE
The total unduplicated count of mental health patients/clients served through State programs, exclusive of Medicaid and Other Coverage.
STATE HOSPITAL
A publicly funded inpatient facility for persons with mental illness.
STATE MENTAL HEALTH AUTHORITY OR AGENCY
State government agency charged with administering and funding its State's public mental health services.
SUBCAPITATION
An arrangement whereby a capitated health plan pays its contracted providers on a capitated basis.
SUBSCRIBER
Employment group or individual that contracts with an insurer for medical services.
SUBSTANCE ABUSE
Misuse of medications, alcohol or other illegal substances.
SUPPORTED EMPLOYMENT
Supportive services that include assisting individuals in finding work; assessing individuals' skills, attitudes, behaviors, and interest relevant to work; providing vocational rehabilitation and/or other training; and providing work opportunities. Includes transitional and supported employment services.
SUPPORTED HOUSING
Services to assist individuals in finding and maintaining appropriate housing arrangements.
SUPPORTIVE RESIDENTIAL SERVICES
Moderately staffed housing arrangements for clients/patients. Includes supervised apartments, satellite facilities, group homes, halfway houses, mental health shelter-care facilities, and other facilities.
SYSTEM OF CARE
A system of care is a method of addressing children's mental health needs. It is developed on the premise that the mental health needs of children, adolescents, and their families can be met within their home, school, and community environments. These systems are also developed around the principles of being child-centered, family-driven, strength-based, and culturally competent and involving interagency collaboration.
T
TELEPHONE HOTLINE
A dedicated telephone line that is advertised and may be operated as a crisis hotline for emergency counseling, or as a referral resource for callers with mental health problems.
THERAPEUTIC FOSTER CARE
A service which provides treatment for troubled children within private homes of trained families. The approach combines the normalizing influence of family-based care with specialized treatment interventions, thereby creating a therapeutic environment in the context of a nurturant family home.
THIRD PARTY PAYER
A public or private organization that is responsible for the health care expenses of another entity.
U
UNDERWRITING
The review of prospective or renewing cases to determine their risk and their potential costs.
UNDUPLICATED COUNTS
Counting a client/patient and their services uniquely. Unduplicated counts can exist at different levels: a program, a local system of care, or at the State level.
UNEMPLOYED
Not currently employed. This could include people looking for work, or people engaged in other activities such as homemakers, students or volunteers.
UNMET NEEDS
Identified treatment needs of the people that are not being met as well as those receiving treatment that is inappropriate or not optimal.
UTILIZATION
The level of use of a particular service over time.
UTILIZATION MANAGEMENT (UM)
A system of procedures designed to ensure that the services provided to a specific client at a given time are cost-effective, appropriate, and least restrictive.
UTILIZATION REVIEW
Retrospective analysis of the patterns of service usage in order to determine means for optimizing the value of services provided (minimize cost and maximize effectiveness/appropriateness).
UTILIZATION RISK
The risk that actual service utilization might differ from utilization projections.
V
VERTICAL DISINTEGRATION
A practice of selling off health plan subsidiaries or provider activities. Vertical disintegration was a trend in the late 1990s.
VOCATIONAL REHABILITATION SERVICES
Services that include job finding/development, assessment and enhancement of work-related skills, attitudes, and behaviors as well as provision of job experience to clients/patients. Includes transitional employment.
W
WRAPAROUND SERVICES
A unique set of community services and natural supports for a child/adolescent with serious emotional disturbances based on a definable planning process, individualized for the child and family to achieve a positive set of outcomes.
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