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Mental Health America of Central
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Partner Agency of
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INSURANCE GLOSSARY Access: The ability to obtain desired health care, determined by the availability of services, acceptability of services, cultural appropriateness, location, hours of operation, transportation, and cost. Admission Certification: A form of utilization review in which an assessment is made of the medical necessity of a patient’s admission to a hospital or other inpatient institution to ensure that such care is needed. AFDC: Aid to Families with Dependent Children Capitation: A method of financing health care services that provides a fixed, per-person amount that a health provider/provider organization is paid for a given time period (usually a year), regardless of the amount of services provided, but with expected client outcomes. Carve-out: A program delivery and financing design wherein a state or other funder arranges services for a certain population through distinct and separate service organizations or through specialized networks of mental health service providers. Case Management: A system requiring that a single individual in the provider organization is responsible for arranging and approving all resources needed under the contract embraced by employers, mental health authorities, and insurance companies to ensure that individuals receive appropriate, reasonable healthcare services. Co-insurance: Refers to money that a patient is required to pay for services (usually after a deductible has been paid). Co-payment: A predetermined (flat) fee that an individual pays for health care services in addition to what the insurance covers. Deductible: The amount an individual must pay for health care expenses before insurance (or a self-insured company) begins to pay its contract share. Diagnosis Related Group (DRG): A classification system of diagnoses developed by the government for Medicare that is used to determine the amount paid to hospitals for a patient with a certain diagnosis. Drug Formulary: The list of prescription drugs for which a state Medicaid program will pay. If a drug is not on the state’s formulary, Medicaid will not pay for it. Employee Assistance Programs: Many companies have an Employee Assistance Program (EAP) which the employee may use if they are experiencing emotional problems. Some of these programs will offer brief therapy, and some do an assessment and refer to a provider in the community. Employee Assistance Programs are sometimes also managed care companies. Though the insurance may provide a certain amount of coverage, the managed care company oversees how treatment is progressing and approves the number of sessions to be allowed. EPSDT: Early Periodic Screening, Diagnosis, and Treatment. EPSDT is a Medicaid program for children and youth to age 21. Fee-for-service: Financing model of traditional insurance where a provider bills for every service and is paid the amounts he or she charges. Group Model HMO: A type of HMO medical center where many different services are provided in unified medical center locations. HCFA (Health Care Financing Administration): The agency within the US Department of Health and Human Services that oversees the Medicaid and Medicare programs. Health Maintenance Organizations (HMO): Pre-paid or capitated insurance plans in which individuals and/or their employers pay a fixed monthly fee for services instead of separate charge for each visit or service. Managed Care: Many insurance companies now have managed care companies overseeing mental health benefits. This means that a therapist may have to have treatment approved or pre-certified by the managed care company who is overseeing the insurance benefits. Though the insurance may provide a certain amount of coverage, the managed care company oversees. Medicaid: A joint federal-state program, enacted in 1965 under Title XIX of the Social Security Act, that helps pay for health care for the poor. Medicaid Waiver: A provision of federal law that allows HCFA to permit a state Medicaid program design that does not comply with all requirements of federal law—so long as certain safeguards and other criteria are met. Medicare: A totally federally run and financed health insurance plan authorized under Title XVIII of the Social Security Act for eligible persons over the age of 65 and certain severely disabled individuals. Open-Ended HMO: HMOs that allow enrolled individuals to use out-of-plan providers or make their choice of provider at the “point of service.” Enrollees still receive partial or full coverage and payment for the services. Pre-admission Certification: The approval by a case manager or insurance company representative for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-existing Condition: A medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company. Preferred Provider Organization (PPO): An arrangement in which you or your employer receive discounted rates if you use doctors or hospitals from a pre-selected group, (the PPO). Primary Care Provider (PCP): A healthcare professional (usually a physician) who is responsible for monitoring an individual’s overall healthcare needs. Provider: Any healthcare professional or organization that provides services, including doctors, hospitals, mental health centers, nurse practitioners, chiropractors, physical therapists, etc. Reasonable and Customary Fees: The average fee charged by a particular type of health care practitioner within a geographic area. |
Glossary of Mental Health Terms
Stamping Out Stigma |
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