a

Affordable Care Act (ACA)

The national health reform law that was signed into law in 2010.

Americans with Disabilities Act

A law that does not allow discrimination based on disability. Disabilities under the ADA include physical and mental conditions, as well as permanent and short-term conditions. The ADA addresses discrimination in the employment setting, discrimination by public entities (such as state and local governments) and on public transportation, discrimination at public accommodations and commercial facilities, and discrimination in telecommunications.

Annual Limits

The highest number of inpatient days or outpatient visits an insurance plan will pay for health services during a year.

Annual Maximum

The highest amount an insurance plan will pay for health services during a year.

Appeals Process

When a person challenges an insurance claim that has been denied. Usually, each insurance company has its own process.

Applied Behavior Analysis (ABA)

A common and scientifically proven way to treat children with autism so that there is a meaningful and positive change in behavior.

Arbitration

A process to settle conflicts or disputes without having to go to court. Arbitration is an option in some insurance plans if your plan denies coverage for your behavioral health care.

Assisted Outpatient Treatment (AOT)

This is when a court orders someone with a behavioral health condition to get outpatient care . AOT is usually ordered for someone who has committed a crime or has been hospitalized very often and who will not voluntarily get treatment. Many states have AOT laws.

b

Behavioral Health

Mental health and Substance Use Disorder (addiction)

Benchmark Plan

The plan that each state designates as the standard plan for essential health benefits. Health insurers can use this plan to create their own plans that adhere to essential health benefit requirements.

Benefits Representative

If you get your insurance through your employer, this is the person at your workplace who can explain your insurance plan to you. Some small employers (less than 51 employees) may not have a benefits representative.

c

Classification of Benefits

Federal parity regulations created six different categories of insurance benefits for all behavioral health services: inpatient in-network , inpatient out-of-network , outpatient in-network , outpatient out-of-network , emergency care, and prescription drugs. All services fall into one of these categories.

Clinical Review Criteria

The standards insurance plans will use when they do utilization review and medical necessity review.

Coinsurance

Money that a person with insurance has to pay for services, after a deductible has been met. Coinsurance is a percentage of the overall cost of the service. So if the service cost $100 and your coinsurance rate is 25%, you will pay $25 for that service and the insurer will pay $75.

Comprehensive Parity Law

A law that requires insurance plans to provide coverage for all behavioral health conditions and provide that coverage at the same terms and conditions as coverage for other medical care.

Copayment

Money that a person with insurance has to pay for services after a deductible has been met. A copayment is a flat dollar amount, like $20 per visit, but may vary by type of doctor you see (for example a specialist may have a higher dollar amount.)

d

Deductible

The money a person must pay on her own, or out-of-pocket , before the insurance company starts to pay for care.

Diagnostic and Statistical Manual of Mental Disorders (DSM)

This is the guide that behavioral health professionals use to identify and diagnose behavioral health conditions. The most recent version is the DSM-V, but many laws and regulations still refer to the DSM-IV, which was in use from 1994 until 2013.

Disclosure

Information an insurer has to tell you about your plan and what rules and laws apply to your plan.

e

ERISA

The federal Employee Retirement Income Security Act. ERISA sets minimum standards for pension and health insurance plans offered by large employers. ERISA also sets health insurance standards for employers who choose to self insure (employers who use their own money to pay all of the claims for their employees’ health care.) Self-insured health insurance plans are often called ERISA plans.

Essential Health Benefits (EHB)

The Affordable Care Act requires health insurance plans to include coverage for 10 different categories of care. Mental health and substance use disorder care is one of the categories.

Exclusions

Specific services an insurance plan will not cover.

Expedited Appeals Process

This is an appeal for a denial of coverage that insurance plans must respond to quickly; usually within 24-48 hours.

Explanation of Benefits

A letter sent from the health insurance company to an insured member listing services that were billed by a healthcare provider, how those charges were processed, and how much the patient may have to pay.

External Review

One of the last steps in the appeal process . A person may ask for an external review once she has completed all of the insurance plan’s appeal processes. Usually a group of people that aren’t part of the insurance company will review everything and decide whether or not the insurance company must pay for treatment. External reviews are usually done by an Independent Review Organization .

f

Fail-First Protocol

A requirement that a patient try a less expensive treatment first before she can get approval for the treatment her provider orders. For example, an insurance plan may not pay for a brand name medication until a person does not improve using a generic medication . This is also known as step therapy .

Federal Parity Law

The Mental Health Parity and Addiction Equity Act (MHPAEA). This is a federal law that requires many insurance plans that offer behavioral health coverage to provide that coverage with the same terms and conditions as other medical coverage. The law doesn’t require insurance plans to cover behavioral health services, but if they do, it has to be equal with other medical coverage. There are also state parity laws .

Financial Requirements

Deductibles , copayments , coinsurance , or other out-of-pocket expenses.

Fully-insured

These are insurance plans that employers purchase from an insurance company to cover their employees’ health care needs. These plans are regulated at the state level.

g

Generic Medication

A prescription medication that has the same active ingredient as the brand name prescription medication, but can be made by any medication company, not just the company that invented the medication. Generic medications are usually less expensive than brand name medications.

Grandfathered Plan

A health insurance plan that was created before 3/23/2010. These plans do not have to comply with all of the requirements of the Affordable Care Act and do not have to comply with the Federal Parity Law.

Grievance Appeal

A complaint by a person about an insurance company’s coverage of his/her care.

Group Health Plan

These are insurance plans employers offer their employees. Both small and large employer health plans fall within this category. Large employers have 51 or more employees.

i

Independent Review Organization (IRO)

The organization that conducts an external review , one of the last steps in the appeal process . A person may ask for an external review once they have gone through all of the insurance plan’s appeal processes. Usually a group of people that aren’t part of the insurance plan will review everything and decide whether or not the insurance plan must pay for treatment.

Individual Plans

These are insurance plans that people can purchase for themselves. Usually these plans are for people who don’t get insurance through their employer.

In-network

Providers and healthcare facilities that are part of a health insurance plan’s network. Patients usually pay less when using an in-network provider or facility.

Inpatient Care

Services given in a hospital after admission with a written doctor’s order.

Intensive Outpatient Care

A type of outpatient treatment that is more thorough than usual outpatient care but not as extensive as partial hospitalization. Intensive outpatient care is often used for people who have substance use disorders or eating disorders.

International Classification of Diseases

A tool that doctors and other medical professionals use to classify diseases and other health conditions. The ICD is sometimes used to diagnose behavioral health conditions

l

Large Employer Fully-Insured Plan

These are insurance plans that large employers purchase from an insurance company to cover their employees’ health care needs. A large employer has 51 or more employees; however, in some states this may change to 101 or more after 1/1/2016. These are different plans than large employer self-insured plans .

Large Employer Plan

These are insurance plans large employers offer their employees. A large employer has 51 or more employees; however, in some states this may change to 101 or more after 1/1/2016.

Large Employer Self-Insured Plan

These are insurance plans in which large employers cover their employees’ medical costs using the employer’s own money rather than paying an insurance company a set fee to cover the employees’ medical costs. A large employer is a business that has 51 or more employees; however, in some states this may change to 101 or more after 1/1/2016. These plans are different than large employer fully-insured plans .

Lifetime Limits

The highest number of inpatient days or outpatient visits an insurance plan will pay for health services over the entire time you are on that plan.

Lifetime Maximum

The highest dollar amount an insurance plan will pay for your care over the entire amount of time you are on that plan.

m

Managed Care

A set of techniques used to reduce costs and improve the quality of care patients receive. Managed care is often provided by an organization that is responsible for providing care, paying for coverage, and administrative functions.

Medically Necessary

Any health-care services or prescription medications that are needed to treat a condition and that meet accepted standards of medicine. This is closely related to medical necessity .

Medical Necessity

A set of standards health insurance companies use to decide if they will pay for health care services. A service meets these standards if it’s considered an accepted treatment for the specific diagnosis and it’s the least expensive option that will help the person recover.

Medical Necessity Appeal

An appeal filed when the health plan has denied or reduced the level of care based on what is medically necessary . Also called a Utilization Management (UM) Appeal.

Medication-Assisted Treatment

Medication-assisted treatment (MAT) combines behavioral therapy and medications to treat substance use disorders.

n

Network Adequacy

The ability of a health insurer to provide health plan participants access to a sufficient number of in-network providers

Non-Grandfathered Plan

These are health insurance plans created after 3/23/2010. Most of these plans must comply with the Affordable Care Act and the Federal Parity Law. All of these plans issued after 10/1/2016 will have to comply with the Affordable Care act and the Federal Parity Law.

Non-Quantitative Treatment Limitation (NQTL)

A limitation that can’t be measured with numbers. Examples include geographic restrictions, facility type restrictions, utilization management , prior authorization , fail-first protocol , prescription medication formularies , etc.

o

Opioid Antagonist

A life-saving medication that can immediately reverse the effects of an opioid such as heroin, oxycodone, or fentanyl.

Out-of-Network

Providers and healthcare facilities that are not part of a health plan’s contracted network and can set their own prices for the services they provide. Insurance plans may cover some of the costs for services given out-of-network or they may not pay for anything.

Out-of-Pocket

Health care costs a person has to pay on his own.

Outpatient Care

Treatment given to a person who can go home after care without being admitted in a hospital or treatment facility.

p

Parity

The concept that insurance plans should cover services for behavioral health conditions the same way they cover other medical conditions, like diabetes or heart disease. Parity is about fairness and equal rights for people who need behavioral health services.

Parity Appeal

An appeal filed with an insurance plan when the plan’s decision to deny or restrict coverage may be in violation of the Federal Parity Law or state parity laws.

Partial Hospitalization

Services given in a hospital setting but the patient leaves the hospital after treatment instead of staying in the hospital. Sometimes these services are a follow-up after a patient has been released from a hospital stay.

Prescription Medication Formulary

A list of prescription drugs that an insurance company will cover. Some health insurance plans might make patients get prior authorization before drugs not on the list are covered. Sometimes the patient will have to pay more for these drugs or pay the whole cost.

Prior Authorization (Pre-Certification)

This is when a patient needs to get pre-approved for coverage of a treatment or medication. An insurance plan may not pay for care if the patient’s condition does not meet certain standards. The insurance company usually won’t approve a drug or service until the patient’s provider gives notes and/or lab results describing the patient’s condition and treatment history.

Public Employee Plans

These are health insurance plans for employees of states, counties, local municipalities, and school districts. State insurance laws apply to these plans even if they are self-insured plans.

q

Qualified Health Plan

An insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.

Quantitative Treatment Limitation

A limitation on treatment that can be measured with numbers. Examples include: outpatient visit limitations and inpatient day limits

r

Rate Filing

A document that contains the amount insurers will charge consumers in premiums, deductibles, and copayments

Reason Codes

Letters or numbers found at the bottom of an Explanation of Benefits (EOB) letter used to explain how the insurance claim was processed. These codes are very important in understanding why the insurance company denied all or part of a claim.

Regulatory Agencies

Government agencies that are responsible for implementing and enforcing the law and issuing rules to help organizations and individuals understand how to do so. For parity , these are usually state insurance departments or the Department of Labor.

Residential Treatment

This is treatment delivered in a setting in which the patient is in the treating facility 24 hours a day, 7 days a week.

s

Self-insured

When an employer covers their employees’ medical costs using the employer’s own money rather than paying an insurance company a set fee to cover the employees’ medical costs. These plans are regulated by the Department of Labor except for non-federal governmental plans, which are regulated by the state.

Self-Insured Employer

Employers who use their own money to pay all of the claims for their employees’ health care. It is often hard for people to figure out whether their employer is self-insured because many self-insured companies use insurance companies only to administer their insurance plan (i.e. handling enrollment and paying providers for services with the company’s money).

Small Employer Fully-Insured Plans

These are insurance plans that small employers purchase from an insurance company to cover their employees’ health care needs. A small employer has 50 or fewer employees; however, in some states this may change to 100 or fewer after 1/1/2016. These are different plans than small employer self insured plans.

Small Employer Plans

Insurance plans offered by employers with 50 employees or less; however, in some states this may change to 100 or fewer employees after 1/1/2016.

Small Employer Self-Insured Plans

These are insurance plans in which small employers cover their employees’ medical costs using the employer’s own money rather than paying an insurance company a set fee to cover the employees’ medical costs. A small employer is an employer that has 50 or fewer employees; however, in some states this may change to 100 or fewer employees after 1/1/2016. These plans are different than small employer fully insured plans.

Standard of Care

A clinically accepted treatment process that a provider should follow for a patient’s care. This is often how insurance companies decide if they will pay for services during medical necessity reviews.

State Parity Laws

State laws that may require insurance plans to provide behavioral health coverage at the same terms and conditions as other medical coverage. State parity laws can be very different in terms of how much they require of insurance plans and to which plans they apply. Some state parity laws require insurance plans to provide more coverage than the Federal Parity Law , and some state laws do not. Whenever both a state parity law and the Federal Parity Law apply to the same insurance plan, the insurance plan has to abide by the law that requires more coverage.

Step Therapy

A requirement that a patient try a less expensive treatment first before he gets approval for the treatment his provider orders. For example, an insurance plan may not pay for a brand name drug until a person does not improve using a generic drug . This can also be called Fail First Protocol .

Substance Use Disorder

Substance use disorders can refer to drug and alcohol use or drug and alcohol dependence.

t

Telemedicine

The use of technology to provide medical care at a distance; For example, a psychologist using an internet-based video chat platform to provide talk therapy to a client who is located in another county.

Treatment Limitations

Any way an insurance plan tries to limit how much a patient uses medical services.

u

Usual, Customary, and Reasonable (UCR) Charge

The term used by insurance companies to justify the amount of money they will pay for specific health care services.

Utilization Management (UM) Appeal

An appeal filed when the health plan has denied or reduced the level of care based on what is medically necessary . Also called a Medical Necessity Appeal.

Utilization Management (Utilization Review)

The way an insurance company decides if health care services are medically necessary , appropriate, and accepted medical practices. Utilization management is also called “medical review” or “utilization review.” There are three different kinds: 1) Concurrent: This review happens during the treatment. 2) Prior: This type of review happens before the treatment happens. It’s also called prior authorization . 3) Retrospective: This type of review happens after the treatment happens.