A list of commonly used terms and their definitions to help guide you during your care journey.
6.2.1 Insurance
General Insurance Terms
InsuranceAn arrangement where an agency run by the government or private company agrees to pay the full or partial price of medical services. You, in exchange, pay for a monthly fee called a premium.
PremiumsPayments to the insurance company for your policy that are monthly, quarterly, semi-annually, or annually in order to receive all of the benefits that come with your plan. The amount varies by insurance company and plan chosen.
CopayFlat-fees that you pay during a visit to a health provider, healthcare service or for prescription medications, these vary by insurance plan.
Coinsurance
This form of payment is similar to copays, but instead of a flat-fee you pay a percentage of the cost of service or prescription. The percentage varies with insurance plan.
Deductible
An amount of money you have to pay for your healthcare service, procedure or treatment before your insurance company starts covering it. For example, a $2,000 deductible means you pay up to that amount and then your insurance starts paying and you are only responsible for a copay or coinsurance for those covered services. Deductibles are normally applied to a calendar year.
Precertification
Prior authorization, prior approval, and precertification are all terms describing the decision from health insurers to either cover your service or not. This decision is on the basis of its medical necessity.
Medical Necessity
This is important when getting prior approval from your insurance. The insurance company makes the decision whether to give prior approval based on the medical necessity of the service.
Referral
Depending on your plan, your PCP may be required to write a referral or make a phone call to your insurer before you receive specialty medical services, for example psychiatry or therapy. A referral is a type of precertification.
Pre-existing condition
A preexisting condition is a condition for which you have received treatment or diagnosis before you enrolled in a new health plan.
Explanation of Benefits (EOB)
A statement from your health insurance plan describing the care your insurance policy covers.
In-Network Provider
An in-network healthcare provider is a professional you can see for as little as a copay or coinsurance. Your insurance company has a contract with in-network healthcare provider, so they’ll charge you less for their services.
Out-of-Network Provider
An out-of-network healthcare provider is a professional that your insurance company does not have a contract with. In other words, a profession who is not in-network. These providers tends to be more expensive to see because they may require a high copay or not be covered by your insurance at all.
Who offers insurance?
Private Health Insurance Company
Companies that are privately owned and issue insurance policies to cover your healthcare costs. Each insurance company has different plans at different tiers (platinum, gold, silver and bronze) which refer to the portion you are responsible to pay for each healthcare service and the premium of the policy.
Medicaid
A federal-state health insurance program available to people with low income that qualify. This program covers children, pregnant women, the blind/disabled, and any other persons that meet the income criterion. For more details on the healthcare delivery of Medicaid benefits, see Medicaid Managed Care Programs.
Medicare
A federal-state health insurance program available to people with low income that qualify. This program covers children, pregnant women, the blind/disabled, and any other persons that meet the income criterion. For more details on the healthcare delivery of Medicaid benefits, see Medicaid Managed Care Programs.
(State) Children's Health Insurance Program ((S)CHIP)
A federal-state health insurance program that covers children with families that have an income that is too high to qualify for Medicaid but are still unable to purchase private insurance. Provides comprehensive health insurance to children until they are 18.
State financed health insurance plan other than MedicaidIncludes health insurance programs funded by the state government that are not categorized under Medicaid. These health insurance plans vary greatly from state to state and are usually in the form of state-run facilities that serve individuals that meet the poverty guideline requirements.
Military Health InsuranceAn insurance program that is available if you are/have been in the military or have a direct family member that is in the military.
Student Health PlansMost colleges require students’ to have health insurance, so they offer a variety of options. You can stay in your parent’s insurance and notify the insurance company about the change in state if applicable, switch to an on-campus health insurance plan endorsed by the university, or a private health insurance plan. Also, at most universities you can receive healthcare services at the health center that are automatically covered completely or partially by the campus plan; mental health services are included.
Health Maintenance Organizations (HMO)
A type of health insurance plan where you pay a set monthly fee (premium) with little to no deductible in exchange for health services from healthcare providers registered with the organization (in-network providers). These healthcare providers agree to meet a determined quality of care and lower their prices for people insured by the organization. However, HMOs do not cover services from healthcare providers outside their network (out-of-network providers) unless it is considered an emergency. You may be required to select a Primary Care Physician (PCP) within their network who then serves your basic healthcare needs and sometimes required to have that PCP refer you to specialty care within network. You may be required to live in the service area of the HMO to be eligible for coverage.
Preferred Provider Organization (PPO)
An insurance plan that has a network of providers that it prefers you to use (in-network providers) and covers out-of-network providers. However, since this plan is less restrictive than most, you pay a higher monthly premium and usually have a deductible. This plan provides more benefits to cover in-network providers. Also, this plan does not require you to visit a Primary Care Physician for a referral before seeing a specialist.
Exclusive Provider Organization (EPO)An EPO provides a network of providers that you must use exclusively. Meaning, EPO plans do not cover services from out-of-network providers. You may seek out specialty care, such as psychiatry, within their organization's network without a referral from your Primary Care Physician.
Point-of-Service (POS)POSs are similar to HMOs, except that under certain circumstances you are allowed to use an out-of-network provider. POS plans may give access to out-of-network providers for a higher fee than in-network providers. Like HMOs, you need a referral from a PCP for all specialty care, whether the provider is in or out-of-network.
Medicaid Managed CareAn arrangement between a state Medicaid agency and Managed Care Organizations (MCOs) to cover all or most Medicaid-covered services for their Medicaid enrollees. Medicaid recipients may be enrolled in a private healthcare plan where the state pays the fixed monthly premium. Most states now offer Medicaid through these programs and the majority of Medicaid beneficiaries are enrolled in managed care. If enrolled in a Medicaid Managed Care plan, it is important for the recipient to know which private insurance company their plan is enrolled in order to contact regarding their benefits.
High-deductible Health Plan / Health Savings Account
In a High-deductible Health Plan (HDHP), you pay a higher deductible than most health plans but pay a lower premium. When you need a healthcare service, you first pay out of pocket, then the insurance company will help you cover the medical costs. Usually people will combine a HDHP with a Health Savings Account (HSA). With an HSA, your pre-tax money that you put in this savings account will contribute to health costs not covered by insurance, such as coinsurance, copays or dental care. For reference, those with employer-based health insurance are eligible to combine HDHP and HSA.
Indemnity Health Insurance Plans
Indemnity plans are known as “fee-for-service” plans. Under an indemnity plan, you are able to see any specialist you like. Usually you will pay an upfront out-of-pocket fee, and then file a claim to be reimbursed for the covered amount by insurance. You are typically responsible for deductibles and coinsurance costs.
Fee for service
A payment model where services are unbundled and paid for separately. Payments are only issued after the service has been provided and are for each separate service (for example: office visits, tests, procedures, or other healthcare services). When using a Preferred Provider Organization (PPO) plan, less money is paid out-of-pocket and typically does not require filing claims or paperwork. When fee for service plans are provided by insurance outside of a PPO, the health plans will either pay the medical provider directly or reimburse you after you have filed claims for each of the covered expenses.
Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs)
A QSEHRA is a health insurance plan designed for small businesses with fewer than 50 employees. A QSEHRA offers employees a monthly allowance of tax free money. Employees then choose and pay for the healthcare services they want, and this includes their individual health insurance policy. Employees file for reimbursement, and the business will reimburse them up to their allowance amount.
Out-of-PocketPaying out of pocket means that rather than using an insurance plan, you cover the full cost of your care. The payment goes directly to your provider (keep in mind some providers only accept this method of payment and do not accept insurance).
Formal Payment PlansAn arranged payment agreement where the consumer pays a set amount of money at a predetermined frequency until the bill has been fully paid. These plans are usually offered by hospital or collection agencies.
Health Credit CardPayment card that can only be used to pay for certain types of healthcare within a certain network of providers that accept the card. Like a credit card, a loan is taken from the issuer and must be paid back at a certain interest rate. These cards are offered by some banks (e.g Wells fargo, Chase, Citi) and by some health insurance companies (e.g Humana). This is an alternative to cash, credit or debit card.
LoansA sum of money borrowed through some form of loan agency that is to be paid back with interest.
Charity Care Programs
These programs ensure that eligible and uninsured individuals can receive necessary medical care, even if they are unable to pay themselves. However, it is only available for medical services that are reasonable and necessary for diagnosis and treatment of the condition. An example are financial/bridge assistance programs that are run by the hospitals delivering the care.
Types of Health Insurance Plans
6.2.2 Paying Out-of-Pocket
6.2.3 Payment Assistance Terms
Grants from Nonprofit and Government AgenciesSome nonprofit and government agencies are given funds which they can then use to fund mental health programs and help individuals that meet requirements pay for mental health services.
Local Assistance ProgramsPrograms that are meant to assist individuals who are having trouble paying for their health services and are usually funded by state and local governments.
Federal, or any government funding for substance abuse programsPrograms that are funded by government in order to provide access to substance abuse treatment services. The amount of funding given is based on financial need. The Substance Abuse and Mental Health Services Administration (SAMHSA) make grant funds available for individuals undergoing substance abuse and/or mental illness. For more information on grant applications, requirements and submission, visit the SAMHSA website at
www.samhsa.gov/grants.
Access to recovery (ATR) voucher
A voucher that is available to those seeking support for treatment and meet the following criteria: 18 years old, a history of substance use or abuse, annual income below 200% of Federal Poverty level, and a resident of a county that provides ATR. ATR allows patients to choose from a wide variety of services and facilities that will help with their treatment and recovery. ATR programs are both state and federally funded, and therefore vary from state to state. To find out more about this program and where is offered, please visit
this website.
U.S Department of VA funds
If you are a Veteran looking for support, the US Department of Veteran Affairs offers support for healthcare expenses. They offer funds to help support the healthcare expenses of US veterans and support through in-person appointments at VA facilities, tele-health sessions and online resources. Learn more and gain access to these resources here:
https://www.mentalhealth.va.gov/.
IHS/Tribal/Urban (ITU) funds
The Indian Health Service (IHS) is a federal health program for American Indians and Alaskan Natives. Nonprofits across the country have funds to be used towards mental health programs and other services for this population.
6.2.4 Mental Health Provider Terms
Caregiver
Family members, as well as specially trained caregivers, who provide care through in-home assistance, community programs, and residential facilities to support everyday living. They allow for patients who need long-term care to be able to live in their homes and participate in their community. These individuals include, but are not limited to: family members, friends, social workers, teachers, psychologists, psychiatrists and mentors.
Case Manager
A mental health provider appointed by a mental health service to plan and oversee the patient's recovery. Often referred to as service coordinators, advocates, and facilitators, they organize and coordinate services for individual patients and their families. Appointed during recovery, they help with things like: scheduling assessments, preparing treatment plans, managing day-to-day issues, making recovery plans with goals and strategies, and ending involvement in mental health services.
Psychologist
A professional with a doctoral degree in psychology who can diagnose and provide psychotherapy to treat mental health disorders in individual or group therapy settings. Typically not licensed to prescribe medication, so they may work with / refer to another provider that can prescribe. They often specialize in a specific type of psychotherapy.
Clinical Social Worker
Health providers trained in counseling and psychotherapy 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. Social workers can also be found in school systems to provide similar aid to students and employees.
Counselor
A provider with a masters degree in psychology or counseling with the specific training to give guidance on personal, social, or psychological problems. They don’t tend to give guidance to individuals with serious mental illness. They work with a variety of patients and mostly operate in private practices, hospitals, rehabilitation centers, and inpatient facilities.
Life Coach
A provider that offers counseling and encouragement to help clients find success and satisfaction in their careers, relationships, and lives. While they can help clients move past challenges and refocus life goals, they do not practice medicine and can only treat clinical disorders alongside other professionals.
Nurse Practitioner (NP)
A nurse practitioner is an advanced practice registered nurse with more responsibilities for administering care than a registered nurse. They can prescribe medication, examine patients, diagnose illnesses and provide treatment, much like physicians do. In some states, nurse practitioners have full authority and do not have to work under the supervision of another doctor. In mental health services, Advanced Practice Psychiatric Nurses play an important role in prescribing medications, diagnosing, and providing psychosocial treatment.
Primary Care Physician (PCP)
The general doctor seen for annual physicals and coordinating additional health care, like referring patients to mental health specialists. They are physicians who provide both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions. They can prescribe medication for a mental health condition.
Psychiatrist
A physician who has completed medical school and a Psychiatric residency program, and specializes in the assessment, diagnosis and treatment of mental illness. This type of doctor can be further specialized in child and adolescent, geriatric or addiction psychiatry. They can diagnose and treat mental health disorders, prescribe medication as treatment and provide psychotherapy (if trained).
Registered Nurse (RN)
A professional with a nursing degree that provides patient care and can administer medicine. These providers coordinate your care with licensed practical nurses, technicians, and other medical providers. They perform more advanced assessments, counseling than a licensed practical nurse. They also teach patients how to use medications or other treatment tools (inhalers, insulin injection, etc.). However, they cannot prescribe medication.
Therapist
A therapist, or psychotherapist, is a licensed mental health provider who helps clients improve their mental health. A common type of therapist is a talk therapist, who uses therapeutic methods not involving the use of medication. A therapist cannot prescribe medication and uses non-medicinal ways to treat mental health disorders. Therapists are similar to counselors, except they tend to provide more long-term care.
