Key Words that Open Doors

Dealing with  service providers can be even harder when everyone else seems to be speaking a foreign language.

The Family Road Map guide contains an extensive glossary of keywords and definitions of common terms you may encounter in dealing with doctors, schools, insurance companies, and social agencies. Knowing the right terminology can be the key to helping your child get the right services.

Accommodations and modifications (Education): Changes made in a regular education program to help a child make educational progress. Children must meet certain criteria to be eligible for these changes (See 504 Plan).

Affected child: A child who shows symptoms of a behavioral health or other disorder.

Annual (IEP) goal: An educational goal that the school system expects your child to reach by the end of a year, as part of his or her individualized Education Program (IEP).

Annual IEP review: A meeting to review a child’s Individualized Education Program and make any necessary changes in goals, placement, or services within the next year.

Annual or lifetime maximum benefit: The maximum amount that your health-care plan will pay for treatment of a particular kind of health problem, either per year (annually) or during the entire time your plan is in effect.

Annual out-of-pocket maximum: The maximum amount that you will be required to pay per year for certain types of treatment under the terms of your health insurance plan.

Appeal: A formal request for a decision to be changed by a higher authority.

Areas of need (Education): Broad categories in which your child needs to improve in order to make progress in school, as determined by the IEP team and included in the IEP document.

Assess: To evaluate a person’s medical, behavioral, or educational condition in order to determine what services the person needs.

Assessment team (Education): A team of school staff or consultants assigned by the school to evaluate a child. For behavioral health issues, the team usually includes a psychologist and may include specialists in certain disorders.

Authorization, pre-authorization, prior-authorization (insurance):Approval given by the insurance company for a treatment that is shown to be medically necessary and covered by the person’s health care benefits.

Behavioral Health Organization (BHO): An insurance company that manages benefit plans for mental (behavioral) health or substance (drug and alcohol) abuse treatment.

Benefits: Also called “coverage.” The contract between an insurance provider and the insured person that obligates the insurance company to pay for certain medical or behavioral health treatments.

Black-box warning: A Food and Drug Administration (FDA) warning that alerts doctors to a possibly serious side effect or complication that might be caused by giving a medication under certain conditions.

Care manager (insurance): A type of case manager for a health insurance plan whose job it is to help people find options for getting treatment approved or to solve unusual problems with the benefits plan.

Case manager: 1) A health or social agency professional who helps set up services for a child and his or her family, and may also provide counseling. 2) An employee of the insurance company, often a nurse or social worker, who pre-authorizes treatment; 3) A school staff member who coordinates the services received by a child in special education.

Certified/certification: Eligible (allowed) to receive special education services. A child has to be certified under one of IDEA 2004 law’s 13 disabilities categories in order to receive special education services.

Child Find: A program provided by every school system to assess children aged 3 through 5 who are likely to develop problems or delays in learning.

Claim (insurance): A request to get a certain service or treatment paid by the insurance company.

Clinical diagnosis: A health professional’s description of a problem, made after an evaluation is performed.

Clinician: A professional who evaluates your child (usually a clinical psychologist or licensed clinical social worker); may also provide therapy.

CMHA (Community Mental Health Agency): A large mental health center that has a contract to provide services to people who are enrolled in public health insurance plans; some- times called a Community Mental Health Organization (CMHO). A CMHA is located in each county of the United States.

Community resources: Agencies, organizations, and programs that provide services for people with different types of needs.

Comorbid diagnosis: An additional or “secondary” diagnosis used when a person meets the criteria for more than one disorder.

Comprehensive assessment: See “School evaluation.”

Confidential information: Information about a patient that a health professional cannot tell police, employers, or others not involved in the person’s treatment except under certain conditions.

Consent: Legal permission.

Continuum of care: The span of care options available for behavioral health patients, ranging from a short office visit to inpatient hospital treatment.

Co-payment: A small amount you must pay when you visit a health-care provider. This amount varies according to your health plan.

Coverage: Also called “benefits.” The contract between an insurance company and the insured person, promising to pay for certain treatments under certain conditions.

Criteria (one criterion, many criteria): Standards that must be met in order to be included in a certain category, usually for the purpose of qualifying to receive certain services.

Cumulative Record (CR): A child’s permanent school record.

Customer Services (or member services) representative: An insurance company employee that answers routine questions or solves problems by phone.

Deductible: The amount of money you must pay out-of- pocket before your insurance plan will begin to pay for certain types of services.

Diagnosis: The overall term that health professionals use to describe a problem. A behavioral health diagnosis is reached after an evaluation that may include conversations with you, your child, and others, as well as tests, examinations, or laboratory studies.

Disability or disabling condition: A condition that interferes with a child’s ability to learn or function at the same level as other children of the same age.

Drug interactions: Possible problems that may occur when one drug is used at the same time as another drug.

DSM (Diagnostic and Statistical Manual of Mental Disorders): A publication of the American Psychiatric Association that lists and describes behavioral health disorders. Health care professionals use the DSM categories to diagnose illnesses. The most current edition is the DSM-V.

Due process rights: Procedures that must be followed in order to appeal a decision made by an organization, such as the school system or a mental health center.

Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT): A public health insurance program aimed at finding, diagnosing, and treating problems in children.

Early intervention services: Services available to help children from birth to age 3 who have medical, behavioral, or develop- mental problems.

Educational impact: The effect of a disability on how a child makes progress in school compared to others of the same age.

Eligibility criteria: Standards a person must meet in order to qualify to receive services.

Eligibility meeting: A meeting of the school individualized Education Program, or IEP team, to determine whether a child is eligible to receive special education services. An IEP team always includes the parent if he or she is willing and able to be involved.

Evaluation: The process of looking at a person’s condition or behavior in order to find out what the problem is. An evaluation can include conversations with you, your child, and others; a physical examination; other tests; and laboratory studies.

Exclusions (insurance): Types of treatment that an insurance plan will not pay for under certain conditions.

Expected progress (Education): How much educational or developmental progress the state expects a child of a certain age to make under typical circumstances.

Extended School Year Program (ESY): An individualized Education Program developed for the summer months in order to help a child keep up with the progress he or she has made during the school year.

Facilitator: A person who runs or directs a meeting.

Family advocacy organization: An organization that provides information, training, or support to families, and works to influence the public, legislators, or government agencies on their behalf.

Family Education Rights and Privacy Act (FERPA): A Federal law regulating how a child’s school records can be used.

FAPE (Free Appropriate Public Education).: Your child’s right, under the federal IDEA 2004 law, to an education “designed to meet his or her unique needs.” This guarantees the right to special educational services when the regular education program cannot meet a child’s needs because of a disability.

Field care manager (insurance): A special case manager employed by a Managed Care Organization or Behavioral Health Organization who is based in the local community.

504 Plan: An educational plan that lists accommodations and modifications that will help a child who meets certain criteria to make progress in a regular education program. Some children with behavioral health disorders who do not qualify for special education services under the IDEA 2004 law will qualify for 504 Plan accommodations.

Flexible benefits: An agreement by the insurance company that money targeted to pay for one type of health plan benefit (for example, in-patient hospital treatment) can be used to pay for another level of care (such as residential treatment).

Genetic predisposition: A tendency to develop an illness that is inherited through one or both parents. A predisposition means a person may develop that illness, and so should be watched carefully for symptoms.

Genetic traits: Physical and mental qualities or conditions a person inherits.

Good-faith effort (Education): An effort on the part of the parent(s) or school to be fair, sincere, and involved.

Guidelines (insurance): Rules set up to determine the conditions under which certain treatment services will be approved for payment by an insurance plan.

Health history: A form that contains basic information about a person’s medical history. This will usually include physical diseases, behavioral health issues, medications, allergies, immunizations, family health history, and developmental history.

IDEA 2004 (Individuals with Disabilities Education Improvement Act of 2004): A federal law that guarantees the right to educational services for students with disabilities aged 3 through 21 (or through the end of the school year in which an eligible student turns 22).

IEP (Individualized Education Program): A program of educational services for a student with a disability. In the school system, this term is often used to refer to 1) a meeting to certify a child for special education services; 2) the education plan written at this meeting; and the legal document that describes the program.

IEP document: A legal agreement, signed by the school system representative and parent(s) that describes goals, placement, and services to be provided for a child with a disability.

Impact on educational performance: See “Educational impact.”

Individualized Family Service Plan: A plan developed by a social agency to provide services to a child or family.

In-network provider: A member of a group of health care providers whom a patient is allowed to use under the terms of a health insurance plan.

Intake interview or appointment: The first appointment with a new health professional or social agency. At an intake interview, you give information or discuss symptoms.

Inpatient psychiatric unit: A special unit in a hospital where patients with severe behavioral health problems stay 24 hours per day while receiving treatment.

Local Education Agency (LEA) representative: The school official at an IEP meeting who has the power to make the final agreement between you and the school system about your child’s educational program.

Managed Care Organization (MCO): An insurance company that the state pays to run a public medical health insurance plan.

Medically necessary: Treatments that are necessary in order for a patient to be appropriately treated for his or her symptoms.

Member’s handbook: A handbook that sums up the benefits that an insurance plan provides, as well as contact information such as providers’ phone numbers and information numbers. This information is often available on the company’s website as well.

Mental health/Substance abuse (MH/SA) telephone number: A phone number (listed in the handbook and on a health insurance ID card) that a person must call to get help with questions or problems relating to behavioral health insurance benefits.

Mood Disorders: Disorders that affect a person’s ability to regulate emotions. Examples: Depression, Bipolar Disorder.

Nurse Practitioner (NP): A registered nurse (RN) who has done further advanced training in patient care. An NP can provide many of the same services as a doctor, including ordering tests and prescribing medicine. An NP with special training in psychiatric disorders may be called a Licensed Psychiatric Nurse Practitioner.

Objectives (also known as data points): In an IEP, specific steps that describe what a child must learn or accomplish in order to master a stated goal. These are also known as data points.

Obligate: Require. If the school system representative signs an agreement with you, the school is legally obligated to do what it says it will do.

Off-label: A drug prescribed for a condition or a type of patient it was not originally intended to treat. This means that the United States Food and Drug Administration (FDA) has not yet approved a drug for a certain use in a certain patient group, but a doctor may prescribe it anyway based on his or her own experience as well as the experience of other doctors and researchers.

Out-of-network: A care provider whose services are not on the list of a certain insurance company’s contracted providers.

Over-the-counter medication: A medication that can be sold without a prescription from a doctor.

Parent advocate: A parent who is involved, aware, and active in the management of his or her child’s care and who speaks up for the child’s best interests.

Pediatrician: A doctor who specializes in children’s overall health care.

Permission to Release Information: See “Release Form.”

Premium: The amount you are expected to pay every month to your health-care plan, whether or not your child sees a provider.

Present level of performance: A portion of the IEP document that describes your child’s cur- rent ability to function and make educational progress in school.

Primary care doctor (PCO): Sometimes known as a family doctor, family practice doctor, or primary care provider; a doctor that sees patients for general health care needs. A pediatrician or family physician may serve as a child’s primary care doctor.

Prior Authorization: See “Authorization”.

Private pay insurance plan: A health insurance plan that you pay for yourself or that you get through an employer.

Professional: A person who is paid to provide services.

Provider: An individual or organization that provides medical or behavioral health services.

Psychiatric crisis: A situation in which a person has a sudden, severe change in behavior that creates a serious risk of harm to that person or someone else.

Psychiatric medications: Drugs prescribed by a doctor or nurse practitioner (NP) to treat behavioral health problems.

Psychiatrist: A medical doctor (MD) who has done several years of extra training in diseases and disorders of the mind. A psychiatrist can prescribe medicines.

Psychologist: A doctor (not an MD, but a PhD or PsyD) who has many years of training in dealing with mental, emotional, or behavioral problems. May do evaluations or therapy, but cannot prescribe medicines.

Referral: A primary care provider’s order that will allow your child to see a specialist under the terms of your health insurance plan.

Release form: A form that you sign giving permission for one health or educational professional to share information with another professional or organization. Also called “Permission to Release Information”.

Residential treatment center: A facility where a person receives behavioral health or substance abuse treatment 24 hours a day.

Respite services: A worker or organization that provides temporary care for a person with an illness so regular caregivers, such as parents or other family members, can have a break.

Response to Intervention (RTI): Evidence of methods a school has tried in order to deal with a child’s problem in the regular classroom.

Rule-out (Education): A condition that would disqualify a child from being certified as having a disability under IDEA 2004. For example, if the main reason for a child’s lack of progress is poor attendance at school, a behavior- al health issue alone would not be enough to qualify that child to receive special educational services.

School evaluation: Also called a “comprehensive assessment.” An evaluation performed by the school system; this evaluation examines many areas of a child’s behavior, abilities, and school performance.

Service coordinator: If a child is eligible for early intervention services because of a medical, behavioral, or developmental problem, a person called a service coordinator is assigned to help the family create a plan for getting treatment and other services.

Sliding scale: A system in which people are charged fees according to what they can afford to pay.

Special education: Services and methods used to educate students with disabilities who qualify under the federal IDEA 2004 law.

Specialized Crisis Services: A unit of trained staff that comes to a child’s location to assess his or her need for emergency care.

Standardized assessment tools: Tests commonly used to evaluate behavioral health or educational problems. Some typical standard assessment tools include cognitive and adaptive tests, psychological evaluations, developmental evaluations, and educational evaluations.

State-only insurance: A state-run program to allow people without other behavioral health insurance to get treatment at a local Community Mental Health Agency.

Supplemental Security Income (SSI): Payments the federal government makes to children and adults who meet certain criteria for having a disability.

Symptoms: Signs of disease that may include physical changes, thoughts, feelings, and behaviors.

System representative: See “LEA representative.

System of care: A community network that brings together public and private organizations such as schools, health providers, churches and social agencies to create an individualized package of services and supports that will be most effective in meeting a family’s needs.

Test battery: A series of tests to help determine your child’s needs.

Timeline: The time frame within which a person or organization must respond to the action taken by another person or organization.

Titration: The process of increasing a person’s medication dosage from a small amount of a drug to a larger dose over a period or days or weeks.

Therapeutic dose: The amount of a drug or medicine that is effective for the patient.

Therapist: A person licensed by the state to give treatment for physical, behavioral health, and developmental disorders.

Transition: A term used in education law to mean a period of years between the late teens and early twenties, when a young person’s task is to gain the skills needed for independent living.

Trauma (Behavioral health): A serious, negative event in a person’s life that can affect behavior, emotions and physical health. Examples: Sexual abuse, family violence, death of a close relative, or involvement in a natural disaster.

Utilization review/Utilization reviewer: The process by which insurance companies decide whether certain health services are covered by a person’s health insurance plan. The reviewers, often nurses or social workers, are employed by the company.