Access to Care Standards: The minimum eligibility requirements that a Medicaid enrollee must meet in order to access behavioral health services through the BHO
- The denial or limited authorization by the BHO of a requested service including the type and level of service;
- The reduction, suspension, or termination by the BHO of a service you have been getting.
- The enrollee disagrees with the treatment plan
- The denial by the BHO, in whole or in part, of payment for a service
- The failure to provide services in a timely manner; and/or
- The failure of the BHO to act within the timeframes in the rules
Appeal: The request for review of an Action
Apple Health: Publically funded treatment. You can apply at www.WAHealthPlanFinder.org
Assessment: An interview by a health provider to decide the services you need
Behavioral Health Agency (BHA): An agency licensed by the State of Washington to provide mental health services and subcontracted by the BHO for this purpose
Behavioral Health Organization (BHO): County authority or group of county authorities or other entity recognized by the state to administer behavioral health services in a defined region.
Behavioral Healthcare: Mental health and/or substance use disorder treatment
Brief Intervention and Referral to treatment: Time limited, to reduce problem use
Brief Intervention and Treatment (mental health): Short term counseling focused on a specific problem
Case Management: Help with finding medical, social education, and other services
Chemical Dependency: See substance use disorder
Child Care Services: Licensed childcare is provided through an approved off-site childcare service for persons who are participating in assessment and treatment activities, support groups, parenting education and other support activities as part of the recovery process and noted in the individual’s treatment plan.
Co-Occurring Disorder: Persons who have both a substance use disorder and a mental health disorder
Crisis Services: Evaluation and treatment services for a behavioral health crisis on a 24-hour basis. Crisis services are intended to stabilize the person in crisis, prevent further deterioration and provide immediate treatment and intervention in a location best suited to meet the needs of the individual and in the least restrictive environment available.
Day Support: Intensive program to learn or assist with independent living skills
Detoxification Services: See withdrawal management
Emergent care: Services provided for a person that, if not provided, would likely result in the need for crisis intervention or for hospital evaluation due to concerns of dangers to self, others, or grave disability
Enrollee: A person who is on Medicaid
Evaluation and Treatment/Community Hospitalization: Medically necessary inpatient crisis care. You do not need an intake evaluation before this service
Evaluations for Special Populations: Treatment planning assistance from a specialist who works with children, older adults and people from multi-cultural backgrounds
Fair Hearing: A hearing before the Washington State Office of Administrative Hearings when Grievance and Appeals processes have not resolved issues of dissatisfaction
Family Treatment: Family centered counseling to help build stronger relationships and solve problems
Grievance: An expression of dissatisfaction about anything that is not an Action. Possible grievances include, but are not limited to, the quality of care or services provided, the lack of dignity and respect of a provider, or failure to respect your rights.
Group Treatment Services: Counseling with others who have similar challenges
Health Care Authority: Thurston and Mason County receive Federal and State funding through this agency
High Intensity Treatment: Services provided by a team of mental health providers to help you meet your goals in your individual plan
Individual Treatment Services: Counseling and/or other activities designed to meet your service plan goals
Intake Evaluation: Identifies your needs and goals, and help you and your mental health care provider to decide a treatment plan
Intensive Outpatient Treatment: More frequent individual and group counseling sessions
Involuntary Commitment Services (ITA): Services to identify and evaluate alcohol and drug involved individuals to determine if they are gravely disabled and requiring protective custody, detention, or involuntary commitment services
Low-Income: Individuals whose gross household monthly income does not exceed the monthly income determined by 220% of the Federal Poverty Guidelines as eligible for low-income services.
Medicaid: See www.WAHealthPlanFinder.org
Medically Necessary or Medical Necessity: A term for describing a requested service which is reasonably expected to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions in the recipient that endanger life, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause of physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the person requesting service. Course of treatment may include mere observation, or where appropriate, no treatment at all.
Additionally, the individual must be determined to 1) have a behavioral health condition covered by Washington State public behavioral health services; 2) the individual’s impairment(s) and corresponding need(s) must be the result of a behavioral health condition; 3) the intervention is deemed to be reasonably necessary to improve, stabilize or prevent deterioration of functioning resulting from the presence of a behavioral health condition; 4) the individual is expected to benefit from the intervention; and 5) any other formal or informal system or support cannot address the individual’s unmet need.
Medication Management: Licensed staff prescribing medicine and talking to you about side effects
Medication Monitoring: Services to check on how your medication is working and to help you take it correctly
Ombuds Service: A free and confidential service to help you when you have grievance, appeal, or fair hearing related to your behavioral health services. The person at the Ombuds service will help you resolve your issues or problems at the lowest possible level. The Ombuds service is independent of the Behavioral Health Organization (BHO).
Opiate Substitution Treatment Services: Outpatient assessment and treatment for opiate dependency. Includes approved medication and counseling
Outpatient Treatment: individual and group counseling sessions
Peer Support: Help and support with navigating the public mental health system and reaching your recovery goals, provided by a trained person who is in recovery from mental illness
Post-Stabilization Services: Services provided upon release from the hospital after a crisis to prevent future hospitalization or crisis
Pregnant and Postpartum Women and Parenting Services: Services for women who are pregnant, postpartum during the first year after pregnancy completion regardless of the outcome of the pregnancy or placement of children, and men or women who are parenting children under the age of six, including those attempting to gain custody of children supervised by the Department of Social and Health Services, Children and Families Services. If eligible for chemical dependency services, a client may receive outpatient treatment, assistance with childcare, as well as transitional housing services.
Prioritized Patient Categories: Individuals in the following categories are given priority status in this order for admission into treatment services: 1) Medicaid eligible individuals, 2) Pregnant injecting drug users, 3) Pregnant substance users, and 4) Injecting drug users.
Psychological Assessment: Testing that helps with diagnosis, evaluation and treatment planning
Recovery: Mental health recovery is a journey of healing and transformation that allows a person with a mental health problem to live a meaningful life in the community while striving to reach full potential.
Rehabilitation Case Management: Coordination between your inpatient and outpatient mental health services. This might be part of your intake evaluation
Residential Treatment: A comprehensive program of individual counseling, group counseling, and education provided in a 24 hour a day supervised facility
Request for Service: The time when services are sought or applied for through a telephone call, walk in or written request by the enrollee or the person who can legally consent to treatment.
Stabilization Services: Provided in your home or home-like setting to help prevent a hospital stay. You do not need an intake evaluation before this service
Substance Use Disorder: A problematic pattern of alcohol/drug use leading to clinically significant impairment or distress as categorized in the DSM 5.
Therapeutic Psychoeducation: Education about mental health conditions, treatment choices, medications and recovery, including supports and/or supportive services
Urgent Care: Service provided to someone approaching a behavioral health crisis. If services are not received within 24 hours of the request, the person’s situation is likely to deteriorate to the point that emergent care is necessary.
Withdrawal Management (Detoxification): Help with decreasing your use of alcohol or other drugs over time, until it is safe to stop using (hospital based treatment is covered under the medical benefit)
Young adult: A person who is age 18 through 20 years old
Youth: A person age 10 through 17 years of age
LINKS – Federal
- Code of Federal Regulations (CFR)
- Excluded Parties(Office of Inspector General US Dept HHS)
- Health Information Privacy (US Dept Health & Human Services)
- HIPAA FAQ’s Centers for Medicare & Medicaid Services
- HIPAA Frequently Asked Questions – For professionals
LINKS- STATE OF WASHINGTON
- Aging and Long-term Support Administration
- Behavioral Health Organization (BHO) State Contacts
- Benefit Handbook (Medicaid)
- Department Children, Youth, Families
- Division of Behavioral Health and Recovery (DBHR)
- Developmental Disabilities Administration (DDA)
- Division of Vocational Rehabilitation (DVR)
- DBHR Directory (Green Book)
- Eligibility Overview for Washington Apple Health (Medicaid) Programs
- Health Care Authority (HCA) – 1-800-562-3022
- Health Plan Finder
- Office of Administrative Hearings
- Washington Administrative Code (WAC) 388-865 (Community mental health and ITA)
- Washington Administrative Code (WAC) 388-877 (Behavioral health administrative)
- Washington Administrative Code (WAC) 388-877A (Outpatient mental health)
- Washington Administrative Code (WAC) 388-877B (Chemical dependency services)
- Washington Administrative Code (WAC) 388-877C (Problem and pathological gambling services)