Glossary of Terms

1115 Waiver
A CMS waiver that gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHP programs. The purpose of these demonstrations, which give States additional flexibility to design and improve their programs, is to demonstrate and evaluate new policy approaches.
1915-i Like Services
Services not typically reimbursed by Medicaid FFS, but reimbursable under a Home and Community Based Services Medicaid Waiver from CMS. Services may include rehabilitation, peer supports, habilitation, respite, non-medical transportation, family support and training, employment supports, education, and supports for self-directed care.
Accountable Care Organization (ACO)
A group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.
Advanced Primary Care (APC)
An augmented patient-centered medical home.
Affordable Care Act (ACA)
Officially named the Patient Protection and Affordable Care Act and often referred to as "ObamaCare," the ACA was signed into law on March 24, 2010, with various provisions phasing into effect over a ten year period. The law's intention is to lower health care costs while expanding access to insurance.
AIDS Drug Assistance Program (ADAP)
Provides free medications for the treatment of HIV/AIDS and opportunistic infections to help people with partial insurance and those who have a Medicaid spend down requirement.
Ambulatory Patient Groups (APGs)
An outpatient payment system designed to reimburse Hospital Outpatient Departments, Hospital Emergency Service Departments, freestanding diagnostic and treatment centers, and ambulatory surgery centers for services provided.
Assertive Community Treatment (ACT)
An evidence-based model to provide treatment, rehabilitation and support services to individuals with severe mental illness whose needs have not been well met by more traditional mental health services.
Assisted Outpatient Treatment (AOT)
Court-ordered participation in outpatient services for certain individuals with serious mental illness who, in view of their treatment history and present circumstances, are considered high-risk in the community without supervision.
Balancing Incentive Plan (BIP)
Authorizes federal grants to States to increase access to non-institutional long-term services and supports as of October 1, 2011.
Behavioral Health (BH)
Includes both mental health conditions and substance use disorders.
Behavioral Health Organization (BHO)
Responsible for concurrent inpatient utilization review, monitoring inpatient discharge planning, and working with inpatient facilities, outpatient providers, and local governments to ensure appropriate service planning and continuity of care for high needs individuals with mental illness. MCOs can subcontract BHOs to oversee behavioral health services.
Behavioral Health Professional (BHP)
An individual with an advanced degree in the mental health or addictions field who holds an active, unrestricted license to practice independently. Can also be an individual with an associate's degree or higher in nursing who is a registered nurse with three years of experience in a mental health or addictions setting.
Care Coordination
Deliberate organization of member care activities by a person or entity (e.g., Health Homes) formally designated as primarily responsible for coordinating services furnished by providers involved in a member's care. This coordination may include care provided by network or non-network providers. Organizing care involves the marshaling of personnel and other resources needed to carry out all required member care activities; it is often facilitated by the exchange of information among participants responsible for different aspects of the member's care.
Care Management
Overall system of benefit package service/management administered by the Plan and which encompasses utilization management, care coordination, facilitating continuity of care during care transitions (i.e., changes in levels of care, aging out of the Children's System of Care or member relocation), management of the quality of care, chronic condition management, and independent peer review.
Case Management
A process managed care plans may use to review the care that patients receive. The goal of case management is to ensure that patients receive the appropriate service from the right provider, at the right time, and in the least costly setting. Case management is typically performed by physicians or nurses who are paid by the plan.
Center for Integrated Health Solutions (CIHS)
A part of SAMHSA, this center promotes the development of integrated primary and behavioral health services to better serve individuals with mental health and substance use conditions.
Clinical Practice Guidelines
Systematically developed statements regarding assessment and intervention practices. These guidelines were created to assist with practitioner and patient/consumer decisions about appropriate health care for specific circumstances. The goals of clinical practice guidelines are to describe appropriate care based on the best available scientific evidence and broad consensus; reduce inappropriate variation in practice; provide a more rational basis for referral; provide a focus for continuing education; promote efficient use of resources; and act as a focus for quality control.
Collaborative Care
The collaborative care model is an evidence-based approach for integrating physical and behavioral health services that can be implemented within a primary care-based setting. It is a multicomponent, system-level intervention that includes care coordination and care management; regular and proactive monitoring using validated clinical rating scales; and routine, systematic caseload reviews and monitoring by psychiatrists who are also available to consult with individuals who do not show improvement. Many randomized controlled trials have shown collaborative care for common mental disorders such as depression to be more effective and cost-efficient than usual care. Collaborative care has been shown to improve symptoms, treatment adherence, quality of life/functional status, and satisfaction with care for individuals with depression.
Community Inclusion
The full participation by an individual living with mental illness and/or substance use disorders in living arrangements, activities, organizations and groups of his/her choosing in the community.
Community Support Specialist (CSS)
Responsible for arranging/providing services to consumers that encourage and promote healthy functioning, recovery efforts, consumer independence/self-care and responsibility.
A member who is receiving or has received mental health/substance use disorder services under the Contract.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
A survey that asks consumers to report on and evaluate their experiences with health care.
Credentialed Alcoholism and Substance Abuse Counselor (CASAC)
Individuals who provide alcoholism and substance abuse counseling services in approved work settings as defined by NYS OASAS.
Cultural Competence
Having the capacity to function effectively within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.
Delegated Entity
Any parent, subsidiary, affiliate, or other related organization, with which the responder to the Managed Care RFQ intends to partner or subcontract for administrative or management services required under the RFQ.
Delivery System Reform Incentive Payment (DSRIP)
This program will promote community-level collaborations and focus on system reform, specifically a goal to achieve a 25 percent reduction in avoidable hospital use over five years. Safety net providers will be required to collaborate to implement innovative projects focusing on system transformation, clinical improvement and population health improvement (DOH).
Developmental Disability Individual Support and Care Coordination Organizations (DISCO)
Provides individualized care coordination and long-term supports and services for individuals with developmental disabilities; voluntary enrollment.
Electronic Health Record (EHR)
A systematic collection of health information about patients/populations that can be shared electonically across different health care settings. The EHR has incentive programs that reward eligible professionals, eligible hospitals, and critical access hospitals if they adopt, upgrade or demonstrate meaningful use of certified EHR technology. Also known as Electronic Medical Record (EMR).
Evidence-Based Practice (EBP)
Clinical interventions, which have demonstrated positive outcomes in several research studies, to assist individuals in achieving their desired goals of health and wellness.
Fee for Service (FFS)
Payment in specific amounts for specific services rendered. Payment may be made by an insurance company, the patient, or a government program such as Medicare or Medicaid. The form of payment is in contrast to payment retainer, salary, or other contract arrangements (to Physicians or other suppliers of service); and premium payment or membership fee for insurance coverage (by the patient).
First Episode Psychosis (FEP)
Members with FEP are individuals who have displayed psychotic symptoms suggestive of recently-emerged schizophrenia. FEP generally occurs in individuals age 16-35. For this RFQ, FEP includes individuals whose emergence of psychotic symptoms occurred within the previous 2 years, who remain in need of mental health services, and who have a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder NOS (DSM-IV), or other specified/unspecified schizophrenia spectrum and other psychotic disorder (DSM-5). The definition of FEP excludes individuals whose psychotic symptoms are due primarily to a mood disorder or substance use.
Full-Time Equivalent Employee (FTE)
The hours worked by full time employees plus the hours worked by part time employees divided by the number of hours worked during a full time year determines how many full-time equivalent employees a business has. This unit is used for health care reform and small business tax credits.
Fully Integrated Dual Advantage (FIDA)
Integrates service delivery for acute care, long-term care, and behavioral health under a single payment per beneficiary for those eligible for both Medicaid and Medicare.
Health and Recovery Plan (HARP)
HARPs will manage care for adults with significant behavioral health needs. They will facilitate the integration of physical health, mental health, and substance use services for individuals requiring specialized expertise, and/or tools and protocols that are not consistently found within most medical plans.
Health Home
A person-centered care management entity created in the Patient Protection and Affordable Care Act (see ACA) enabling individuals with chronic care illnesses to better manage their conditions, reduce the need for hospitalizations, and avoid emergency room visits.
Health Insurance Portability and Accountability Act (HIPAA)
This act protects the privacy of individually identifiable health information and sets the national standard for the level of security necessary to protect the electronic storage of health information. Signed into law by President Clinton in 1996, updated in 2013 to include implementation of the HITECH Act via the Final Omnibus Rule.
Healthcare Effectiveness Data and Information Set (HEDIS)
A tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 75 measures across 8 domains of care.
Home and Community Based Services (HCBS)
Home and community-based services provide opportunities for Medicaid beneficiaries to receive services in their own home or community; HCBS refers to 1915(i)-like services. Adult HCBS services include Crisis Respite, Education and Employment, Family Supports, Peer Supports, Non-Medical Transportation and Habilitation/Rehabilitation.
Integrated Delivery System (IDS)
An organized, coordinated, and collaborative network of various healthcare providers that are connected with the goal of offering a continuum of services to a particular patient population or community.
Integrated Dual Disorder Treatment (IDDT)
A way of treating individuals with mental illness and substance use disorder. IDDT provides individualized coordinated treatment and rehabilitation of both disorders in one setting and by one team of clinicians. Studies have shown this method of dual intervention leads to better patient outcomes than non-integrated interventions in substance abuse, psychiatric symptoms, housing, hospitalization, arrests, functional status and quality of life.
Integrated Treatment
The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.
Intellectual and Developmental Disability (I/DD)
Intellectual disability disorders are characterized by a limited mental capacity and difficulty with adaptive behaviors. Developmental disability refers to severe long-term disability that affects cognitive ability and/or physical functioning. The latter encompasses the former but also includes physical disabilities and manifests by age 22.
Interim Access Assurance Fund (IAAF)
(part of DSRIP) - Time limited funding to ensure current trusted and viable Medicaid safety net providers can fully participate in the DSRIP transformation without disrupting productivity.
Key Personnel
A plan's senior staff hired to oversee behavioral health benefits for individuals enrolled in Medicaid managed care.
Level of Care (LOC)
The intensity of medical care being provided by the physician or health care facility.
Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)
The patient placement criteria system required for use in making SUD level of care decisions in NYS.
Level of Care Guidelines
Written criteria designed for use by qualified BH professionals in making level of care decisions based on an individual's symptoms, history, likelihood of treatment response, available resources and other relevant clinical information. The purpose of the level of care determination is to assure that a Plan member in need of service is placed in the least restrictive, but most clinically appropriate level of care available, consistent with NYS medical necessity criteria. May also be called placement criteria.
Local Governmental Unit (LGU)
As defined under Article 41 of the NYS Mental Hygiene Law, each LGU has a Director of Community Services responsible for the oversight and planning of the local mental hygiene system. This includes mental health, substance use, and developmental disability services.
Long Term Care (LTC)
Care that recurs or continues over long periods of time, often serving people with chronic physical or mental disorders.
Mainstream Managed Care Organization (MCO)
Qualified Mainstream Managed Care Organization that meets the qualifications established by this RFQ to manage behavioral health services for Medicaid beneficiaries.
Managed Care Plans
Includes the Mainstream MCO, Managed Care Organizations, and Health and Recovery Plans.
Managed Care Technical Assistance Center (MCTAC)
Provides trainings and resources to support BH providers in New York State with the successful transition to Medicaid managed care.
Managed Long Term Care (MLTC)
A care management program for individuals in the community as an alternative to a nursing home or health-related facility.
Medicaid Redesign Team (MRT)
The Medicaid Redesign Team was established by Governor Cuomo in January 2011 as a means of finding new ways to lower Medicaid spending in New York State (CHC NYS).
Medical Loss Ratio (MLR)
The percent of premium an insurer spends on claims and expenses that improve health care quality. New York State has imposed an MLR of 89%. This means that for every dollar spent in the transition to managed care, 89 cents must be used to pay for services.
Medical Necessity
New York law defines "medically necessary medical, dental, and remedial care, services, and supplies" in the Medicaid program as those "necessary to prevent, diagnose, correct, or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap and which are furnished an eligible person in accordance with state law" (N.Y. Soc. Serv. Law, ยง 365-a).
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
A federal law that prohibits group health plans and health insurance issuers from imposing less favorable benefit limitations on mental health or substance use disorder benefits than on medical/surgical benefits.
Multipayer Advanced Primary Care Practice Demonstration Program (MAPCP)
A CMS Innovations program where Medicare will take part in existing state multi-payer health reform initiatives. The program will pay a monthy care management fee, designed to cover care coordination; improved access; patient education; and other services to support chronically ill patients, to beneficiaries receiving primary care from APC practices. The goal of the program is to make advanced primary care practices more widely available.
Natural Supports
Relationships that occur in everyday life in the community where a consumer lives and works. Natural supports can include, but are not limited to, family members, friends, neighbors, clergy, and other acquaintances. Such supports help consumers develop a sense of social belonging, dignity, and self-esteem.
Office for People with Developmental Disabilities (OPWDD)
The New York State office that coordinates services for more than 126,000 New Yorkers with developmental disabilities. OPWDD provides services directly and oversees a network of nonprofit service providing agencies.
Office of Alcoholism and Substance Abuse Services (OASAS)
The New York State office that oversees the addiction services system including nearly 1,600 prevention, treatment, and recovery programs.
Office of Mental Health (OMH)
The New York State office that operates psychiatric centers and regulates/oversees more than 4,500 programs across the state. These programs include inpatient and outpatient programs, emergency, community support, and residential and family care programs.
Opioid Treatment Program (OTP)
A federally regulated (overseen by SAMHSA), accredited, and certified program that provides treatment for opioid dependence.
Patient-centered Medical Homes (PCMH)
A model of care where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care.
Peer Specialist
Individuals who hold a credential from a certifying authority recognized by the commissioner of OASAS or OMH. Peer specialists are supervised by a credentialed or licensed clinical staff member to provide peer support services or other authorized services based on clinical need as identified in patients' treatment/recovery plans.
Per Member Per Month (PMPM)
The amount a provider receives per month for each patient he or she is treating.
Performance Improvement Project (PIP)
A concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements.
Performing Provider System (PPS)
An entity responsible for performing a DSRIP project, requires collaboration between a number of hospitals and/or agencies.
Permanent Supportive Housing (PSH)
Housing with continued occupancy for a qualified tenant as long as the tenant's household pays the rent and complies with the lease or applicable landlord/tenant laws. The tenants are linked with supportive services that are: flexible and responsive to their individualized needs; available when needed by tenants; and if necessary, accessible where the tenant lives. Housing meets the U.S. Department of Housing and Urban Development housing quality standards and is made available by New York State, its designee, or directly with other qualified housing organizations. Housing is affordable to the eligible target population (monthly rent and utilities do not exceed 30% of monthly income).
Personalized Recovery Oriented Services (PROS)
A comprehensive recovery oriented program for indivduals with severe and persistent mental illness. PROS integrates treatment, support, and rehabilitation to improve functioning, reduce inpatient utilization, reduce emergency services, reduce contact with the criminal justice system, increase employment, attain higher levels of education and secure preferred housing.
Primary Care Provider (PCP)
The health care professional mainly responsible for the care of a patient, especially in an outpatient setting.
Primary/Behavioral Health Care Integration (PBHCI)
A SAMHSA program that supports communities coordinating and integrating primary care services into publicly funded, community-based behavioral health settings with the goal of improving access to primary care; prevention, early identification, and intervention efforts; integrated holistic care; and overall health status of patients.
Prospective Payment System (PPS)
A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services).
Psychiatric Advance Directive
A legal document giving instructions for future mental health treatment or appointing an agent to make future decisions about mental health treatment. The document is used when the person who created the document experiences acute episodes of psychiatric illness and becomes unable to make or communicate decisions about treatment.
Quality Assurance Reporting Requirements (QARR)
Federal and New York State tool used to measure the performance of health plans and practitioners on important aspects of care and service.
Recovery Focus
A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
Regional BH Planning Consortium (RPC) (RPC)
Comprised of each LGU in a region, and representatives of mental health and substance use disorder service providers, child welfare system, peers, families, Health Home leads, and Medicaid MCOs. RPCs work closely with State agencies to guide behavioral health policy, problem solve regional service delivery challenges, and recommend provider training topics.
Request for Qualification (RFQ)
RFQ- Request for Qualification, RFP - Request for Proposals, RFI - Request for Information
Safety Net Assistance (SNA)
A New York State temporary assistance program. Individuals who receive little or no income and less than $2000 in resources are eligible, especially those who aren't eligible for other programs such as single adults, childless couples, children living apart from adults, etc.
Screening, Brief Intervention and Referral to Treatment (SBIRT)
A screening and intervention procedure conducted in primary care, ED or in some specialty care settings to screen for risky substance use and provide a brief intervention or when indicated, a referral to treatment.
Serious Mental Illness (SMI)
A diagnosable mental disorder experienced by an adult that is sufficiently severe and enduring to cause functional impairment in one or more life areas and a recurrent need for mental health services.
Special Needs Plan (SNP)
Can be any type of Medicare Advantage coordinated care plan including HMO, and local or regional PPO. SNPs allow improved coordination and continuity of care to improve care for Medicare beneficiaries with special needs.
Start-Up Date
The date the managed care organization or Health and Recovery Plan providers begin providing behavioral health services identified in the request for qualifications.
State Medicaid Agency (SMA)
For New York State this is the NYS Department of Health.
State Plan Amendment (SPA)
An agreement between a state and the federal government describing how that state administers its Medicaid and CHIP programs.
Substance Abuse and Mental Health Services Administration (SAMHSA)
The agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation by reducing the impact of substance abuse and mental illness.
Substance Use Disorder (SUD)
Refers to substance abuse and substance dependence and measured on a continuum from mild to severe depending on how many relevant symptoms an individual exhibits. Each substance has its own separate use disorder but is diagnosed based on the same overarching criteria symptoms.
Supplemental Security Income (SSI)
A program that pays benefits to disabled adults and children who have limited income and resources.
Temporary Assistance to Needy Families (TANF)
A program geared at helping families achieve self-sufficiency where children can be cared for in their own homes and parents are less dependent on assistance.
The Centers for Medicare and Medicaid Services (CMS)
The federal agency that administers or oversees Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP). Covers 100 million people and strives to coordinate better care at lower costs.
The New York State Department of Health (DOH)
A statewide government department that focuses on issues related to the general health of the residents of New York.
The Plan
For the purposes of this request for qualifications, the term Plan refers to the managed care organization and Health and Recovery Plan (HARP) collectively. Any requirement under the request for qualifications that references the Plan shall apply to both the HARP and the managed care organization. Requirements that reference only the HARPs shall apply only to the HARPs.
Transition Age Youth (TAY)
Individuals under age 23 transitioning into the adult system from any OMH, OASAS or OCFS licensed, certified, or funded children's program. This also includes individuals under age 23 transitioning from State Education 853 schools (These are operated by private agencies and provide day and/or residential programs for students with disabilities).
Triple Aim
Improved Health, Better Healthcare and Consumer Experience, Lower Costs
Utilization Management (UM)
Procedures used to monitor or evaluate clinical necessity, appropriateness, efficacy, or efficiency of behavioral health care services, procedures, or settings and includes ambulatory review, prospective review, concurrent review, retrospective review, second opinions, care management, discharge planning, and service authorization.
Utilization Review (UR)
A review to determine whether health care services that have been provided, are being provided or are proposed to be provided to a patient, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary.
Wellness Recovery Action Plan (WRAP)
A self-management recovery system designed to decrease symptoms, increase personal responsibility and improve the quality of life for people who experience psychiatric symptoms. This self-designed plan teaches individuals how to keep themselves well, to identify and monitor symptoms and to use simple, safe, personal skills, supports, and strategies to reduce or eliminate symptoms. WRAP is not meant to replace, but to complement, professional health support and medications, though in more and more cases people are able to shift the balance of care to this self-management approach over time.