2014 Mental Health and Substance Abuse Coverage

Mental health and substance abuse coverage is administered by a Behavioral Health Benefits Manager through a network of qualified Network Providers to promote the delivery of care in the most appropriate settings. If you are in an HMO or Medicare Advantage plan option, please refer to your Certificate of Coverage for a description of covered services.

There is a special predetermination or “managed care” process for mental health and substance abuse services. Most services must be approved in advance by the Behavioral Health Benefits Manager to determine the appropriateness of the treatment. The Behavioral Health Benefits Manager evaluates each case and approves treatment, which may include an acute inpatient Hospital or Residential Substance Abuse Treatment Facility admission, an appointment for assessment and diagnosis, outpatient mental health services, or a referral to a Network Provider (Network Provider means any approved Provider of mental health or substance abuse benefits). The Behavioral Health Benefits Manager can be reached through a toll-free number available 24 hours a day, seven days a week.

If services for treatment of a mental health condition are needed, you should call the Behavioral Health Benefits Manager listed in the Contact Information page of your Schedule of Benefits. If you choose to contact a Network Provider first, the Network Provider will assess your condition, develop a preliminary treatment plan, and then must call the Behavioral Health Benefits Manager for treatment authorization.

If services for treatment of a substance abuse condition are needed, you must contact the Behavioral Health Benefits Manager directly for assessment and referral to a Network Provider. Remember, you must use Network Providers to receive full benefits.

The Plan provides benefits up to the Allowed Amount for the following Medically Necessary mental health/substance abuse services:

Up to a maximum of 45 days mental health and/or substance abuse inpatient care within a benefit period at a Hospital or Residential Substance Abuse Treatment Facility;
Covered outpatient mental health/substance abuse services are subject to visit restrictions;
Up to 90 days in a Skilled Nursing Facility for mental health care. Each day of inpatient care for mental health treatment within the benefit period reduces by two the number of available days for Skilled Nursing Facility care. Each two days of medical care for the treatment of mental disorders in a Skilled Nursing Facility reduces by one the number of days of inpatient medical care available for the treatment of mental health related disorders in a Hospital;
Up to 90 days/nights of care in an approved mental health and/or substance abuse Partial Hospitalization Treatment Facility. Each day of inpatient care for mental health treatment within the benefit period reduces the number of partial hospitalization treatment days by two. Each two days of medical care for the treatment of mental disorders in a Partial Hospitalization Treatment Facility reduces by one the number of days of inpatient medical care available for the treatment of mental health related disorders in a Hospital;
Psychological testing, when authorized by the Behavioral Health Benefits Manager.

If outpatient mental health services are rendered by a Non-Network physician, the first visit will be covered. Any additional visits must be authorized by the Behavioral Health Benefits Manager. Unauthorized visits to a Non-Network physician will be paid at 50% of the amount that would have been paid to a Network Provider. These payments will be made to you, not to the Provider. You are responsible for paying the Provider. Mental health services rendered by Non-Network, non-physician Providers (psychologists, social workers, etc.) are not covered under the Plan.

Coverage is not available for treatment of mental disorders that are not amenable to improvement (except that coverage is available to determine that the disorder is not amenable to favorable modification) or for the evaluation and diagnosis of mental deficiency of retardation.

If substance abuse services are rendered by a Non-Network Provider, the services are not covered unless an out-of-network authorization is secured from the Behavioral Health Benefits Manager prior to treatment.

The following mental health and substance abuse services are not covered under the Plan:

Coverage is not available for services for treatment of mental disorders that, according to generally accepted medical standards, are not amenable to favorable modification, except that coverage is available for the period necessary to determine that the disorder is not amenable to favorable modification, or for the period necessary for the evaluation and diagnosis of mental deficiency or retardation.
Coverage for substance abuse treatment does not include professional services such as dispensing methadone, testing urine specimens, or performing physical or x-ray examinations or other diagnostic procedures unless therapy, counseling, or psychological testing are provided on the same day.
Coverage does not include family counseling that is rendered by a Provider other than the Provider for the family member in the course of treatment. Reimbursement will be provided only for services rendered to individuals covered under the Plan.
Coverage does not include diversional or recreation therapy, e.g., an organized program of leisure-based activity programs which, in addition, may include activities that improve or sustain an individual’s skills of self care and daily living.
Coverage does not include psychological testing if used as part of, or in connection with, vocational guidance, training, or counseling.