Mental health, substance-related and addictive disorder and neurobiological disorder services
Mental health and substance-related and addictive disorder services include those received on an inpatient or outpatient basis in a hospital, alternate facility or in a provider's office.
Covered neurobiological disorder services include behavioral services for Autism Spectrum Disorder, including intensive behavioral therapies, such as applied behavior analysis (ABA) that are:
- Focused on the treatment of core deficits of Autism Spectrum Disorder;
- Provided by or under the direction of a behavioral health provider who is properly licensed and qualified by law and acting within the scope of their license; and
- Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others or property and impairment in daily functioning.
Note: The benefits described here are for the behavioral component of treatment for Autism Spectrum Disorders only. Medical treatment of Autism Spectrum Disorders is a covered health service for which benefits are available under the applicable medical covered health services categories.
Mental health, substance-related and addictive disorder and neurobiological disorder benefits include the following levels of care:
- Inpatient treatment.
- Residential Treatment.
- Partial Hospitalization/Day Treatment.
- Intensive Outpatient Treatment.
- Outpatient treatment.
Inpatient treatment and residential treatment includes room and board in a semi-private room (a room with two or more beds).
Services include the following:
- Diagnostic and evaluation assessment
- Treatment planning
- Treatment and/or procedures
- Referral services
- Medication management
- Individual, family, therapeutic group and provider-based case management services
- Crisis intervention
- Partial hospitalization/day treatment
- Inpatient treatment and residential treatment including room and board in a semi-private room (a room with two or more beds)
- Services for intensive outpatient treatment.
The Mental Health or Substance-Related and Addictive Disorder Administrator provides administrative services for all levels of care.
You are encouraged to contact the Mental Health or Substance-Related and Addictive Disorder Administrator for assistance in locating a provider and for coordination of care.
For Out-of-Network Benefits for a scheduled admission for Mental Health Care and Substance-Related and Addictive Disorders Services (including an admission for services at a Residential Treatment facility) you must obtain prior authorization five business days before admission or as soon as is reasonably possible for non-scheduled admissions.
In addition, for Out-of-Network Benefits you must obtain prior authorization before the following services are received. Services requiring prior authorization: Partial Hospitalization/Day Treatment; Intensive Outpatient Treatment programs; outpatient electro-convulsive treatment; psychological testing; transcranial magnetic stimulation; Intensive Behavioral Therapy, including Applied Behavior Analysis (ABA).
In addition to any exclusions or limits that may be described in "Expenses not covered", the Plan does not pay benefits for the following:
- Services performed in connection with conditions not classified in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association.
- Outside of an initial assessment, services as treatments for a primary diagnosis of conditions and problems that may be a focus of clinical attention, but are specifically noted not to be mental disorders within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
- Outside of initial assessment, services as treatments for the primary diagnoses of learning disabilities, gambling disorder, and paraphilic disorders.
- Services that are solely educational in nature or otherwise paid under state or federal law for purely educational purposes.
- Tuition for or services that are school-based for children and adolescents required to be provided by, or paid for by, the school under the Individuals with Disabilities Education Act.
- Outside of initial assessment, unspecified disorders for which the provider is not obligated to provide clinical rationale as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
- Transitional Living services.
- Following the American Society of Addiction Medicine (ASAM) criteria, non-medical 24-hour withdrawal management.
- High intensity residential care, including American Society of Addiction Medicine (ASAM) criteria, for covered persons with substance-related and addictive disorders who are unable to participate in their care due to significant cognitive impairment.