Common use of Mental Health and Chemical Dependency Services Clause in Contracts

Mental Health and Chemical Dependency Services. This benefit covers inpatient, residential and outpatient Medically Necessary treatment of mental health and substance use disorders. This benefit includes services provided to individuals requiring Chemical Dependency treatment for substance use disorders, including Chemical Dependency detoxification. Covered Medically Necessary care under this benefit includes treatment and services for mental health and psychiatric conditions, including neurodevelopmental therapies, and substance use disorders, for patients with a DSM category diagnosis, including behavioral health treatment for those conditions, except as excluded. Neurodevelopmental therapies consist of physical, occupational and speech therapy and maintenance to restore or improve function based on developmental delay. Neurodevelopmental therapies under this benefit will not be combined with rehabilitative services for the same condition. All inpatient admissions related to mental health and substance use disorders require Pre-Authorization, unless the patient is involuntarily committed. To obtain Pre-Authorization for an inpatient admission related to a mental health or substance use disorder, call (000) 000-0000. Emergency admissions require notification as described in the Notification for Emergency Hospital Admissions in the Utilization Management section of this Agreement. Care and services for mental health and substance use disorders must be Medically Necessary and provided at the least restrictive level of care. Facilities offering an inpatient level of care must have a medical model with physician and/or nursing staffing on-site 24 hours a day. A clear treatment plan must be established on admission, and must include measurable progress toward a rehabilitative goal or goals, including movement to a less restrictive setting, if applicable, or other Medically Necessary goals as determined by your Provider and the plan’s Medical Management staff. Care may be received at a Hospital or treatment facility, or received through residential treatment programs, partial hospital programs, intensive outpatient programs, through group or individual outpatient services, or in a home health setting. Prescription Drugs prescribed during an inpatient admission related to mental health or substance use disorders are covered. This benefit also covers services provided by a licensed behavioral health Provider, practicing within the scope of their license, for a covered diagnosis in a Skilled Nursing Facility, as well as acupuncture treatment. When provided to treat Chemical Dependency, the acupuncture maximum benefit limit of this plan does not apply. Family counseling, psychological testing and psychotherapeutic programs are covered only if related to the treatment of an approved Mental Health Condition, specifically, those noted in the DSM. Eating disorder treatment is covered when associated with the treatment of a DSM category diagnosis. The following DSM “V” code diagnoses are also covered under this benefit: medically necessary services for parent-child relational problems for children under 5 years of age; bereavement for children under 5 years of age; and gender dysphoria. Mental health care listed below is not covered: • Adventure-based or wilderness programs that focus primarily on education, socialization or delinquency; • Biofeedback; • Court-ordered assessments when not Medically Necessary; • Custodial Care, including housing that is not integral to a Medically Necessary level of care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior, or to achieve family respite; • Housing for individuals in a Partial Hospital Program or Intensive Outpatient Program; • Marriage and couples counseling; • Family therapy, in the absence of an approved mental health diagnosis; • Nontraditional or alternative therapies not based on American Psychiatric and American Psychological Association accepted techniques and theories; • Sensitivity training; • Treatment for sexual dysfunctions, and paraphilic disorders; and • Therapeutic group homes, residential community homes, therapeutic schools, adventure-based and wilderness programs, or other similar programs. Chemical Dependency care listed below is not covered: • Alcoholics Anonymous or other similar Chemical Dependency programs or support groups; • Biofeedback, pain management and stress reduction classes; • Care necessary to obtain shelter, to deter antisocial behavior, or to deter runaway or truant behavior; • Chemical Dependency benefits not specifically listed; • Court-ordered or other assessments to determine the medical necessity of court-ordered treatments; • Court-ordered treatments or treatments related to deferral of prosecution, deferral of sentencing or suspended sentencing, or treatments ordered as a condition of retaining driving rights, when not Medically Necessary; • Custodial Care, including housing that is not integral to a Medically Necessary level of care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior, or to achieve family respite, including: o Emergency patrol services; o Information or referral services; o Information schools; o Long-term or Custodial Care; and o Treatment without ongoing concurrent review to ensure that the treatment is being provided in the least restrictive setting required; • Housing for individuals in a Partial Hospital Program or Intensive Outpatient Program; • Non substance related disorders; and • Therapeutic group homes, residential community homes, therapeutic schools, adventure-based and wilderness programs, or other similar programs.

Mental Health and Chemical Dependency Services. This benefit covers inpatient, residential and outpatient Medically Necessary treatment of mental health and substance use disordersdisorder services. This benefit includes services provided to treatment of individuals requiring Chemical Dependency treatment rehabilitation for substance use disordersdisorders such as alcohol or DEA‐controlled oral, intravenous, or inhaled medications and materials, including Chemical Dependency detoxification. Covered Medically Necessary care under this benefit includes treatment and services for mental health and psychiatric conditions, including neurodevelopmental therapies, conditions and substance use disorders, disorders for patients with a DSM category diagnosis, including behavioral health treatment for those conditions, except as excluded. Neurodevelopmental therapies consist of physical, occupational and speech therapy and maintenance to restore or improve function based on developmental delay. Neurodevelopmental therapies under this benefit will not be combined with rehabilitative services for the same condition. All inpatient admissions related to mental health and substance use disorders require Pre-Authorizationpre‐ authorization by calling (800) 640‐7682, unless the patient a person is involuntarily committed. To obtain Pre-Authorization for an inpatient admission related to a mental health or substance use disorder, call (000) 000-0000. Emergency admissions require notification as described in the Notification for Emergency Hospital Admissions in the Utilization Management section of this Agreement. Care and services for mental health and substance use disorders disorder services must be Medically Necessary and provided at the least restrictive level of care. Facilities offering an inpatient level of care must have a medical model with physician and/or nursing staffing on-site 24 hours a day. A clear treatment plan must be established on admission, and must include containing measurable progress toward a rehabilitative goal or goalsgoal(s), including but not limited to movement to a less restrictive setting, setting (if applicable), or other Medically Necessary goals as determined by your Provider and the planCHPW’s Medical Management staff. Care may be received at a Hospital or treatment facilityHospital, or a Chemical Dependency rehabilitation Facility, and/or received through residential treatment programs, partial hospital programs, intensive outpatient programs, through group or individual outpatient services, or in a home health setting. Prescription Drugs prescribed during an inpatient admission related to mental health or substance use disorders are covered. This benefit also covers services provided by a licensed behavioral health Provider, Provider practicing within the scope of their license, license for a covered diagnosis in a Skilled Nursing Facility, Facility as well as acupuncture treatment. When treatment visits without application of the visit limitation requirements when provided to treat for Chemical Dependency, the acupuncture maximum benefit limit of this plan does not apply. Family counseling, psychological testing and psychotherapeutic programs are covered only if related to the treatment of an approved Mental Health Conditiona clinical mental health diagnosis, specifically, those noted in as Axis I diagnoses per the DSM. Eating disorder treatment is covered when associated with the treatment a diagnosis of a DSM category diagnosis. The following DSM “V” code diagnoses are also covered under this benefit: medically necessary services for parent-child relational problems for children under 5 years of age; bereavement for children under 5 years of age; and gender dysphoria. Mental health care listed below is not covered: • Adventure-based or  Adventure‐based and/or wilderness programs that focus primarily on education,   Marriage and couples counseling; Family therapy, in the absence of a mental  socialization or delinquency; • Biofeedback; • Court-ordered  health diagnosis; Nontraditional, alternative therapies that are  Court‐ordered assessments when not not based on American Psychiatric and  Medically Necessary; • Custodial Care, including housing that is not integral to a Medically Necessary level of  American Psychological Association acceptable techniques and theories; Sensitivity training; care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter   Sexual dysfunction; or Sexual and gender identity disorders (DSM runaway or truant behavior or to achieve codes 302.0 – 302.9).  family respite; Developmental delay disorders; Chemical Dependency care listed below is not covered:  Alcoholics Anonymous or other similar Chemical Dependency programs or support groups;  Biofeedback, pain management and/or stress reduction classes;  Care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior;  Chemical Dependency benefits not specifically listed;  Court‐ordered or other assessments to determine the medical necessity of court‐ordered treatments;  Court‐ordered treatments or treatments related to deferral of prosecution, deferral of sentencing or suspended sentencing or treatments ordered as a condition of retaining driving rights, when no medical necessity exists; or  Custodial Care, including housing that is not integral to a Medically Necessary level of care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior, or to achieve family respite; • Housing for individuals in a Partial Hospital Program or Intensive Outpatient Program; • Marriage and couples counseling; • Family therapy, in the absence of an approved mental health diagnosis; • Nontraditional or alternative therapies not based on American Psychiatric and American Psychological Association accepted techniques and theories; • Sensitivity training; • Treatment for sexual dysfunctions, and paraphilic disorders; and • Therapeutic group homes, residential community homes, therapeutic schools, adventure-based and wilderness programs, or other similar programs. Chemical Dependency care listed below is not covered: • Alcoholics Anonymous or other similar Chemical Dependency programs or support groups; • Biofeedback, pain management and stress reduction classes; • Care necessary to obtain shelter, to deter antisocial behavior, or to deter runaway or truant behavior; • Chemical Dependency benefits not specifically listed; • Court-ordered or other assessments to determine the medical necessity of court-ordered treatments; • Court-ordered treatments or treatments related to deferral of prosecution, deferral of sentencing or suspended sentencing, or treatments ordered as a condition of retaining driving rights, when not Medically Necessary; • Custodial Care, including housing that is not integral to a Medically Necessary level of care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior, behavior or to achieve family respite, including: o Emergency patrol services; o Information or referral services; o Information schools; o Long-term Long‐term or Custodial Care; and or o Treatment without ongoing concurrent review to ensure that the treatment is being provided in the least restrictive setting required. Newborn Care Medical services and supplies for a newborn child following birth to a female Subscriber or an enrolled dependant, including newborn Hospital nursery charges, the initial physical examination and a PKU test are covered. Benefits apply under the newborn's own coverage, in connection with nursery care for the natural newborn or newly adoptive child. Coverage for newborns (including newborns born to dependent female children) is provided for the first 3 weeks of life as described in the Schedule of Medical Benefits, even if the newborn is not enrolled. Benefits will be provided at a level not less than the enrolled mother’s coverage, even if there are separate Hospital admissions. In order for coverage to continue after the first 3 weeks of life, the newborn child must be eligible and enrolled, if applicable, as explained later in the Eligibility and Enrollment sections. Nutritional and Dietary Formulas Coverage for nutritional and dietary formulas is provided when Medically Necessary. The following conditions must be met:  The formula is a specialized formula for treatment of a recognized life‐threatening metabolic deficiency such as phenylketonuria; • Housing for individuals or  The formula is the significant source of a patient’s primary nutrition or is administered in a Partial Hospital Program or Intensive Outpatient Program; • Non substance related disordersconjunction with intravenous nutrition; and • Therapeutic group homes The formula is administered through a feeding tube (nasal, residential community homesoral or gastrostomy). Oral Surgery Coverage for oral surgery is offered when Medically Necessary. Oral Surgery required for a dental diagnosis such as periodontal disease is not covered. Examples of Covered Services include:  The reduction or manipulation of fractures of facial bones;  Excision of lesions, therapeutic schoolscysts, adventure-based and wilderness programstumors of the mandible, mouth, lip or tongue; and  Incision of accessory sinuses, mouth salivary glands or ducts. Orthotics Benefits are covered for the fitting and purchase of braces, splints, orthopedic appliances and Orthotic supplies or apparatuses used to support, align or correct deformities or to improve the function of moving parts of the body. This benefit does not cover off‐the shelf shoe inserts and orthopedic shoes. Pediatric Vision Pediatric vision services, including professional fees, supplies and materials, are covered for children under the age of 19 according to the limitations described in the Schedule of Benefits section above. Covered services include:  Routine vision screening and eye exam, with dilation and refraction;  Prescription lenses or contacts, including polycarbonate lenses and scratch resistant coating;  Lenses may include single vision, conventional lined bifocal or conventional lined trifocal, or other similar programs.lenticular;  One pair of frames or contact lenses in lieu of lenses and frames, once each Calendar Year;  Evaluation, fitting and follow up care; and  Low vision optical devices, services, training and instruction. In addition to the exclusions and plan limitations, the following services and materials are not covered by this pediatric vision benefit:  Orthoptics or vision training and any associated supplemental testing; plano lenses (less than ± .50 diopter power); or two pair of glasses in lieu of bifocals;  Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are otherwise available;  Medical or surgical treatment of the eyes (these services are covered under your Medical Benefits);  Corrective vision treatments that are considered Experimental or Investigational;  Costs for services and materials above the limitations indicated in the Schedule of Benefits section; or Prescription Drugs