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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

Inpatient: $200 copayment plus 20% coinsurance after deductible

Other: 20% coinsurance after deductible

Non-Network

Inpatient: $200 copayment plus 40% coinsurance after deductible

Other: 40% coinsurance after deductible

PPO 1250 Plan

Network

Inpatient: $200 copayment plus 20% coinsurance after deductible

Other: 20% coinsurance after deductible

Non-Network

Inpatient: $200 copayment plus 40% coinsurance after deductible

Other: 40% coinsurance after deductible

Please refer to the Office Visit section to determine costs for a mental health office visit.

The plan will pay the following covered expenses for services ordered by a provider for the treatment of a mental health disorder:

 Inpatient services

Inpatient services

Covered subject to all of the following:

  • Mental health services must be received in a residential treatment facility that is licensed by the state in which it operates and provides treatment for mental health disorders. This does not include services provided at a group home. If outside of the United States, the residential treatment facility must be licensed or approved by the foreign government, an accreditation agency or licensing body working in that foreign country;
  • Member must be ill in more than one area of daily living to such an extent that they are rendered dysfunctional and requires the intensity of an inpatient setting for treatment. Without such inpatient treatment, the member's condition would deteriorate;
  • The member's mental health disorder must be treatable in an inpatient facility;
  • The member's mental health disorder must meet diagnostic criteria as described in the most recent edition of the American Psychiatric Association Diagnostic and Statistical Manual (DSM). If outside of the United States, the member's mental health disorder must meet diagnostic criteria established and commonly recognized by the medical community in that region; and
  • The attending provider must be a psychiatrist. If the admitting provider is not a psychiatrist, a psychiatrist must be attending to the member within 24 hours of admittance. Such psychiatrist must be United States board-eligible or board-certified. If outside of the United States, inpatient services must be provided by an individual who has received a diploma from a medical school recognized by the government agency in the country where the medical school is located. The attending provider must meet the requirements, if any, set out by the foreign government or regionally-recognized licensing body for treatment of mental health disorders.

 Day Treatment (partial hospitalization)

Day Treatment (partial hospitalization)

Day Treatment (partial hospitalization) for mental health services means a day treatment program that offers intensive, multidisciplinary services provided on less than a full-time basis. The program is designed to treat patients with serious mental or nervous disorders and offers major diagnostic, psychosocial and prevocational modalities. Such programs must be a less-restrictive alternative to inpatient treatment.

 Outpatient services

Outpatient services

Payable subject to all of the following:

  • Must be in person at a therapeutic medical or mental health facility; and
  • Includes measurable goals and continued progress toward functional behavior and termination of treatment. Continued coverage may be denied when positive response to treatment is not evident; and
  • Treatment must be provided by one of the following:
    • A United States board-eligible or board-certified psychiatrist licensed in the state where the treatment is provided.
    • A therapist with a doctorate or master's degree that denotes a specialty in psychiatry (Psy.D.).
    • A state licensed psychologist.
    • A state licensed or certified social worker practicing within the scope of his or her license or certification.
    • Licensed professional counselor.

 Additional provisions and benefits

Additional provisions and benefits

  • A medication evaluation by a psychiatrist may be required before a physician can prescribe medication for psychiatric conditions. Periodic evaluations may be requested by the Plan.
  • Any diagnosis change after a payment denial will not be considered for benefits unless the plan is provided with all pertinent records along with the request for change that justifies the revised diagnosis. Such records must include the history and initial assessment and must reflect the criteria listed in the most recent American Psychiatric Association Diagnostic and Statistical Manual (DSM) for the new diagnosis, or, if in a foreign country, must meet diagnostic criteria established and commonly recognized by the medical community in that region.

Except for observation, preauthorization by medical plan required.


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