Chemical
Dependency – 80%
Benefits are provided for
services and supplies at an approved treatment facility for the effective
treatment of chemical dependency with no more than $5,000 paid in any 24 month
period with a
lifetime
maximum of $10,000. If expenses exceed
this $10,000 lifetime maximum, this plan will not pay the additional costs.
All
inpatient hospital and facility admissions must be
precertified.
These services always require 20 percent coinsurance and these coinsurance
expenses do not apply toward the $2,300 annual coinsurance maximum. Services and
supplies received at an approved treatment facility or hospital, including
physician’s charges and charges for prescription drugs, are covered only
to the extent they are in connection with the effective treatment of chemical
dependency. Care at a chemical dependency treatment facility is limited to
intensive inpatient treatment and outpatient chemical dependency counseling.
Benefits for therapeutic and supporting services provided to the
individual’s family to assist in the individual’s diagnosis and
treatment are applied to the individual’s benefit maximums.
Outpatient services can be
billed in phases. If one phase is completed, the claim for that phase can be
submitted.
In situations in which the
individual is under court order to undergo an assessment of, or treatment for,
chemical dependency, the plan may require the individual to furnish, at his or
her expense and no less than 15 and no more than 30 working days
before
treatment is to begin, an initial
assessment of the need for treatment and a treatment plan, prepared by a
provider who is a physician or qualified chemical dependency counselor employed
by an approved treatment facility to enable the plan to make its own evaluation
of medical necessity prior to scheduled treatment.
If there is another medical
condition which is serious in nature, the plan, through its medical review
agency, may require that the individual be treated for that medical condition
prior to being admitted for chemical dependency. In this way, benefits for
chemical dependency will be preserved until the individual can fully participate
in the program.
Benefits
are not
provided for:
- Any
individual who does not successfully complete the prescribed course of
treatment, who is discharged before the prescribed course of treatment is
complete, or who voluntarily leaves treatment against medical
advice.
- Any
individual who has not been examined and diagnosed by a physician or a qualified
chemical dependency counselor to have a chemical dependency.
- Recovery
houses which provide an alcohol or drug free residential setting; alcohol or
drug information and referral services; residential treatment centers; schools;
emergency service patrols; or detoxification, except when the individual
immediately (within five days) enrolls in and successfully completes a chemical
dependency program.
- Diversional
activities such as recreational, hobby or craft equipment, or related
fees.
- Methadone,
Antabuse or antagonists, anticraving, or similar drugs in the absence of
treatment in an approved treatment facility.
- Services,
supplies or drugs for smoking cessation, except as provided for under Tobacco
Cessation Program.
- Ambulance
service to or from a treatment facility, hospital or skilled nursing
facility.
- Inpatient
hospital treatment when that treatment can be provided safely in an outpatient
setting without adversely affecting the individual’s physical
condition.
- Services,
supplies or testing required as a condition of employment.
- Expenses
incurred while an individual is in the custody of, or confined by, any law
enforcement officer or agency.
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