Outpatient Mental Health

Benefits are provided for services and supplies for mental health conditions up to a maximum of 30 visits per calendar year. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum. If treatment exceeds the 30-visit per year maximum, this plan will not pay the additional costs. Benefits for therapeutic and supportive services provided to the individual’s family to assist in the individual’s diagnosis and treatment are applied to the individual’s benefit maximum.

Each individual is responsible for the first $10 of covered expenses when a preferred or nonpreferred physician or mental health care provider bills an office visit. This $10 office visit copayment is in addition to the $10 office visit copayment for an office visit billed by a nonpreferred provider, and these office visit copayments do not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum.

Benefits are provided for:

• Individual or group therapy provided by a licensed psychiatrist, clinical psychologist, advanced registered nurse practitioner (ARNP) whose specialty is mental health care, or social worker (MSW).
• Laboratory tests required to monitor prescribed medications.

Benefits are not provided for (inpatient or outpatient care):

1. Mental health admissions which are primarily to control or change the individual’s environment or during which mental health care could be safely and adequately provided on an outpatient basis or in a lesser facility than a hospital.
2. Care in a skilled nursing facility.
3. Court-ordered care or assessments; care in lieu of incarceration; residential treatment centers; detention centers; reform schools; or nonmedical self-help such as “outward bound” or “wilderness survival.”
4. Room and board for any day in which the individual is released from the hospital on a temporary pass, or for any charge related to a late discharge from the hospital when the late discharge is for the individual’s or the provider’s convenience.
5. State-required medical assessments for specialized educational programs; services or supplies required by law to be provided by any school system; or treatment for learning disabilities. This exclusion applies regardless of the recommendation of the attending physician.
6. Sexual dysfunctions or dementia.
7. Services furnished in connection with obesity, even if the obesity is affected by psychological factors.
8. Electro-convulsive therapy including anesthesia.
9. Biofeedback.
10. Marriage counseling, family counseling, career counseling, social adjustment counseling, pastoral counseling, or financial counseling; recreational, vocational, educational, or cognitive therapy; anger management classes; or the completion of any forms or reports.
11. Treatment of a mental illness  accompanying or resulting from chemical dependency. Treatment of any such related, accompanying or resulting disorder or condition is considered to be treatment of chemical dependency and is covered under Chemical Dependency.

Key Point

Treatment of a mental illness  accompanying or resulting from chemical dependency is not covered under the mental health care benefit. Treatment of any such related, accompanying or resulting disorder or condition is considered to be treatment of chemical dependency and is covered under Chemical Dependency.

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