Mental Health Care—80%

Inpatient Hospital Mental Health

Inpatient Admissions Must Be Precertified With the Medical Review Agency (non-Medicare Patients)
Benefits are provided for services and supplies for mental health conditions at an approved mental health facility or hospital up to a maximum of 15 inpatient days 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 15 inpatient day per year maximum, this plan will not pay the additional costs. Benefits for therapeutic and supportive services provided to the patient's family to assist in the patient's diagnosis and treatment are applied to the patient's benefit maximum.

Benefits are provided for:

• A semiprivate room.
• Diagnostic or therapeutic items or services that are ordinarily furnished by the hospital for the care and treatment of a patient.
• Drugs, biologicals, supplies, appliances, and equipment for use in the hospital that are ordinarily furnished by the hospital for the care and treatment of a patient.
• Individual or group therapy provided by a psychiatrist, clinical psychologist, advanced registered nurse practitioner (ARNP) whose specialty is mental health care, licensed social worker (MSW), licensed mental health counselor (LMHC), and licensed marriage and family therapist (LMFT). Licensed mental health counselors (LMHC) and licensed marriage and family therapist (LMFT) are not covered for Medicare-eligible patients.

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 patient's family to assist in the patient's diagnosis and treatment are applied to the patient's benefit maximum.

Each patient is responsible for a $10 copayment when a preferred or nonpreferred physician or mental health care provider bills an office visit. There is an additional $10 copayment for an office visit billed by a nonpreferred provider. These office visit copayments do not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum. This provision applies only to patients without Medicare.

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, social worker (MSW), licensed mental health counselor (LMHC), and licensed marriage and family therapist (LMFT). Licensed mental health counselors (LMHC) and licensed marriage and family therapist (LMFT) are not covered for Medicare-eligible patients.
• 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 patient'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; or care in lieu of incarceration.
4. Residential treatment centers or services or supplies received in a residential treatment center; nonmedical self-help such as "outward bound" or "wilderness survival." This exclusion applies regardless of the recommendation of the attending physician.
5. Detention centers or reform schools.
6. Room and board for any day in which the patient 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 patient's or the provider's convenience.
7. 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.
8. Sexual dysfunctions.
9. Dementia.
10. Services furnished in connection with obesity, even if the obesity is affected by psychological factors.
11. Electro-convulsive therapy including anesthesia unless preauthorized with the Trust Office.
12. Biofeedback and neurofeedback.
13. 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.
14. 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" on pages 55-56.
15. Expenses incurred while the patient is in the custody of, or confined by, any law enforcement officer or agency.
16. Neuropsychological or psychological assessments or tests except as provided under "Neuropsychological or Psychological Assessments or Tests" on pages 69-70.
17. Services or supplies provided by a provider who is not a licensed psychiatrist, clinical psychologist, advanced registered nurse practitioner (ARNP) whose specialty is mental health care, social worker (MSW), licensed mental health counselor (LMHC), or licensed marriage and family therapist (LMFT).