Cost Sharing: Copayment applies.

Excludes: Treatment of mental retardation, defects, and deficiencies. Covers referral to family counseling services, but not payment for services.

Limits: Coverage is limited to 30 days per calendar year for purposes of short-term evaluation and crisis intervention.

Cost Sharing: A copayment required for each day of inpatient admission.

Excludes: Coverage for developmental delay and/or learning differences, or for inpatient confinement needed to change the member’s environment.

With the purchase of a supplemental policy--

Covers: Inpatient services provided by Cigna Behavioral Health, Inc., a specialized managed care organization that provides mental health and substance abuse services. Also covers care in day treatment facilities. Emergency services are available 24 hours a day.

Limits: Members must obtain pre-authorization from MCC in order for services to be paid. Inpatient care is approved only when the physician determines that outpatient treatment is not appropriate. Coverage is limited to short-term therapy medically necessary for diagnosis, crisis intervention, and treatment of mental health conditions.

Cost-sharing: Copayments and day visits/limits apply based on the benefit supplemental policy purchased.

Excludes: Evaluation and treatment of learning disabilities, delayed speech and stuttering.

Limits: Limited to 30 days per contract year. Care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422).

Limits: Benefits limited to maximum of 30 days inpatient facility services per contract year. Care must be authorized by Magellan.

• Services for treatment of psychiatric conditions that can be significantly improved through crisis-oriented intervention and follow-up therapy.
• Hospitalization, including services of physicians and other health professionals.
• Room and board, medications, injectibles and medical supplies.
• Inpatient psychiatric treatment including individual, group, and family therapy.
• Psychiatric hospital care and nursing care.
• Shock therapy.
• Drug therapy.
• Involuntary admission, when deemed necessary by the evaluating psychiatric physician.

Limits: Services must be provided by PCP or by referral from PCP. Once referred by the PCP, the member will be evaluated by a Psychiatric Physician. Group therapy is covered when prescribed by the treating psychiatric physician for care of specific symptoms. Member is also limited to one individual psychotherapy session and up group session per hospital day, unless medically necessary and authorized by OCCI. Members are limited to a maximum of 30 days inpatient services.

Cost Sharing: Copayments apply.

Excludes:

• Confinement, treatment, services or supplies related to mental retardation and/or mental deficiency
• Special education, counseling, therapy, confinement, treatment, or services related to learning disabilities or behavioral problems.
• Treatment for organic mental disorder when the disorder is due to permanent brain dysfunction.
• Treatment related to autism and treatment of pervasive development disorder. The assessments for these disorders are covered.
• Conditions that are determined by a psychiatric physician to be untreatable, or untreatable through crisis-oriented intervention therapy.
• Psychiatric intermediate or residential care. Also services in a psychiatric residential facility are excluded.
• Psychoanalysis.

With purchase of a supplemental rider covers: Inpatient and Partial hospital services for acute care.

Limits: All services, except for emergencies, must be prior approved by the Plan’s designated mental health provider. Benefits are limited to 30 days of care per member per contract year for inpatient services. One inpatient day may be exchanged for two partial hospital therapy visits. Prior approval by the plan’s designated mental health provider is required in order to exchange inpatient benefits for partial hospitalization benefits.

Cost Sharing: Copayments apply.

Excludes: Treatment of learning disabilities and developmental and learning disorders. Long-term rehabilitation, treatment of chronic conditions, and treatment of conditions not subject to favorable modification according to generally accepted standards of psychiatric care are also excluded. Partners excludes vocational rehabilitation, or employment, religious, adoption, pastoral, psychic and other counseling for relationships not attributable to a mental disorder. Services needed for involuntary commitments, police detentions or other arrangements are also excluded unless medically necessary. Partners excludes services for patients who are deliberately non-compliant with their recommended treatment, when such non-compliance is not a direct result of psychiatric illness.

With the purchase of a supplemental policy, covers: Inpatient care in a participating hospital or residential treatment facility.

Cost Sharing: Copayments apply.

Excludes:

• Inpatient services for chronic mental health conditions including psychotherapy.
• Mental health services for mental retardation or autism after diagnosis.
• Vocational, marriage, and/or sex counseling
• Remedial education, including evaluation or treatment of learning disabilities, speech difficulties, etc.
• Individual treatment for smoking, weight loss or personal growth.
• Any services mandated by court order, or as a condition of parole or probation.

Notification: You must call QualChoice prior to an admission to a hospital or inpatient facility, or for partial hospitalization treatment.

You will be charged a non-notification penalty if you fail to call QualChoice, except in cases where you are not medically able to comply.

Limits: Services are limited to those that are appropriate for treatment or diagnosis of mental health conditions. Services are limited to those which can reasonably be expected to improve your condition or prevent further deterioration. Certain day limits apply.

Limits: A behavioral health case manager picked by TWP-NC will manage the care. Services must be provided by participating providers. The member may obtain a referral for mental health services by his or her PCP or directly by calling the behavioral health case manager.

Excludes: Treatments for chronic disorders, unless there is an acute episode. Excludes services for mental disorders or disabilities which can not be improved, according to generally accepted professional standards.

Limits: Covered only when provided by a participating provider. Treatment must be medically necessary and approved in advance by United Behavioral Health. Specific limitations vary according to benefits purchased.

Cost Sharing: Copayments may apply.

Excludes: Services which are:

• Beyond a short-term evaluation or crisis intervention period.
• For psychological testing, except when related to the evaluation and diagnosis of learning disabilities, behavioral disorders and mental retardation.
• Beyond the period necessary for the evaluation and diagnosis for learning disabilities, behavioral disorders and mental retardation.
• Marriage or family counseling.
• Psychoanalysis.

Psychiatric or psychological examinations, testing or treatments for purposes related to career education, travel, employment, insurance, marriage or adoption. Also excludes exams, testing or treatments for judicial or administrative proceedings or orders or which are conducted for medical research or to obtain or maintain any type of license.

Covers with the purchase of a rider: Mental health inpatient services for evaluation of a recognized mental illness or disorder. Services must be provided by a hospital, residential facility, day care or day treatment program, or other approved facility.

Limits: Coverage limited to the equivalent of 30 inpatient days of covered treatment per calendar year. One-day treatment (outpatient treatment) visit equals one-half day of inpatient treatment. The mental health services participating provider shall provide or arrange for the services. Services must reasonably be expected to improve significantly the member’s condition.

Cost Sharing: Copayments apply.

Excludes:

• Services for chronic psychosis, intractable personality disorders, mental retardation, mental deficiency, Alzheimer’s disease, and chronic organic brain syndrome. However, acute episodes due to chronic brain syndrome will be covered.
• Chronic behavioral disorders if the member is not likely to improve significantly with short-term therapeutic management.
• Psychiatric therapy ordered by a court or administrative agency.