Limits:

• Referral by PCP to participating mental health provider is required. Member may exchange one mental health inpatient benefit for up to 4 outpatient visits. Member may exchange up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient visits.
• Member may exchange one inpatient day for 2 days of treatment in a partial hospitalization program in lieu of hospitalization up to the maximum benefit limitation upon approval by HMO.
• Requests for benefit exchange must be initiated by the member’s mental health provider and approved in advance by Aetna. Member must use all outpatient mental health benefits available under the certificate and pay all applicable copayments before an exchange will be considered.

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 limited to a combined total of 20-30 visits per calendar year for short-term evaluation and crisis intervention.

Cost Sharing: Copayments vary for individual and group sessions, and number of visits by plan.

With the purchase of a supplemental policy, covers: Outpatient services provided by Cigna Behavioral Health, Inc. (see inpatient services). Emergency services are available 24 hours a day.

Limits: Outpatient care is preferred and is approved for up to 30 visits per year. Coverage is limited to short-term therapy medically necessary for diagnosis, crisis intervention, and treatment of mental health conditions. Member must obtain pre-authorization from MCC in order for services to be paid.

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

Limits: Limited to 20 visits per contract year. Care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422).

Cost Sharing: Copayments may apply.

Excludes: Treatment of mental retardation; mental evaluations required by third parties; marriage, family and child counseling.

Limits: Benefits limited to maximum of 20 visits per contract year. Care must be authorized by Magellan.

Excludes: Services for learning or behavioral disabilities, mental retardation or autism.

• Services for treatment of psychiatric conditions that can be significantly improved through crisis-oriented intervention and follow-up therapy.
• Diagnostic evaluation.
• Individual, group, and family therapy.

Limits: Services must be provided by PCP or by referral from PCP. A missed appointment will be considered a visit unless the provider was notified in advance. Members are responsible for the payment of missed visits. Members are limited to a maximum of 20 visits per year.

Cost Sharing: 50% coinsurance applies.

Excludes:

• Conditions that are determined by a psychiatric physician to be untreatable, or untreatable through crisis-oriented intervention therapy.
• Psychiatric therapy or psychological testing on court order or as a condition of parole.
• Psychiatric or psychological evaluation that is primarily for legal or administrative purposes, such as disability determination or security clearances purposes.
• Court appearances by a mental health provider.
• Testing for specific learning disabilities, intelligence, or for career aptitude and interests.
• 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.
• Psychoanalysis.
• Marriage counseling, psychotherapy and other consultations done by telephone, or sexual therapy.

With purchase of a supplemental rider covers: Outpatient therapy for acute care is covered, including individual therapy, intensive outpatient therapy, and group therapy. Outpatient medication checks are also covered, as well as treatment of Attention Deficit/Hyperactivity Disorder (ADHD). ADHD treatment includes evaluation, psycho-educational treatment.

Limits: All services, except for emergencies, must be prior approved by the Plan’s designated mental health provider. Benefits are limited to a total of 20 outpatient therapy visits per member per contract year, regardless of which kind or combination of kinds of therapies received (individual, intensive, or group). One outpatient visit may be exchanged for 2 medication check visits. Prior approval by the plan’s designated mental health provider is required in order to exchange inpatient benefits for partial hospitalization benefits. ADHD medication is covered only with the purchase of a prescription drug supplemental policy.

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: Ambulatory care, including evaluation, crisis intervention and therapy. These services may include individual/group therapy or diagnostic evaluation and medical evaluations and medication management.

Excludes:

• 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.

Under the HMO gatekeeper option only (Option 1), QualChoice will cover up to two evaluations to diagnose Attention Deficit Disorder (ADD/ADHD). If ADD is diagnosed, QualChoice will pay for six parent education classes. No services are covered for ADD/ADHD under the point-of-service or open-access models (Options 2 and 3).

Limits: Services are limited to those that are appropriate for treatment or diagnosis of mental health conditions. Services are limited to those that can reasonably be expected to improve your condition or prevent further deterioration. Coverage is limited to a maximum number of visits per benefit year.

Cost Sharing: Copayments may apply.

Excludes:

• Services related to the treatment of chronic pain by any means other than psychotherapy, if it is determined that such pain has a psychological origin.
• Treatments that are considered experimental such as psychosurgery, megavitamin therapy, and treatments for so-called sexual addictions or co-dependency.
• Services for educational testing or treatment of learning disabilities or developmental delay disorder.

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.

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

Cost Sharing: Copayments may apply.

Excludes: Same exclusions as for mental health inpatient services.

Limits: Limited to 20 treatment visits per calendar year. Only covered if the condition can reasonably be expected to improve significantly with short-term treatment. Services must be provided, arranged, and managed by a participating mental health services provider.

Cost Sharing: Copayment applies. Copayments made for mental health services do not apply toward copayment annual maximum.