Mental health and substance abuse benefits
Your Trust group health plan provides benefits for inpatient, transitional, and outpatient treatment of nervous and mental disorders and substance abuse. Your Benefit Summary describes the coverage amounts and coinsurance requirements that apply to your mental health benefits. Refer to Section 6 of your group health policy for a complete description of your mental health and substance abuse benefits.
We reimburse you for mental health and substance abuse treatment if:
- You receive treatment from a provider that we consider qualfied, and
- You obtain our approval in advance, and we determine that the proposed services are medically necessary and medically appropriate as those terms are defined in the policy.
Inpatient mental health treatment
Your policy covers hospital confinement for the inpatient treatment of mental health and substance abuse disorders for each day for which clinical records substantiate that hospital confinement is medically necessary and medically appropriate.
Transitional mental health treatment
Transitional mental health treatment services include day and evening treatment, intensive outpatient, and partial hospitalization programs. Transitional treatment is medically necessary, medically appropriate, and cost-effective only if the required intensity and frequency of treatment cannot be safely and effectively provided through outpatient treatment. To qualify for reimbursement, the transitional treatment program must be certified by the State of Wisconsin. Call us to find out if your provider meets these requirements.
Note: The Trust will provide reimbursement only up to the amount mandated by Wisconsin law for inpatient and transitional treatment at a facility that does not meet the policy's definition of a Hospital but has been certified by the State of Wisconsin for treating mental health and substance abuse disorders (e.g., private, state, and county mental health facilities). After we have paid the mandated amount for all inpatient and transitional care during a Benefit Period, we will provide reimbursement for additional inpatient and transitional treatment only if it is received at a general medical and surgical Hospital as defined in Section 2 of your policy. There is one exception: This limit does not apply to a facility that is a Network provider.
Outpatient mental health treatment
Your policy covers outpatient mental health treatment if the clinical records substantiate that the visit was both medically necessary and medically appropriate. The treatment must be received from one of the following qualified mental health professionals:
- A state-licensed psychiatrist. This is a state-licensed physician specializing in psychiatry.
- A state-licensed psychologist.
- A provider who is a member of our Mental Health Network.
You may also obtain services from the providers listed below if they provide services in an outpatient clinic certified by the State of Wisconsin.
- Licensed Independent Clinical Social Worker (LICSW) or Licensed Independent Social Worker (LISW).
- Licensed Professional Counselor (LPC).
- Registered nurse with a master’s degree and certified as a specialist in psychiatric and mental health nursing.
- Certified Alcohol and Drug Counselors.
Services received in states outside of Wisconsin are covered only if that state has similar certification requirements and the provider, facility, and program meet those requirements.
Services not covered
Examples of mental health and substance abuse services that are never covered by your policy include the following:
- Custodial lor long term care. By this, we mean services which are primarily to maintain the patient’s existing physical or mental condition of health or to preserve it from further decline, to assist the patient in the activities of daily living, or to meet the patient’s personal needs.
- Services for the treatment of a behavioral or psychological problem which isn’t traced to a clinically diagnosed illness. For example, codependency, antisocial behavior, occupational problems, academic problems, marital problems, normal bereavement, parent-child problems, and other interpersonal problems.
- Mental health services associated with developmental delays (e.g., Autistic Disorder, Rett’s Disorder, and Asperger’s Disorder).
- Services associated with smoking cessation, weight loss, or compulsive gambling.
- Services to educate or help adapt to a diagnosis or a chronic physical or mental condition.
- Residential mental health and eating disorder programs.
- Group homes and halfway houses for supportive and maintenance care for mental health and substance abuse illnesses.
|
|