Mental health and substance abuse benefits
Your Trust health plan provides benefits for inpatient, transitional, and outpatient treatment of nervous and mental disorders and substance abuse. Refer to your Uniform Benefits 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 qualified, 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.
Qualified providers of outpatient treatment
A qualified outpatient mental health provider is a provider who is a member of our Network or a state-licensed:
- Psychiatrist. This is a state-licensed Physician with a specialty in psychiatry.
- Psychologist.
- Independent Clinical Social Worker (LICSW).
- Independent Social Worker (LISW).
- Professional Counselor (LPC).
Unless the provider is a member of our Network, services by these providers are covered only if the outpatient clinic in which the services are provided has been certified by the State of Wisconsin:
- Registered nurse with a master's degree and certified as a specialist in psychiatric and mental health nursing.
- Certified Substance Abuse Counselor (CSAC).
Services received in states outside of Wisconsin are covered only if the provider is licensed or certified by the state in which covered services are received and the services received are within the scope of the provider's license or certification. We do not reimburse for these services until you prove to our satisfaction that your out-of-state provider meets these requirements.
Services not covered
Examples of mental health and substance abuse services that are never covered by your policy include the following:
- Custodial or 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 for, or in connection with, developmental delays (e.g., Rett'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.
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