Common use of CONTRACTOR Behavioral Health Benefits Chart Clause in Contracts

CONTRACTOR Behavioral Health Benefits Chart. SERVICE BENEFIT LIMIT Psychiatric Inpatient Hospital Services (including physician services) As medically necessary. 24-hour Psychiatric Residential Treatment Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary. Outpatient Mental Health Services (including physician services) As medically necessary. Inpatient, Residential & Outpatient Substance Abuse Benefits1 Medicaid/Standard Eligible, Age 21 and older: Covered as medically necessary. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary. Behavioral Health Intensive Community Based Treatment As medically necessary. Psychiatric- Rehabilitation Services As medically necessary. Behavioral Health Crisis Services As necessary. Lab and X-ray Services As medically necessary. Non-emergency Medical Transportation (including Non- Emergency Ambulance Transportation) Same as for physical health (see Section A.2.6.1.3 above). 1When medically appropriate, services in a licensed substance abuse residential treatment facility may be substituted for inpatient substance abuse services. Methadone clinic services are not covered for adults.

CONTRACTOR Behavioral Health Benefits Chart. SERVICE BENEFIT LIMIT Psychiatric Inpatient Hospital Services (including physician services) As medically necessary. 24-hour Psychiatric Residential Treatment Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary. Outpatient Mental Health Services (including physician services) As medically necessary. Inpatient, Residential & Outpatient Substance Abuse Benefits1 Medicaid/Standard Eligible, Age 21 and older: Covered as medically necessary. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary. Behavioral Health Intensive Community Based Treatment As medically necessary. Psychiatric- Rehabilitation Services As medically necessary. Behavioral Health Crisis Services As necessary. Lab and X-ray Services As medically necessary. SERVICE BENEFIT LIMIT Non-emergency Medical Transportation (including Non- Emergency Ambulance Transportation) Same as for physical health (see Section A.2.6.1.3 above). 1When medically appropriate, services in a licensed substance abuse residential treatment facility may be substituted for inpatient substance abuse services. Methadone clinic services are not covered for adults.

CONTRACTOR Behavioral Health Benefits Chart. SERVICE BENEFIT LIMIT Psychiatric Inpatient Hospital Services (including physician services) As medically necessary. 24-hour Psychiatric Residential Treatment Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary. Outpatient Mental Health Services (including physician services) As medically necessary. Inpatient, Residential & Outpatient Substance Abuse Benefits1 Medicaid/Standard Eligible, Age 21 and older: Covered as medically necessary. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary. Behavioral Mental Health Intensive Community Based Treatment Case Management As medically necessary. Psychiatric- Rehabilitation Services As medically necessary. Behavioral Health Crisis Services As necessary. Lab and X-ray Services As medically necessary. Non-emergency Medical Transportation (including Non- Emergency Ambulance Transportation) Same as for physical health (see Section A.2.6.1.3 above). 1When medically appropriate, services in a licensed substance abuse residential treatment facility may be substituted for inpatient substance abuse services. Methadone clinic services are not covered for adults.