Common use of Mental Health and Substance Abuse Treatment Clause in Contracts

Mental Health and Substance Abuse Treatment. Network (a) Inpatient Mental Health Treatment (general acute or psychiatric hospital or clinic including inpatient and partial hospitalization, intensive outpatient and day treatment programs and 23 hour extended and 72 hour crisis beds) 1. Medically necessary inpatient mental health care is covered in full subject to a $200 copayment per person per admission. A new $200 copayment is required if the admission occurs more than 90 days after the previous admission. All elective admissions must be pre-certified. If pre-certification of an elective admission does not occur, the Plan payment equals 50 percent of the network allowance less the $200 copayment. (b) Inpatient Mental Health Treatment (residential treatment center, group home or halfway house) 1. Medically necessary inpatient mental health care in an approved facility is covered for up to 30 days per person per year. The Plan pays up to 80 percent of the network allowance less a $200 copayment. A new $200 copayment is required if the admission occurs more than 90 days after the previous admission. All elective admissions must be pre-certified. If pre-certification of an elective admission does not occur, the Plan pays up to 50 percent of the network allowance less the $200 copayment. (c) Outpatient Mental Health Treatment 1. Medically necessary outpatient mental health treatment is covered up to 15 visits per person per calendar year from a network practitioner subject to a $10 copayment per visit. Beginning with the sixteenth visit, the Plan pays up to 80 percent of the reasonable and customary allowance after the combined annual $100 per person deductible has been met. 2. Medically necessary treatment in a hospital emergency room is covered subject to a $25 copayment (waived if admitted as an inpatient directly from the emergency room).