Common use of Substance Abuse Benefits Clause in Contracts

Substance Abuse Benefits. Substance Abuse Benefits are managed by HMO or an independently contracted organization. HMO or the independently contracted organization makes initial coverage determinations and coordinates referrals. Any behavioral health care referrals will generally be made to Providers affiliated with the contracted organization, unless the Member’s needs for covered services extend beyond the capability of Participating Providers. A Member is covered for the following services as authorized and provided by Participating Behavioral Health Providers. 1. Outpatient care benefits are covered for Detoxification. Benefits include diagnosis, medical treatment and medical referral services (including referral services for appropriate ancillary services) by the Member’s PCP for the abuse of or addiction to alcohol or drugs. Member is entitled to outpatient visits to a Participating Behavioral Health Provider upon Referral by the PCP for diagnostic, medical or therapeutic Substance Abuse Rehabilitation services. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The HMO, or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit the number of outpatient Substance Abuse Rehabilitation visits to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless of the maximum number of visits described in the Schedule of Benefits. This means the Member may not receive the maximum number of visits specified in the Schedule of Benefits, or the number of visits the Member and the treating provider believe to be appropriate, for a single course of treatment or episode. 2. Inpatient care benefits are covered for Detoxification. Benefits include medical treatment and referral services for Substance Abuse or addiction. The following services shall be covered under inpatient treatment: lodging and dietary services; Physicians, psychologist, nurse, certified addictions counselor and trained staff services; diagnostic x-ray; psychiatric, psychological and medical laboratory testing; and drugs, medicines, equipment use and supplies. Member is entitled to medical, nursing, counseling or therapeutic Substance Abuse Rehabilitation services in an inpatient, or non-hospital residential facility, appropriately licensed by the Department of Health, upon referral by the Member’s Participating Behavioral Health Provider for alcohol or drug abuse or dependency. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The HMO, or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit the number of inpatient Substance Abuse Rehabilitation days to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless of the maximum number of days described in the Schedule of Benefits. This means the Member may not receive the maximum number of days specified in the Schedule of Benefits, or the number of days the Member and the treating provider believe to be appropriate, for a single course of treatment or episode.

Substance Abuse Benefits. Substance Abuse Benefits are managed by HMO or an independently contracted organization. HMO or the independently contracted organization makes initial coverage determinations and coordinates referrals. Any behavioral health care referrals will generally be made to Providers affiliated with the contracted organization, unless the Member’s needs for covered services extend beyond the capability of Participating Providers. A Member is covered for the following services as authorized and provided by Participating Behavioral Health Providers.by 1. Outpatient care benefits are covered for DetoxificationDetoxification and Rehabilitation services. Benefits include diagnosis, medical treatment and medical referral services (including referral services for appropriate ancillary services) by the Member’s PCP for the abuse of or addiction to alcohol or drugs. Member is entitled to outpatient visits to a Participating Behavioral Health Provider upon Referral by the PCP for diagnostic, medical or therapeutic Substance Abuse Rehabilitation services. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The HMO, Member shall be covered under the same terms and conditions and which are no less extensive than coverage provided for any other type of health care for physical illness upon diagnosis of drug or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit the number of outpatient Substance Abuse Rehabilitation visits to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless of the maximum number of visits described in the Schedule of Benefits. This means the Member may not receive the maximum number of visits specified in the Schedule of Benefits, or the number of visits the Member and the treating provider believe to be appropriate, for alcohol dependency by a single course of treatment or episodeParticipating Provider. 2. Inpatient care benefits are covered for DetoxificationDetoxification and Rehabilitation services. Benefits include medical treatment and referral services for Substance Abuse or addiction. The following services shall be covered under inpatient treatment: lodging and dietary services; Physicians, psychologist, nurse, certified addictions counselor and trained staff services; diagnostic x-ray; psychiatric, psychological and medical laboratory testing; and drugs, medicines, equipment use and supplies. Member is entitled to medical, nursing, counseling or therapeutic Substance Abuse Rehabilitation services in an inpatient, Hospital or non-hospital residential facility, appropriately licensed by the Department of Health, upon referral by the Member’s Participating Behavioral Health Provider for alcohol or drug abuse or dependency. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. Member shall be covered under the same terms and conditions and which are no less extensive than coverage provided for any other type of health care for physical illness upon diagnosis of drug or alcohol dependency by a Participating Provider. HMO DE PARITY AMEND (09/05) 1 The HMO, or its contractor, will use prior authorizations definitions of Allowable Expense and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit Coordination of Benefits shown in the number of inpatient Substance Abuse Rehabilitation days to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless Definitions section of the maximum number Certificate are hereby deleted. The Coordination of days described Benefits section of the Certificate is deleted in its entirety and is replaced with the Schedule of Benefits. This means the Member may not receive the maximum number of days specified in the Schedule of Benefits, or the number of days the Member and the treating provider believe to be appropriate, for a single course of treatment or episode.following:

Substance Abuse Benefits. The diagnosis and Medically Necessary inpatient and outpatient treatment of a Substance Abuse Benefits are managed by HMO or an independently contracted organization. HMO or covered under the independently contracted organization makes initial coverage determinations same terms and coordinates referrals. Any behavioral health care referrals will generally be made to Providers affiliated with the contracted organization, unless the Member’s needs for covered services extend beyond the capability of Participating Providersconditions as any other medical condition. A Member is covered for the following services as authorized and provided by Participating Behavioral Health Providers. 1. : • Outpatient care benefits are covered for Detoxification. Benefits include diagnosis, medical treatment and medical referral services (including referral services for appropriate ancillary services) by the Member’s PCP for the abuse of or addiction to alcohol or drugs. Member is entitled to outpatient visits to a Participating Behavioral Health Provider upon Referral by the PCP for diagnostic, medical or therapeutic Substance Abuse Rehabilitation services. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The HMO, or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit the number of outpatient Substance Abuse Rehabilitation visits to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless of the maximum number of visits described in the Schedule of Benefits. This means the Member may not receive the maximum number of visits specified in the Schedule of Benefits, or the number of visits the Member and the treating provider believe to be appropriate, for a single course of treatment or episode. 2. • Inpatient care benefits are covered for Detoxification. Benefits include medical treatment and referral services for Substance Abuse or addiction. The following services shall be covered under inpatient treatment: lodging and dietary services; Physicians, psychologist, nurse, certified addictions counselor and trained staff services; diagnostic x-ray; psychiatric, psychological and medical laboratory testing; and drugs, medicines, equipment use and supplies. Member is entitled to medical, nursing, counseling or therapeutic Substance Abuse Rehabilitation services in an inpatient, Hospital or non-hospital residential facilityResidential Treatment Facility, appropriately licensed by the Department of Health, upon referral by the Member’s Participating Behavioral Health Provider for alcohol or drug abuse or dependency. The Residential Treatment Facility must also meet any and all applicable licensing standards established by the jurisdiction in which it is located. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The HMO, or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit the number of inpatient Substance Abuse Rehabilitation days to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless of the maximum number of days described in the Schedule of Benefits. This means the Member may not receive the maximum number of days specified in the Schedule of Benefits, or the number of days the Member and the treating provider believe to be appropriate, for a single course of treatment or episode.

Substance Abuse Benefits. Substance Abuse Benefits are managed by HMO or an independently contracted organization. HMO or the independently contracted organization makes initial coverage determinations and coordinates referrals. Any behavioral health care referrals will generally be made to Providers affiliated with the contracted organization, unless the Member’s needs for covered services extend beyond the capability of Participating Providers. A Member is covered for the following services as authorized and provided by Participating Behavioral Health Providers. 1. Outpatient care benefits are covered for Detoxification. Benefits include diagnosis, medical treatment and medical referral services (including referral services for appropriate ancillary services) by the Member’s PCP for the abuse of or addiction to alcohol or drugs. Member is entitled to outpatient visits to a Participating Behavioral Health Provider upon Referral by the PCP for diagnostic, medical or therapeutic Substance Abuse Rehabilitation services. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The Group outpatient care visits may be substituted on a two-for-one basis for individual outpatient care visits as deemed appropriate by the Member’s PCP. Outpatient benefit exchanges are a Covered Benefit. When authorized by HMO’s Medical Director or Designee, services in a day Hospital, residential Hospital or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Prenon-Authorizations) to limit hospital or intensive outpatient services may be may be exchanged on a two-for-one basis for inpatient Rehabilitation. Requests for a benefit exchange must be initiated by the number of Member’s Participating Behavioral Health Provider under the guidelines set forth by the HMO’s Medical Director or Designee. Member must utilize all outpatient Substance Abuse Rehabilitation benefits available under the Certificate and pay all applicable Deductibles and Copayments before an inpatient and outpatient visit exchange will be considered. The Member’s Participating Behavioral Health Provider must demonstrate Medical Necessity for extended visits and be able to support the minimum it deems need for hospitalization if additional visits were not offered. Request for exchange must be approved in writing by HMO’s Medical Director or Designee prior to be Covered Benefits that are Medically Necessary services regardless of the maximum number of visits described in the Schedule of Benefits. This means the Member may not receive the maximum number of visits specified in the Schedule of Benefits, or the number of visits the Member and the treating provider believe to be appropriate, for a single course of treatment or episodeutilization. 2. Inpatient care benefits are covered for Detoxification. Benefits include medical treatment and referral services for Substance Abuse or addiction. The following services shall be covered under inpatient treatment: lodging and dietary services; Physicians, psychologist, nurse, certified addictions counselor and trained staff services; diagnostic x-ray; psychiatric, psychological and medical laboratory testing; and drugs, medicines, equipment use and supplies. Member is entitled to medical, nursing, counseling or therapeutic Substance Abuse Rehabilitation services in an inpatient, Hospital or non-hospital residential facility, appropriately licensed by the Department of Health, upon referral by the Member’s Participating Behavioral Health Provider for alcohol or drug abuse or dependency. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. The HMO, or its contractor, will use prior authorizations and ongoing reviews (see HMO Procedure Sections; Ongoing Reviews, and Referrals and Pre-Authorizations) to limit the number of inpatient Substance Abuse Rehabilitation days to the minimum it deems to be Covered Benefits that are Medically Necessary services regardless of the maximum number of days described in the Schedule of Benefits. This means the Member may not receive the maximum number of days specified in the Schedule of Benefits, or the number of days the Member and the treating provider believe to be appropriate, for a single course of treatment or episode.