NEW JERSEY

SMALL EMPLOYER HEALTH BENEFITS PROGRAM

20 West State Street, 10th Floor

PO Box 325

Trenton, NJ 08625

Phone: 609-633-1882, ext. 50302

Fax: 609-633-2030

E-Mail: ellen.derosa@dobi.state.nj.us

ADVISORY BULLETIN

99-SEH-06

October 6, 1999

To: SEH Program Member Carriers

From: Ellen F. DeRosa, Deputy Executive Director

Re: Adoption of Changes to Standard Small Employer Health Benefits Plans

Text to Include on Compliance and Variability Rider

The Small Employer Health Benefits Program Board (SEH Board) has adopted changes to Appendix Exhibits A, F, G, H, V, W, Y, Z, HH, and II. The proposal noted that carriers would have the option to use the Compliance and Variability Rider, N.J.A.C. 11:21 Appendix Exhibit DD, to implement the forms changes. This Bulletin specifies the text that all carriers that elect to use the Compliance and Variability Rider to implement changes must include on such Rider. Carriers may elect to re-issue the standard plans rather than use the Rider option.

The forms changes that were proposed and adopted included some re-phrasing of existing text. The SEH Board believes that including such text on a rider might be confusing to consumers. The rider, therefore, includes only those changes that would have an impact on the coverage provided under the standard plans.

The adoption specifies a November 1, 1999 Operative Date. Please be guided accordingly with respect to new business and renewals business.

The SEH Board will begin a thorough review of the standard plans and expects to propose changes to the standard plans in 2000. If you would like to provide input with respect to the SEH Board’s consideration of policy language, feel free to send comments and suggestions to me before the end of October 1999.

If you would like the text of this Bulletin along with the text for the Compliance and Variability Rider provided to you via e-mail, please send me an e-mail request. In addition, if you would like to receive the text of all of the forms that were amended in this recent adoption, please send me an e-mail request. My e-mail address is at the top of the Bulletin. Our system uses WORD 97. If you are using an earlier version of WORD or are using another software program, I can send the attachment in Rich Text Format. Please indicate in any e-mail request whether you can open a WORD 97 document or if you need it converted to Rich Text Format. If you do not use e-mail and would like to receive the text of the Bulletin on disk, please fax a request to me at the fax number given at the top of this Bulletin. As with e-mail files, you must indicate whether the text on the disk sold use WORD 97 or Rich Text Format.

If you have any questions, feel free to contact me.

Text for Compliance and Variability Rider to amend Standard Plans B – E

SECTION: DEFINITIONS

The definitions of Alcohol Abuse and Substance Abuse are deleted and replaced with the following:

Alcohol Abuse means abuse of or addiction to alcohol. Alcohol Abuse does not include abuse of or addiction to a substance. Please see the definition of Substance Abuse.

Substance Abuse means abuse of or addiction to drugs. Substance Abuse does not include abuse of or addiction to alcohol. Please see the definition of Alcohol Abuse.

The definition of Mental or Nervous Condition is deleted in its entirety. All references to Mental or Nervous Conditions are replaced with the term, Non-Biologically-based Mental Illness, as defined in this Rider.

The definitions of Biologically-based Mental Illness and Non-Biologically-based Mental Illness are added to the Definitions section of the Policy and Certificate.

Biologically-based Mental Illness means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.

Non-Biologically-based Mental Illness means an Illness which manifiests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, [Carrier] may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.

SECTION: COVERED CHARGES

NEW SUBSECTION: TREATMENT OF BIOLOGICALLY BASED MENTAL ILLNESS

The Covered Charges section is amended to include the following benefit, immediately following the Alcohol Abuse benefit.

Treatment for Biologically-based Mental Illness

[Carrier] pays benefits for the Covered Charges a Covered Person incurs for the treatment of Biologically-based Mental Illness the same way [Carrier] would for any other Illness, if such treatment is prescribed by a Practitioner. [Carrier] does not pay for Custodial Care, education, or training.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS

SUBSECTION: DENTAL CARE AND TREATMENT

The Dental Care and Treatment subsection is amended to include the following:

For a Covered Person who is severely disabled or who is a Child under age 6, [Carrier] covers:

  1. general anesthesia and Hospitalization for dental services; and
  2. dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by the Policy which requires Hospitalization or general anesthesia.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS

SUBSECTION: PROSTHETIC DEVICES

The last sentence of the Prosthetic Devices subsection is amended to state:

[Carrier] does not pay for repairs, or wigs. [Carrier] does not cover dental prosthetics or devices other than as a replacement for natural teeth lost due to Injury, as stated in the Dental Care and Treatment provision of the Policy.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS

SUBSECTION: MENTAL OR NERVOUS CONDITIONS AND SUBSTANCE ABUSE

The Mental or Nervous Conditions and Substance Abuse subsection is deleted and replaced with the following:

Non-Biologically-based Mental Illnesses and Substance Abuse

[Carrier] limits what [Carrier] pays for the treatment of Non-Biologically-based Mental Illnesses and Substance Abuse as those terms are defined in this Policy.

A Covered Person may receive treatment as an Inpatient in a Hospital or a Substance Abuse Center. He or she may also receive treatment as an Outpatient from a Hospital, Substance Abuse Center, or any properly licensed or certified Practitioner, psychologist or social worker.

The Covered Person must pay the Coinsurance shown on the Schedule for Covered Charges for such treatment. [Carrier] limits coverage for all treatment of Non-Biologically-based Mental Illnesses and Substance Abuse per Calendar Year to:

  1. thirty (30) days of Inpatient confinement; and
  2. twenty (20) Outpatient visits.

One or more of any unused Inpatient days may be exchanged for additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits.

[Carrier] does not pay for Custodial Care, education, or training.

["DC" NOTE: ANY NON-BIOLOGICALLY-BASED MENTAL ILLNESSES AND SUBSTANCE ABUSE SERVICES AND SUPPLIES A COVERED PERSON RECEIVES UNDER THE ASSOCIATED HMO PLAN WILL REDUCE THE NON-BIOLOGICALLY-BASED MENTAL ILLNESSES AND SUBSTANCE ABUSE BENEFITS AVAILABLE UNDER THIS INDEMNITY PLAN.]

 

Text for Compliance and Variability Rider to amend Standard Plan A

SECTION: DEFINITIONS

The definitions of Alcohol Abuse and Substance Abuse are deleted and replaced with the following:

Alcohol Abuse means abuse of or addiction to alcohol. Alcohol Abuse does not include abuse of or addiction to a substance. Please see the definition of Substance Abuse.

Substance Abuse means abuse of or addiction to drugs. Substance Abuse does not include abuse of or addiction to alcohol. Please see the definition of Alcohol Abuse.

The definition of Mental or Nervous Condition is deleted in its entirety. All references to Mental or Nervous Conditions are replaced with the term, Non-Biologically-based Mental Illness, as defined in this Rider.

The definitions of Biologically-based Mental Illness and Non-Biologically-based Mental Illness are added to the Definitions section of the Policy and Certificate.

Biologically-based Mental Illness means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.

Non-Biologically-based Mental Illness means an Illness which manifiests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, [Carrier] may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.

SECTION: COVERED CHARGES

NEW SUBSECTION: TREATMENT OF BIOLOGICALLY BASED MENTAL ILLNESS

The Covered Charges section is amended to include the following benefit, immediately following the Alcohol Abuse benefit.

Treatment for Biologically-based Mental Illness

[Carrier] pays benefits for the Covered Charges a Covered Person incurs for the treatment of Biologically-based Mental Illness the same way [Carrier] would for any other Illness, if such treatment is prescribed by a Practitioner. [Carrier] does not pay for Custodial Care, education, or training.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS

NEW SUBSECTION: DENTAL CARE

The following Dental Care subsection is added immediately following the Immunizations and Lead Screening subsection.

Dental Care

For a Covered Person who is severely disabled or who is a Child under age 6, [Carrier] covers:

  1. general anesthesia and Hospitalization for dental services; and
  2. dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by the Policy which requires Hospitalization or general anesthesia.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS

SUBSECTION: PROSTHETIC DEVICES

The last sentence of the Prosthetic Devices subsection is amended to state:

[Carrier] does not pay for repairs, or wigs. [Carrier] does not cover dental prosthetics or devices other than as a replacement for natural teeth lost due to Injury, as stated in the Dental Care and Treatment provision of the Policy.

Text for Compliance and Variability Rider to amend Standard Plan HMO

SECTION: DEFINITIONS

The definitions of Alcohol Abuse and Substance Abuse are deleted and replaced with the following:

ALCOHOL ABUSE. Abuse of or addiction to alcohol. Alcohol Abuse does not include abuse of or addiction to a substance. Please see the definition of Substance Abuse.

SUBSTANCE ABUSE. Abuse of or addiction to drugs. Substance Abuse does not include abuse of or addiction to alcohol. Please see the definition of Alcohol Abuse.

The definition of Mental or Nervous Condition is deleted in its entirety. All references to Mental or Nervous Conditions are replaced with the term, Non-Biologically-based Mental Illness, as defined in this Rider.

The definitions of Biologically-based Mental Illness and Non-Biologically-based Mental Illness are added to the Definitions section of the Policy and Certificate.

BIOLOGICALLY BASED MENTAL ILLNESS. A mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.

NON-BIOLOGICALLY-BASED MENTAL ILLNESS. An Illness which manifiests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, We may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.

[SECTION: MEMBER PROVISIONS

SUBSECTION: THE ROLE OF THE CARE MANAGER

The Role of the Care Manager subsection is deleted and replaced with the following:

The Care Manager will manage a [Member's] treatment for [a Biologically-based Mental Illness, a Non-Biologically-based Mental Illness, Substance Abuse, or Alcohol Abuse]. A [Member] must contact the Care Manager or the [Member's] Primary Care Physician when a [Member] needs treatment for one of these conditions.]]

SECTION: COVERED SERVICES AND SUPPLIES

SUBSECTION: (a) OUTPATIENT SERVICES

The last sentence of item (8), Prosthetic Devices is deleted and replaced with the following:

We do not provide for replacements (unless Medically Necessary and Appropriate), repairs, or wigs. We do not cover dental prosthetics or devices other than as a replacement for natural teeth lost due to Injury, as stated in the Dental Care and Treatment provision of this Contract.

SECTION: COVERED SERVICES AND SUPPLIES

SUBSECTION: (d) BENEFITS FOR SUBSTANCE ABUSE AND MENTAL OR NERVOUS CONDITIONS

The Benefits for Substance Abuse and Mental or Nervous Conditions subsection is deleted and replaced with the following:

(d) BENEFITS FOR SUBSTANCE ABUSE AND NON-BIOLOGICALLY-BASED MENTAL ILLNESSES. The following Services are covered when rendered by a Participating Provider at Provider's office or at a Participating Substance Abuse Center [or Health Center] upon prior written referral by a [Member]'s Primary Care Physician [or the Care Manager]. This section does not address coverage for a Biologically-based Mental Illness.

1. Outpatient. [Members] are entitled to receive up to twenty (20) outpatient visits per Calendar Year. Benefits include diagnosis, medical, psychiatric and psychological treatment and medical referral services by a [Member]'s Primary Care Physician [or the Care Manager] for the abuse of or addiction to drugs and Non-Biologically-based Mental Illnesses. Payment for non-medical ancillary services (such as vocational rehabilitation or employment counseling) is not provided, but information regarding appropriate agencies will be provided if available. [Members] are additionally eligible, upon referral by a [Member]'s Primary Care Physician [or the Care Manager], for up to sixty (60) more outpatient visits by exchanging one or more of the inpatient hospital days described in paragraph 2 below where each exchanged inpatient day provides two outpatient visits.

2. Inpatient Hospital Care. [Members] are entitled to receive up to thirty (30) days of inpatient care benefits for detoxification, medical treatment for medical conditions resulting from the substance abuse, referral services for substance abuse or addiction, and Non-Biologically-based Mental Illnesses. The following services shall be covered under inpatient treatment: (1) lodging and dietary services; (2) physician, psychologist, nurse, certified addictions counselor and trained staff services; (3) diagnostic x-ray; (4) psychiatric, psychological and medical laboratory testing; (5) drugs, medicines, equipment use and supplies.

3. Chemical Dependency Admissions. Repeated detoxification treatment for chronic Substance Abuse will not be covered unless in Our sole Discretion it is Determined that [Members] have been cooperative with an on-going treatment plan developed by a Participating Provider. Failure to comply with treatment shall constitute cause for non-coverage of Substance Abuse services. Court-ordered chemical dependency admissions are not covered unless Medically Necessary and Appropriate and only to the extent of the covered benefit as defined above.

["DC" NOTE: ANY NON-BIOLOGICALLY-BASED MENTAL ILLNESSES AND SUBSTANCE ABUSE BENEFITS A [MEMBER] RECEIVES UNDER THE ASSOCIATED INDEMNITY PLAN WILL REDUCE THE NON-BIOLOGICALLY-BASED MENTAL ILLNESSES AND SUBSTANCE ABUSE SERVICES AND SUPPLIES AVAILABLE UNDER THIS HMO PLAN.]

SECTION: COVERED SERVICES AND SUPPLIES

NEW SUBSECTION: (e) BENEFITS FOR BIOLOGICALLY-BASED MENTAL ILLNESS OR ALCOHOL ABUSE.

The following new subsection (e) is added to the HMO Contract and Evidence of Coverage.

    1. BENEFITS FOR BIOLOGICALLY-BASED MENTAL ILLNESS OR ALCOHOL ABUSE. We cover treatment of a Biologically-based Mental Illness or Alcohol Abuse the same way We would for any other illness, if such treatment is prescribed by a Participating Provider upon prior written referral by a [Member]'s Primary Care Physician [or the Care Manager]. We do not pay for Custodial care, education or training.

SECTION: COVERED SERVICES AND SUPPLIES

SUBSECTION: (i) DENTAL CARE AND TREATMENT

The Dental Care and Treatment subsection is amended to include the following text:

For a [Member] who is severely disabled or who is a Child under age 6, We cover:

    1. general anesthesia and Hospitalization for dental services; and
    2. dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by this Contract which requires Hospitalization or general anesthesia.

 

Text for Compliance and Variability Rider to amend Standard Plan HMO-POS

SECTION: DEFINITIONS

The definitions of Alcohol Abuse and Substance Abuse are deleted and replaced with the following:

ALCOHOL ABUSE. Abuse of or addiction to alcohol. Alcohol Abuse does not include abuse of or addiction to a substance. Please see the definition of Substance Abuse.

SUBSTANCE ABUSE. Abuse of or addiction to drugs. Substance Abuse does not include abuse of or addiction to alcohol. Please see the definition of Alcohol Abuse.

The definition of Mental or Nervous Condition is deleted in its entirety. All references to Mental or Nervous Conditions are replaced with the term, Non-Biologically-based Mental Illness, as defined in this Rider.

The definitions of Biologically-based Mental Illness and Non-Biologically-based Mental Illness are added to the Definitions section of the Policy and Certificate.

BIOLOGICALLY BASED MENTAL ILLNESS. A mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.

NON-BIOLOGICALLY-BASED MENTAL ILLNESS. An Illness which manifiests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, We may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.

[SECTION: MEMBER PROVISIONS

SUBSECTION: THE ROLE OF THE CARE MANAGER

The Role of the Care Manager subsection is deleted and replaced with the following:

The Care Manager will manage a [Member's] treatment for [a Biologically-based Mental Illness, a Non-Biologically-based Mental Illness, Substance Abuse, or Alcohol Abuse]. A [Member] must contact the Care Manager or the [Member's] Primary Care Physician when a [Member] needs treatment for one of these conditions.]]

SECTION: COVERED SERVICES AND SUPPLIES APPLICABLE TO [NETWORK] SERVICES AND SUPPLIES

SUBSECTION: (a) OUTPATIENT SERVICES

The last sentence of item (8), Prosthetic Devices is deleted and replaced with the following:

We do not provide for replacements (unless Medically Necessary and Appropriate), repairs, or wigs. We do not cover dental prosthetics or devices other than as a replacement for natural teeth lost due to Injury, as stated in the Dental Care and Treatment provision of this Contract.

SECTION: COVERED SERVICES AND SUPPLIES APPLICABLE TO [NETWORK] SERVICES AND SUPPLIES

SUBSECTION: (d) BENEFITS FOR SUBSTANCE ABUSE AND MENTAL OR NERVOUS CONDITIONS

The Benefits for Substance Abuse and Mental or Nervous Conditions subsection is deleted and replaced with the following:

(d) BENEFITS FOR SUBSTANCE ABUSE AND NON-BIOLOGICALLY-BASED MENTAL ILLNESSES. The following Services are covered when rendered by a [Network] Provider at Provider's office or at a [Network] Substance Abuse Center [or Health Center] [upon prior Referral by a [Member's] Primary Care Physician] [or the Care Manager]. This section does not address coverage for a Biologically-based Mental Illness.

  1. Outpatient. [Members] are entitled to receive up to twenty (20) outpatient visits per Calendar Year. Benefits include diagnosis, medical, psychiatric and psychological treatment and medical referral services by a [Member's] Primary Care Physician [or the Care Manager] for the abuse of or addiction to drugs and Non-Biologically-based Mental Illnesses. Payment for non-medical ancillary services (such as vocational rehabilitation or employment counseling) is not provided, but information regarding appropriate agencies will be provided if available. [Members] are additionally eligible, upon referral by a [Member’s] Primary Care Physician, for up to sixty (60) more outpatient visits by exchanging one or more of the inpatient hospital days described in paragraph 2 below where each exchanged inpatient day provides two outpatient visits.
  1. Inpatient Hospital Care. [Members] are entitled to receive up to thirty (30) days of inpatient care benefits for detoxification, medical treatment for medical conditions resulting from the substance abuse, referral services for substance abuse or addiction, and Non-Biologically-based Mental Illnesses. The following services shall be covered under inpatient treatment: (1) lodging and dietary services; (2) physician, psychologist, nurse, certified addictions counselor and trained staff services; (3) diagnostic x-ray; (4) psychiatric, psychological and medical laboratory testing; (5) drugs, medicines, equipment use and supplies.
  2. Chemical Dependency Admissions. Repeated detoxification treatment for chronic Substance Abuse will not be covered unless in Our sole Discretion it is Determined that [Members] have been cooperative with an on-going treatment plan. Failure to comply with treatment shall constitute cause for non-coverage of Substance Abuse services. Court-ordered chemical dependency admissions are not covered unless Medically Necessary and Appropriate, and only to the extent of the covered benefit as defined above.

NOTE: ANY SUBSTANCE ABUSE AND NON-BIOLOGICALLY-BASED MENTAL ILLNESSES BENEFITS A [MEMBER] RECEIVES AS [NON-NETWORK] BENEFITS WILL REDUCE THE BENEFITS AVAILABLE AS [NETWORK] NON-BIOLOGICALLY-BASED MENTAL ILLNESSES AND SUBSTANCE ABUSE SERVICES AND SUPPLIES.

SECTION: COVERED SERVICES AND SUPPLIES APPLICABLE TO [NETWORK] SERVICES AND SUPPLIES

NEW SUBSECTION: (e) BENEFITS FOR BIOLOGICALLY-BASED MENTAL ILLNESS OR ALCOHOL ABUSE.

The following new subsection (e) is added to the HMO-POS Contract and Evidence of Coverage.

BENEFITS FOR BIOLOGICALLY-BASED MENTAL ILLNESS OR ALCOHOL ABUSE. We cover treatment of a Biologically-based Mental Illness or Alcohol Abuse the same way We would for any other Illness, if such treatment is prescribed by a Participating Provider upon prior written referral by a [Member]'s Primary Care Physician [or the Care Manager]. We do not pay for Custodial care, education or training.

SECTION: COVERED SERVICES AND SUPPLIES APPLICABLE TO [NETWORK] SERVICES AND SUPPLIES

SUBSECTION: (i) DENTAL CARE AND TREATMENT

The Dental Care and Treatment subsection is amended to include the following text:

For a [Member] who is severely disabled or who is a Child under age 6, We cover:

  1. general anesthesia and Hospitalization for dental services; and
  2. dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by this Contract which requires Hospitalization or general anesthesia.

SECTION: COVERED CHARGES APPLICABLE TO [NON-NETWORK] BENEFITS

NEW SUBSECTION: TREATMENT OF BIOLOGICALLY-BASED MENTAL ILLNESS

The following new subsection is added immediately following the Alcohol Abuse subsection.

Treatment for Biologically-based Mental Illness

We pay benefits for the Covered Charges a [Member] incurs for the treatment of Biologically-based Mental Illness the same way We would for any other Illness, if such treatment is prescribed by a Practitioner. We do not pay for Custodial Care, education, or training.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS APPLICABLE TO [NON-NETWORK] BENEFITS

SUBSECTION: DENTAL CARE AND TREATMENT

The Dental Care and Treatment subsection is amended to include the following:

For a [Member] who is severely disabled or who is a Child under age 6, We cover:

  1. general anesthesia and Hospitalization for dental services; and
  2. dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by the Contract which requires Hospitalization or general anesthesia.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS APPLICABLE TO [NON-NETWORK] BENEFITS

SUBSECTION: PROSTHETIC DEVICES

The last sentence of the Prosthetic Devices subsection is amended to state the following:

We do not pay for repairs, or wigs. We do not cover dental prosthetics or devices other than as a replacement for natural teeth lost due to Injury, as stated in the Dental Care and Treatment provision of the Contract.

SECTION: COVERED CHARGES WITH SPECIAL LIMITATIONS APPLICABLE TO [NON-NETWORK] BENEFITS

SUBSECTION: MENTAL OR NERVOUS CONDITIONS AND SUBSTANCE ABUSE

The Mental or Nervous Conditions and Substance Abuse subsection is deleted and replaced with the following:

Non-Biologically-based Mental Illnesses and Substance Abuse

We limit what We pay for the treatment of Non-Biologically-based Mental Illnesses and Substance Abuse as those terms are defined in this Contract.

A Member may receive treatment as an Inpatient in a Hospital or a Substance Abuse Center. He or she may also receive treatment as an Outpatient from a Hospital, Substance Abuse Center, or any properly licensed or certified Practitioner, psychologist or social worker.

The Member must pay the Coinsurance shown on the Schedule for such treatment. We limit coverage for all treatment of Non-Biologically-based Mental Illnesses and Substance Abuse per Calendar Year to:

  1. thirty (30) days of Inpatient confinement; and
  2. twenty (20) Outpatient visits.

One or more of any unused Inpatient days may be exchanged for additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits.

We do not pay for Custodial Care, education, or training.

NOTE: ANY SUBSTANCE ABUSE AND NON-BIOLOGICALLY-BASED MENTAL ILLNESSES SERVICES AND SUPPLIES A [MEMBER] RECEIVES AS [NETWORK] SERVICES AND SUPPLIES WILL REDUCE THE BENEFITS AVAILABLE AS A [NON-NETWORK] COVERED CHARGE.