|
Mental Health, Serious Mental Illness
and
Substance Abuse Benefits
How
to Access Mental Health, Serious Mental Illness and Substance
Abuse Benefits
Your Child’s Mental Health
and Serious Mental Illness Benefits—What is Covered
Your Child’s Substance
Abuse Benefits—What is Covered
Mental Health, Serious
Mental Illness and Substance Abuse Exclusions—What is Not
Covered
Complaints and Grievances
Your child is eligible for mental health, serious mental illness and substance abuse benefits under CHIP. Benefits are provided in a managed care setting and offered through an arrangement with Magellan Behavioral Health Services, Inc.
All services must be coordinated and authorized through Magellan. Unauthorized services are not covered. If your child receives mental health, serious mental illness or substance abuse services without an authorization or outside of the Magellan Behavioral Health Network, you will be responsible for paying the entire bill.
How to Access Mental Health, Serious Mental Illness and Substance Abuse Benefits
 |
|
|
|
All mental health, serious mental illness and substance abuse services are accessed
through Magellan’s help line:
1-800-294-0800
TTY Service for hearing and speech impaired: 1-800-409-8640 |
|
|
|
|
|
Call this number when you need help or information on any of the following:
- Referral to a Magellan Behavioral Health Network provider
- Preapproval of mental health, serious mental illness or substance abuse care
- Emergency assistance 24 hours a day, every day of the year
- General information about Magellan and your child’s mental health, serious mental illness and substance abuse benefits
Your Child’s Mental Health and Serious Mental Illness Benefits—What is Covered
Outpatient Services—Mental Health Care (Other Than Serious Mental Illness)
Your child is eligible for up to 50 mental health outpatient visits per calendar year. The following mental health benefits are provided in an outpatient setting:
- Psychiatric visits
- Psychiatric consultations
- Individual counseling
- Group counseling
|
|
- Family counseling
- Medication management
- Electroconvulsive therapy
|
Outpatient Services—Serious Mental Illness
The following biologically based mental illnesses are defined as serious mental illnesses by the American Psychiatric Association in the most recent edition of the Diagnostic and Statistical Manual:
|
A. |
|
Schizophrenia |
|
B. |
|
Bipolar disorder |
|
C. |
|
Obsessive-compulsive disorder |
|
D. |
|
Major depressive disorder |
|
E. |
|
Panic disorder |
|
F. |
|
Anorexia nervosa |
|
G. |
|
Bulimia nervosa |
|
H. |
|
Schizo affective disorder |
|
I. |
|
Delusional disorder |
|
J. |
|
Any other mental illness that is considered to be “Serious Mental Illness” by law |
Benefits are provided for treatment of these conditions when determined to be medically necessary. Covered services may be provided in an outpatient or inpatient mental health care facility or through a partial hospitalization program.
Your child is eligible for up to 60 serious mental illness outpatient visits per calendar year.
The following serious mental illness benefits are provided in an outpatient setting:
- Psychiatric visits
- Psychiatric consultants
- Individual counseling
- Group counseling
|
|
- Family counseling
- Medication management
- Electroconvulsive therapy
|
Emergency Care—Mental Health and Serious Mental Illness
If your child is in a crisis or emergency situation, call the toll-free hotline number, 1-800-294-0800. A Magellan professional will help you assess the seriousness of the situation. If it is an emergency, Magellan will assist you in getting the treatment needed as quickly as possible.
A psychiatric emergency is the sudden onset of a potentially life-threatening condition where you believe, with a prudent layperson’s judgement, that your child is at risk of injury to himself/herself or others if immediate medical attention is not given.
The initial treatment for psychiatric emergencies is covered even when provided by non-participating mental health providers or hospitals if the symptoms are severe enough to need immediate attention.
If the condition is not a life-threatening one that requires inpatient admission, Magellan will schedule your child for an urgent care appointment.
When there is need for immediate medical treatment, you
need to first seek appropriate medical care. To do this,
follow the steps for Emergency Services. More
information available.
Inpatient Services—Mental Health Care (Other Than Serious Mental Illness)
Your child is eligible for a maximum of 90 mental health inpatient days per calendar year. The 90 day maximum is a combination of both medical/surgical and mental health services.
During a mental health admission your child will be eligible for:
- Psychiatric visits
- Psychiatric consultations
- Individual counseling
- Group counseling
|
|
- Electroconvulsive therapy
- Psychological testing
- Medication management
- Concurrent care
|
Inpatient Services—Serious Mental Illness
Your child is eligible for a maximum of 30 serious mental illness inpatient days per calendar year. If needed, you can exchange one inpatient day for two outpatient visits.
During a serious mental illness admission your child will be eligible for:
- Psychiatric visits
- Psychiatric consultations
- Individual counseling
- Group counseling
|
|
- Electroconvulsive therapy
- Psychological testing
- Medication management
- Concurrent care
|
Partial Hospitalization—Mental Health and Serious Mental Illness
Partial hospitalization is care which is more intensive than outpatient care, but does not require an inpatient hospital stay. It is a day or evening treatment program which is:
- a minimum of three visits per week; and
- a maximum of five visits per week lasting three hours each.
Partial hospitalization includes medical, nursing, counseling or therapeutic services. These services are provided on a planned and regularly scheduled basis in a network mental health facility or hospital.
All partial hospitalization services must be preapproved by Magellan and are covered in place of an inpatient hospital stay. For every two partial hospitalization days your child uses, the available inpatient days are reduced by one.
Your Child’s Substance Abuse Benefits—What is Covered
Outpatient Services—Substance Abuse
Your child is eligible for up to 30 substance abuse outpatient visits per calendar year. There is a lifetime limit of 120 visits. If needed, you can exchange one inpatient day for two outpatient visits for your child.
The following substance abuse benefits are provided in an outpatient setting:
- Substance abuse evaluations
- Individual counseling
- Group counseling
- Family counseling
- Medication management
- Detoxification
 |
|
Your child is eligible for seven visits of outpatient detoxification per episode with a limit of four episodes per lifetime. |
Intensive Outpatient Program (IOP)—Substance Abuse
Intensive Outpatient Program (IOP) is care that is more intensive than outpatient care, but does not require an inpatient stay. IOP is a day or evening treatment program that lasts a minimum of two hours per session, with your child attending three to five sessions weekly.
Intensive Outpatient Program includes counseling or therapeutic services. These services are provided on a planned and regularly scheduled basis in a network substance abuse health facility or network outpatient provider group.
All IOP services must be preapproved by Magellan. One IOP session equals one outpatient session.
Inpatient Services—Substance Abuse
Your child is eligible for a maximum of 30 substance abuse inpatient days per calendar year. There is also a lifetime limit of 90 substance abuse inpatient days.
During a substance abuse admission your child will be eligible for:
- Individual counseling
- Group counseling
- Family counseling
- Medication management
- Detoxification
|
|
Your child is eligible for seven days of detoxification per admission with a limit of four admissions per lifetime. |
Mental Health, Serious Mental Illness and Substance Abuse Exclusions—What is Not Covered
- Chronic Care - services for the seriously mentally ill as defined by the Department of Public Welfare
- Court ordered care
- Educational activities
- EPSDT wraparound services and intensive case management services as defined by the Department of Public Welfare
- Evaluation or testing (and completion of forms) for:
adoption
attention deficit disorder
child custody
insurance
legal
neuropsychological
school
travel
- Mental retardation services
- Psychological testing, except brief testing to establish a diagnosis
- Long term care services provided in extended care facilities and state mental health facilities
- Psychiatric consults during a medical admission, unless authorized by Magellan
- Emergency room services or services provided by a non-participating provider unless deemed a psychiatric emergency or preapproved by Magellan
- Acupuncture, biofeedback, hypnosis, pastoral counseling, psychoanalysis
- Treatment of autism, sleep disorders or neuropsychiatric disorders
- Weight reduction or weight control services
- Services which are not medically necessary
- Treatment programs, medicines or drugs for obesity
- Methadone maintenance
Complaints and Grievances
If you have a concern about your child’s mental health,
serious mental illness or substance abuse services call
the Caring Foundation at 1-800-464-5437. If a Caring Foundation
representative is not able to resolve your problem, you
may file a formal complaint or grievance with Keystone.
See “You Can File a Complaint or Grievance For Your Child”.
More information available.
|