5.18 TREATMENT FOR MENTAL ILLNESS/SUBSTANCE ABUSE
Any confinement is subject to Precertification. See Section 6.5.1 for the Plan’s
coverage limitations on benefits that require Precertification.
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Benefits are extended for the treatment of Mental Illness, and alcohol, drug, or chemical dependency, on the same basis as for treatment of any other condition, except the following limits apply to the total combined benefits for these conditions:
- Inpatient treatment must be at a Substance Abuse Facility or Hospital.
- For detoxification (treatment of withdrawal from the physiological effects of alcohol or drugs or chemicals) while confined as an inpatient in a Substance Abuse Facility or Hospital, the maximum benefit payable is limited to two confinements of no more than three days per confinement over the entire period(s) a Participant is eligible under the Plan.
- The Plan provides benefits for up to a total of 30 inpatient days (including Medically Necessary services provided in conjunction with inpatient treatment) or 26 outpatient visits per calendar year for any combination of treatment for Mental Illness and substance abuse.
- For outpatient treatment for substance abuse, outpatient psychotherapy, and psychological testing for treatment of Mental Illness benefits are provided for up to a maximum of 26 visits per calendar year for services provided by or under the direction of a psychiatrist, psychologist, physician, licensed clinical social worker, a health professional with a Masters of Social Work Degree, licensed professional counselor, licensed psychological associate or a certified mental health counselor. Covered Expenses are payable at 50%, not subject to the annual deductible. The balance not paid by the Plan will not apply to your annual out-of-pocket limitation nor will benefits be paid at a rate greater than the 50% benefit level even if you reach the annual out-of-pocket maximum.
The Maximum Lifetime Benefit for any combination of inpatient and outpatient treatment for substance abuse is $50,000 per Participant. This $50,000 limit does not apply to treatment for Mental Illness.
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