Blue Choice HMO Benefits - Harford County Public Schools

SECTION 7
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
WHERE
In Contracting Physician’s
offices or other CareFirst
BlueChoice approved
facilities, or
In a CareFirst BlueChoice
approved Hospital or
Qualified Substance Abuse
Treatment Facility when
admitted under the care of a
Contracting Physician.
CAREFIRST BLUECHOICE
PROVIDES
Coverage for the services listed below.
Coverage for the services listed below.
MEMBER PAYS
Deductible, Copayments or
Coinsurance, if any,
required under the
Member's coverage as
stated in the Schedule of
Benefits.
Deductible, Copayments or
Coinsurance, if any,
required under the
Member's coverage as
stated in the Schedule of
Benefits.
HOSPITALIZATION MUST BE AUTHORIZED OR
APPROVED BY THE MENTAL HEALTH AND SUBSTANCE ABUSE MANAGEMENT
PROGRAM
7.1 Definitions.
A. The Mental Health Management and Substance Abuse Program refers to utilization
management, benefits administration and provider network activities administered by or on
behalf of CareFirst BlueChoice to ensure that mental health and substance abuse services
are Medically Necessary and provided in a cost-effective manner.
B. Qualified Substance Abuse Treatment Facility means a non-residential facility or distinct
part of a facility which is licensed in the jurisdiction(s) in which it operates and/or
accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
as a substance abuse and alcohol treatment facility that operates a program for the treatment
and rehabilitation of alcohol and substance abuse.
C. Partial Hospitalization means the provision of medically directed intensive or
intermediate short-term treatment for mental illness, emotional disorders, drug abuse or
alcohol abuse for a period of less than 24 hours but more than 4 hours in a day for a
Member or Subscriber in a licensed or certified facility or program.
D. Substance Abuse means a disease that is characterized by a pattern of pathological use
of alcohol and or a drug and repeated attempts to control its use, and which has caused
significant harmful effects in at least one of the following aspects of the Member’s daily
life: medical, legal, financial or psycho-social.
7.2 Outpatient Mental Health and Substance Abuse Services. Outpatient services must be
obtained from Contracting Providers upon referral from the Mental Health and Substance Abuse
Management Program.
A. Coverage of mental illness, emotional disorders, and alcohol abuse and drug abuse
services includes evaluation, diagnosis and treatment of acute and non-acute conditions.
B. Medication management visits in connection with mental illness, emotional disorders,
alcohol abuse or drug abuse will be covered in the same manner as medication
management visits for physical illnesses and will not be counted as outpatient mental
MD/GHMSI/CFMI BC (R. 10/10)
CareFirst BlueChoice
Harford County Public Schools 26 7/1/2011