9.17 The program for managed care of mental health services and alcohol and other substance abuse treatment shall continue. The Joint Committee on Health Benefits will work with the State on the ongoing review of this program.

The Empire Plan shall continue to provide comprehensive coverage for medically necessary mental health and substance abuse treatment services through a managed care network of preferred mental health and substance abuse care providers. As soon as is reasonably practicable, the The providers will be included in all lists of Empire Plan providers, including on-line directories. In addition to the in-network care, limited non-network care will be available

Benefits shall be as follows:

IN-NETWORK BENEFIT

Mental Health Coverage

• Paid-in-full medically necessary hospitalization services and inpatient physician charges when provided by or arranged through the network;
• Outpatient care provided by or arranged through the network will be covered subject to a $15 $18 per visit copay; Effective January 1, 2007, July 1, 2009, the Managed Mental Health services copayment will be $18; $20.
• Up to three visits for crisis intervention provided by, or arranged through, the network will be covered without copay.

Alcohol and Other Substance Abuse Coverage

• Paid-in-full medically necessary care for hospitalization or alcohol/substance abuse facilities when provided by or arranged through the network;
• Outpatient care provided by or arranged through the network will be subject to the participating provider office visit copay.

Benefit Maximums

• Annual and lifetime dollar maximums for covered expenses will be at the same level as the basic medical annual and lifetime dollar maximums;
• Medically necessary inpatient alcohol and substance abuse treatment will be limited to three stays per lifetime. However, the managed care vendor will review on an individual, case by case, basis the appropriateness of additional treatment and may approve coverage for such treatment if it can be demonstrated that significant improvement will occur.

NON-NETWORK BENEFIT

Medically necessary care rendered outside of the network will be subject to the following provisions:

• 30 inpatient days and 30 outpatient visits maximum per year for mental health treatment; Non-network coverage for mental health treatment is subject to the same deductibles and coinsurance maximums as the non-network Hospital and Basic Medical coverages;
• Inpatient and outpatient reimbursement will be no greater than 50 percent of the in-network discounted fees;
• Inpatient deductible will be $2000 per year and the outpatient deductible will be $500 per year;
• No out of pocket maximum;
• Maximum dollar limit for medically necessary alcohol and substance abuse care provided by non-network providers for covered expenses will be $50,000 per calendar year and $250,000 lifetime;
• Medically necessary inpatient alcohol and substance abuse treatment will be limited to one stay per year and three stays per lifetime. There will be a maximum of 30 outpatient visits approved per calendar year.

Expenses applied against the deductible, coinsurance and/or copay levels indicated above will not apply against any deductible, coinsurance, or copay levels or maximums under the basic medical portion of the Plan.

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