General Information About Mental Health and
Substance Use Services Coverage
Date Issued: 10/17/2014
With the exception of Medicare plans, the following general principles apply to EmblemHealth’s coverage of mental health and substance use services. These general principles supplement member handbooks applicable to non-Medicare plans that provide coverage for mental health and substance use services, effective January 1, 2014. Please refer to your plan documents (e.g. your contract or certificate of coverage) for specific details regarding the cost-sharing terms, and other terms and conditions applicable to your benefits for these services.
- EmblemHealth provides broad-based coverage for the diagnosis and treatment of behavioral health conditions, at least equal to the coverage provided for other health conditions. Behavioral health conditions include mental health and substance abuse disorders.
- EmblemHealth provides, subject to medical necessity, unlimited benefits for inpatient and outpatient behavioral health care, as well as for residential treatment for behavioral health conditions.
- For EmblemHealth members’ outpatient behavioral health visits, EmblemHealth applies the member’s primary care cost-sharing schedule. If a member receives behavioral health services in a facility on an outpatient basis, facility cost-sharing requirements may apply in addition to the member’s primary care cost-sharing schedule, but any such facility charges must be equal to EmblemHealth’s facility charges for medical/surgical services. Self-funded health plans for which EmblemHealth provides administrative services only may opt out of this requirement.
- The utilization review conducted by EmblemHealth for behavioral health benefits is comparable to, and applied no more stringently than, the utilization review conducted by EmblemHealth for medical/surgical benefits.
- Any annual or lifetime limits on behavioral health benefits for EmblemHealth plans are no stricter than such limits on medical/surgical benefits.
- EmblemHealth does not apply any cost-sharing requirements that are applicable only to behavioral health benefits.
- EmblemHealth does not apply any treatment limitations that are applicable only to behavioral health benefits, except for family counseling services, which may be capped at 20 visits per year.
- The criteria for medical necessity determinations made by EmblemHealth regarding behavioral health benefits are made available on a public website, and, upon request, to any current or potential participant, beneficiary, or contracting provider.
- Where an EmblemHealth plan covers medical/surgical benefits provided by out-of-network providers, the plan covers behavioral health benefits provided by out-of-network providers.
- EmblemHealth members are charged a single deductible for all benefits, whether services rendered are for medical/surgical or behavioral health conditions, with the exception that EmblemHealth charges a separate deductible for prescription drugs.
- EmblemHealth offers its members the services of Behavioral Health Advocates, who are trained to assist EmblemHealth members in accessing their behavioral health benefits, by supplying them detailed, accurate, and current information regarding: treatment options in the member’s area; utilization review determinations and processes; medical necessity criteria; and appeals.