Exclusions/Limitations Under the Mental Health & Chemical Dependency Benefits Program

The Mental Health and Chemical Dependency Benefits Program does not provide benefits or pay for the following:

• Inpatient or Outpatient treatment for any medically treated physical illness.
• For Inpatient/Alternate Care Treatment of mental health problems that are not "severe mental illnesses" or "serious emotional disturbances of a child" as defined in the California Mental Health Parity Act (AB 88), there is a maximum of 20 days per eligible participant per calendar year for the medically necessary and clinically appropriate treatment of mental illness.
• Treatment of detoxification in newborns. Such treatment will be provided under the medical portion of the PacifiCare HMO Plan, under the terms and conditions of each of those plans.
• Treatment of congenital and/or organic disorders, including, but not limited to, Organic Brain Disease, Alzheimer's Disease and Parkinson’s Disease.
• Treatment of mental retardation, other than the initial diagnosis, and medically necessary services for accompanying behavioral and/or psychological symptoms if amenable to psycho-therapeutic or psychiatric treatment.
• Court ordered testing, counseling, and treatment.
• Case management and administrative supervision, when billed separately. This is considered an essential part of the billing for daily hospital care by the attending physician, and will not be paid by this Program as a separate billing.
• Uncomplicated withdrawal (withdrawal that does not present symptoms requiring patient detoxification) from the following substances:
• Amphetamines or similarly acting drugs
• Cannabis (marijuana)
• Cocaine
• Nicotine
• Psychoactive substance abuse, without dependence.
• Other administrative services such as expert testimony, medical records review and maintenance, preparation of reports regarding civil or legal matters (child custody issues), ability to stand trial, consultation with attorneys or other representatives of social control systems.
• Consultation with a counselor or professional for adjudication of marital, child support and custody cases.
• Private hospital rooms and/or private duty nursing, unless determined to be a Clinically/Medically Appropriate service and authorized by PBH.
• Ancillary services such as vocational rehabilitation, behavioral training, sleep therapy, and employment counseling, training or education therapy for learning disabilities or other educational services.
• Treatment for any condition not covered in the standard nomenclature of the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders such as co-dependency.
• Sexual addiction and gambling problems based solely on the 12 Step Model.
• Treatment of obesity.
• Services in excess of those authorized by PBH.
• Broken appointments, except in cases where the Participating Provider is notified at least twenty-four (24) hours in advance that the appointment will not be kept or in circumstances in which the covered participant has no control over missing the appointment and could not notify the Participating Provider at least twenty-four (24) hours prior to the scheduled appointment. A broken appointment shall count as one (1) session for the purpose of computing benefit expenditure.
• All prescription or non-prescription drugs, except for drugs prescribed by a physician in connection with the participant's treatment as an inpatient at a hospital or as a patient at a Facility providing Alternate Treatment. For information on prescription drugs that you may be covered, consult your Retired Employees Summary Plan Description.
• Inpatient services, treatment, or supplies
rendered without Pre-admission Certification, except in the event of an emergency.
• Damage to a Hospital or Alternate Care Facility caused by a participant. The actual cost of such damage may be billed directly to the participant.
• Health care services, treatment or supplies determined to be experimental by PBH in accordance with accepted mental health standards.
• Health care services, treatment, or supplies provided as a result of any Workers' Compensation law or similar legislation or obtained through, or required by, any governmental agency or program, whether Federal, State, or any subdivision thereof or caused by the conduct or omission of a third party for which the participant has a claim for damages or relief, unless such participant provides this Program with a lien against such claim for damages or relief in a form and manner satisfactory to this Program.
• Health care services, treatment, or supplies for military service disabilities for which treatment is reasonably available under governmental health care programs.
• Health care services, treatment, or supplies rendered to a participant, which are primarily for rest, custodial, domiciliary, or custodial care.