MENTAL HEALTH/CHEMICAL DEPENDENCY ADMINISTRATIVE SERVICES ADDENDUM?.
MENTAL HEALTH/CHEMICAL DEPENDENCY
ADMINISTRATIVE SERVICES ADDENDUM
This Mental Health/Chemical Dependency Administrative Services Addendum ("MHCD
Addendum") is attached to and made a part of the Service Agreement Between City of
Clearwater ("Employer") and MHNet Specialty Services, LLC ("MHNet"), effective January 1,
2011 ("Agreement") and is effective as of the Effective Date of the Agreement.
The capitalized terms used in this MHCD Addendum shall have the meaning set forth herein or
elsewhere in the Agreement or in another attachment to the Agreement.
RECITALS
WHEREAS MHNet has the capabilities to provide and/or arrange for the provision of certain
mental health and substance abuse services to Covered Persons; and
WHEREAS, Employer wishes to sub-contract to or hereby designate MHNet as the
administrator of the mental health/chemical dependency benefits offered by Employer through or
in conjunction with a licensed Insurance Company; and
WHEREAS, Employer wishes to utilize these services offered by MHNet in conjunction with its
benefits plans and policies, and for Covered Persons;
NOW, THEREFORE, in consideration of the mutual promises contained herein, and
intending to be legally bound, the parties hereto agree as follows:
SECTION 1: DEFINITIONS
1.1 Acute Psychiatric Hospital: A facility duly licensed as an acute psychiatric hospital
having a duly constituted governing body with overall administrative and professional
responsibility and an organized medical staff which provides 24-hour inpatient care for
mentally disordered, incompetent, or other patients and which provides the following
basic services: medical, nursing, rehabilitative, pharmacy, and dietary services.
1.2 Behavioral Health Services: Services, supplies and/or accommodations provided by
a Provider in a Practitioner's office, a Covered Person's home, a Facility, or at the
scene of an accident, which services, supplies and/or accommodations are generally
recognized as appropriate for diagnostic or therapeutic purposed in the treatment of
Mental Illness or Chemical Dependency. Behavioral Health Services include, but are
not limited to, the following: assessment; diagnosis; treatment planning; medication
management; individual, family, and group psychotherapy; and psychological testing.
1.3 Case Management Services: MHNet's program by which MHNet determines under
written standards whether supplies, service and/or accommodations proposed in a
treatment plan prepared by a Practitioner meet written criteria for medical necessity,
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appropriateness and indicated level of care as defined by MHNet. Case Management
Services include, but are not limited to the following: pre-certification, prospective,
concurrent and retrospective utilization review; discharge planning; and quality
assurance activities.
1.4 Chemical Dependency: A condition of psychological and/or physiological
dependence or addiction to alcohol or psychoactive drugs or medications, which
results in functional (physical, cognitive, mental, affective, social or behavioral)
impairment wherein treatment can reasonably be anticipated to result in improvement.
1.5 Chemical Dependency Counselor: A person who is qualified and duly certified as a
counselor in the medical treatment of Chemical Dependency by an accredited
institution of higher learning.
1.6 Chemical Dependency Treatment Facility: A Facility duly licensed as a Chemical
Dependency Treatment Facility that provides 24-hour inpatient care for persons
recovering from Chemical Dependency and which provides the following basic
services: patient counseling, group therapy, physical conditioning, family therapy,
outpatient services, and dietetic services.
1.7 Day Care: Treatment at any Facility that provides non-medical care and supervision
to. persons with a Mental Illness or Chemical Dependency on a less-than-24-hours per-
day basis.
1.8 Day Treatment: No less than three (3) and no more than twelve (12) hours per day of
clinical care provided in a non-residential, structured, supervised therapeutic
environment that specializes in the treatment of Mental Illness or Chemical
Dependency.
1.9 DSM-IV: The fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders published by the American Psychiatric Association ("APA") copyrighted
1994, and as such publication may be updated and /or amended from time to time.
1.10 Facility: Any Hospital, Day Treatment center, Day Care hospital, Chemical
Dependency Treatment Facility, or outpatient treatment center duly licensed or
certified.
1.11 Home Health Care: Treatment provided at a person's place of residence under orders
of a Practitioner to a person who is essentially homebound as a result of a Mental
Illness or Chemical Dependency and unable to obtain services on an outpatient basis.
1.12 Hospital: A facility that:
A.) Is licensed as a general acute care hospital, is accredited by the Joint Commission
on Accreditation of Health Care Organization (JCAHO), and/or is Medicare
certified.
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B.) Provides 24-hour nursing services by registered nurses (RNs) on duty or on-call;
and
C.) Provides services under the supervision of a staff of one or more Physicians to
diagnose and treat ill or injured patients hospitalized for surgical, medical or
psychiatric conditions.
1.13 Insurance Company: A health maintenance organization, preferred provider
organization, health insurance company, or similar entity that is appropriately licensed
and able to design, underwrite, and sell Benefit Plans in the state where Insurance
Company offers such Benefit Plans.
1.14 Managed Behavioral Health Services: Administrative service, including but not
limited to: provider recruitment, selection, credentialing, re-credentialing, training;
quality assurance activities; utilization management activities; claims payment; and the
development and implementation of policies and procedures which are necessary to
provide comprehensive managed mental health and chemical dependency services to
Employer's Covered Persons.
1.15 Medical Director: A licensed Physician certified or eligible for certification by the
American Board of Psychiatry and Neurology who has been designated by MHNet to
oversee the provision of Case Management Services to Covered Person.
1.16 Mental Illness: A pathological state of mind producing clinically significant
psychological symptoms including, but not limited to, affective, cognitive, and
behavioral or physiological symptoms (distress) together with impairment in one or
more major areas of functioning (disability) wherein treatment can reasonably be
anticipated to result in improvement.
1.17 Outpatient Treatment Program: Treatment provided in a non-residential treatment
and rehabilitation program including Day Care, Day Treatment, or Partial
Hospitalization to a person with a Mental Illness or Chemical Dependency whereby a
person receiving treatment does not reside at the location where such program is
conducted. A person participates in a treatment program, with or without medication,
and receives counseling and supportive services according to a predetermined
attendance schedule that includes one or more of the following basic services:
A.) Individual Counseling: Provided between the person and professional or
trained paraprofessional counselor on a scheduled, one-to-one basis.
B.) Group or Family Counseling: Provided in a staffed, structured support group,
or where the counseling process involves one or more members of the person's
family.
C.) Aftercare Services: Provided to a person who has been formally discharged
from a Facility or an Outpatient Treatment Program, in order to provide
support and encouragement for the person as needed.
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1.18 Partial Hospitalization: No less than three (3) and no more than twelve (12) hours
per day of continuous treatment provided in a Hospital.
1.19 Participating Facility: Any Facility that has entered into a contract with MHNet to
provide services to Covered Persons.
1.20 Participating Practitioner: A Practitioner who has entered into a contract with
MHNet to provide services to Covered Persons.
1.21 Participating Provider: A Participating Practitioner or Participating Facility.
1.22 Payor: A "Payor" means entity offering health benefit plan(s) on an insured or
administrative service contract (ASO) to its employees and/or employers and who is
legally responsible for the payment of service fees to MHNet and /or to fund provider
claims under such benefit plan(s). Payor may be either the Employer or Insurance
Company.
1.23 Physician: A person who is qualified and duly licensed to practice medicine and
surgery who has the degree of Doctor of Medicine (MD) or Doctor of Osteopathy
(D.O.).
1.24 Plan: A group contract, certificate, policy, plan document or any other legally
enforceable instrument and amendments thereto issued or sponsored by Employer
under which a Covered Person may be entitled to health services or health service
benefits.
1.25 Practitioner: A person who is qualified and duly licensed to practice the healing arts
when such an individual is acting within the scope of his/her license or certification.
1.26 Provider: Any Practitioner, Outpatient Treatment Program or Facility who or which
is qualified and duly licensed or certified to furnish Covered Services.
1.27 Service Fee: The fees paid by Employer to MHNet for contracted services for each
Covered Person per month.
SECTION 2: TERM AND TERMINATION OF AGREEMENT OR THIS MHCD
ADDENDUM
2.1 Term and termination of this MHCD Addendum shall follow Section 2 of the Service
Agreement.
SECTION 3: SERVICE FEE
The Service Fee Schedule is listed in MHCD Attachment A.
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3.1 Compensation and Billies is to be in accordance with Section 3 of the Agreement.
3.2 Service Fee Adjustments: In the event that a Covered Person is enrolled hereunder
with an effective date on or before the fifteenth (1S) day of a month, Payor shall remit
to MHNet the full Service Fee for such Covered Person for the month in which the
Covered Person is enrolled. In the event that a Covered Person is enrolled hereunder
with an effective date after the fifteenth (15) day of the month, no Service Fee is due
for such Covered Person for the month in which the Covered Person is enrolled.
Covered Persons terminating coverage with an effective date before the 15th of a
month shall have no Service Fee due for that month; Covered Persons terminating
coverage with an effective date after the 15th will be subject to the full Service Fee.
SECTION 4: ELIGIBILITY
4.1 Effective Dates of Coverage: Subject to Payor's payment of the applicable Service
Fee for each Covered Person, as set forth in Section 3, and Payor's submission to
MHNet prior to the first day of each month a list containing Covered Persons and
dependents eligible to receive services under the Benefit Plans and subject to the
provisions of this Agreement, persons shall be eligible for Covered Services on the
date they become eligible Covered Persons under Employer's Plan, and appropriate
notification as required above is received by MHNet.
SECTION S: RESPONSIBILITIES OF PAYOR
5.1 Com liance with Policies Procedures and Inte retations: Payor shall assist MHNet
in the development and compliance with reasonable policies, procedures, and
interpretations necessary for the administration of the Agreement.
5.2 ID Cards/Member Information: Employer or Payor will provide Covered Persons with
MHNet's telephone number as well as other telephone numbers, delineating whom to
call for specific services. MHNet's telephone number will be identified as the number
to call for the specific Covered Services to be managed and administered by MHNet.
Payor will arrange for the distribution of Covered Persons' identification cards
containing a toll-free number Providers may use during normal business hours to
check eligibility for coverage and to obtain general coverage information.
5.3 Offering age: Subject to Payor's payment of the applicable Service Fee for each
Covered Person as set forth in Section 3, Payor's submission to MHNet prior to the
first day of each month of a list containing Covered Persons eligible to receive
services, and the provisions of the Agreement, persons shall be eligible for Covered
Services on the date they become eligible Covered Persons under the Payor's medical
benefits plan.
5.4 Compensation of MHNet: Payor shall compensate MHNet in accordance with Section
3 and MHCD Attachment A.
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5.5 Inte retation and Pa ent of Benefit: Payor shall interpret, be liable for and make all
benefit payments under the Employer's Benefit Plans.
5.6 Description of Health Benefits: Payor agrees to provide Benefit Plan documents with
descriptions of Covered Services to MHNet. Payor shall ensure that such Benefit Plan
documents are in compliance with applicable law and consistent with the description
of services set forth in MHCD Attachment B.
5.7 Service Area: Employer agrees to use MHNet as the exclusive provider of all
Managed Behavioral Health Services for its Covered Persons.
SECTION 6: RESPONSIBILITIES OF MHNET
MHNet shall provide the Managed Behavioral Health Services set forth in MHCD
Attachment B.
6.1 Written Notice to Covered Persons and Providers: If applicable, MHNet shall provide
written notice and correspond with Covered Persons and Providers or their authorized
representatives, regarding assessments, medical necessity, referrals and authorizations
subject to appropriate written authorization consistent with pre-established procedures
and time frames and applicable law for the release of clinical information. MHNet
shall provide written notice to Covered Persons and Providers, as to the reasons(s) for
denial of benefits for lack of medical necessity. MHNet shall provide both a standard
and expedited appeals process when an appeal is requested. If requested by Employer,
MHNet shall provide for a review of denied claims; provided, however, that such
review shall be deemed advisory to Employer.
6.2 Medical Director: MHNet shall appoint a Medical Director to oversee the provision of
Managed Behavioral Health Services to Covered Persons.
6.3 Record Keeping: MHNet shall establish and maintain a record-keeping system
concerning the services to be performed hereunder. All such records shall be the
property of MHNet and shall be available for inspection by Employer at any time
during normal business hours at the offices of MHNet, upon reasonable prior notice
and subject to appropriate written authorization consistent with applicable law for
release of clinical information.
6.4 Corn liance with Policies Procedures and Interpretations: MHNet shall assist
Employer in the development and compliance with reasonable policies, procedures,
and interpretations necessary for the administration of the Agreement.
6.5 Benefit Plan Desi and Consultation: MHNet shall provide benefit plan design and
consultation when requested by Employer.
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6.6 Statistical Reports: MHNet shall provide monthly statistical reports regarding the
Case Management Service activities within twenty (20) days following the end of each
quarter during the term(s) of this Agreement.
6.7 Medical Services: MHNet represents that Participating Providers are contractually
obligated to conduct their practices in accordance with the recognized, professional
standards of care in the health care community, and that Participating Providers shall
not discriminate against Covered Persons in any way, but shall provide them the same
availability, service, care and treatment as patients who are not beneficiaries under this
Agreement.
6.8 Res onsibili for Care: MHNet acknowledges that MHNet and Employer have no
responsibility regarding the admission, treatment and discharge of Covered Persons
under a Participating Provider's care and that such matters are solely the responsibility
of the Participating Provider in consultation with the Covered Person, notwithstanding
any benefit decision made by Employer or on its behalf by way of utilization review,
precertification or preauthorization.
6.9 Participating Provider Listings: MHNet shall provide Employer with a complete
listing of all Participating Providers to include name, address, telephone number, and
tax identification number (`Provider Information"). MHNet shall provide Participating
Providers' name and address information in a format mutually acceptable to both
Employer and MHNet. MHNet will provide such Provider Information on a periodic
basis as required by Employer.
6.10 Rate Determination: MHNet represents and warrants that the Participating Provider
fee schedules prepared by MHNet are the product of discussion with laymen, doctors,
business advisors and other individuals in the medical field and insurance business;
and that fee schedules are determined by MHNet in its sole and exclusive judgment
and not in combination with the health care providers of any particular geographical
area. The fee schedules may change from time to time.
SECTION 7: GENERAL PROVISIONS
7.1 ERISA: Employer agrees that MHNet should not be identified as or understood to be
the "Plan Administrator" or a "Named Fiduciary" of the plan, as those terms are used
in ERISA. MHNet shall have no responsibility for the preparation or distribution of
the "Plan Document" or "Summary Plan Descriptions", as those terms are used in
ERISA, or for the provision of any notices or for the filing of any reports or
information required to be filed in regard to the Benefit Plan.
7.2 Notice: Any notice required to be given pursuant to the terms and provisions of this
Agreement shall be in writing and shall be sent by certified or registered mail, return
receipt requested, postage prepaid, at addresses listed in the
Agreement.
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MHCD ATTACHMENT A
SERVICE FEE
In consideration of the services described in this Agreement, Payor will pay MHNet the
following:
MHCD
EAP Services
(See Attached EAP Addendum)
Initial Number of Covered Employees,
Retirees, or Survivors:
1,$00
The Service Fee may be increased for each Subsequent Term, pursuant to Section 3.6 of the
Agreement.
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PER EMPLOYEE PER MONTH
$6.76
$1.39
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MHCD ATTACHMENT B
MHNet Managed Behavioral Health Services
MHNet will provide access to Participating Provider Network. Inpatient and Outpatient case
management and utilization review will be conducted as described below:
1. 24 Hours Access -- 24-hour telephonic access to emergency triage and case managers.
All emergency behavioral health authorization inquiries and service requests are
coordinated through a centralized, telephone system.
2. Pre-certification - Interpretation of benefit limits before hospitalization or outpatient
treatment and establishment of treatment plan.
During certification review of a recommended/requested hospital admission or outpatient
services, a case manager reviews the Covered Person's history and current
symptomatology with the Covered Person and/or their family members and/or treating
professional, as appropriate within the confines of confidentiality limitations.
The case manager determines if the Covered Person's current condition and needs meet
the criteria of medical necessity for benefit coverage. Any denial of certification is always
reviewed and authorized by a peer review psychiatrist.
When discussing the Covered Person's needs, the case manager informs the Covered
Person of the preferred network and offers to refer the Covered Person to a network
provider or facility (responsibility for treatment remains with the treating clinician).
3. Concurrent Review - Ongoing interpretation of benefit and treatment plan congruence
during hospitalization and outpatient treatment.
During treatment, Covered Person's status is monitored by MHNet personnel to determine
current congruence with Covered Services. Certification can be made for up to three days
at a time for an inpatient and six visits at a time for outpatient. Frequency of monitoring
will be determined by the time frame of the certification.
4. Retrospective Review --- Interpretation of benefits following emergency service response or
hospitalization.
When MHNet is notified following an emergency hospitalization, retrospective review
will be conducted. In this case, MHNet will request a copy of the intake assessment,
psychiatric evaluation and progress notes, to assist in determining whether the Covered
Person's condition meets criteria for benefit coverage. Retrospective review of
certification should be requested within 24 hours of admission.
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Retrospective review is a process to determine the match of Covered Person's condition
and treatment plan with Covered Services. Deciding the most appropriate service, type of
care, and care environment is always the responsibility of the treating clinician. The
Employer always retains the prerogative to exercise treatment options that are not Covered
Services.
5. Discharge and Aftercare Planning - Follow-up planning post-hospitalization.
Prior to discharge, post-hospitalization treatment plans are coordinated with the clinicians
involved. If appropriate, referrals are made to other community agencies or services.
6. Appeals Review - Reviewing contested utilization review decisions.
When an initial medical necessity review determination is made not to certify a health care
service and an appeal is requested, MHNet will provide standard and expedited appeals
processes.
7. Claims Payment - MHNet will reprice claims and make payment to providers on behalf of
Employer in accordance with the claims funding arrangements mutually agreeable to
Employer and MHNet.
SEE EXHIBIT 1 FOR BENEFIT INFORMATION
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AD-
ATTACHMENT C
MHCD SERVICES ADDENDUM
The following services and supplies are MHCD Services only to the extent that they are for
Medically Necessary Covered Services for mental health and/or substance abuse diagnoses
which are identified in the Mental Disorders (290-319) section of the International
Classification of Diseases, 9th Revision (ICD-9) and which are not identified in the Exclusions
from the MHCD Services Addendum, which have been authorized by MHNet and which are
identified as MHNet's financial responsibility in the Cost Allocation Schedule. With the
exception of inpatient detoxification, all inpatient services are only for medically stable
patients in a psychiatric or substance abuse bed, unless a psychiatric or substance abuse bed is
unavailable. All inpatient detoxification services are only for patients who do not have a
complicating disorder causing medical instability and requiring placement in an intensive care
unit.
Psychiatric hospitalization is provided when Medically NecegLgy- for acute conditions which
are a Covered Service. MHNet will be responsible for those hospital costs identified in the
attached Cost Allocation Schedule.
Day Treatment may also be provided and is defined as Treatment that is no less than three (3)
hours but no more than twelve (12) hours per day.
Detoxification is limited to the acute abuse of or addiction to alcohol, narcotic substances,
tranquilizers and/or psychotropic substances which, when withdrawn from, can cause medical
complications.
When a Covered Person's condition requires treatment for both physical and mental health or
chemical dependency problems, see "Exclusions from the MHCD Services Addendum".
The Covered Services are subject to the limitations and exclusions in the Benefit Plan.
When a Participating Provider that is a psychiatric provider orders medical tests or supplies
for a condition not related to a psychiatric or CD diagnosis such as oxygen, physical therapy,
computer axial tomography (C.A.T. scans), position photon emission tomography (P.P.E.T.
scans), and magnetic resonance imaging (M.R.I.), they will be instructed to obtain
authorization from the Insurance Company or medical benefit Plan administrator if no
Insurance Company and the patient should be referred to a provider that is in the network of
the Insurance Company/medical benefit Plan administrator whenever possible, for the
procedure. Payor will be responsible for the cost of the procedure.
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DESCRIPTION OF SERVICES INCLUDED
SERVICES
Emergency Room • Psychiatric consultations only if a mental health problem or
chemical dependency is suspected. All other emergency
room professionals, technical and facility charges are
excluded.
Outpatient Mental • Mental health and or substance abuse professional services.
Health/Substance Abuse • Psychiatric diagnostic assessment and outpatient treatment
including but not limited to individual and group therapy,
psychiatric consultations and medication management.
• Psychological testing.
• Intensive outpatient treatment programs (I.O.P.)
• Specialized psychological treatment programs or services.
• ECT not including anesthesiology.
Partial Hospital Days or • Facility services.
Day Treatment . Mental health and/or substance abuse professional services.
• All partial hospital treatment or day treatment necessary to
prevent full-time hospitalization or to provide transition
services to allow early discharge from full-time
hospitalization.
• Routine diagnostic procedures and services related to the
admission diagnosis.
Inpatient Mental • Facility services.
Health/Substance Abuse . Inpatient treatment programs and services.
• Routine diagnostic procedures related to admission diagnosis.
• ECT not including anesthesiology.
• Inpatient medication related to mental health/substance abuse
condition.
Inpatient Medical/Surgery • Psychiatric consultations for Covered Persons in medical
beds.
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4.
C
EXCLUSIONS FROM MHCD SERVICES ADDENDUM
The following do not constitute MHCD Services. Provision of these services shall remain the
sole responsibility of Payor to the extent that they are Covered Services under a Covered
Person's Benefit Plan.
1. Treatment rendered in connection with illness classified in ICD-9 as delineated in the
table below. Provided, however, initial assessment and/or differential diagnosis of the
illnesses listed below, and treatment for Covered Persons who have additional diagnoses
that can be treated separately from the primary diagnosis shall not be excluded.
Disease Category ICD-9
Dementias and Other Organic 290.00 - 290.99, 293.00 - 293.99, 294.00 - 294.99,
Disorders 310.00 - 310.99
Pervasive Developmental
Disorders and Autism 299.00 - 299.99
Antisocial Personality Disorder 301.70 - 301.79
Sexual Deviations, Disorders
and Dysfunctions 302.00 - 302.99
Physiological Malfunction
Arising from Mental Factors 306.00 - 306.99
Stammering and Stuttering 307.00 - 307.09
Tics 307.20 - 307.29
Stereotyped Repetitive
Movements 307.30 - 307.39
Sleep Disorders 307.40 - 307.49
Unspecified Special Symptoms 307.90 - 307.99
Conduct Disorder and Impulse 312.00 - - 312.29, 312.30 - 312.39, 312.40 -- 312.49,
Control Disorders 312.80 - 312.89, 312.90 - 312.99
These ICD-9 Codes are Not
Used 312.50 - 312.79
Developmental Disorders and
Mental Retardation 315.00 - 315.99, 317.00 - 319.99
All "V" Codes
2. Conditions not subject to favorable modification according to generally accepted
standards of psychiatric care; provided, however, MHCD Services shall include services
that have been established by the psychiatric profession to be effective for the Covered
Person's condition.
3. Relationship, marriage, academic and other counseling when not attributable to a mental
disorder (e.g., V-Codes).
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4. Treatment for pain with physiological origins, unless MHNet determines such pain has
psychological or psychosomatic components.
5. Services and treatment provided in connection with or to comply with a court order,
involuntary commitments, police detentions and other similar arrangements.
6. Experimental, investigational, controversial or unproven services, treatments, devices, or
pharmacological regimens as determined by MHNet including services utilizing
methadone treatment, L.A.A.M., Cyclazocine or their equivalents.
7. Services for Covered Persons who are consciously and deliberately non-compliant with
MHNet's recommended treatment, when such non-compliance is not a direct result of a
psychiatric illness.
8. Assessment services, including psychological testing, that are for educational, vocational,
rehabilitational or legal purposes, notwithstanding that the evaluation may have been
ordered by a physician. This includes, but is not limited to, the following:
a. Child custody evaluations; for example, to assist a court in awarding custody.
b. Evaluation of abuse for legal purposes; for example, videotaped interviews of an
actual or suspected victim of sexual abuse for use in a legal proceeding.
c. Suitability for employment, licensure, etc.
d. Learning disability evaluations.
e. Attention Deficit/Hyperactivity Disorder evaluation.
f. Educational placement planning.
g. "Baseline" or other evaluations related to a rehabilitation therapy program for an
acquired physical disability,
h. Fitness for Duty Evaluations
9. Neuropsychological testing as part of the medical diagnostic process of determining the
presence of an organic brain disease or functional deficit.
10. Residential treatment or institutional care.
11. Services specifically for conditions that are not currently included in the ICD-9; for
example, "codependency", "sexual addiction", "adult child", "compulsive overeating".
12. Services provided outside mental health treatment units, facilities or outpatient clinics for
the following:
a. Eating disorders.
b. Chronic pain disorders.
c. Impulse control disorders.
d. AIDS.
e. Head injuries.
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13. Speech evaluations or therapy.
14. Weight loss treatments.
15. Any service provided outside of a medical emergency room not pre-certified by MHNet.
Concurrent Physical and Psychiatric Disorders and Services
1. General Considerations: When a Covered Person is hospitalized, determination of
financial responsibility will be based on consideration of:
a. The type of treatment unit in which the patient resides.
b. The specialty of the physician who has primary responsibility for the Covered
Person's care.
c. Whether the services in question are generally considered primary or adjunctive.
d. The primary diagnosis and cause for the hospitalization.
e. Customary standards of treatment for patients with the same primary diagnosis.
2. Psychiatric services for medical patient: MHNet will not be responsible for services
provided or ordered by the physician responsible for the patient's hospital care, except for
psychiatric/psychological consultation for a medical inpatient that is authorized by
MHNet.
3. Psychiatric dia osis assi ed to medical patient: If a Covered Person is admitted for a
medical complaint, but the medical evaluation leads to a psychiatric diagnosis, MHNet
will not be responsible for the cost of care (except for psychiatric/psychological
consultations as described in Section 2 above) up to the point the patient is admitted to an
MHNet-authorized treatment facility. MHNet will be responsible for subsequent mental
health/chemical dependency care that is pre-authorized by MHNet.
4. Non- s chiatric services for psychiatric patient: MHNet will be responsible only for
those non-psychiatric medical services and supplies that are customary for the patient's
psychiatric condition. For example, a patient with a primary diagnosis of alcohol
dependence is admitted to a detoxification unit and as part of the medical evaluation is
determined to also have a liver disorder. The patient received physician and hospital
services for the liver disorder while continuing to receive hospital-based detoxification.
MHNet would only be responsible for the charges that would normally apply to a patient
with the same detoxification on the same unit who did not have a concurrent physical
disorder.
5. Medical patient admitted to psychiatric unit for management: If a Covered Person is
admitted for a medical problem but is placed on a psychiatric unit for behavioral
management purposes because of a concurrent psychiatric diagnosis that otherwise would
not have required hospitalization, MHNet will not be responsible. In cases where
hospital confinement exacerbates the concurrent psychiatric condition and necessitates
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transfer to a psychiatric unit, MHNet will be responsible for the psychiatric portion of the
charges.
6. Treatment for Dementia and other Organic Disorders: MHNet will be responsible only
for psychiatric consultation and adjunctive supportive family therapy. If a dementia
patient is hospitalized in a psychiatric unit because of placement issues, behavioral
management purposes, or respite care, MHNet will only be responsible for psychiatric
professional fees.
Out-of-Network Care
When a patient receives services from a non-MHNet Provider, MHNet will not be financially
responsible, except where MHNet has agreed to pay for Out-of-Network MHCD services. In
those cases where MHNet has agreed to pay for Out-of-Network MHCD services, MHNet
shall use its fee schedule for professional services and its average per diem for the market for
facility charges, or such other amounts as may be required by law or agreed upon by the
parties.
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t.
f
COST ALLOCATION SCHEDULE
SERVICES FINANCIAL
RESPONSIBILITY
Room and Board Charges (Psychiatric) MHNet
_...__ ._._.._....................... _......._..........................................._... _.................... .................................
Room and Board (Chemical Dependency Detox)
.
_
...... _.................. _.__................ ...-... .....
..... ........ .......__._..._..._ --- .__..............._.....................................
MHNet
.................................. .................................................................
....... ..
.
............. .......-.......-................. .............................._..._............. _.._.-_ -.----.....-...................._................................- - _......................... ..................................
Room and Board Charges (Chemical Dependency Rehabilitation) MHNet
..W._.._......._...........,........................__.-...... __................. _........ _......... _................................
Room and Board Charges (General Medicine, including hospital-based ..... ...................................... ..... ......... ...._....
Health Plan
professional fees)
_._- ..........................................._. _ ._.....-..................................... _......... -._...... .................... _............. ....
.....
....
........................ .................................. ..................................... _..............
Professional services of a psychiatrist, psychologist, social worker, or
other mental health counselor (when authorized by MHNet) for a MHNet
psychiatric condition.
........................................... ........._._..._..-....... _..__................................ _....... ..........................................................................
.....
............................... ............ ..... .... ................. _..........
Professional services of a psychiatrist, psychologist, social worker, or
other mental health counselor (when authorized by MHNet) for MHNet
chemical dependency...detoxification ....................................... _............-._..__-._.__...._......................._.........-_._........................._..........._...-- -... ..................... _....... _..._...... _.._._...........................................................
?
Professional services of a psychiatrist, psychologist, social worker, or
other mental health counselor (when authorized by MHNet) for MHNet
chemical dependent ...,rehabilitation,
.
History & Physical for Psychiatric Hospitalization
.
.
.
.. Health Plan
..
.
..
.
........;
.............. _.... _..------..._.....................................................
......
.
....
................. .......................................... .._.........m................................................................................. _.-..._.._.._ ................................................................ .................................
History & Physical for Chemical Dependency Detoxification . .
.
.
.
Health Plan
Hospitalization
.......................?....?.....?_.? .._..?..,_ ---.._..__....... _._.......................... ............_..-............. .........._............. .....--.._ .__ .................................................... ................... ................................ .....T
....
...............................................__.,...,.......................__......
........................
History & Physical for Chemical Dependency Rehabilitation Health Plan
Hospitalization
. -- ----- -_.._......._ ........................................................................................................_-------.._..-- ---__.._.-.__._.._._.................----- ...........................--
....
....................................................... .._......... ...... ...... ..... ..... .........__._.....
.
Medical Tests: including any associated professional fees: EEG, EKG, CT
i Health Plan
Scan, MRI, X-Rays, etc,.._ ..................._....... .- ... . .. .................. ............... ................... .......... .. .. ll? .....",.".,?--,--,-?Ill'-""--",-,-,-I . . . ... . . .. . .... . ....... . ...................................
Drugs: Inpatient drugs (Psychiatric)
i MHNet
........... ...........—_...-_............-....... _........... _ ............................ ............... -.......... ....................................................._......._ _-._.._._..-------................................. ....... _..._....
Inpatient drugs (Non-Psychiatric) ..._ ._._..._.. ---.----_._..... _.................................... _............ _.
Health Plan
.............................Hospital agrees..to...obtain PCP authorization
..........................................................
....
....................................................................................................................
Take home drugs (provided by Hospital)
.......... _...... _.._......... _._......... - ....-....... ...._..._ .......................................................... ................... .._..._....._._._._.......... _............................................. _-......................... _........... .............._.._.... i
:.... MHNet
..._..._.......-- ....__._....._.............................................................,
Outpatient drugs
.
..................................................._ .. m...._...._..._.......................,....................................... -----...,............. _.._.... __...- ---- ._....-............................................................ ............. .........................................................
.... Health Plan
........................................................................................................._...'
Inpatient Psychiatric 1
.
.
.
..... _.__.
....................................................................................... .................... .....
Laboratory Services excluding any associated professional fees. .... ..... ........... ......................... ....
..................
............
..................
Limited to the following tests when and only when ordered by an MHNet MHNet
psychiatrist:
.................................................................................... _... _ _?. _ ..__ _.-._......
_ ---...._....._......- ._...?
1
• Complete Blood Count (CBC) MHNet
• 20 Item Chemistry (SMA20) MHNet
• Thyroid Function Studies (TS-4 & TSH/or profile) MHNet
-- ._._ .. .... .................... __........... .._.........,.......... ..... .,m............. .....,..
City of Clearwater Confidential and Proprietary 1/6/11
MHCD Addendum
17
COST ALLOCATION SCHEDULE
SERVICES I FINANCIAL
..---.._ ......................................... ....-._ RESPONSIBILITY
-.................... ...... .
• Urinalysis
........................
i M H N e t
. ............. _ _..._._._.................. .................. ..__ _..._........ -....................................................... ..................... .................
• Urine Drug Screen (UDS) ..
... ................. _...__._._._._........................... . 1
MHNet
........._._..._..._._.-_-_- ........ ................... ..............................__............................................... ..... .
• Drug Levels (Dilantin, Nortriptyline, Antidepressant level & .... ... _.._..._.__...... ,...,................................ ..._......................... ...................
Lithium
.................................._... _....................... .............. _....-................... _.... _....._........ ___..._...... _ ._-............... .................................. ........................ --.... .............
'... MHNet
.......................... -........------._.... _.................................
..................,
• Folate & B-12 Levels MHNet
• Blood Alcohol Level MHNet
Inpatient Substance Abuse Detoxification
......... ........... .........._..........._.,._..................................... ......... ___._...._...._._...................................... _ _?._._.._........................_.._.. _. _....... ........__......... .-...-.___............................................... _.......................................... ,._. ..................................... ...----...__............................................
.............................. ..... -...-._.__............................................................. ............ __....... ._.-.._........................ ........... ..........._._._ .._........................................... ...... --..................................... .........._.....
Laboratory Services excluding any associated professional fees. .... ......... _._..... _............................ ................................. _.._..--.._......... _....
j Limited to the following tests when and only when ordered by an MHNet MHNet
psychiatrist W...... __...... . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... _ ...................
• Complete Blood Count (CSC) MHNet
• 20 Item Chemistry (SMA20) ..............................
MHNet
• Thyroid Function Studies (TS-4 & TSH/or profile) . ......................................... _... _............ _....................................
MHNet
• RPR ................................................
MHNet
• Urinalysis
.......... .._................. -----...................... _ .................................................. _._ _._.__........... _........................ _
.
. -. ........................... . . . . ..... _ ....................... . . . . . . . . . . . . . . . .............
.
MHNet
.
.
............................. ..._..._._._._.... _
Urine Drug Screen (LTDS)
.....
...................................... ......................................
{
MHNet
.................... .._._ _......................._.._..__.......................................................... ................................. ............... _..-__.-_- --------------------------------- _-. ..... .........................
• Drug Levels (Dilantin, Nortriptyline, Antidepressant level & ..... ... ..........-----..._.................................. ....._._._...-- ._ ;
Lithium MHNet j
J
• Folate & B-12 Levels
........... ........... -_ _....... ----............................ -..._.._.----..... ................................ .....-.. --............................................ ... _............................... .....-.-
. MHNet
_
._.._._......... ........................ ....................... _._..
• Blood Alcohol Level ..._ ................................. ....-.._.__._...........................................................
MHNet
.................................. ...--_
Inpatient Substance Abuse Rehabilitation ----- ---- ..................... I'll ..... ...... ............_.._............... ........................
.................
....................... ..... .................... .....- ....... ..-................. .......... _..,.......... ................ _.......-._.._...... __-__..... __.......... _..__-..................... .................. ..........._.-.......... -.......... ........................ ..........
Laboratory Services excluding any associated professional fees. .._.. ......... _................ ................ ..........._............ _...... ............................
.........
Limited to the following tests when and only when ordered by an MHNet MHNet
psychiatrist:
_ .._._ ...............................................-......................................._.-_.........................................................----__............................_.._..._..._..._.__........................................__..._.__............
.....
................................._._.._._...............................
• Complete Blood Count (CBC) MHNet
.... ..
• 20 Item Chemistry (SMA20)
......... ..--...---........ -..._.... ................... ........ _.................. ...- _._...................__ ..... ....................._.. ................................. _..- --,
MHNet
?
. .._.............. .................... .
• Thyroid Function Studies (TS-4 & TSH/or profile) - ----._._.............................. ...___._..................
................
MHNet
• RPR ... ...............................- --.---........................_..._.
MHNet
. ....................
• Urinalysis . .............................
MHNet
----------------------- ------........ ..
• Urine Drug Screen (UDS) ..... ......... .........._....... _.....
_....__........................
MHNet
City of Clearwater Confidential and Proprietary 1/6/11
MHCD Addendum
18
?Y
COST ALLOCATION SCHEDULE
SERVICES FINANCIAL
RESPONSIBILITY
• Drug Levels (Dilantin, Nortriptyline, Antidepressant level & MHNet
Lithium)
• Folate & B-12 Levels MHNet
• Blood Alcohol Level MHNet
Inpatient Laboratory
...... __..
_
..
..
.
.
.
.
_------. ...... .......
,
.
..._.
..... .._ .... ......
_..... _.__ ..
.. .
......... _.......................................................................................
.
.
. ....
All other Laboratory services not specifically delineated above and all ..... ................................................ ..... ........ ...... .........................................
......
medical professional fees associated with any inpatient laboratory Health Plan
services.
..................................................... .................._ .............................................- ----........ _........................ .......................................................................
.....
................................................................................................
Outpatient Laboratory
_ ............... ....__. _..-.......... _............................................ ........................................................... . _.._..._..... _._.
_
. _....
...
.
..
.
.
.
.
.
.
.
.
..
........... _ .... ....................................... .._
All outpatient laboratory services
_.? ................................................................._............................................................. ._.............. .........._......... ..._................................................... .
. ... .......................................................................................................................
Health Plan
.............. ............................................................... _......... _............ _...............
Emergency Room Charges
Mental health consultations provided in the Emergency Room Health Plan
All other charges, including room charges, laboratory, medical tests,
drugs and professional fees, except for mental health consultation Health Plan
services provided by MHNet.
Ambulance:
_ .......................... _............................................... _ __..
_.
..
....
.
....
..
....
.
_.
.
.
.
.
.
.
....
._.._
_...__._ .....................................
,
Transport to In-Plan Hospital prior to admit
........................................................................................_............. _............................... __...
........ _
.. _...
...
........
......
.
.. ..... .......................
Health Plan
.
.
.
.
.
.
.
...........................
Transfer to In-Plan Hospital prior to admit
....................... ........_....... .. _......._..._.................._................-...._........................,_.,_......... ...... .............................................................. ......... ............................................... .....
.. .. .................................................... ............ .._...... _.........................................
Health Plan
................. ---- --......................................................................
{
Transfer during In-Plan Hospitalization Health Plan
_ ..................................................................................................................
Miscellaneous: ._. ........................._.......-----._...................................................
ECT, not including anesthesiology and anesthesia services Health Plan
Physical Therapy Health Plan
Occupational Therapy in an inpatient setting Health Plan
Recreational Therapy in an inpatient setting MHNet
Durable Medical Equipment .................
Health Plan
_._... ................................. ..... _..._........... .._...__. --- -- ._.-..................... __._................................ ........... _. _ .--- ----.._...................................
Personal Convenience Items (includes, but not limited to: toothbrush, ... ............................................. _....... ._._.._...... _.........__
toothpaste, shampoo, slippers, feminine napkins, humidifiers, Aqua K- NOT COVERED
J Units, etc.)
City of Clearwater Confidential and Proprietary 1/6/11
MHCD Addendum
19
R
EXHIBIT 1 - BENEFIT SUMMARY
yy }
1 Accq ?sl I' n x
N _.
i'+ r I
I,
FIT '?
M
?? W.'s"A"
t
fit
bu tof Ne ork
Il7gatlpW` OSA?
p,n 1a
t
P.'
Authorized Authorized
services paid services paid at
at in-network in-network rate
rate minus 10 minus $200
Authorized in- copayment copayment per
network services per outpatient Authorized admission. Up to 5 visits
10 Copayment per visit. Members services $200 Members are See attached
outpatient office are subject to copayment per subject to EAP
City of Clearwater visit balance billing admission. balance billing. Addendum
City of Clearwater Confidential and Proprietary 1/6/11
MHCD Addendum
20