content top new

WHAT IS NOT COVERED

Charges Not Covered in the Behavioral Health Program

Exclusions for expenses incurred in the treatment of mental illness or chemical dependency include all the services, supplies and treatments listed as not being covered in the medical benefits section. In addition, the following expenses incurred in the treatment of mental illness or chemical dependency are not covered under the MILA National Health Plan as behavioral health services:

  • Experimental treatments or treatments deemed not medically necessary including, but not limited to, custodial care for chronic conditions, educational rehabilitation or treatment of learning disabilities;
  • Illness covered by Workers’ Compensation benefits;
  • Inappropriate treatment as determined by the Behavioral Health Claim Administrator;
  • Services in a government hospital or facility for which no charges are normally made;
  • Services, supplies and treatment (including hospitalization) not approved by a physician as necessary for the treatment of the covered individual’s behavioral health condition;
  • Services for conditions not attributable to a mental disorder as defined in the Diagnostic and Statistical Manual (DSM);
  • Court-ordered or other externally mandated treatment, unless such treatment is medically necessary;
  • Medications or laboratory services not prescribed, dispensed or provided within the protocols established by the Plan’s Behavioral Health Claim Administrator;
  • Speech therapy except as part of an approved autism therapy plan;
  • Educational, employment and custody evaluations;
  • Professional training;
  • Services provided by self-help groups;
  • Behavioral dysfunctions that result primarily from organic conditions (e.g., organic brain syndrome, Alzheimer’s, mental retardation and autism), except for acute interventions for stabilization of psychiatric conditions adn for treatment of autism under an approved autism therapy plan;
  • Marriage or stress counseling, except when rendered in connection with treatment of a DSM mental disorder;
  • Services that would have been paid first by Medicare for any covered person who failed to enroll in that program;
  • Behavioral treatment that is not medically necessary;
  • Treatment for smoking cessation, weight reduction, obesity, stammering and stuttering;
  • Treatment for codependency, except when rendered in connection with treatment of a DSM mental disorder;
  • Non-abstinence based and nutritionally based chemical dependency treatment except when medically necessary;
  • Treatment for sexual addiction, except when rendered in connection with treatment of a DSM mental disorder;
  • Treatment of chronic pain, except when rendered in connection with treatment of a DSM mental disorder;
  • Treatment or consultations provided by the person’s parents, siblings, children, spouse, former spouse or domestic partner; and
  • Ambulance services or other transportation, except when medically necessary and pre-approved by the Plan’s BehavioralHealth Claim Administrator. However, pre-approval is not necessary in the case of an emergency.

Note

If you have questions about the mental health and substance abuse benefits or required approvals or to determine if a particular expense is covered, you can call Cignadirectly at the toll-free number shown on the Resources chart in the Administrative Information section.
bottomBar