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> Employee Benefits > Benefits > Mental Health <-- Your are Here
Mental Health/Substance Abuse Plan
General Description of Coverage
Mental Health and Substance Abuse Plan coverage is available to all individuals and their dependents who carry
medical plan coverage with the State of Maryland. The State's Mental
Health and Substance Abuse plan for individuals enrolled in PPO and POS medical
plans is administered by APS Healthcare.
Individuals enrolled in HMO medical plans receive all mental health and
substance abuse coverage through their HMO. You cannot obtain mental health
and substance abuse benefits through the State if you do not enroll in a State
medical plan.
You automatically have mental health
and substance abuse benefits when you enroll in any of the University
sponsored medical plans.
However, your mental health and
substance abuse benefits vary depending on the medical plan you are enrolled
in. You cannot obtain mental health and substance abuse benefits through
the University if you do not enroll in a University medical plan.
POS and PPO Medical Plans:
If you are enrolled in a PPO or POS plan, APS
administers your mental health and substance abuse benefits. No
additional premium is required. The cost of your coverage is included in your
medical plan premium.
HMO Medical Plan:
If you
are enrolled in an HMO medical plan, all of your mental health and substance
abuse benefits will be provided by your HMO
How to Receive Mental Health and Substance Abuse Benefits
POS and PPO Medical Plans:
If you are enrolled in a POS or PPO medical plan, your
mental health and substance abuse benefits are provided by APS Healthcare. To
receive the maximum available benefits, you must contact APS before receiving
any services. The University's/State's Company Code is SOM2002. The professionals
at APS will work with you to select an appropriate referral for care. Your
mental health and substance abuse benefits include coverage for the following
types
of treatment for mental health and substance abuse:
- inpatient facility and professional services
- partial hospitalization, and
- outpatient facility and professional
services.
HMO Medical Plans:
If
you are enrolled in an HMO medical plan, all mental health and substance abuse
services must be authorized by your HMO. Please contact your medical
plan for more details.
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Standard Mental Health
and Substance Abuse Benefits Chart for
Individuals Enrolled in an
HMO Medical Plans
Administered by: HMO
Plan |
| Benefit |
In-Network: Care
Preauthorized |
In-Network: Care Not
Preauthorized |
Out-of-Network Care
Preauthorized |
Out-of-Network Care: Not
Preauthorized |
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Outpatient
Services: |
80% for
outpatient
care visits 1-5;
65% for outpatient
care, visits 30+ per calendar year. |
None |
None |
None |
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| Inpatient & Partial
Hospitalization: |
100% for inpatient
care up to 365
days when
preauthorized
by Plan. |
None |
None |
None | |
HMO Plan Exclusions
Contact your HMO Plan to find out what
exclusions there are to your Medical/Substance Abuse Plan.
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Standard Mental Health
and Substance Abuse Benefits Chart for
Individuals Enrolled in
PPO or POS Medical Plans
Administered by:
APS |
| Benefit |
In-Network: Care
Preauthorized |
In-Network: Care Not
Preauthorized |
Out-of-Network Care
Preauthorized |
Out-of-Network Care: Not
Preauthorized |
Coverage
Limits |
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| Outpatient
Services: |
80% (first 5 visits) 65%
(next 25 visits) 50% (further visits) of APS negotiated fee
maximum |
40% (first 5 visits) 32.5%
(next 25 visits) 25% (further visits) of APS's negotiated fee
maximum |
40% (first 5 visits) 32.5%
(next 25 visits) 25% (further visits) of APS's negotiated fee
maximum |
20% (first 5 visits) 16.25%
(next 25 visits) 12.5% (further visits) of APS's negotiated fee
maximum |
No limit on the number of
medically necessary/treatable visits per year. Benefit
reduction if preauthorized is not obtained. No limit on
out-of-pocket expenses. |
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- All percentages refer to APS's negotiated fee maximum
- All services must be deemed medically necessary by APS to
obtain any benefits.
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| Medication
Management: |
100% of APS's negotiated fee
maximums after a $20 copay is met |
50% of APS's negotiated fee
maximum |
50% of APS's negotiated fee
maximum |
25% of APS's negotiated fee
maximum |
No limit on the number of
medically necessary visits per year. Benefit reduction if
preauthorization is not obtained. No limit on out-of-pocket
expenses. |
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- All percentages refer to APS's negotiated fee maximum
- All services must be deemed medically necessary by APS to
obtain any benefits.
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| Inpatient & Partial
Hospitalization: |
100% of APS's negotiated fee
maximum |
Not Covered |
80% of APS's negotiated fee
maximum |
Not Covered |
Benefit reduction if
preauthorized is not obtained. Out-of-Network: Expenses during
any one inpatient stay is limited to $1,500 of APS's negotiated fee
maximum. No limit to medically necessary and treatable
preauthorized inpatient days. 60 days per benefit period
for partial hospitalization. |
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- All percentages refer to APS's
negotiated fee maximum
- All services must be deemed medically
necessary by APS to obtain any benefits
- Covered charges for mental health and
substance abuse are the same
- To reserve maximum benefits, are must
be preauthorized by calling APS at 1-877-239-1458
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APS Healthcare
The following is a list of excluded services.
APS does not cover services and supplies:
- that are not preauthorized and medically necessary;
- not prescribed, performed, or guided by eligible practitioners;
- for inpatient treatment (or for an inpatient stay) for conditions that
require only observation , diagnostic examinations, or diagnostic laboratory
testing;
- for inpatient treatment that might be safely and adequately rendered in a
home, provider's office, or at any lesser level of institutional care;
- that APS determines are experimental or investigative in nature or for
services related to them. Experimental or investigative describes any
service or supply that is judged to be experimental or investigative by APS in
its sole discretion. APS will apply the following criteria to decide
this: any supply or drug used must have received final approval to
market by the U.S. Food & Drug Administration; there must be enough
information in the peer-reviewed medical and scientific literature to let APS
judge the safety and efficacy; the available scientific evidence must show a
good effect on health outcomes outside of a research setting; the
service or supply must be safe and effective outside a research setting as
current diagnostic or therapeutic options; for lab tests and prescription
drugs;
- when you are not legally obligated to pay for the charge, or where the
charge is made only to insured persons;
- for telephone consultations, for failure to keep scheduled visit, for
completion of forms, or other non-medical or administrative services;
- charged through separate billings by a provider's employee normally
included in such provider's charges and billed for by them;
- provided as a result of failure or refusal to obtain treatment or follow a
plan of treatment prescribed or directed by a practitioner;
- that are part of a hospital, facility, or institutional stay if the
patient is discharged and readmitted to the hospital, facility, or institution
within 14 days in order to qualify for insurance coverage where the patient
was not previously covered;
- for travel whether or not it is prescribed by a practitioner;
- for guest meals, telephones, televisions, and other convenience items;
- for routine examinations or testing;
- for the treatment of any injury, illness, or medical condition that is not
medically necessary;
- for illnesses resulting from an act of war or relating to the commission
of a felony;
- for treatment of organic brain syndrome;
- for acupuncture;
- for examinations of an inpatient that are not related to the diagnosis;
- for educational or teacher's services, or separate charges by interns,
residents, house physicians, or other health care professionals employed by
the covered facility;
- for smoking cessation;
- for weight loss and weight management programs;
- for court-ordered treatment (unless medically necessary);
- for psychoanalysis to complete degree or residency requirements;
- for experimental treatment or treatment performed for the purpose of
research;
- for marriage counseling, educational therapy, speech therapy, behavior
therapy, vocational therapy, coma-stimulation therapy, activities therapy, and
recreational therapy;
- for pastoral counseling;
- for psychological testing for education purposes.
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