Carelon Behavioral Health makes the following disclosures to it fully funded and state and local governmental health plans in New York:
- Carelon Behavioral Health administers broad-based coverage for the diagnosis and treatment of behavioral health conditions, and works with its clients to ensure that such coverage is at least equal to and no more restrictive than the coverage provided for other health conditions. Behavioral health conditions include mental health and substance abuse disorders.
- On behalf of its clients, Carelon Behavioral Health administers, subject to medical necessity, benefits for inpatient and outpatient behavioral health care, which are at least equal to and no more restrictive than medical/surgical benefits under the plan, as well as for residential treatment for behavioral health conditions if its client health plans offer a comparable medical/surgical benefit.
- For outpatient behavioral health visits, Carelon Behavioral Health recommends that its client health plans apply the member’s primary care cost-sharing schedule.
- The utilization review conducted by Carelon Behavioral Health for behavioral health benefits is at least equal to, and no more restrictive than, and applied no more stringently then, the utilization review conducted for medical/surgical benefits by the health plans for which Carelon Behavioral Health administers behavioral health benefits.
- Any annual or lifetime limits on behavioral health benefits for plans that Carelon Behavioral Health administers are no stricter than such limits on medical/surgical benefits.
- For plans it administers, Carelon Behavioral Health does not apply any cost-sharing requirements that are applicable only to behavioral health benefits, unless there is a unique behavioral health benefit for which there is no comparable medical/surgical benefit, and Carelon Behavioral Health has provided notice of same to the Office of the Attorney General.
- Carelon Behavioral Health does not apply any treatment limitations that are applicable only to behavioral health benefits, except for family counseling services, which may be capped at twenty (20) visits per year, or any other limitation required by law, for which Carelon Behavioral Health has provided notice to the Office of the Attorney General.
- The criteria for medical necessity determinations made by Carelon Behavioral Health 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 a plan administered by Carelon Behavioral Health covers medical/surgical benefits provided by out-of-network providers, the plan covers behavioral health benefits provided by out-of-network providers.
- Carelon Behavioral Health members are charged a single deductible for all benefits, whether services rendered are for medical/surgical or behavioral health conditions, with the exception that some plans may charge a separate, combined deductible for prescription drugs.
- MVP and Emblem, for which Carelon Behavioral Health administers behavioral health benefits, offer members the services of Behavioral Health Advocates, who are trained to assist 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.