MMC Benefits Handbook
Mental Health/Substance Use
NOTE: Out-of-network services are not covered under the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN)) except for urgent and emergency care. There are some providers in New Jersey and Philadelphia that are listed as Tier 2 on Anthem BCBS's provider search (National Blue High Performance Network (Blue HPN)) that can be used and are covered at the out-of-network benefit level. Providers not labeled as Tier 2 cannot be used for out of network coverage.
Does the Plan cover mental health/substance use services?
The Plan covers medically necessary inpatient and outpatient mental health/substance use treatment services, including residential treatment.
Does the Plan cover services in connection with autism?
The Plan covers medically necessary inpatient and outpatient treatment services for autism, including Applied Behavioral Analysis.
The Autism Spectrum Disorders (ASD) Program is comprised of a specialized, dedicated team of clinicians who have been trained on the unique challenges and needs of families with a participant who has a diagnosis of ASD. The Plan provides specialized case management services for participants with autism spectrum disorders and their families. The ASD Program also includes precertification and Medical Necessity reviews for Applied Behavior Analysis, a treatment modality targeting the symptoms of autism spectrum disorders.
For families touched by ASD, the ASD Program provides support for the entire family, giving assistance wherever possible and making it easier for the family to understand and utilize care, resulting in access to better outcomes and more effective use of benefits. The ASD Program has three main components:
- Educates and engages the family on available community resources, helping to create a system of care around the participant.
- Increases knowledge of the disorder, resources, and appropriate usage of benefits
- Applied Behavior Analysis management, including clinical reviews by experienced licensed clinicians. Precertification delivers value, ensuring that the participant receives the right care, from the right provider, at the right intensity.
- Increased follow-up care encouraged by appointment setting, reminders, attendance confirmation, proactive discharge planning, and referrals.
- Ensure that parents and siblings have the best support to manage their own needs.
- Enhanced participant experience and coordination of care.
- Assistance in exploration of medical services that may help the participant, including referrals to medical case management.
- Licensed Behavior Analysts and Program Managers provide support and act as a resource to the interdisciplinary team, helping them navigate and address the unique challenges facing families with a participant diagnosed with autism.