Maternity and Mental Health Care Coverage from Lumenos Georgia Health Insurance

Maternity Care

Benefits are payable for pregnancy-related expenses of female employees or eligible spouses/dependents on the same basis as a covered illness. The expenses must be incurred while the person is covered under the Lumenos plan.

If you become pregnant, you are invited to enroll in the FutureFootsteps maternity program provided by FutureHealth. The Lumenos plan has important information to help you have a healthy pregnancy. Depending on your needs, a nurse will follow you throughout your pregnancy to provide support and help you carry out your doctor's instructions.

Also covered are services rendered in a birthing facility, provided that the physician in charge is acting within the scope of his license and the birthing facility meets all legal requirements; and midwife delivery services provided that the state in which such services are performed has legally recognized midwife delivery, and provided the midwife is licensed at the time delivery is performed.

NOTE: Home births are not covered, even if attended by a mid-wife.

Nursery facility charges for a baby will be covered under the enrolled mother until discharge from the nursery. Only charges for a nursery will be considered. Children admitted to or transferred to a more intensive level of care including, but not limited to, ICU, PICU, NICU are not covered under the Plan unless they are enrolled.

In order for any additional costs (including, but not limited to physician charges, labs, drugs) to be considered, the baby must be enrolled as per the Plan's enrollment and eligibility guidelines. No coverage exists until enrollment is completed.

Contact your payroll location to add the baby.

NOTE: Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Mental Health/Chemical Dependency

The Lumenos plan provides coverage for both mental health and chemical dependency care services. For mental health and chemical dependency services, the Lumenos plan pays 90% of discounted fees for providers who offer discounts or 60% Reasonable and Customary charges for providers who do not offer Discounts.

Services covered under your mental health and chemical dependency coverage include:

• Inpatient Mental Health and Chemical Dependency Confinement
• Outpatient Mental Health and Chemical Dependency Treatment

Inpatient and Residential Treatment Center Mental Health and Chemical Dependency Confinement

An acute inpatient hospitalization is described as treatment that includes 24-hour nursing and daily, active treatment under the direction of a psychiatrist, or for children and adolescents, a board certified/eligible child and adolescent psychiatrist.

Charges of a facility and/or professional provider related to or because of psychiatric illness are covered as follows:

• Inpatient facility charges;
• Individual Psychotherapy;
• Group Psychotherapy;
• Psychological Testing;
• Family Counseling (counseling with family members to assist in the covered person's diagnosis and treatment);
• Electro-Convulsive Therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider.

Benefits for mental health and chemical dependency inpatient confinement are limited to 30 days per person per Plan year combined on an aggregate basis.

Outpatient Mental Health and Chemical Dependency Treatment

Outpatient mental health treatment and chemical dependency treatment is described as the diagnosis or treatment of a mental disease, disorder, or condition listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as revised, whether or not the cause of the disease, disorder, or condition is physical, chemical, or mental in nature or origin. Care must be provided by a physician or licensed mental health/chemical dependency provider. Covered services include but are not limited to:

• Assessment
• Diagnosis
• Individual, group, family or conjoint psychotherapy,
• Medication management
• Psychological testing and assessment,
• Electroconvulsive treatment (ECT)
• Crisis intervention
• Rehabilitation (drug and alcohol related)

ECT, medication management, biofeedback treatments for mental health, and methadone maintenance treatments are covered under this benefit, but do not apply to the outpatient mental health/chemical dependency limits.

Outpatient services are limited to 30 visits per Plan year for individual and group therapy combined. The 30-visit maximum applies to outpatient mental health treatment and outpatient chemical dependency treatment combined.

Alternative Levels of Care

Alternative levels of care are covered as follows and apply toward annual inpatient day limits:

• Acute Partial Hospitalization: This is treatment that includes daily nursing and active treatment in a structured treatment program lasting 5-7 days per week and delivering at least 20 hours of active treatment per week, with patients going home each evening and/or weekend.
• Intensive Outpatient Treatment (IOP): IOP is a structured program that includes combinations of individual and group process therapy, meeting at least three times per week, and delivering at least 4 hours of treatment per week.