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<br /> <br />MENTAL HEALTH BENEFITS AMENDMENT <br />FOR USE ONLY WITH TEXAS HEALTH PLANS, INC. <br />GROUP MASTER CONTRACT/ENROLLEES <br />CERTIFICATE OF COVERAGE AND SCHEDULE OF BENEFITS <br /> <br />This amendment shall be included as an addition to the Group Master <br />Contract/Enrollees Certi'ficate o'f Coverage and Schedule of Bene'fits. <br />This amendment is in effect 'for all Enrollees in accordance with the <br />terms of such Group Master Contract/Enrollees Certificate of Coverage <br />and Schedule of Bene'fits. <br /> <br />DELETE: <br /> <br />SECTION XI, SCHEDULE OF BENEFITS, E.4. <br /> <br />ADD: <br /> <br />SECTION XI, SCHEDULE OF BENEFITS, Page 5, E.4. <br /> <br />4. <br /> <br />Mental Health <br /> <br />The fallowing Mental Health Services are covered when authorized <br />in advance by Health Plan and its Psychiatric Primary Provider: <br /> <br />a. Outpatient mental health evaluations <br />and treatment for mental health conditions <br />which are not chronic or organic in nature <br />and which are responsive to short-term <br />treatment as determined by a Health Plan <br />Medical Director and for crisis intervention. <br /> <br />$20 per visit <br />no t to exceed <br />20 visits per <br />Contract <br />Year, a visit <br />not to exceed <br />one hour in <br />duration. <br /> <br />b. Inpatient services and supplies on a <br />semi-private accommodation basis Tar that <br />period of time deemed Medically Necessary <br />in a Participating Hospital or other <br />approved Health Care Facility or program <br />for conditions listed in 4.a. <br /> <br />20:1. aT <br />Eligible <br />Expenses, not <br />to exceed <br />30 days per <br />Contract <br />Year. <br /> <br />c. Services and supplies provided in an <br />approved psychiatric day treatment 'facility <br />under the direction of a participating <br />physician for that period of time deemed <br />medically necessary. Each full day of <br />services shall count as one-half of one day <br />inpatlent Mental Health services. A combin- <br />ation of benefits for these services and <br />inpatient services shall not exceed the <br />maximum benefit as stated for inpatient <br />Mental Health services. <br /> <br />20% aT <br />Eligible <br />Expenses, not <br />to exceed <br />60 days per <br />Contract <br />Year. <br /> <br />MHR(1/88) <br /> <br />1 <br />