Sec. 204. Exclusions and limitations
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/bill/113/hr/1200/ih/section-204·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Subject to section 201(e), benefits for service are not available under this Act unless the services meet the standards specified in section 201(a). A State health security program shall ensure that mental health services and substance abuse treatment services are furnished through an organized system of care, as described in paragraph (2), if— the services are provided to an individual less than 22 years of age; the individual has a serious emotional disturbance or a substance abuse disorder; and the individual is, or is at imminent risk of being, subject to the authority of, or in need of the services of, at least 1 public agency that serves the needs of children, including an agency involved with child welfare, special education, juvenile justice, or criminal justice.
In this subsection, an organized system of care is a community-based service delivery network, which may consist of public and private providers, that meets the following requirements: The system has established linkages with existing mental health services and substance abuse treatment service delivery programs in the plan service area (or is in the process of developing or operating a system with appropriate public agencies in the area to coordinate the delivery of such services to individuals in the area).
The system provides for the participation and coordination of multiple agencies and providers that serve the needs of children in the area, including agencies and providers involved with child welfare, education, juvenile justice, criminal justice, health care, mental health, and substance abuse prevention and treatment. The system provides for the involvement of the families of children to whom mental health services and substance abuse treatment services are provided in the planning of treatment and the delivery of services.
The system provides for the development and implementation of individualized treatment plans by multidisciplinary and multiagency teams, which are recognized and followed by the applicable agencies and providers in the area. The system ensures the delivery and coordination of the range of mental health services and substance abuse treatment services required by individuals under 22 years of age who have a serious emotional disturbance or a substance abuse disorder. The system provides for the management of the individualized treatment plans described in subparagraph
(D)and for a flexible response to changes in treatment needs over time. In applying subsection (a), the Board shall make national coverage determinations with respect to those services that are experimental in nature. Such determinations shall be made consistent with a process that provides for input from representatives of health care professionals and patients and public comment. In the case of services for which the American Health Security Quality Council (established under section 501) has recognized a national practice guideline, the services are considered to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline or in accordance with such guidelines as are provided by the State health security program consistent with title V. For purposes of this subsection, a service shall be considered to have been provided in accordance with a practice guideline if the health care provider providing the service exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline. Subject to section 201(e), the Board may impose such limits relating to the costs and frequency of replacement of eyeglasses, contact lenses, hearing aids, and durable medical equipment to which individuals enrolled for benefits under this Act are entitled to have payment made under a State health security program as the Board deems appropriate. The coverage of services described in section 201(a) (other than paragraph (3)) which also are preventive services are required to be covered only to the extent that they are required to be covered as preventive services. Covered services under this Act do not include the following: Surgery and other procedures (such as orthodontia) performed solely for cosmetic purposes (as defined in regulations) and hospital or other services incident thereto, unless— required to correct a congenital anomaly; required to restore or correct a part of the body which has been altered as a result of accidental injury, disease, or surgery; or otherwise determined to be medically necessary and appropriate under section 201(a). Personal comfort items or private rooms in inpatient facilities, unless determined to be medically necessary and appropriate under section 201(a). The services of a professional practitioner if they are furnished in a hospital or other facility which is not a participating provider. Nursing facility services and home health services (other than post-hospital services, as defined by the Board) furnished to an individual who is not described in section 203(a) are not covered services unless the services are determined to meet the standards specified in section 201(a) and, with respect to nursing facility services, to be provided in the least restrictive and most appropriate setting.