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We cover Services specified in this "Mental Health Services" section only when the Services are for the diagnosis or treatment of Mental Disorders.

A Mental Disorder is a mental health condition as identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM)

that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning.

Mental Disorders include the Severe Mental Illness of a person of any age and the Serious Emotional Disturbance of a Child:

• "Severe Mental Illness" means the following mental disorders: schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive- compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, and bulimia nervosa.

• A "Serious Emotional Disturbance" of a child under age 18 means mental disorders as identified in the

DSM, other than a primary substance use disorder or developmental disorder, that results in behavior inappropriate to the child's age according to expected developmental norms, if the child also meets at least one of the following three criteria:

♦ as a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community; and either (1) the child is at risk of removal from the home or has already been removed from the home, or (2) the mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment

♦ the child displays psychotic features, or risk of suicide or violence due to a mental disorder

♦ the child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570) of Division 7 of Title 1 of the California Government Code

Any outpatient visit limits specified under "Outpatient mental health Services" and inpatient day limits specified under "Calendar-year day limit for inpatient psychiatric hospitalization and intensive psychiatric treatment programs" do not apply to Severe Mental Illness of a person of any age and the Serious Emotional Disturbance of a child. For all other mental health conditions, we cover evaluation and treatment only when a Plan Physician or other Plan Provider who is a license health care professional acting within the scope of his or her license believes the condition will significantly improve with relatively short-term therapy.

Outpatient mental health Services

We cover the following Services when provided by Plan Physicians or other Plan Providers who are licensed health care professionals acting within the scope of their license:

• Up to a combined visit limit of 20 individual and group visits per Member calendar year that include

Services for mental health evaluation and treatment as described in this "Outpatient mental health Services" section. Members who have exhausted the 20-visit limitation and who meet Medical Group criteria may receive up to 20 additional group visits in the same calendar year

• Psychological testing when necessary to evaluate a Mental Disorder

• Outpatient Services for the purpose of monitoring drug therapy

You pay the following for these covered Services:

• Individual mental health evaluation and treatment: a $25 Copayment per visit

• Group mental health treatment: a $12 Copayment per visit

Note: Outpatient intensive psychiatric treatment programs are not covered under this "Outpatient mental health Services" section (refer to "Intensive psychiatric treatment programs" under "Inpatient psychiatric hospitalization and intensive psychiatric treatment programs" in this "Mental Health Services" section).

Inpatient psychiatric hospitalization and intensive psychiatric treatment programs

Inpatient psychiatric hospitalization. Subject to the day limit described under "Calendar-year day limit for inpatient psychiatric hospitalization and intensive psychiatric treatment programs" in this "Inpatient psychiatric hospitalization and intensive psychiatric treatment programs" section, we cover inpatient psychiatric hospitalization in a Plan Hospital. Coverage includes room and board, drugs, and Services of Plan Physicians or other Plan Providers who are licensed health care professionals acting within the scope of their license. We cover these Services at a $200 Copayment per day.

Intensive psychiatric treatment programs. Subject to the day limit described under "Calendar-year day limit for inpatient psychiatric hospitalization and intensive psychiatric treatment programs" in this "Inpatient psychiatric hospitalization and intensive psychiatric treatment programs" section, we cover at no charge the following intensive psychiatric treatment programs at a Plan Facility:

• Short-term hospital-based intensive outpatient care (partial hospitalization)

• Short-term multidisciplinary treatment in an intensive outpatient psychiatric treatment program

• Short-term treatment in a crisis residential program in licensed psychiatric treatment facility with 24-hour-a- day monitoring by clinical staff for stabilization of an acute psychiatric crisis

• Psychiatric observation for an acute psychiatric crisis

Calendar-year day limit for inpatient psychiatric hospitalization and intensive psychiatric treatment programs. There is a combined day limit of 30 days per Member per calendar year for psychiatric care described under "Inpatient psychiatric hospitalization" and "Intensive psychiatric treatment programs" in this "Inpatient psychiatric hospitalization and intensive psychiatric treatment programs" section, except that the day limit does not apply to psychiatric care for the treatment of Severe Mental Illnesses and Serious Emotional Disturbance of a child under age 18. The number of days is determined by adding up the number of days of inpatient psychiatric hospitalization and intensive psychiatric treatment program Services we cover in a calendar year that are subject to the limit as follows:

• Each day of inpatient psychiatric hospitalization counts as one day

• Two days of hospital-based intensive outpatient care (partial hospitalization) count as one day

• Three days of treatment in an intensive outpatient psychiatric treatment program count as one day

• Each day of treatment in a crisis residential program counts as one day

• Two psychiatric observation treatment periods of 23 consecutive hours or less count as one day

If you reach the day limit, we will not cover any more inpatient psychiatric hospitalization or intensive psychiatric treatment program Services in that calendar year if they are subject to the day limit.

Services not covered under this "Mental Health Services" section

Coverage for the following Services is described under these headings in this "Benefits and Cost Sharing" section:

• Outpatient drugs, supplies, and supplements (refer to "Outpatient Prescription Drugs, Supplies, and Supplements")

• Outpatient laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures")