Title I, SEC. 1115. MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES. (a) Coverage. The mental health and substance abuse services that are described in this section are the following items and services for eligible individuals, as defined in section 1001(c), who satisfy the eligibility requirements in subsection (b): (1) Inpatient and residential mental health and substance abuse treatment. (2) Intensive nonresidential mental health and substance abuse treatment. (3) Outpatient mental health and substance abuse treatment, including case management, screening and assessment, crisis services, and collateral services. (b) Eligibility. The eligibility requirements referred to in subsection (a) are as follows: (1) Inpatient, residential, nonresidential, and outpatient treatment. An eligible individual is eligible to receive coverage for inpatient and residential mental health and substance abuse treatment, intensive nonresidential mental health and substance abuse treatment, or outpatient mental health and substance abuse treatment (except case management and collateral services) if the individual (A) has, or has had during the 1-year period preceding the date of such treatment, a diagnosable mental or substance abuse disorder; and (B) is experiencing, or is at significant risk of experiencing, functional impairment in family, work, school, or community activities. For purposes of this paragraph, an individual who has a diagnosable mental or substance abuse disorder, is receiving treatment for such disorder, but does not satisfy the functional impairment criterion in subparagraph (B) shall be treated as satisfying such criterion if the individual would satisfy such criterion without such treatment. (2) Case management. An eligible individual is eligible to receive coverage for case management if (A) the health plan in which the individual is enrolled has elected to offer case management and determines that the individual should receive such services; and (B) the individual is eligible to receive coverage for, and is receiving, outpatient mental health and substance abuse treatment. (3) Screening and assessment and crisis services. All eligible individuals enrolled under a health plan are eligible to receive coverage for outpatient mental health and substance abuse treatment consisting of screening and assessment and crisis services. (4) Collateral services. An eligible individual is eligible to receive coverage for outpatient mental health and substance abuse treatment consisting of collateral services if the individual is a family member (as defined in section 1011(b)) of an individual who is receiving inpatient and residential mental health and substance abuse treatment, intensive nonresidential mental health and substance abuse treatment, or outpatient mental health and substance abuse treatment. (c) Inpatient and Residential Treatment. (1) Definition. For purposes of this subtitle, the term ``inpatient and residential mental health and substance abuse treatment'' means the items and services described in paragraphs (1) through (3) of section 1861(b) of the Social Security Act when provided with respect to a diagnosable mental or substance abuse disorder to (A) an inpatient of a hospital, psychiatric hospital, residential treatment center, residential detoxification center, crisis residential program, or mental health residential treatment program; or (B) a resident of a therapeutic family or group treatment home or community residential treatment and recovery center for substance abuse. The National Health Board shall specify those health professional services described in section 1112 that shall be treated as inpatient and residential mental health and substance abuse treatment when provided to such an inpatient or resident. (2) Limitations. Coverage for inpatient and residential mental health and substance abuse treatment is subject to the following limitations: (A) Least restrictive setting. Such treatment is covered only when (i) provided to an individual in the least restrictive inpatient or residential setting that is effective and appropriate for the individual; and (ii) less restrictive intensive nonresidential or outpatient treatment would be ineffective or inappropriate. (B) Licensed facility. Such treatment is only covered when provided by a facility described in paragraph (1) that is legally authorized to provide the treatment in the State in which the facility is located. (C) Day limits. Subject to subparagraph (D), such treatment is covered for each period beginning on the date an episode of inpatient or residential treatment begins and ending on the date the episode ends, except that, prior to January 1, 2001, such treatment is not covered after such an episode exceeds 30 days unless the individual receiving treatment poses a threat to their own life or the life of another individual. Whether such a threat exists shall be determined by a health professional designated by the health plan in which the individual receiving treatment is enrolled. For purposes of this subtitle, an episode of inpatient and residential mental health and substance abuse treatment shall be considered to begin on the date an individual is admitted to a facility for such treatment and to end on the date the individual is discharged from the facility. (D) Annual limit. Prior to January 1, 2001, such treatment in all settings is subject to an aggregate annual limit of 60 days. (E) Inpatient hospital treatment for substance abuse. Substance abuse treatment, when provided to an inpatient of a hospital or psychiatric hospital, is covered under this section only for medical detoxification associated with withdrawal from alcohol or drugs. (d) Intensive Nonresidential Treatment. (1) Definition. For purposes of this subtitle, the term ``intensive nonresidential mental health and substance abuse treatment'' means diagnostic or therapeutic items or services provided with respect to a diagnosable mental or substance abuse disorder to an individual (A) participating in a partial hospitalization program, a day treatment program, a psychiatric rehabilitation program, or an ambulatory detoxification program; or (B) receiving home-based mental health services or behavioral aide mental health services. The National Health Board shall specify those health professional services described in section 1112 that shall be treated as intensive nonresidential mental health and substance abuse treatment when provided to such an individual. (2) Limitations. Coverage for intensive nonresidential mental health and substance abuse treatment is subject to the following limitations: (A) Discretion of plan. A health plan may cover intensive nonresidential mental health and substance abuse treatment at its discretion. (B) Treatment purposes. Such treatment is covered only when provided (i) to avert the need for, or as an alternative to, treatment in residential or inpatient settings; (ii) to facilitate the earlier discharge of an individual receiving inpatient or residential care; (iii) to restore the functioning of an individual with a diagnosable mental health or substance abuse disorder; or (iv) to assist the individual to develop the skills and gain access to the support services the individual needs to achieve the maximum level of functioning of the individual within the community. (C) Annual limit. (i) In general. Prior to January 1, 2001, such treatment in all settings is subject to an aggregate annual limit of 120 days. (ii) Relationship to other annual limits. For each 2 days of intensive nonresidential mental health and substance abuse treatment provided to an individual, the number of treatment days available to the individual before the annual aggregate limit on inpatient and residential mental health and substance abuse treatment described in subsection (c)(2)(D) is exceeded shall be reduced by 1 day. The preceding sentence shall not apply after an individual has received 60 days of intensive nonresidential mental health and substance abuse treatment in a year. (iii) Additional days. A maximum of 60 additional days of intensive nonresidential mental health and substance abuse treatment may be provided to an individual if a health professional designated by the health plan in which the individual receiving treatment is enrolled determines that such additional treatment is medically necessary or appropriate. (D) Out-of-pocket maximum. Prior to January 1, 2001, expenses for intensive nonresidential mental health and substance abuse treatment that an individual incurs prior to satisfying a deductible applicable to such treatment, and copayments and coinsurance paid by or on behalf of the individual for such treatment, that substitute for inpatient and residential mental health and substance abuse treatment (up to 60 days) may be applied toward the annual out-of-pocket limit on cost sharing under any cost sharing schedule described in part 3 of this subtitle. (e) Outpatient Treatment. (1) Definition. For purposes of this subtitle, the term ``outpatient mental health and substance abuse treatment'' means the following services provided with respect to a diagnosable mental or substance abuse disorder in an outpatient setting: (A) Screening and assessment. (B) Diagnosis. (C) Medical management. (D) Substance abuse counseling and relapse prevention. (E) Crisis services. (F) Somatic treatment services. (G) Psychotherapy. (H) Case management. (I) Collateral services. (2) Limitations. Coverage for outpatient mental health and substance abuse treatment is subject to the following limitations: (A) Health professional services. Such treatment is covered only when it constitutes health professional services (as defined in section 1112(c)(2)). (B) Substance abuse counseling. Substance abuse counseling and relapse prevention is covered only when provided by a substance abuse treatment provider who (i) is legally authorized to provide such services in the State in which the services are provided; and (ii) provides no items or services other than substance abuse counseling and relapse prevention, medical management, or laboratory and diagnostic tests for individuals with substance abuse disorders. (C) Annual limits. (i) Pychotherapy and collateral services. Prior to January 1, 2001, psychotherapy and collateral services are subject to annual limits of 30 visits for each type of service. Additional visits may be covered, at the discretion of the health plan in which the individual receiving treatment is enrolled, to prevent hospitalization or to facilitate earlier hospital release, for which the annual aggregate limit on inpatient and residential mental health and substance abuse treatment described in subsection (c)(2)(D) shall be reduced by 1 day for each 4 visits. (ii) Substance abuse. At the discretion of the health plan in which an individual receiving outpatient substance abuse treatment is enrolled, the annual aggregate limit on inpatient and residential mental health and substance abuse treatment described in subsection (c)(2)(D) may be reduced by 1 day for each 4 outpatient visits. Within 12 months after inpatient and residential treatment or intensive nonresidential treatment, 30 visits in group therapy shall be covered for substance abuse counseling and relapse prevention. For individuals who were not initially treated in an inpatient, residential, or intensive nonresidential setting, additional visits shall be covered for which the annual aggregate limit on inpatient and residential mental health and substance abuse treatment described in subsection (c)(2)(D) shall be reduced by 1 day for each 4 visits. (D) Out-of-pocket maximum. Prior to January 1, 2001, expenses for outpatient mental health and substance abuse treatment that an individual incurs prior to satisfying a deductible applicable to such treatment, and copayments and coinsurance paid by or on behalf of the individual for such treatment, may not be applied toward any annual out-of-pocket limit on cost sharing under any cost sharing schedule described in part 3 of this subtitle. (E) Detoxification. Outpatient detoxification shall be provided only in the context of a treatment program. If the first detoxification treatment is unsuccessful, subsequent treatments are covered if a health professional designated by the health plan in which the individual receiving treatment is enrolled determines that there is a substantial chance of success. (f) Other Definitions. For purposes of this subtitle: (1) Case management. The term ``case management'' means services that assist individuals in gaining access to needed medical, social, educational, and other services. (2) Diagnosable mental or substance abuse disorder. The term ``diagnosable mental or substance abuse disorder'' means a disorder that is listed in any authoritative text specifying diagnostic criteria for mental or substance abuse disorders that is identified by the National Health Board. (3) Psychiatric hospital. The term ``psychiatric hospital'' has the meaning given such term in section 1861(f) of the Social Security Act, except that such term shall include (A) in the case of an item or service provided to an individual whose applicable health plan is specified pursuant to section 1004(b)(1), a facility of the uniformed services under title 10, United States Code, that is engaged in providing services to inpatients that are equivalent to the services provided by a psychiatric hospital; (B) in the case of an item or service provided to an individual whose applicable health plan is specified pursuant to section 1004(b)(2), a facility operated by the Department of Veterans Affairs that is engaged in providing services to inpatients that are equivalent to the services provided by a psychiatric hospital; and (C) in the case of an item or service provided to an individual whose applicable health plan is specified pursuant to section 1004(b)(3), a facility operated by the Indian Health Service that is engaged in providing services to inpatients that are equivalent to the services provided by a psychiatric hospital.