SMALL EMPLOYER HEALTH BENEFITS PROGRAM
20 West State Street, 10th Floor
PO Box 325
Trenton, NJ 08625
May 27, 1999
To: SEH Program Member Carriers
From: Ellen F. DeRosa, Deputy Executive Director
Re: Coverage for Intensive Outpatient Services
The standard health benefit plans provide coverage for the treatment of mental or nervous conditions or substance abuse subject to a limit of 30 days per calendar year for inpatient care and 20 visits per calendar year for outpatient care. The SEH Board understands that some patients receive treatment that is termed "intensive outpatient services." The length of each intensive outpatient services session may be several hours and typically includes both individual and group therapy. Although the SEH Board understands that an outpatient visit is usually about one hour in length, and involves either individual or group therapy, the SEH Board advises carriers that intensive outpatient services must be covered in the same manner as a typical outpatient visit. The language in the standard plans does not support any other interpretation. That is, each intensive outpatient services session must be counted as one outpatient visit, subject to the payment of a single physician visit copayment, and reducing the available number of outpatient visits by one.
If you have any questions, feel free to contact me.
Published: July 1, 1999