Covered Behavioral Health Services
Medicare Advantage Prescription Drug Plan
Virginia Premier provides coverage for traditional inpatient and outpatient behavioral health and substance abuse services for Virginia Premier Medicare Advantage members. Traditional services are covered at both the individual and group levels of care.
In addition to inpatient mental health hospitalization, Medicare Part B (medical Insurance) helps to pay for these outpatient behavioral health services:
- A one-time “Welcome to Medicare” preventive visit (you must use within the first 12 months of Part B enrollment)
- One depression screening per year to include necessary treatment recommendations and referral to services
- Individual psychotherapy with professionals licensed in the state where you receive the services
- Group psychotherapy with professionals licensed in the state where you receive the services
- Family counseling focusing on assisting the Virginia Premier member with your treatment that is provided by a professional licensed in the state where you receive the services
- Outpatient mental health services for treatment of alcohol and substance use
- Diagnostic testing to identify problems and ensure receipt of appropriate and effective services
- Psychiatric evaluation
- Medication management
- Medicare-approved prescription drugs
- A yearly Wellness visit to talk with your doctor or other health care providers about changes in your mental health
How to Access Medicare Behavioral Health Services
For more information about coverage for Medicare behavioral health and substance abuse services, contact Virginia Premier Member Services at 1-877-739-1370, TTY:711 Monday through Friday 8:00 am to 8:00 pm or go to https://www.medicare.gov/coverage/mental-health-care-outpatient.
Medicaid Covered Services
Behavioral health services offer a wide range of treatment options for individuals with a mental health or substance use disorder. Many individuals struggle with mental health conditions such as depression, anxiety, or other mental health issues. Substance use may also be a factor.
These behavioral health services aim to help people live in their community and maintain the most independent and satisfying lifestyle possible. Services range from outpatient counseling to hospital care, including day treatment and crisis services. These services can be provided in your home or in the community, over a short or long time frame. All services are performed by qualified individuals and organizations.
Virginia Premier provides most of the Medicaid EPSDT covered services, including Applied Behavioral Analysis (ABA) services. Behavioral therapy services must be designed to enhance communication skills and decrease maladaptive patterns of behavior before there is a need for more restrictive level of care.
- Are available to members under 21 years of age
- Include assessments (up to 5 hours per child, per provider)
- Should ensure the member’s family or caregiver is trained to support the member in the home and community using the skills learned while actively participating in behavioral therapy
- Are only allowed after the service provider documents that lesser services such as Community Mental Health Rehabilitation Services (CMHRS) services are not the best option
Please reach out to case management at telephone number for assistance with accessing EPSDT services.
How to Access Medicaid Behavioral Health Services
To access behavioral health services, you can call Virginia Premier Member Services at 1-800-727-7536 (TTY: 711), Monday through Friday, 8:00 am to 5:00 pm. The call is free and you can also be connected to your care coordinator during the call. You can also contact your Care Coordinator.
Behavioral Health Services Administrator (BHSA)
Some behavioral health services, such children’s residential treatment and therapeutic foster care case management, are covered for you through Magellan of Virginia until April 2019. Magellan of Virginia is the behavioral health services administrator (BHSA) for the Department of Medical Assistance Services (DMAS). Virginia Premier’s Member Services Department can help coordinate the services you need, including those that are provided through the BHSA.
Community Mental Health Rehabilitation Services (CMHRS) and Trauma Informed Care
Virginia Premier provides coverage for traditional inpatient and partial psychiatric hospitalization. We also cover Community Mental Health Rehabilitation Services (CMHRS) for Medallion 4.0 members. CMHRS services are also available for members who have experienced potentially traumatic events in their lifetime.
Trauma refers to intense and overwhelming experiences that involve serious loss, threat or harm to a person’s physical and/or emotional well-being. These experiences may occur at any time in a person’s life. They may involve a single traumatic event or may be repeated over many years. People often find a way of coping that may work in the short run, but can cause serious harm in the long run.
Virginia Premier’s in-network providers deliver services to members through a trauma-informed care framework.
Addiction and Recovery Treatment Services (ARTS)
Virginia Premier offers a variety of services that help individuals who are struggling with substance use. This includes alcohol and drug use. Addiction is a medical illness, just like diabetes. Many people face addiction, and can benefit from treatment. If you need treatment for addiction, we cover services that can help you.
Virginia Premier covers the following ARTS services:
- Inpatient acute detoxification hospitalization;
- Partial hospitalization;
- Group home / halfway house;
- Residential treatment facility services;
- Substance abuse intensive outpatient treatment;
- Outpatient (individual, family, and group) substance abuse treatment;
- Opioid treatment services (includes individual, group counseling; family therapy and medication administration); and
- Substance abuse peer specialist services.
Medication-assisted treatment options are also available for addiction involving prescription or non-prescription drugs. Peer services are provided by someone who has experienced similar issues and in recovery. Case management services are also available.
How to Access Addiction and Recovery Treatment Services (ARTS)
Talk to your Primary Care Provider (PCP) or call a Virginia Premier Care Coordinator to determine the best option for you and how to get help in addiction and recovery treatment services.
To find an ARTS provider, you can do any of the following:
- look in the Provider and Pharmacy Directory
- visit our website at virginiapremier.com
- call your Virginia Premier Care Coordinator
- contact Member Services at 1-800-727-7536, 8:00 am to 5:00 pm, Monday through Friday
If you have any questions or if you are interested in finding out more about ARTS, please do not hesitate to reach out to us. We hope you will take advantage of these services that are a benefit and are available at no cost to you.
Prior Authorizations for Behavioral Health and ARTS
Virginia Premier requires a prior service authorization for:
- all inpatient behavioral health and substance abuse admissions to hospitals
- partial hospitalization
- residential treatment
- substance abuse group home / halfway house treatment
- intensive outpatient substance abuse services
We also require a prior service authorization for the following Community Mental Health and Rehabilitation services (CMHRS) services:
- mental health case management
- therapeutic day treatment (TDT) for children
- day treatment / partial hospitalization for adults
- crisis intervention and stabilization
- intensive community treatment
- mental health skill-building services (MHSS)
- intensive in-home
- psychosocial rehab
- mental health peer support services (individual)
- mental health peer support services (group)
To find out more about how to request approval for these treatments or services, contact Member Services at 1-800-727-7536, 8:00 am to 5:00 pm, Monday through Friday, or call your Care Coordinator.
Any person or child admitted to a psychiatric residential treatment facility will be temporarily excluded from the Medallion 4.0 program until they are discharged. Any person or child admitted to a therapeutic group home (TGH) will not be excluded from the Medallion 4.0 Program; however, the TGH per diem service is “carved out” of the Medallion 4.0 contract and will be administered through Magellan of Virginia until April 1, 2019. Any professional medical services rendered to individuals in the TGH will be administered by Virginia Premier.