What the Program Does Not Cover
The following list includes, but is not limited to, the benefits the Plan will not pay for:
  • Any services performed by a non-licensed provider for mental health treatment.
  • Treatment programs for which the primary diagnosis is not a mental health condition or substance abuse.
  • Treatment programs which are not certified as medically necessary.
  • Growth/personal exploration or learning disabilities.
  • Treatment that does not meet the national standards established by mental health and substance abuse treatment professionals or is deemed to be experimental.
  • Court-ordered testing and treatment (unless otherwise covered and medically necessary).
  • Services or supplies rendered or furnished before the patient became covered by the Program or after the patient's coverage terminated.
  • Treatment for tobacco addiction and treatment of eating disorders, except disorders listed in the DSM V.
  • Ancillary services for vocational rehabilitation, behavioral training and employment counseling.
  • Medical detoxification that must be provided in an acute medical unit of a hospital. (This expense may be covered under your medical plan.)
  • Charges in excess of usual and customary fees, or negotiated rates in the case of a network provider.
  • Outpatient or take-home prescription drugs and medicines, outpatient diagnostic laboratory tests, and ambulance transportation for covered conditions. (These expenses may be covered under your medical plan.)
  • Any conditions for which benefits are recoverable under Workers' Compensation or any similar law.
  • Treatment of family members other than as a patient (unless it is part of an approved treatment plan for the patient).
  • Psychological testing unless determined to be both appropriate and medically necessary by the claims administrator and authorization is obtained.
  • Outpatient ElectroConvulsive Therapy (ECT), unless determined to be both appropriate and medically necessary by the claims administrator and authorization is obtained.
  • Mental health treatment if enrolled in an HMO or the Kaiser EPO plan.
  • Outpatient substance abuse and detoxification if enrolled in Kaiser Permanente EPO or Kaiser Permanente Senior Advantage.
  • Custodial care for a mental health condition. Custodial care is defined as care rendered to a patient who:
    • is disabled mentally or physically, and such disability is expected to continue and to be prolonged; and
    • requires a protected, monitored and controlled environment, whether in an institution or in the home; and
    • requires assistance to support the essentials of daily living; and
    • is not under active and specific medical/surgical or psychiatric treatment which will reduce the disability to the extent necessary to enable the patient to function outside the protected, monitored or controlled environment.
A custodial care determination is not precluded by the fact that a patient is under the care of a supervising or attending physician and that services are being ordered and prescribed to support and generally maintain the patient's comfort. Further, a custodial care determination is not precluded because the ordered and prescribed services and supplies are being provided by a Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.) or Licensed Visiting Nurse (L.V.N.).