Mental health Services are subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser. You may request these criteria by calling Member Services. We cover Participating Provider Services under this “Mental Health Services” section only if they are provided by a licensed psychiatrist, licensed psychologist, licensed clinical social worker, licensed mental health counselor, licensed professional counselor, licensed marriage and family therapist, advanced practice psychiatric nurse, licensed behavioral analyst, licensed assistant behavioral analyst or registered behavioral analyst interventionist. The benefits described in this “Mental Health Services” section comply with the Mental Health Parity and Addiction Equity Act. This Plan will cover court-ordered treatment only if determined to be Medically Necessary by a Participating Provider. All costs for mental health Services in excess of the coverage provided under this EOC, including the cost of any care for which the Member failed to obtain prior authorization, or any Services received from someone other than a Participating Provider will be the Member’s sole responsibility to pay. Outpatient Services Services for diagnosis and treatment of mental illness are covered for intensive outpatient visit, partial hospitalization, and without charge for Assertive Community Treatment (ACT) Services for mental health. ACT Services are designed to provide comprehensive outpatient treatment and support to Members who are diagnosed with a severe mental illness and whose symptoms of mental illness lead to serious dysfunction in daily living. We cover mental health Services in a skilled nursing facility, when all of the following are true:  You are substantially confined to a skilled nursing facility in lieu of Medically Necessary hospitalization.  Your Participating Provider determines that it is feasible to maintain effective supervision and control of your care in a skilled nursing facility and that the Services can be safely and effectively provided in a skilled nursing facility.  You receive prior authorization from Kaiser in accordance with Utilization Review criteria developed by Medical Group and approved by Kaiser. We cover in home mental health Services, when all of the following are true:  You are substantially confined to your home (or a friend’s or relative’s home), or the care is provided in lieu of Medically Necessary hospitalization.  Your Participating Provider determines that it is feasible to maintain effective supervision and control of your care in your home and that the Services can be safely and effectively provided in your home.  You receive prior authorization from Kaiser in accordance with Utilization Review criteria developed by Medical Group and approved by Kaiser. Inpatient Hospital Services We cover inpatient hospital Services for mental health, including drugs that are prescribed as part of your plan of care and administered to you by medical personnel in the inpatient facility. Prior authorization is not required for Members who are involuntarily committed and subsequently treated in a state hospital. Residential Services We cover residential Services in a residential facility, including drugs that are prescribed as part of your plan of care and administered to you by medical personnel in the residential facility. Psychological Testing If, in the professional judgment of a Participating Provider you require psychological testing as part of diagnostic evaluation, prescribed tests are covered in accord with this “Mental Health Services” section. We EWCLGDED1983ACT0124 53 WAPEBB-CL-ACT