Amendment to Scripps HMO Evidence of Coverage — MH/SUD benefits
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This amendment modifies the Scripps Health Plan HMO Evidence of Coverage to clarify how members obtain MH/SUD services, prior authorization rules, benefit descriptions, exclusions, general provisions, and definitions; it affects Scripps Health Plan HMO enrollees and providers administering MH/SUD benefits.
How enrollees can obtain prior authorization for Mental Health/Substance Use Disorder (MH/SUD) services was revised.
Member Benefit and Out-of-Pocket Maximum section revised to clarify prior authorization requirements.
Inpatient Mental Health and Substance Abuse Services amended to include medically necessary treatment of persons of any age and serious emotional disturbances of a child; clarified inpatient drug coverage under inpatient hospital copayment.
Outpatient Mental Health and Substance Abuse Services clarified which MH/SUD conditions and provider types are covered and differentiated 'Outpatient Office Visits' from 'Outpatient Other Items and Services' with revised cost-sharing.
Exclusion for reading/vocational therapy was clarified.
Member Responsibility section revised to note that prior authorization and treatment plans are not required for all MH/SUD benefits and to explain how to obtain a utilization review policy for MH/SUD benefits.
Definitions of 'Serious Mental Illness', 'Serious Emotional Disturbance', and Emergency Services were revised.
Coverage Criteria and Scope
Amended coverage descriptions
Amendments describing coverage changes and clarifications
From Benefit Descriptions, page 62
This amendment clarifies the scope of the exclusion for reading and vocational therapy as reflected in the Exclusions and Limitations section (page 72). The update narrows and specifies how these therapeutic services are treated under the EOC so that providers and billing staff can determine when such services are not covered and therefore should not be billed to the plan.
Provider Actions, Prior Authorization, and Utilization Review
Prior authorization for MH/SUD services — how enrollees obtain authorization
The EOC was revised to explain how enrollees can obtain prior authorization for Mental Health/Substance Use Disorder (MH/SUD) services and to state that prior authorization and treatment plans are not required for all MH/SUD benefits; procedures for obtaining authorization are described in the EOC and the Amendment (see pages 18–19 and Member Responsibility).
- Enrollees should follow the prior authorization procedures described in the EOC (pages 18–19).
- Not all MH/SUD benefits require prior authorization or a treatment plan; the Member Responsibility section explains which benefits do.
Step therapy (not specified) — prescription drug administration
This Amendment does not specify any step therapy rules for MH/SUD medications; prescription drug benefits (including any step therapy requirements) are administered by MedImpact and governed by the prescription drug plan documents.
- Contact MedImpact for coverage rules and any step therapy requirements at 1-844-282-5343 (TTY: 711).
Utilization review policy availability — how members obtain it
Members may obtain the utilization review policy for MH/SUD benefits; the Member Responsibility section was revised to explain which MH/SUD benefits require prior authorization and how to get a utilization review policy (page 78, #15).
- Copies of the amended EOC and SBC (including utilization review information) are available at www.scrippshealthplan.com/member-information under 'Benefit Information & Forms.'
- Questions may be directed to Scripps Customer Service at 1-844-337-3700 (TTY: 1-888-515-4065) or to Cigna BH for MH/SUD provider access at 1-800-866-6534 (TTY: 711).
Prior authorization implications — coverage and cost-sharing risks
Services that require prior authorization under the EOC and Member Benefit/Out‑of‑Pocket Maximum provisions may be subject to benefit limitations or different cost‑sharing if prior authorization is not obtained.
- The Member Benefit and Out‑of‑Pocket Maximum section was revised to clarify prior authorization requirements and associated cost‑sharing (pages 22–23).
- Providers should verify authorization requirements before delivering services to avoid coverage or cost‑sharing consequences.
Background and Policy Purpose
The amendment updates benefit descriptions and definitions to ensure parity with the Mental Health Parity and Addiction Equity Act (MHPAEA) and to clarify coverage distinctions between inpatient and outpatient mental health/substance use disorder (MH/SUD) services. Notable clarifications include: coverage for medically necessary inpatient treatment for persons of any age and for serious emotional disturbance in children, revised outpatient benefit categories that distinguish Outpatient Office Visits from Outpatient Other Items and Services with corresponding cost-sharing adjustments, and revised definitions for Serious Mental Illness, Serious Emotional Disturbance, and emergency services to guide benefit application.
Key Definitions
Inpatient and Outpatient Level-of-Care Clarifications
Inpatient / Outpatient (amendment clarifies covered conditions and age applicability)
Clarified distinctions between inpatient and outpatient MH/SUD benefits, including age applicability and covered conditions
From Benefit Descriptions, pages 62-65
General Mental Health/Substance Use Disorder Services
General MH/SUD services
Covered treatment modalities and service scope for MH/SUD benefits
From Outpatient Mental Health and Substance Abuse Services clarification (pages 63-65)
Outpatient Visit Types and Limits
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