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Behavioral health services are covered benefits. Covered benefits include outpatient mental health counseling, outpatient treatment services, and inpatient treatment services for members who are diagnosed with severe mental illness (SMI), serious emotional disturbances (SED), substance use disorders (SUD), or autism spectrum disorder (ASD).
Provider Expectations: Integrating Physical and Behavioral Care VHP encourages and supports collaborative efforts among PCPs, as well as other medical/surgical health care providers. VHP supports whole-person health care because physical conditions and mental illness and substance use are interdependent and the treatment of both must be coordinated. Physical health conditions can and often do exacerbate behavioral health conditions or can trigger behavioral health issues, for example, the onset of depression following a cardiac event. Behavioral health conditions can and often do impact physical health conditions. For example, a person with depression may lack the motivation or energy to follow the physical therapist’s recommendations for rehabilitation after a surgery. The treatment and medication regimens for physical and behavioral health conditions may interact. For example, many psychotropic medications can cause weight gain, which can exacerbate metabolic syndromes or diabetes. Even a differential diagnosis can be complicated if the assessment fails to consider potential physical causes for apparent mental conditions, such as psychosis-like symptoms triggered by high liver enzymes in members with liver disease.
Communication with the Primary Care Providers VHP encourages ongoing consultation between PCPs and their members’ behavioral health providers. In many cases, the PCP has extensive knowledge about the member’s medical condition, mental status, psychosocial functioning, and family situation. Communication of this information at the point of referral or during treatment is encouraged with member consent, when required. Behavioral health providers may find the member’s PCP on the front-side of the member ID Card or providers may contact Case Management at 1.408.885.2600 (see Chapter 3, “Enrollment and Eligibility” and the section entitled “Sample ID Card” for the location of the PCP’s name and telephone number). Behavioral health providers should refer members with known or suspected untreated physical health problems or disorders to the member’s PCP for examination and treatment. Behavioral health providers should also communicate with the member’s PCP when there is a behavioral health problem or treatment plan that can affect the member’s medical condition, or the treatment being rendered by the PCP. In addition, the behavioral health provider should communicate with other
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CH 19: Behavioral Health Services
2021 / Provider Manual
