Mental Health Exception Benefits

In-Network Providers

To find a list of in-network mental health providers or to see if your mental health provider is in the Cigna network, please use the link below:

Behavioral Health Providers

• Enter your zip code

• Click DOCTOR BY CHOICE and Select the specific type of mental health provider from the full drop down list to get a listing of in-network mental health providers.

• Click DOCTOR BY NAME and enter your existing mental health provider's name to see if they are in the Cigna network.

Out-of-Network Providers

Out-of-Network Providers are not contracted with Cigna Health and are allowed to charge more than the maximum amount allowed by Cigna.   When using out of network providers, you may be responsible for these  additional charges, not covered by your insurance plan.  You may also be required to pay at the time of service, submit your own claims to the insurance carrier and wait for reimbursement to arrive.

First 12 (Lifetime) Visits Covered at 90%

Dartmouth has worked with Cigna to develop a short-term benefit that helps to pay for 90% of  your first twelve (12) lifetime, out-of-network, mental health visits. This benefit is available to employees and their dependents enrolled in a Dartmouth medical plan.

Required Documentation

To access the Exception benefit, a Cigna mental health claim form needs to be submitted to Cigna. An itemized bill is also required. It's important to note that neither a credit card receipt nor a canceled check qualifies as an itemized bill. 

Cigna will make a payment directly to the individual or their provider depending on the instructions on the claim form (e.g. a signature under "payment instructions" indicates payment should be made directly to the provider). 

Cigna Mental Health Benefit Claim Form

If you have any questions, please call the Cigna customer service department at the phone number listed on the back of your Cigna member identification card (1-855-869-8619) or contact the Dartmouth Benefits Office at 603-646-3588 or human.resources.benefits@dartmouth.edu.

How Does the "12 Lifetime Visit" Benefit Work?

• OAP, CCF and HDHP with HRA Plan:
  When enrolled in the OAP, CCF and HDHP with HRA plans, your first twelve visits with an out-of-network mental health provider will be processed to pay 90% of the provider's billed charges. You will be responsible for the remaining 10% (i.e. if the provider bills a total of $200/visit, you are responsible for $20/visit).  See "What happens if I exhaust the 12 mental Health Exception visits" section below.

• HDHP with HSA Plan:
  When enrolled in the HDHP with HSA plan, the IRS requires that you first meet your annual in-network deductible each calendar year, before the 12 lifetime mental health exception benefit coverage can be utilized (See the "Visits 13 and Beyond" for HDHP below for how visits will pay prior to the 12 lifetime visits, each year).  Once your annual deductible has been met, the plan will cover up to a maximum of 12 visits at 90% of the provider's billed charges. You will be responsible for the remaining 10% of the billed charges (i.e. if the provider bills a total of $200/visit, you are responsible for $20/visit)  If you cross into a new calendar year prior to exahausting your 12 lifetime visits, you will again need to meet your annual deductible before you can utilize any more of the 12 lifetime visits.  See "What happens if I exhaust the 12 mental Health Exception visits" section below.

Will my 10% coinsurance be applied to my out-of-pocket maximum?

Yes, the 10% that you pay during the 12 Lifetime visit exception period is considered eligible coinsurance paid, and will be applied toward your annual out-of-pocket maximum.

VISITS 13 AND BEYOND

What happens if I exhaust the 12 lifetime Mental Health Exception visits but want to continue to treat with an out-of-network provider?

On January 1, 2023 Dartmouth expanded the out of network behavioral benefit.  This change is in recogntion of the current difficulty of receiving in-network behavioral health services in our area. The additional coverage now allows all out-of-network mental health claims to be paid at the same copay and deductible/coinsurance levels that you pay for in-network visits.  However, balance billing may apply even after the annual out-of-pocket maximum has been met. 

Examples:

• OAP and CCF plans: You will pay either a $25 or $35 in-network copay per visit, if enrolled in the OAP or CCF medical plans. The remainder of each claim will be paid at 100% up to the Maximum Reimbursable Charge (MRC).  This means that any additional out-of-network balance billing may apply even after out-of-pocket maximum has been met.

• HDHP plan:  You will pay 100% toward the cost of each visit, and only the portion of the cost up to the Maximum Reimbursable Charge (MRC) amount is applied toward your in-network deductible.  If your provider is charging $200/visit, and MRC is $150, then only $150 counts toward your in-network deductible. The remaining $50 is balance billed and does not count toward deductibles or out-of-pocket maximums.  Once your annual in-network deductible of $3,200 has been met for the year, then you will be responsible for 10% of the MRC amount.  In the example above the 10% of MRC would equate to $15/visit plus the balance billed amount of $50, resulting in a total out-of-pocket cost of $65/visit.

What is a Maximum Reimbursable Charge (MRC)?

Cigna will reimburse up to the Maximum Reimbursable Charge (MRC) also refered to as the  "allowed" amount shown on your Explanation of Benefits (EOB).  A Maximum Reimbursable Charge (MRC), is the most your insurance plan will allow an out-of-network provider to charge for a given service. The amount is based on the lesser of the normal charge for the service or a percentile of what other doctors or facilities in your area typically charge for the same service.  Billed charges at or below the MRC will be applied toward your annual deductible and out-of-pocket maximums. Billed charges above MRC will be balance billed.

What is Balance Billing?

When a provider is out-of-network, and not contracted with Cigna, the provider is allowed to charge you for any additional amount that is greater than the Maximum Reimbursable Charge (MRC). These balance billed amounts display on your Explanation of Benefits as a "not covered" amount. Balance billed amounts are not applied toward the annual deductible or out-of-pocket maximum, they are simply an additional charge for the service.

What is an itemized Bill?

An itemized bill is given to you by your mental health provider and must contain the following information:

• Provider's name
• Provider's address
• Provider's tax identification number o
• patient's name
• date of service
• location of service
• procedure code of service provided
• diagnosis code
• charge for the service

If the outlined process is not followed or if all necessary information is not submitted, there may be a delay in payment. Upon receipt of accurate and complete information, 

What if my provider will not submit the claim?

Some mental health providers will require you to pay the full cost of your visit at the time of service.  In these cases, you will be responsible for filling out a claim form and submitting the form to Cigna for processing and reimbursement. 

Who should I contact if I have any questions regarding the Mental Health Exception benefits?

The Dartmouth Benefits Office at 603-646-3588 or human.resources.benefits@dartmouth.edu