Behavioral health benefits must incorporate the primary diagnosis and procedure code as a primary driver for benefit categorization and cost share application. These changes result in additional services applying a behavioral health cost share, where previously they would have applied a medical cost share. Examples include, but are not limited to, the following:

• Example 1: A primary care physician who bills for an office visit with a primary behavioral health diagnosis code will apply a Mental Health Office Visit cost share.
• Example 2: Outpatient habilitative therapy session billed with a primary behavioral health diagnosis will apply the Mental Health Outpatient-Other cost share.
• Example 3: Inpatient facility services are driven by the bed type (revenue code) billed on the claim. A mental health bed-type revenue code will apply the Mental Health Inpatient benefit and cost share.
• Example 4: Gender affirming surgery performed in an inpatient setting and billed with a primary mental health diagnosis (i.e., gender dysphoria) will apply the Mental Health Inpatient benefit and cost share instead of the medical surgery benefit and cost share.
• Example 5: Diagnostic radiology services billed with a primary behavioral health diagnosis will apply the Mental Health Outpatient-Other benefit and cost share, instead of the medical radiology benefit cost share.
• Example 6: Physical, occupational and/or speech therapy billed with a primary behavioral health diagnosis (e.g., autism) will apply the Mental Health Outpatient-Other benefit and cost share, instead of the medical PT/OT/ST cost share.