Member Benefits

The Chilren's Health Insurance Program (CHIP) includes a broad range of psychiatric and substance use services. The Health and Human Services Commission decides how many services members may receive each year. However, if more services are needed, Tejas staff may provide a clinical review to make an exception to these limits. See below for a summary of services.

Inpatient Mental Health Services

Mental health services, including those for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities.

Inpatient mental health services are limited to 45 days per 12-month enrollment period and include, but are not limited to:

  • Neuropsychological and psychological testing
  • Inpatient psychiatric services, up to 12-month period limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities. Court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination
  • 25 days of the inpatient benefit can be converted to residential treatment, therapeutic foster care or other 24-hour therapeutically planned and structured services or sub-acute outpatient (partial hospitalization or rehabilitative day treatment) mental health services on the basis of financial equivalence against the inpatient per diem cost
  • 20 of the inpatient days must be held in reserve for inpatient use only

Inpatient Mental Health Services do not require a primary care physician referral.

Outpatient Mental Health Services

These mental health services, including for serious mental illness, are provided on an outpatient basis.

Outpatient mental health services are limited to 60 outpatient visits per 12-month enrollment period and include, but are not limited to:

  • Visits that can be furnished in a variety of community-based settings (including school and home-based) or in a state-operated facility;
  • Outpatient psychiatric services, up to 12-month period limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities. Court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.
  • Up to 60 days with a 12-month period limit for rehabilitative day treatment
  • 60 rehabilitative day treatment days can be converted to outpatient visits on the basis of financial equivalence against the day treatment per diem cost.
  • 60 outpatient visits can be converted to skills training (psycho educational skills development) or rehabilitative day treatment on the basis of financial equivalence against the outpatient visit cost

Medication management visits do not count against the outpatient visit limit.

Outpatient Mental Health Services do not require a primary care physician referral.

Inpatient Substance Abuse Treatment Services

Services include, but are not limited to:

  • Inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs
  • Medically necessary detoxification/stabilization services, limited to 14 days per 12-month period.
  • 24-hour residential rehabilitation programs, or the equivalent, up to 60 days per 12-month period
  • 30 days may be converted to partial hospitalization or intensive outpatient rehabilitation, on the basis of financial equivalence against the inpatient per diem cost
  • 30 days must be held in reserve for inpatient use only.

Inpatient Substance Abuse Treatment Services do not require a primary care physician referral.

Outpatient Substance Abuse Treatment Services

Services include, but are not limited to, the following:

  • Prevention and intervention services that are provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders.
  • Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day
  • Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training
  • Outpatient treatment services up to a maximum of:
  • Intensive outpatient program (up to 12 weeks per 12-month period)
  • Outpatient services (up to six-months per 12-month period)

Outpatient Substance Abuse Services do not require a primary care physician referral.

If you need any of these health plan services, contact a Tejas Member Services Representative at 1-800-852-7691.