2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 98
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 98
Section 5(e). Mental Health and Substance Use Disorder Benefits
Important things you should keep in mind about these benefits:
- Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
- If you have an acute chronic and/or complex condition, you may be eligible to receive the services of a professional case manager to assist in assessing, planning, and facilitating individualized treatment options and care. For more information about our Case Management process, please refer to page 128. Contact us at the phone number listed on the back of your Service Benefit Plan ID card if you have any questions or would like to discuss your healthcare needs.
- Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
- Every year, we conduct an analysis of the financial requirements and treatment limitations which apply to this Plan’s mental health and substance use disorder benefits in compliance with the federal Mental Health Parity and Addiction Equity Act (the Act), and the Act’s implementing regulations. Based on the results of this analysis, we may suggest changes to program benefits to OPM. More information on the Act is available on the following Federal Government websites:
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html
https://www.dol.gov/ebsa/
www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act
https://www.dol.gov/ebsa/
www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act
- YOU MUST GET PRECERTIFICATION FOR HOSPITAL OR RESIDENTIAL TREATMENT CENTER STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3.
- PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
- Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
- You may choose to receive care from In-Network (Preferred) or Out-of-Network (Non-preferred) providers. Cost-sharing and limitations for In-Network (Preferred) and Out-of-Network (Non-preferred) mental health and substance use disorder benefits are no greater than for similar benefits for other illnesses and conditions.
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
- Under Basic Option,
- You must use Preferred providers in order to receive benefits. See page 20 for the exceptions to this requirement.
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits. See page 20 for the exceptions to this requirement.
- You should be aware that some Non-preferred (non-PPO) professional providers may provide services in Preferred (PPO) facilities.