2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 101
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 101
Benefit Description
Residential Treatment Center (cont.)
We cover inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Note: Benefits are not available for noncovered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of practice; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; hippotherapy/equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long term care (see Definitions, page 153); and domiciliary care provided because care in the home is not available or is unsuitable.
Note: For outpatient residential treatment center services, see the next Section.
Standard Option - You Pay
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: Non-member facilities must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.
Basic Option - You Pay
See previous page
Residential Treatment Center (cont.)
We cover inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:
- Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility (see page 99 for services billed by professional providers)
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Note: Benefits are not available for noncovered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of practice; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; hippotherapy/equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long term care (see Definitions, page 153); and domiciliary care provided because care in the home is not available or is unsuitable.
Note: For outpatient residential treatment center services, see the next Section.
Standard Option - You Pay
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: Non-member facilities must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.
Basic Option - You Pay
See previous page
Benefit Description
Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility
Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: $30 copayment per day per facility
Member/Non-member: You pay all charges
Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility
Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.
- Individual psychotherapy
- Group psychotherapy
- Pharmacologic (medication) management
- Partial hospitalization
- Intensive outpatient treatment
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: $30 copayment per day per facility
Member/Non-member: You pay all charges
Outpatient Hospital or Other Covered Facility - continued on next page