2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 102
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 102
Benefit Description
Outpatient Hospital or Other Covered Facility (cont.)
Outpatient services provided and billed by a covered facility
Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, 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: Nothing
Member/Non-member: Nothing
Outpatient Hospital or Other Covered Facility (cont.)
Outpatient services provided and billed by a covered facility
- Diagnostic tests
- Psychological testing
Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, 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: Nothing
Member/Non-member: Nothing
Benefit Description
Not Covered (Inpatient or Outpatient)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not Covered (Inpatient or Outpatient)
- Marital, family, educational, or other counseling or training services
- Services performed by a noncovered provider
- Testing for and treatment of learning disabilities and intellectual disability
- Inpatient services performed or billed by residential treatment centers, except as described on pages 87-88 and 100-101
- Services performed or billed by schools, halfway houses, group homes or members of their staffs
Note: We cover professional services as described on pages 99-100 when they are provided and billed by a covered professional provider acting within the scope of their license.
- Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present
- Services performed or billed by residential therapeutic camps (e.g., wilderness camps, Outward Bound, etc.)
- Hippotherapy/equine therapy (exercise on horseback)
- Light boxes
- Custodial or long term care (see Definitions)
- Costs associated with enabling or maintaining providers’ telehealth (telemedicine) technologies, non- interactive telecommunication such as email communications, or asynchronous store-and-forward telehealth services
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges