2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 100
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 100
Benefit Description
Professional Services (cont.)
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: 35% of the Plan allowance (no deductible)
Non-participating: 35% of the Plan allowance (no deductible), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Professional Services (cont.)
- Inpatient professional services
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: 35% of the Plan allowance (no deductible)
Non-participating: 35% of the Plan allowance (no deductible), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Benefit Description
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
- Professional charges for facility-based intensive outpatient treatment
- Professional charges for outpatient diagnostic tests
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Benefit Description
Inpatient Hospital or Other Covered Facility
Inpatient services provided and billed by a hospital or other covered facility (See below for residential treatment center care.)
Note: Inpatient care to treat substance use disorder includes room and board and ancillary charges for confinements in a hospital/treatment facility for rehabilitative treatment of alcoholism or substance use disorder.
Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance for unlimited days (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Inpatient Hospital or Other Covered Facility
Inpatient services provided and billed by a hospital or other covered facility (See below for residential treatment center care.)
- Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
- Diagnostic tests
Note: Inpatient care to treat substance use disorder includes room and board and ancillary charges for confinements in a hospital/treatment facility for rehabilitative treatment of alcoholism or substance use disorder.
Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance for unlimited days (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Benefit Description
Residential Treatment Center
Precertification prior to admission is required.
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center
Precertification prior to admission is required.
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center - continued on next page