| |
Section
5(e). Mental health and substance abuse
benefits |
 |
You may choose to get care In-Network or Out-of-Network.
When you receive In-Network care, you must get our
approval for services and follow a treatment plan we
approve. If you do, cost-sharing and limitations for
In-Network mental health and substance
abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
| Important
things you should keep in mind about these
benefits: |
- Services
must be provided by a PPO provider
to receive In-Network 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.
- We have
a separate calendar year deductible
of $250 per person ($500 per family)
under the High Option and $300 per
person ($600 per family) under the
Standard Option which applies to
almost all benefits for the
treatment of mental health and
substance abuse. For example,
doctors' inpatient hospital visits
for a physical illness or disease
applies to the Plan's regular
calendar year deductible. If the
services are rendered to treat
mental health or substance abuse,
the separate mental health and
substance abuse calendar year
deductible applies. We added
"(No deductible)" to show
when a deductible does not apply.
- Be sure
to read Section
4, Your costs for covered
services, for valuable information
about how cost sharing works. Also
read Section
9 about coordinating benefits
with other coverage, including with
Medicare.
- YOU MUST
GET PREAUTHORIZATION FOR THESE
SERVICES. See the instructions after
the benefits descriptions below.
- In-Network
mental health and substance abuse
benefits are below, then
Out-of-Network benefits begin on page
50.
|
| Benefit
Description |
You
Pay
After the calendar year deductible... |
Note:
The calendar year deductible applies to
almost all benefits in this Section.
We say "(No deductible)" when it
does not apply. |
| In-Network
benefits |
High
Option |
Standard
Option |
All
diagnostic and treatment services contained
in a treatment plan that we approve. The
treatment plan may include services, drugs,
and supplies described elsewhere in this
brochure. Note: In-Network benefits are
payable only when we determine the care is
clinically appropriate to treat your
condition and only when you receive the care
as part of a treatment plan that we approve.
|
Your
cost sharing responsibilities are no greater
than for other illnesses or conditions
|
Your
cost sharing responsibilities are no greater
than for other illnesses or conditions
|
- Outpatient
professional services by providers
such as psychiatrists, psychologists,
or clinical social workers
including:
- individual
or group therapy
- collateral
visits with members of the
patient's immediate family
- convulsive
therapy visits
- Medication
management
Note: Preauthorization is required; see page
49.
|
$20
copayment per visit (No deductible)
|
$20
copayment per visit (No deductible)
|
Other
outpatient care including:
- Day or
after care (partial hospitalization)
in a hospital
Note:
Preauthorization is required; see page
49.
|
10%
of the Plan allowance
|
15%
of the Plan allowance
|
|
|
10%
of the Plan allowance |
15%
of the Plan allowance |
Covered
inpatient hospital
and rehabilitation facility charges
including:
- Room and
board, including general nursing
care, in semiprivate accommodations
- Other
charges for hospital services and
supplies (other than professional
services) including but not limited
to the use of operating, treatment
and recovery rooms; X-rays; surgical
dressings; and drugs and medicines
Note:
Precertification is required for an
inpatient confinement; see page
49. A confinement is defined in Section
10, page 72.
|
$200
copayment per confinement, nothing for room
and board and 10% of the Plan allowance for
other hospital services (No deductible)
|
$200
copayment per confinement, nothing for room
and board and 15% of the Plan allowance for
other hospital services (No deductible)
|
- Services
of a doctor for inpatient hospital
visits
|
10%
of the Plan allowance
|
15%
of the Plan allowance
|
Not
covered:
- Marital
counseling
- Treatment
for learning disabilities
- Telephone
consultations and/or therapy
- On-line
consultations
- Travel
time to the patient's home to
conduct therapy
- Services
we have not approved.
Note: OPM
will base its review of disputes about
treatment plans on the treatment plan's
clinical appropriateness. OPM will generally
not order us to pay or provide one
clinically appropriate treatment plan in
favor of another.
|
All
charges
|
All
charges
|
| Preauthorization |
To
be eligible to receive these enhanced mental
health and substance
abuse benefits you must obtain a
treatment plan and follow all of the
following network authorization processes:
- The
medical necessity of your admission
to a hospital or other covered
facility must be preauthorized prior
to admission. Emergency admissions
must be reported within two business
days following the day of admission
even if you have been discharged.
Otherwise, benefits will be reduced
by $500.
- Prior
authorization is required for
outpatient treatment and day or
after care treatment (partial
hospitalization). In order to
maximize your benefits, your
provider must submit a treatment
plan to CIGNA/CareAllies prior to
your 9th outpatient visit. In
determining when your treatment plan
must be submitted, we count all
outpatient psychotherapy visits,
even if you use different providers.
When we approve the treatment plan,
we will give your provider
authorization for additional visits.
If you change providers, a new
treatment plan must be submitted. If
prior authorization is not obtained,
we will reduce our Plan allowance by
20%.
Note: To obtain
preauthorization call CIGNA/CareAllies at
1-800/887-9735.
|
|
| Network
limitation |
If
you do not obtain an approved treatment
plan, we will provide only Out-of-Network
benefits. |
|
| Out-of-Network
benefits |
You
Pay |
| High
Option |
Standard
Option |
We
will cover the office visit fee for therapy
sessions rendered by providers such as
psychiatrists, psychologists, or clinical
social workers.
Therapy sessions include:
- Office
visits, group therapy, and
collateral visits with members of
the patient's immediate family
- Medication
management
Benefits are
based on a maximum allowance of $100 per
visit and 50 visits per person per calendar
year under High Option and 25 visits
per person per calendar year under Standard
Option -- including visits you paid for
while satisfying the mental health and
substance abuse calendar year deductible.
Other outpatient care includes:
- Convulsive
therapy visits, and
- Day or
after care (partial hospitalization)
in a hospital
Note: Almost all
benefits for the treatment of mental health
and substance abuse require
precertification, see page
51. During the precertification process,
we may establish an approved treatment plan.
|
50%
of the Plan allowance and any difference
between our allowance and the billed amount
until benefits stop at 50 visits
|
50%
of the Plan allowance and any difference
between our allowance and the billed amount
until benefits stop at 25 visits
|
|
30%
of the Plan allowance and any difference
between our allowance and the billed amount
|
30%
of the Plan allowance and any difference
between our allowance and the billed amount
|
Covered
inpatient hospital and rehabilitation
facility charges include:
- Room
and board including general
nursing care, in semiprivate
accommodations
- Other
charges for hospital services and
supplies (other than professional
services) including but not limited
to the use of operating, treatment
and recovery rooms; X-rays; surgical
dressings; and drugs and medicines
Limited
benefits:
Confinement in a rehabilitation facility is
limited to 1) a maximum of 30 days per
confinement and 2) two confinements per
person per lifetime.
Note: Precertification is required for an
inpatient confinement, see page
51. |
$300
copayment per confinement plus 30% of the
Plan allowance and any difference between
our allowance and the billed amount (No
deductible)
Note: You pay any charges above the Plan's
limits.
|
$300
copayment per confinement plus 30% of the
Plan allowance and any difference between
our allowance and the billed amount (No
deductible)
Note: You pay any charges above the Plan's
limits.
|
- Services
of a doctor for inpatient hospital
visits
|
30%
of the Plan allowance and any difference
between our allowance and the billed amount
|
30%
of the Plan allowance and any difference
between our allowance and the billed amount
|
Not
covered out-of-network:
- The
same exclusions contained in this
brochure that apply to other
benefits apply to mental health and
substance abuse benefits. OPM's
review of disputes about
out-of-network treatment plans will
be based on the treatment plan's
clinical appropriateness. OPM will
generally not order us to pay or
provide one clinically appropriate
treatment plan in favor of another.
- Marital
counseling
- Treatment
for learning disabilities
- Telephone
consultations and/or therapy
- On-line
consultations
- Travel
time to the patient's home to
conduct therapy
- Any
charges in excess of the stated
limitations
|
All
charges
|
All
charges
|
| Lifetime
maximum |
Out-of-Network
inpatient care for the treatment of
alcoholism and drug abuse is limited to two
treatment programs (30-day each maximum) per
lifetime.
|
|
| Precertification |
To
be eligible to receive mental
health and substance
abuse benefits you must follow your
treatment plan and all of our authorization
processes. These include obtaining prior
authorization for:
- The
medical necessity of your admission
to a hospital or other covered
facility prior to admission.
Emergency admissions must be
reported within two business days
following the day of admission even
if you have been discharged.
Otherwise, benefits will be reduced
by $500. See Section
3 for details.
- Outpatient
treatment and day or after care
treatment (partial hospitalization).
In order to maximize your benefits,
your provider must submit a
treatment plan to CIGNA/CareAllies
prior to your 9th outpatient visit.
In determining when your treatment
plan must be submitted, we count all
outpatient psychotherapy visits,
even if you use different providers.
When we approve the treatment plan,
we will give your provider
authorization for additional visits.
If you change providers, a new
treatment plan must be submitted. If
prior authorization is not obtained,
we will reduce our Plan allowance by
20%.
To obtain
preauthorization call CIGNA/CareAllies at
1-800/887-9735.
|
|
See
these sections of the brochure for more
valuable information about these benefits:
- Section
4, Your cost for covered
services, for information about
catastrophic protection for these
benefits.
- Section
7, Filing a claim for covered
services, for information about
submitting out-of-network claims.
|
To print this entire FEHB Brochure or a section
of this Brochure, click
here.
|
