Medical Benefits > How Your Prescription Drug Works Under The Plan > Mental Health And Substance Abuse Benefits
Mental
Health And Substance Abuse Benefits - POV
Establishing
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Mental health and substance abuse (MH&SA) benefits for hospital and
professional services are part of your cove rage under the Fund's medical
plans, as shown in the following chart :
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Who's Covered
You and your covered dependents are covered for MH&SA benefits if you're
enrolled in the Regular Plan or the Low Option Plan. Your
coverage begins when you become eligible for medical benefits. Coverage for
your dependents begins after you enroll them in the plan and pay the required
dependent coverage premium.
How Your Mental Health And Substance Abuse Benefits Work
If you or a covered dependent needs inpatient or outpatient mental health
or substance abuse care, you'll receive a higher level of benefits if you use
providers in the OptumHealth Behavioral Solutions network. Under the Regular
Plan and the Low Option Plan, you can always choose a non-OptumHealth Behavioral Solutions provider, but
you'll pay more and be eligible for fewer visits if you do.
When you go to a OptumHealth Behavioral Solutions
provider:
- You must call and receive precertification for inpatient or outpatient mental
health or substance abuse care. (See "How to
Precertify Mental Health and/or Substance Abuse Care").
- You'll receive a higher maximum number of visits per year for the treatment
of a serious mental illness (SMI).(For information about SMIs, see "Serious
Mental Illness".)
- You'll receive a higher maximum number of visits per year for the treatment
of other mental health or substance abuse conditions.
- You must file a claim with OptumHealth Behavioral Solutions. Benefits will be paid at the higher coinsurance
level.
To select a OptumHealth Behavioral Solutions network provider, call the OptumHealth Behavioral Solutions member services number or log
on to the OptumHealth Behavioral Solutions website. (See the Summary Of Benefits
for contact information.) Keep in mind that network providers occasionally
change, so you'll want to make sure the mental health provider you choose is
still in the OptumHealth Behavioral Solutions network before you make an appointment. For the most up-to-date
information, including whether a provider is accepting new patients, call the
provider.
When you go to a non-OptumHealth Behavioral Solutions provider:
- Precertification of inpatient or outpatient mental health or substance abuse
care isn't required (but is recommended).
- You'll receive a lower maximum number of visits per year for the treatment
of SMIs.
- You'll receive a lower maximum number of visits per year for the treatment
of other mental health or substance abuse conditions.
- You'll have a lifetime limit of inpatient days, after which you'll receive
benefits only if you see a OptumHealth Behavioral Solutions provider.
- You must file a claim with OptumHealth Behavioral Solutions. Benefits will be paid at a coinsurance level
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Serious Mental Illness
(SMI)
Although the Fund isn't required to comply with the mental health parity legislation
that took effect in California on July 1, 2000, the Trustees have designed the
plan to take into account the spirit of this legislation and have expanded benefits
for the treatment of serious mental illness (SMI). The following conditions
are covered under the SMI benefit:
- Anorexia nervosa;
- Bulimia nervosa;
- Bipolar disorder;
- Major depressive disorder;
- Manic depressive disorder;
- Obsessive compulsive disorder;
- Pervasive development disorder;
- Severe emotional disturbances of children;
- Schizophrenia; and
- Schizoaffective disorder.
What You Pay
When you go to a OptumHealth Behavioral Solutions provider:
- You're responsible for a copay for each inpatient admission and outpatient
visit.
- The plan pays 100% of outpatient expenses after you pay your copay, up
to the maximum number of outpatient visits per year for SMI or non-SMI treatment.
- The plan pays 100% of inpatient expenses after you pay your copay, up to
the maximum number of inpatient days per year for the treatment of eligible
MH&SA conditions.
- You must submit claims to OptumHealth Behavioral Solutions.
When you go to a non-OptumHealth Behavioral Solutions provider:
- You pay the coinsurance based on R&C charges, plus any amount above
R&C limits.
- You pay a copay for each inpatient admittance.
- There's no out-of-pocket maximum.
- You pay for any expenses that aren't covered.
- You're covered for fewer inpatient days and outpatient visits than you are
when you see a OptumHealth Behavioral Solutions provider.
- You must submit claims to OptumHealth Behavioral Solutions.
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