Mental Health And Substance Abuse Benefits - POV

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 PacifiCare Behavioral Health (PBH) network. Under the Regular Plan and the Low Option Plan, you can always choose a non-PBH provider, but you'll pay more and be eligible for fewer visits if you do.

When you go to a PBH 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 PBH. Benefits will be paid at the higher coinsurance level.

To select a PBH network provider, call the PBH member services number or log on to the PBH 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 PBH 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-PBH 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 PBH provider.
• You must file a claim with PBH. Benefits will be paid at a coinsurance level .

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 PBH 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 PBH.

When you go to a non-PBH 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 PBH provider.
• You must submit claims to PBH.