The benefits are summarized below in four charts.
The first chart (A.) provides the benefits for the Member Assistance Program,
the second chart (B.) shows the benefits for mental health problems that are not
"severe mental illnesses" or "serious emotional disturbances
of a child" as defined in the California Mental Health Parity Act (AB 88),
the third chart (C.) shows the benefits for "serious mental
illnesses" or "serious emotional disturbances of a child" as
defined in the California Mental Health Parity Act (AB 88), and the fourth chart
(D.) shows the benefits for chemical dependency.
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Benefit
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In-Network (PBH-Contracted
Providers)
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Non-Network
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- Member Assistance Program (MAP)
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Up to a maximum of three (3) PacifiCare Behavioral
Health (PBH) authorized outpatient assessment sessions with a PBH contracted
Network Provider per eligible participant per calendar year for the assessment
of personal, mental health and chemical dependency related problems that are
paid for by the Program.
Note: To access the MAP 24-hour,
365-days-a-year hotline, call toll-free 1 (877-225-2267).
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No Non-Network MAP Benefits
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- The following schedule of benefits shall be applicable to
the medically necessary and clinically appropriate diagnosis and treatment of
mental health problems by a licensed/certified Mental Health Professional with
the specific exception of "severe mental illnesses" and
"serious emotional disturbances of a child" listed under
"C." below.
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|
Benefit
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In-Network (PBH – Contracted Providers)
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Non-Network |
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B. Mental Health Outpatient |
Individual Session Treatment: Maximum of 30 PBH
authorized Individual Outpatient Sessions per eligible participant per calendar
year
with a PBH contracted Network Provider for the medically necessary and
clinically appropriate treatment of mental health problems - $10 participant
co-pay per authorized session.
Group Session Treatment: Maximum of 60 PBH
authorized Group Outpatient
Sessions
per eligible participant per calendar year with a PBH contracted Network
Provider for the medically necessary and clinically appropriate treatment of
mental health problems-no participant co-pay per authorized
session.
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50% of the UCR for the medically necessary and
clinically appropriate outpatient treatment of a mental health problem by a
Non-Network Provider, up to a maximum of $1000 per eligible participant per
calendar year. |
|
Calendar
Year Mental Health Outpatient Session Maximum – Total Outpatient
Sessions, including "Individual Sessions" in combination with
"Group Sessions", whether obtained from an In-Network Provider or a
Non-Network Provider, shall not, in any event, exceed a maximum of 30 Individual
Outpatient sessions per eligible participant per calendar year; provided,
however, that a participant who has reached the Program’s $1,000 maximum
on Non-Network Mental Health Outpatient Treatment in a calendar year shall not
be eligible for any further Mental Health Outpatient Benefits in that year
regardless of the total number of Individual Outpatient sessions that may have
been received by the participant during the involved calendar year.
A Group
Session is considered to be one-half Individual Session for the purposes of the
30 Individual Sessions per calendar year maximum on Mental Health Outpatient
Treatment. |
B. Cont’d.
Mental Health Inpatient/Alternate
Care
All Inpatient/Alternate Care services,
treatment or supplies must be both pre-authorized by PBH and provided by a PBH
contracted Network Facility, except in the event of an emergency.
Emergency Admissions require authorization from PBH within 48 hours of the
admission.
|
Inpatient Treatment: Maximum of 20 days of PBH
authorized Inpatient Treatment per eligible participant per calendar year for
the medically necessary and clinically appropriate treatment of mental health
problems by a PBH contracted Network Facility. Program pays 100% of
contracted Facility charges after participant’s payment of a $200 per
calendar year deductible.
Residential Treatment: 2 days of Residential
Treatment are equal to 1 day of Inpatient Treatment. Residential Treatment
days in combination with Inpatient and Partial Treatment days shall not exceed a
maximum of 20 calendar days per eligible participant per calendar
year.
Partial Treatment: 2 days of Partial Treatment
are equal to 1 day of Inpatient Treatment. Partial Treatment days in
combination with Inpatient and Residential Treatment Days shall not exceed a
maximum of 20 days per eligible participant per calendar year. |
No Non-Network Mental Health Inpatient Benefits
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Benefit
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In-Network (PBH – Contracted
Providers)
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Non-Network
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C. The following schedule of benefits shall be
applicable to the medically necessary and clinically appropriate Mental Health
diagnosis and treatment of "severe mental illnesses 3" and
"serious emotional disturbances of a child 4", as defined
in the California Mental Health Parity Act (AB 88), by a licensed/certified
Mental Health Professional only. No benefits are payable under the Program
for the diagnosis and treatment of "severe mental illnesses" and
"serious emotional disturbances of a child" that has not been both
authorized by PBH and provided by a PBH contracted Network
Provider/Facility.
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- Mental Health Outpatient
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The Program provides eligible participants with
medically necessary and clinically appropriate Mental Health Outpatient
and "Individual" and "Group Sessions’" for the
diagnosis and treatment of "severe mental illnesses" and
"serious emotional disturbances of a child" by a licensed/certified
PBH contracted Network Mental Health Provider that has been authorized by PBH.
No participant co-pay per authorized session.
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No Non-Network Mental Health Outpatient Benefit
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Mental Health Inpatient/Alternate
Care
All Inpatient/Alternate Care services,
treatment or supplies must be both pre-authorized by PBH and provided by a PBH
contracted Network Facility, except in the event of an emergency.
Emergency Admissions require authorization from PBH within 48 hours of the
admission.
|
The Program provides eligible participants with
medically necessary and clinically appropriate Mental Health
Inpatient/Alternate Care for the diagnosis and treatment of "severe mental
illnesses" and "serious emotional disturbances of a child" by
a licensed/certified PBH contracted Network Provider/Facility that has been
authorized by PBH. Program pays 100% of contracted Provider/Facility
charges for authorized Inpatient/Alternate Care treatment.
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No Non-Network Mental Health Inpatient/Alternate
Benefit
|
|
"Severe mental illnesses"
include schizophrenia; schizo-affective disorder; bipolar disorder
(manic-depressive illness); major depressive disorders; panic disorder;
obsessive-compulsive disorder; pervasive developmental disorder or autism;
anorexia nervosa and bulimia nervosa.
"Serious emotional disturbances of
a child" is defined as a child who (1) has one or more mental disorders as
identified in the most recent edition of the Diagnostic and Statistical Manual
of Mental Disorders, other than a primary substance abuse disorder or
developmental disorder, that result in behavior inappropriate to the
`child’s age according to expected developmental norms and (2) who meets
the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the
California Welfare and Institutions Code. |
| Benefit |
In-Network (PBH – Contracted Providers) |
Non-Network |
D. Chemical Dependency Treatment
All Inpatient/Alternate Care services, treatment or supplies must be both pre-authorized by PBH and provided by a PBH contracted Network Facility, except in the event of an emergency. Emergency Admissions require authorization from PBH within 48 hours of the admission. |
Maximum Per Episode: Maximum of $10,500 per Episode*, including Detox, per eligible participant for PBH authorized medically necessary and clinically appropriate treatment of Chemical Dependency problems by a PBH contracted Network Facility. Plan pays 100% of contracted Facility charges after participant’s payment of a $200 per episode of Chemical Dependency Treatment deductible up to the $10,500 per Episode maximum.
*An Episode is defined as any continuous course of treatment that focuses on a particular occurrence of a chemical dependency problem. An Episode may involve various levels of care and/or treatment by one or more providers or facilities as a part of a continuum of medically necessary and clinically appropriate treatment of the presenting problem. Treatment of a relapse of the treated condition within 30 days is considered to be the same episode.
Lifetime Maximum Episode: Lifetime maximum of 2 Episodes of Chemical Dependency Treatment per eligible participant, including Detox.
Detox: Maximum of $2,000 per Episode per eligible participant. Lifetime maximum of 2 Episodes of Detox per eligible participant.
Inpatient Treatment: Maximum of 20 days of Inpatient Treatment, including Detox days, per eligible participant per Episode of Chemical Dependency Treatment up to the $10,500 per Episode maximum.
Residential Treatment: 2 days of Residential Treatment are equal to 1 day of Inpatient Treatment. Residential Treatment days in combination with Inpatient, Partial and Intensive Outpatient Treatment days shall not exceed a maximum of 20 calendar days per eligible participant per Episode of Chemical Dependency Treatment.
Partial Treatment: 2 days of Partial Treatment are equal to 1 day of Inpatient Treatment. Partial Treatment days in combination with Inpatient, Residential and Intensive Outpatient Treatment Days shall not exceed a maximum of 20 days per eligible participant per Episode of Chemical Dependency Treatment.
Intensive Outpatient Treatment: 3 days of Intensive Outpatient Treatment are equal to 1 day of Inpatient Treatment. Intensive Outpatient Treatment days in combination with Inpatient, Residential and Partial Treatment days shall not exceed a maximum of 20 days per eligible participant per Episode of Chemical Dependency Treatment. |
No Non-Network Chemical Dependency Treatment Benefits |
