IBEW-NECA

What Are the Benefits?

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.

Important:

Inpatient Care:
For Inpatient Care, no benefits are payable for Mental Health or Chemical Dependency Treatment at a facility that has not been both pre-authorized by PBH prior to admission and provided by a PBH-contracted Network Facility. Emergency Admissions require authorization from PBH within 48 hours of the admission.

Mental Health Outpatient Care:
To receive maximum benefits under the Program, all Mental Health Out-patient care must be both pre-authorized by PBH and provided by a PBH-contracted Network Provider. As chart (B.) on the following page indicates, there is a limited benefit for medically necessary and clinically appropriate out-of-network mental health outpatient treatment.

Benefit	In-Network (PBH-Contracted Providers)	Non-Network
A. Member Assistance Program (MAP)	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).	No Non-Network MAP Benefits
B. 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.
Benefit	In-Network (PBH – Contracted Providers)	Non-Network
B. Mental Health Outpatient	Individual Session Treatment: Maximum of 30 PBH authorized Individual Outpatient Sessions per eligible participant per calendar year¹ 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 Sessions² 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.	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.¹
	^1. 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. ^2. 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. Day/Partial Treatment: 2 days of Day/Partial Treatment are equal to 1 day of Inpatient Treatment. Day/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
Benefit	In-Network (PBH – Contracted Providers)	Non-Network
C. The following schedule of benefits shall be applicable to the medically necessary and clinically appropriate Mental Health diagnosis and treatment of “severe mental illnesses³” and “serious emotional disturbances of a child⁴”, 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.
C. Mental Health Outpatient	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.	No Non-Network Mental Health Outpatient Benefit
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.	No Non-Network Mental Health Inpatient/Alternate Benefit
	^3. “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. ^4.“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.	No Non-Network Chemical Dependency Treatment Benefits
D. Cont’d. Chemical Dependency Treatment	Day/Partial Treatment: 2 days of Day/Partial Treatment are equal to 1 day of Inpatient Treatment. Day/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.