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You are eligible for benefits under the Integrated Member Assistance Program and Mental Health & Chemical Dependency Benefits Program as described herein, if you meet the eligibility requirements for an active eligible employee under the Southern California IBEW-NECA Active Health Plan, and are enrolled in the Indemnity Medical Plan or the PacifiCare HMO Plan.

This Program provides benefits only for the specific Mental Health & Chemical Dependency benefits described below. The Program requires that all benefits be pre-authorized by PacifiCare Behavioral Health (PBH).

This is a Managed Care Program, and PBH will refer you, when appropriate, to a PBH provider or facility that is under contract with PBH, called an In-Network Provider or Facility.  For example, there are no benefits provided for any inpatient mental health or chemical dependency benefits unless the treatment plan is authorized in advance by PBH, and the authorized treatment is provided by an In-Network PBH contracted facility.

By having your care managed by PBH, you will be assured of receiving the treatment best suited to your particular problem.  In addition, managed care means that the length and quality of treatment is monitored in order to curb any claim abuses.

Kaiser participants are eligible for benefits under the Member Assistance Program (MAP).  Mental Health and Chemical Dependency benefits are available only at Kaiser.  Kaiser participants should refer to their Kaiser-provided literature for a complete explanation of benefits.

All rules, regulations, and eligibility requirements, as contained in the Summary Plan Description (SPD), apply to active eligible participants covered under this Program.  For example, if you have any questions about how you become eligible for Program benefits or what the definition of “eligible dependents” is, refer to table of contents “Plan Benefits Available to You”. If you have an appeal, for example, you dispute the benefit allowance under this Program; refer to table of contents “Disclosure Information” subtitled “Claims Review and Appeals Procedure” for an explanation of “Request for Reconsideration of Denial and Appeals Procedures”.

If you have any questions concerning your eligibility for benefits under this Program, or your entitlement to benefits, contact the Administrative Office. The address and phone number are as follows:

Southern California IBEW-NECA Trust Fund

6023 Garfield Ave.
Commerce, CA  90040

Mailing Address
PO Box 910918
Los Angeles, CA 90091

Phone:  (323) 221-5861 or (800) 824-6935

If you are enrolled in PacifiCare, the benefits of this Program are only applicable for the treatment of Mental Health & Chemical Dependency. All other medical care is provided through PacifiCare under the terms and conditions as contained in the Evidence of Coverage booklet, which has been provided to you by PacifiCare.

PacifiCare HMO Plan & Indemnity Medical Plan Participants

Important:
The Board of Trustees has implemented a Member Assistance Program, called MAP for short. The purpose of the Member Assistance Program is to provide you and your spouse with a professional consultation and referral program for personal, mental health, and chemical dependency problems. For example, typical reasons for which the MAP is accessed are problems with drug and alcohol abuse, eating disorders, marriage and family issues, work issues, parenting and childcare issues.

This Program provides benefits only for the specific Mental Health & Chemical Dependency benefits as described in this Summary Plan Description. The Program requires that all benefits be pre-authorized by PacifiCare Behavioral Health.

This is a Managed Care Program, and PBH will refer you, when appropriate, to a PBH provider or facility that is under contract with PBH, called an In-Network Provider or Facility.  For example, there are no benefits provided for any inpatient mental health or chemical dependency benefits unless the treatment plan is authorized in advance by PBH, and the authorized treatment is provided by an In-Network PBH contracted facility.

By having your care managed by PBH, you will be assured of receiving the treatment best suited to your particular problem.  In addition, managed care means that the length and quality of treatment is monitored in order to curb any claim abuses.

PacifiCare Behavioral Health can be reached toll-free 1-877-225-2267, 24-hours a day, 365-days a year or visit www.pbhi.com.

Kaiser participants are eligible for benefits under the Member Assistance Program.  Mental Health and Chemical Dependency benefits are available only at Kaiser.  Note:  Kaiser maintains a Behavioral Healthcare Member help line – toll-free 1-800-900-3277.

The chart below shows you how to use this Program and provides two common examples of the benefits provided.

All Inpatient Care must be pre-approved by PacifiCare Behavioral Health (PBH) 1- (877-225-2267). Benefits are only payable for Inpatient Care provided by an In-Network facility under contract with PBH.

Services for the treatment of nervous and mental disorders and chemical dependency are a covered benefit, only if such services offer a reasonable expectation of improvement, and are at the least restrictive level of care providing effective treatment as determined by PBH and consistent with safe medical practices.

For the purposes of this Program, a Mental Disorder and Chemical Dependency are defined below, and all treatment must meet this definition to be eligible for the benefits under the Program.

A Mental Disorder or Chemical Dependency is any disorder that involves a clinically-significant behavioral or psychological syndrome or pattern; is associated with serious symptoms; impairs a participant's ability in one or more major life functions or activities; is a condition listed as an Axis I Disorder (except V Codes) of the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and is not solely a character disorder Axis II), problem of living, or for personal exploration, desire of self-fulfillment, or forensic evaluation. The services must be clinically/medically appropriate for the condition being treated.

The Mental Health and Chemical Dependency Benefits Program provides benefits only for clinically/medically appropriate treatment as determined by PBH and must meet all of the following conditions.

The managed Mental Health and Chemical Dependency Benefits Program is a comprehensive professional consultation, referral and treatment program that is geared to address mental health and chemical dependency problems that cannot be effectively resolved or treated under the Member Assistance Program.

In cases in which more specialized or extensive treatment is needed for a mental health or chemical dependency problem than that available under the MAP, the MAP counselor may suggest an alternative referral to a high-quality clinical specialist or facility for treatment that meets your specific medical needs.

Whenever a referral is necessary, the MAP counselor stays personally involved in order to monitor both your progress and the quality and appropriateness of the care that you receive to make sure that you continue to receive the most effective help available.

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.

Questions and Answers About the Program

The following Questions and Answers will be of assistance to you in understanding the Mental Health and Chemical Dependency Benefits Program, and in getting maximum benefits with the continuum of care management services provided by PBH.

Q. What is continuum of care?
A. Continuum of care means getting treatment which directs you to a level of care and a provider appropriate for your treatment needs. As you improve, PBH will progressively move you to a less restrictive level of care that provides effective treatment until you complete treatment.

Q. Show me how PBH uses the continuum of care treatment option.
A. Referring to the outline of benefits above for mental health, an example of continuum of care would be if you had been hospitalized for a mental disorder and had improved to the point that you no longer required full-time hospitalization, but needed more intensive care than traditional outpatient visits, you could be placed in alternate care such as residential or partial treatment until you had recovered sufficiently to be placed in outpatient treatment.

Q. Will PBH arrange for me to see a provider who is convenient to where I live or work?
A. Yes. PBH has a comprehensive network of providers throughout the state of California. Your MAP counselor will assist you in making certain that your provider is both convenient to where you live or work and is the appropriate provider to treat you for your particular problem.

Q. What if I use a provider for Inpatient/Alternate Care Mental Health or Chemical Dependency that is not under contract with PBH?
A. This would be considered a Non-Network Provider. As indicated on the above charts, no benefits are payable under the Program for mental health or chemical dependency inpatient/alternate care services received from a Non-Network Provider.

Q. If I have other group coverage, does coordination of benefits apply?
A. Yes. The benefits of the other plan would be taken into consideration in computing the benefits which are payable under this Program.

An In-Network provider is a provider who has contracted with PBH and agreed to provide services for a negotiated and reduced rate.

When you use an In-Network provider, there are no claim forms required. All In-Network claims are forwarded directly to PBH by the In-Network provider.

Report claims promptly when any individual has incurred covered expenses. This Program only covers claims that are filed within 12 months from the date the services were provided.

After the claim has been adjudicated, you will receive an Explanation of Benefits (EOB) form from PBH. This form will show the total cost of all services, what has been paid to the In-Network provider, and what portion of the claim is your responsibility.

Non-Network providers have not contracted with PBH and have not agreed to provide services at a negotiated rate. As previously stated, there are no benefits for In-Patient/Alternate Care services received from a Non-Network provider.

For Mental Health Outpatient services from a Non-Network provider, you will be responsible for paying the entire cost of the bill. To receive reimbursement under the Program, you will need to submit copies of your bills directly to PacifiCare Behavioral Health.  PBH will determine the amount payable by this Program, if any. The claim will be adjudicated by PBH. You will then receive an Explanation of Benefits (EOB) form from PBH indicating if benefits are payable. If they are, a check will accompany the EOB form.

Report claims promptly when any individual has incurred covered expenses. This Program only covers claims which are filed within 12 months from the date the services were provided.

Submit copies of your bills to PBH. You need to include the social security number of the active eligible electrician, and the social security number of the eligible dependent if appropriate. Indicate that you are covered for benefits under the Southern California IBEW-NECA Local 11 Health Plan.

PBHI Claims
Post Office Box 31053
Laguna Hills, CA 92654
M/S CS56-700

The Mental Health and Chemical Dependency Benefits Program does not provide benefits or pay for the following:

• Inpatient or Outpatient treatment for any medically treated physical illness;
• For Inpatient/Alternate Care Treatment of 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), there is a maximum of 20 days per eligible participant per calendar year for the medically necessary and clinically appropriate treatment of mental illness.
• Treatment of detoxification in newborns. Such treatment will be provided under the medical portion of the Indemnity Medical Plan and/or PacifiCare HMO Plan, under the terms and conditions of each of those plans.
• Treatment of congenital and/or organic disorders, including, but not limited to, Organic Brain Disease, Alzheimer's Disease and Parkinson’s Disease.
• Treatment of mental retardation, other than the initial diagnosis, and medically necessary services for accompanying behavioral and/or psychological symptoms if amenable to psycho-therapeutic or psychiatric treatment.
• Court ordered testing, counseling, and treatment.
• Case management and administrative supervision, when billed separately. This is considered an essential part of the billing for daily hospital care by the attending physician, and will not be paid by this Program as a separate billing.
• Uncomplicated withdrawal (withdrawal that does not present symptoms requiring patient detoxification) from the following substances:
  • Amphetamines or similarly acting drugs
  • Cannabis (marijuana)
  • Cocaine
  • Nicotine
• Psychoactive substance abuse, without dependence.
• Other administrative services such as expert testimony, medical records review and maintenance, preparation of reports regarding civil or legal matters (child custody issues), ability to stand trial, consultation with attorneys or other representatives of social control systems.
• Consultation with a counselor or professional for adjudication of marital, child support and custody cases.
• Private hospital rooms and/or private duty nursing, unless determined to be a Clinically/Medically Appropriate service and authorized by PBH.
• Ancillary services such as vocational rehabilitation, behavioral training, sleep therapy, and employment counseling, training or education therapy for learning disabilities or other educational services.
• Treatment for any condition not covered in the standard nomenclature of the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders such as co-dependency.
• Sexual addiction and gambling problems based solely on the 12 Step Model.
• Treatment of obesity.
• Services in excess of those authorized by PBH.
• Broken appointments, except in cases where the Participating Provider is notified at least twenty-four (24) hours in advance that the appointment will not be kept or in circumstances in which the covered participant has no control over missing the appointment and could not notify the Participating Provider at least twenty-four (24) hours prior to the scheduled appointment. A broken appointment shall count as one (1) session for the purpose of computing benefit expenditure.
• All prescription or non-prescription drugs, except for drugs prescribed by a physician in connection with the participant's treatment as an inpatient at a hospital or as a patient at a Facility providing Alternate Treatment. For information on prescription drugs that you may be covered consult your Retired Employees Summary Plan Description.
• Inpatient services, treatment, or supplies rendered without Pre-admission Certification, except in the event of an emergency.
• Damage to a Hospital or Alternate Care Facility caused by a participant. The actual cost of such damage may be billed directly to the participant.
• Health care services, treatment or supplies determined to be experimental by PBH in accordance with accepted mental health standards.
• Health care services, treatment, or supplies provided as a result of any Workers' Compensation law or similar legislation or obtained through, or required by, any governmental agency or program, whether Federal, State, or any subdivision thereof or caused by the conduct or omission of a third party for which the participant has a claim for damages or relief, unless such participant provides this Program with a lien against such claim for damages or relief in a form and manner satisfactory to this Program.
• Health care services, treatment, or supplies for military service disabilities for which treatment is reasonably available under governmental health care programs; and
• Health care services, treatment, or supplies rendered to a participant, which are primarily for rest, custodial, domiciliary, or custodial care.

This Mental Health and Chemical Dependency Benefits Program provides benefits only for clinically/medically appropriate treatment as determined by PBH.

The conditions which must be met for treatment to be deemed clinically/medically appropriate treatment are contained under the section titled “Integrated Employee Assistance and Managed Mental Health & Chemical Dependency Benefits Program” subtitled  "What Is Clinically/Medically Appropriate Treatment”?

The Program’s procedures for Reconsideration of a Denial and the Appeals Procedure for Denial of Treatment because it is deemed not clinically/medically necessary by PBH are outlined below.

In cases of emergency admission to a contracted PBH Network Facility, you should contact PBH within 48 hours or as soon thereafter as possible.  This is for the purpose of having PBH manage your stay.  In the event you do not notify PBH, you will still be eligible for plan benefits for medically necessary services.

PacifiCare Behavioral Health maintains a 24-hour toll free hotline at 1-877-225-2267.  You can access this hotline at any time to find out how to receive treatment for mental health and/or chemical dependency needs.