2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 87
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 87
Benefit Description
Inpatient Hospital or Other Covered Facility
Inpatient services to treat mental health and/or substance use disorders provided and billed by a hospital or other covered facility (see below for residential treatment center care) includes:
Notes:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member) facilities: You pay all charges
Inpatient Hospital or Other Covered Facility
Inpatient services to treat mental health and/or substance use disorders provided and billed by a hospital or other covered facility (see below for residential treatment center care) includes:
- Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
- Diagnostic tests
Notes:
- Inpatient care to treat substance use disorders includes room and board and ancillary charges for confinements in a hospital/treatment facility for rehabilitative treatment of alcoholism or substance use disorder.
- You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member) facilities: You pay all charges
Benefit Description
Residential Treatment Center
Precertification prior to admission is required.
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission
We cover up to a combined total (medical and mental health) of 30 days of inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:
Notes:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member) facilities: You pay all charges
Residential Treatment Center
Precertification prior to admission is required.
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission
We cover up to a combined total (medical and mental health) of 30 days of inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:
- Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility (see page 86 for services billed by professional providers)
Notes:
- RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
- Benefits are not available for noncovered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of practice; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; hippotherapy/equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long-term care (see Definitions); and domiciliary care provided because care in the home is not available or is unsuitable.
- For outpatient residential treatment center services, see next page.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member) facilities: You pay all charges