BEHAVIORAL HEALTH
(FOR MEMBER AND DEPENDENTS)
Behavioral Health Benefits (for the treatment of mental health and alcohol/substance abuse issues) must be
coordinated through Total Care Network (“TCN”), the Fund’s Behavioral Health
Administrator. Total Care Network may be reached at 1-800-298-2299 or
1-215-425-8140 (24 hours a day / seven days a week for emergency services).
This
benefit is administered through both closed and open panels of providers.
Closed
Panel: The Fund,
through Total Care Network, has contracted with a panel of licensed behavioral
health providers. Providers on this panel have agreed to accept the Fund's
allowance for particular behavioral health services as payment in full with no
balance billing to the patient and without any up-front deductible or copayment.
You will, however, be responsible for services excluded from coverage or which
exceed the overall maximum benefit allowance for the patient for the plan year.
Names of participating behavioral health providers may be obtained, without
charge, from Total Care Network.
Open
Panel: Means any
licensed behavioral health provider of your choice. However, the benefit payable
will be limited to 80% of the Fund's allowance for participating providers, and
subject to the out-of-network deductible of $300/patient, $600/family per year.
Mental Health/Psychiatric Care
Benefits for the treatment of mental illness and serious mental illness are
based on the services provided and reported by the provider. Those services
provided by and reported by the provider as mental health/psychiatric services
are subject to the mental health/psychiatric limitations in this program. When
a provider renders medical care, other than mental health/psychiatric care, for
a covered person with mental illness or serious mental illness, payment for such
medical care will be based on the medical benefits available, and will not be
subject to the mental health/psychiatric limitations in this program.
Preauthorization information
must be submitted by the provider to TCN for review and evaluation so that a
plan of treatment may be precertified for the covered person. Precertification
must be obtained for all treatments, other than emergency care, in order to
verify eligibility and to assure the medical appropriateness/necessity of the
proposed treatment based on the nature and severity of the covered person's
condition. In appropriate cases, a personal assessment by a preferred
professional provider may be provided by the Fund at no cost to the covered
person to accommodate the precertification process. Emergency care is exempt
from the requirements for precertification and will be considered preferred
care. However, emergency admissions or services must be reviewed and authorized
within one business day of the admission or services, or as soon as possible
thereafter as determined by the Fund and/or its Behavioral Health Administrator.
Inpatient Treatment
Benefits are provided,
subject to the benefit period limitations stated in the Schedule of Benefits,
for an inpatient admission for treatment of mental illness and serious mental
illness. Inpatient visits for the treatment of mental illness and serious
mental illness are covered when performed by a licensed professional
provider/preferred facility provider.
For treatment of serious
mental illness, the covered person may trade one (1) for two (2) basis,
inpatient days for additional outpatient partial hospitalization days and
outpatient facility/professional visits.
Covered services include
treatments such as: psychiatric visits, psychiatric consultations, individual,
family and Fund assessments, psychotherapy, electroconvulsive therapy and
psychopharmacologic management.
Outpatient Treatment
Benefits are provided,
subject to the benefit period limitations shown in the Schedule of Benefits for
outpatient treatment of mental illness and serious mental illness. Outpatient
mental health/psychiatric services shall be covered for the full number of
outpatient session visits or an equivalent number of partial hospitalization
visits per benefit period. Partial hospitalization is considered as inpatient
treatment. For treatment of mental illness, the covered person may trade off:
(a) on a one (1) for two (2) basis, inpatient days for additional separate
partial hospitalization services; or (b) on a one (1) for two (2) basis,
inpatient days for additional outpatient visits. See the Schedule of Benefits
for limits on the number of inpatient days that may be exchanged in any benefit
period. For treatment of serious mental illness, the covered person may trade
on a one (1) for two (2) basis, inpatient days for additional outpatient partial
hospitalization days/outpatient session visits. For maximum benefits, treatment
must be performed by a preferred professional provider/preferred facility
provider. All preferred outpatient services must be precertified by TCN.
Covered services include
treatments such as: psychiatric visits, psychiatric consultations, individual,
family and Fund assessments, psychotherapy electroconvulsive therapy,
psychopharmacologic management, and psychoanalysis.
Benefits are not payable for
the following services:
a)
vocational or religious counseling;
b)
activities that are primarily of an educational nature;
c) treatment
modalities that have not been incorporated into the commonly accepted
therapeutic
repertoire as
determined by broad-based professional consensus, such as primal therapy,
rolfing
or structural
integration, bioenergetic therapy, and obesity control therapy;
d)
psychological testing.
Benefit Period Maximums for Mental Health/Psychiatric Care
All inpatient and outpatient
mental health/psychiatric services for both mental illness and serious mental
illness are covered up to the maximum day and visit limitations per benefit
period specified in the Schedule of Benefits. Non-preferred benefit period
maximums are part of, not separate from, preferred benefit period maximums.
TREATMENT FOR ALCOHOL
OR DRUG ABUSE AND DEPENDENCY
Alcohol
or drug abuse and dependency means a pattern of pathological use of alcohol or
other drugs which causes impairment in social and/or occupational functioning
and which results in a psychological dependency evidenced by physical tolerance
or withdrawal.
Benefits are payable for the
care and treatment of alcohol or drug abuse and dependency provided by a
hospital or facility provider, subject to the maximums shown in the Schedule of
Benefits, according to the provisions outlined below. For maximum benefits,
treatment must be received from a preferred provider.
Preauthorization
information must be submitted by the provider to the Behavioral Health
Administrator for review and evaluation so a plan of treatment may be
precertified for the covered person. Precertification must be obtained for all
treatments other than emergency care in order to verify eligibility and to
assure the medical appropriateness/necessity of the proposed treatment based on
the nature and severity of the covered person's condition. In appropriate
cases, a personal assessment by a preferred professional provider may be
provided by the Fund at no cost to the covered person to accommodate the
precertification process.
If a patient is facing a
crisis and is currently in treatment, contact should be made with the patient's
therapist because he/she is most familiar with the patient's condition.
Emergency care is exempt from the requirements for precertification and will be
considered preferred care. However, emergency admissions or services must be
reviewed and authorized within one business day of the admission or service, or
as soon as possible as determined by the Behavioral Health Administrator.
Inpatient Detoxification
Inpatient covered services
for detoxification shall be covered for 7 days per admission for detoxification
with a lifetime maximum of 4 admissions for detoxification per covered person.
Covered services are
limited to:
a)
Lodging and dietary services;
b)
Physician, psychological, nurse, certified addictions counselor and trained
staff services;
c)
Diagnostic x-rays;
d)
Psychiatric and medical laboratory testing;
e) Drug,
medicines, use of equipment and supplies.
Hospital and Non-Hospital Residential Treatment
Hospital or non-hospital residential treatment of alcohol or drug abuse and
dependency shall be covered on the same basis as any other illness covered under
the program, but services are limited to 30 days per calendar year.
Additional days may be
available as specified below in "Outpatient Alcohol or Drug Services." There is
a lifetime maximum of 90 days per covered person.
Cover services include:
a)
Lodging and dietary services;
b)
Physician, psychological, nurse, certified addictions counselor and trained
staff services;
c)
Rehabilitation therapy and counseling;
d)
Family counseling and intervention;
e)
Psychiatric and medical laboratory testing;
f)
Drug, medicines, use of equipment and supplies.
Outpatient Alcohol or Drug
Services
Outpatient alcohol or drug
services shall be covered for 30 full outpatient sessions or an equivalent
number of partial hospitalization visits per calendar year.
Benefits are available for
an additional 30 separate sessions of outpatient or partial hospitalization
services per year, which may be exchanged on a 2 to 1 basis to receive up to 15
more days of non-hospital residential alcohol or drug treatment (i.e., the
covered person may trade off on a 2 for 1 basis, up to 30 separate sessions of
outpatient services per year, in order to receive up to 15 additional days of
hospital and non-hospital residential alcohol or drug abuse treatment days).
Any benefits exchanged or traded off under terms of this provision are subject
to, and do not increase, the overall lifetime maximum.
There is a lifetime maximum
of 120 full session visits or an equivalent number of partial hospitalization
visits per covered person. Partial hospitalization is considered as inpatient
treatment.
Covered services include:
a)
Physician, psychological, nurse, certified addictions counselor and trained
staff services;
b)
Rehabilitation therapy and counseling
c)
Family counseling and intervention;
d)
Psychiatric and medical laboratory testing;
e) Drug,
medicines, use of equipment and supplies.
Health
& We
lfare
and Pension Funds