2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(e). Mental Health and Substance Use Disorder Benefits


Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.
 
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:

 
  • 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 88 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 non-covered 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, telephone, 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

Non-preferred (Member/Non-member) facilities: You pay all charges
 

List Item:

treatment
center
mental
health
substance
disorder
precertification
prior
admission
preliminary
Residential
RTC
medical
ancillary
medically
local
room
board
semiprivate
nursing
meals
diets
therapy