2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services


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
Inpatient 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 and substance use disorder) of 30 days per calendar year 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 89 for services billed by professional providers).

Notes:

 
  • For inpatient care received overseas, refer to Section 5(i), page 109.
     
  • For outpatient residential treatment center services, see pages 90.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member): You pay all charges
 
Benefit Description
Not covered services, such as:

 
  • Biofeedback
     
  • Custodial or long term care (see Definitions)
     
  • Domiciliary care provided because care in the home is not available or is unsuitable
     
  • Educational therapy or educational classes
     
  • Equine/hippotherapy provided during the approved stay
     
  • Recreational therapy
     
  • Respite care
     
  • Outdoor residential programs
     
  • Outward Bound programs
     
  • Personal comfort items, such as guest meals and beds, telephone, television, beauty and barber service
     
  • Services provided outside of the provider’s licensure/scope of practice
     
Note: Residential treatment center benefits are not available for facilities licensed as skilled nursing facilities, group home, halfway house or similar type facilities.


You Pay
All charges
 

List Item:

residential
treatment
precertificattion
precertified
admission
inpatient
center
RTC
medical
mental
health
board
semiprivate
ancillary
therapy
outpatient
biofeedback
domiciliary
educational
equine
hippotherapy
horse
recreational
respite
outward
licensure