2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 87


Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.
 
Important things you should keep in mind about these benefits:
 
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
     
  • If you have an acute chronic and/or complex condition, you may be eligible to receive the services of a professional case manager to assist in assessing, planning, and facilitating individualized treatment options and care. For more information about our Case Management process, please refer to page 106. Contact us at the telephone number listed on the back of your ID card if you have any questions or would like to discuss your healthcare needs.
     
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
     
  • Every year, we conduct an analysis of the financial requirements and treatment limitations which apply to this Plan’s mental health and substance use disorder benefits in compliance with the federal Mental Health Parity and Addiction Equity Act (the Act), and the Act’s implementing regulations. Based on the results of this analysis, we may suggest changes to program benefits to OPM. More information on the Act is available on the following Federal Government websites:
    https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html
    https://www.dol.gov/ebsa/mentalhealthparity/
    https://www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act

     
  • YOU MUST GET PRECERTIFICATION FOR HOSPITAL OR RESIDENTIAL TREATMENT CENTER STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3.
     
  • The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
     
  • You must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.
     
  • You should be aware that some PPO inpatient facilities may have non-PPO professional providers on staff.
     
  • There is a $10 visit copayment for each of the first 10 visits to a professional provider per calendar year. This applies to a combined total for medical and mental health and substance use disorder conditions.
 
Benefit Description

Professional Services
We cover professional services by licensed professional mental health and substance use disorder practitioners when acting within the scope of their license.

You Pay
Your cost-sharing responsibilities are no greater than for other illnesses or conditions.
 
Professional Services - continued on next page