2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 96
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 96
Benefit Description
Residential Treatment Center (cont.)
Note: 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; and domiciliary care provided because care in the home is not available or is unsuitable.
Note: For outpatient residential treatment center services, see the next Section.
Standard Option - You Pay
Continued from previous page:
Note: Non-member facilities must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center (cont.)
Note: 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; and domiciliary care provided because care in the home is not available or is unsuitable.
Note: For outpatient residential treatment center services, see the next Section.
Standard Option - You Pay
Continued from previous page:
Note: Non-member facilities must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Benefit Description
Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility
Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: $35 copayment per day per facility
Member/Non-member: You pay all charges
Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility
Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.
- Individual psychotherapy
- Group psychotherapy
- Pharmacologic (medication) management
- Partial hospitalization
- Intensive outpatient treatment
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: $35 copayment per day per facility
Member/Non-member: You pay all charges
Benefit Description
Outpatient services provided and billed by a covered facility
Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: Nothing
Member/Non-member: Nothing
Outpatient services provided and billed by a covered facility
- Diagnostic tests
- Psychological testing
Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: Nothing
Member/Non-member: Nothing
Benefit Description
Not Covered (Inpatient or Outpatient)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not Covered (Inpatient or Outpatient)
- Educational or other counseling or training services
- Services performed by a noncovered provider
- Testing for and treatment of learning disabilities and intellectual disability
- Inpatient services performed or billed by residential treatment centers, except as described in Sections 5(a) and 5(e)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not Covered (Inpatient or Outpatient) - continued on next page