2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 95
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 95
Benefit Description
Professional Services (cont.)
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: 35% of the Plan allowance (no deductible)
Non-participating: 35% of the Plan allowance (no deductible), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Professional Services (cont.)
- Inpatient professional services
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: 35% of the Plan allowance (no deductible)
Non-participating: 35% of the Plan allowance (no deductible), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Benefit Description
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
- Professional charges for facility-based intensive outpatient treatment
- Professional charges for outpatient diagnostic tests
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Benefit Description
Inpatient Hospital or Other Covered Facility
Inpatient services provided and billed by a hospital or other covered facility
Note: Inpatient care to treat substance use disorder includes room and board and ancillary charges for confinements in a hospital/treatment facility for rehabilitative treatment of alcoholism or substance use disorder.
Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance for unlimited days (no deductible), and any remaining balance after our payment
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
Inpatient Hospital or Other Covered Facility
Inpatient services provided and billed by a hospital or other covered facility
- Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
- Diagnostic tests
Note: Inpatient care to treat substance use disorder includes room and board and ancillary charges for confinements in a hospital/treatment facility for rehabilitative treatment of alcoholism or substance use disorder.
Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance for unlimited days (no deductible), and any remaining balance after our payment
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
Residential Treatment Center
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC when the care is medically necessary for the treatment of a medical, mental health, and/or substance use disorder:
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
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
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC when the care is medically necessary for the 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
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
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 - continued on next page