All mental health and substance abuse treatment benefits for Self-Funded PPO Plan and Blue Shield HMO enrollees are administered by OptumHealth (formerly PBH). Kaiser enrollees will receive Substance Abuse Treatment Plan through OptumHealth, but will be entitled to mental health coverage administered through Kaiser facilities only. All in network treatment services must be pre-authorized (877) 225 2267 and out of network claims will be reimbursed based on medical necessity. Note that treatment assessments are available through OptumHealth Member Assistance Plan counseling program and that the Plan provides three visits per year at no cost to the participant. More information concerning the network is available through the OptumHealth website at www.liveandworkwell.com (access code: SFEW). | |
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Eligibility |
Member Assistance and Behavioral Health is provided through OptumHealth Coverage described below and is covered in 4 categories.
- Member Assistance Program (MAP): covers all eligible participants and members of their household.
- Behavioral Health: covers eligible participants and their dependents who have opted for the Self Funded PPO Plan or BlueShield (HMO) (Kaiser participants receive this care through Kaiser).
- Chemical Dependency: covers all eligible participants and their dependents. Kaiser enrollees also
have Chemical Dependency Coverage available at Kaiser facilities
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Member Assistance Program (MAP)
1-877-225-2267 |
This a free confidential counseling and referral service to help you assess a variety of personal problems and suggest ways to resolve them. The following types are examples of typical problems:
- stress, depression, anger management, grief, domestic violence
- child rearing and elder-care
- legal and financial problems
- substance abuse
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Covered Services |
- 24 hour, toll free phone access
- 1-3 face-to-face
MAP counseling session per calendar year
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The following is a summary of your Behavioral Health and Chemical Dependency
Benefits which, as required under the Federal Mental Health Parity Act, were
brought into parity with other medical benefits effective February 1, 2010. | |
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Behavioral Health & Chemical Dependency Provided Through OptumHealth for Self Funded PPO and Blue Shield HMO Enrollees |
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In Network |
Out of Network |
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Annual Maximum |
$750,000 |
$750,000 |
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Calendar Year Deductible |
$100 per person/$200 maximum per Family |
$100 per person/$200 maximum per Family |
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Out-of-Pocket Maximum (OOP) |
$1,500 |
$1,500 |
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Per Admission Fee |
None |
$0 |
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Day Limit Inpatient |
Unlimited |
Unlimited |
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Copayment/Coinsurance Inpatient |
80% Coverage Until OOP is met, then 100% Coverage |
60% Coverage Until OOP is met, then 80% Coverage |
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Visit Limit Outpatient |
Unlimited |
Unlimited |
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Copayment/Coinsurance Outpatient |
80% Coverage Until OOP is met, then 100% Coverage |
60% Coverage Until OOP is met, then 80% Coverage |
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Emergency Room Services |
Covered at 100% Contract Rate |
60% Coverage Until OOP is met, then 80% Coverage |
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Chemical Dependency Services |
100% coverage Based Upon Medical Necessity |
60% Coverage Until OOP is met, then 80% Coverage
Coverage |
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Chemical Dependency Provided Through OptumHealth for Kaiser Plan Enrollees and Dependents |
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In Network |
Out of Network |
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Chemical Dependency Services |
80% Coverage Until OOP is met, then 100% Coverage |
Not Covered |
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Annual Maximum |
$750,000 |
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Calendar Year Deductible |
$100 per person/$200 maximum per Family |
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Out-of-Pocket Maximum (OOP) |
$1,500 |
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Chemical Dependency Coverage Provided at Kaiser Facilities for Kaiser Plan Enrollees and Dependents |
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You Pay |
| Inpatient detoxification |
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No charge |
| Outpatient individual visits |
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$20 per individual visit |
| Outpatient group visits |
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$5 per group visit |
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Behavioral Health Coverage Provided at Kaiser Facilities for Kaiser Plan Enrollees and Dependents |
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You Pay |
Inpatient psychiatric
hospitalization and intensive
psychiatric treatment programs |
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No charge |
| Outpatient individual visits |
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$20 per individual visit |
| Outpatient group visits |
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$10 per group visit |
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