Mental Health and Substance Abuse Benefits

Provided by Carelon Behavioral Health (CBH)

All mental health and substance abuse care, both inpatient and outpatient, is covered through CBH. There is no prior authorization requirement.

Mental health and substance abuse care are covered the same as all other medical care:

• 90% coverage when a CBH Network provider is used
• 70% for non-Network providers after satisfaction of the deductible

If You Are Admitted to a Hospital in an Emergency

If you are admitted to a hospital or treatment center in an emergency, you or someone acting on your behalf should notify CBH at (866) 250-1555, as soon as possible to ensure maximum benefits and coverage are available to you.

Mental Health Benefits

• Outpatient visits are covered at 90% of the contracted rate, after a $20 co-payment for CBH participating providers, subject to the annual in-network deductible of $250. If you use mental health providers who are not contracted with CBH, the Plan pays a maximum benefit of $15 after satisfaction of the $500 non-network calendar year deductible.
• Inpatient care is covered at an approved mental health facility. When you obtain services from a CBH contracted provider, you pay only 10% of the contract rate and the in-network calendar year deductible applies. If you are admitted to a facility that is not contracted with CBH, you must pay 30% of the Reasonable and Customary Charge plus any amount that exceeds the Reasonable and Customary Charge, as determined by CBH. The non-network calendar year deductible also applies.

Substance Abuse Benefits

• Outpatient (including detoxification) visits are covered at 90% of the contracted rate, after a $20 co-payment for CBH participating providers, subject to the annual in-network deductible of $250. If you use providers who are not contracted with CBH, the Plan pays a maximum benefit of $15 after satisfaction of the $500 non-network calendar year deductible.
• Inpatient treatment (including detoxification and residential treatment) is covered at an approved substance abuse treatment facility. When you obtain services from an CBH contracted provider, you pay only 10% of the contract rate and the in-network calendar year deductible applies. If you are admitted to a facility that is not contracted with CBH, you must pay 30% of the Reasonable and Customary Charge plus any amount that exceeds the Reasonable and Customary Charge, as determined by CBH. The non-network calendar year deductible also applies.
• Alternate Levels of Care: (including partial hospitalization, day, and intensive outpatient treatment). Alternate levels of care are covered at an approved facility. When you obtain services from an CBH contracted provider, you pay 10% of the contract rate and the calendar year deductible applies. If you are admitted to a facility that is not contracted with CBH, you must pay 30% of the Reasonable and Customary Charge plus any amount that exceeds the Reasonable and Customary Charge, as determined by CBH. The non-network calendar year deductible also applies.

Online Services through Talkspace

• Members have access to convenient online therapy, medication evaluation and medication management services through Talkspace as part of your benefits with Carelon Behavioral Health.
  Click here for more details.

Exclusions and Limitations

No benefits are payable for:

• Treatment of intellectual disability, developmental or learning disabilities other than the initial diagnosis
• Court-ordered testing, counseling and treatment, including detention under Welfare and Institutional Code, Section 5150
• Ancillary services such as psychological testing, neuropsychiatric testing, vocational rehabilitation, behavioral training, sleep therapy, speech therapy, employment counseling, training or educational therapy for learning disabilities or other education services
• Services, treatment or supplies which are not Medically Necessary or Clinically Appropriate, such as those primarily for rest, custodial care, Domiciliary Care or convalescent care
• Charges for smoking cessation or weight loss programs (however, there is coverage for smoking cessation treatments under the Comprehensive Medical Plan and prescription drug program)
• Services, treatment or supplies provided as a result of any Workers’ Compensation law or similar legislation or obtained through or required by any governmental agency or program, whether federal, state or any subdivision thereof (exclusive of Medi-Cal)
• Benefits, services, treatment or supplies that exceed the maximums allowed by the Fund

Definitions

For purposes of this section:

• Domiciliary Care means inpatient institutional care provided not because it is Medically Necessary but because care in the home setting is not available, is unsuitable or members of the patient’s family are unwilling to provide the care. Institutionalization because of abandonment constitutes domiciliary care.
• Clinically Appropriate means that the health care services, treatment or supplies meet all of the following conditions:
  • Are rendered for the purpose of diagnosis or treatment of a mental disorder or chemical dependency;
  • Are non-experimental treatments that can be reasonably expected to improve the patient’s condition or level of functioning;
  • Are not mainly for the convenience of the patient or the patient’s health care provider;
  • Are rendered in an environment in which services are performed at the least restrictive level of care providing effective treatment;
  • Are “appropriate,” that is:
    1. Consistent with the symptoms and diagnosis
    2. The type, level, length and setting to provide safe and adequate care and treatment; and
    3. In keeping with generally accepted standards for good medical practice within the organized medical community

  Rights and Responsibilities

  Dignity and Respect

  You have the right to be treated with consideration, dignity and respect and the responsibility to respect the rights, property, and environment of all providers and other health care professionals, Employees and other patients. You have the right to access your own treatment records and have the privacy and the confidentiality of those records maintained. You are also entitled to exercise these rights regardless of gender, age, sexual orientation, marital status or culture; or economic, educational, or religious background.

  Member Accountability/Autonomy

  As a partner in your own health care, you have the right to refuse treatment providing you accept responsibility and the consequences of such a decision and the right to refuse to participate in any medical research projects. You also have the responsibility to:

  • Identify yourself as a CBH member when receiving services.
  • Provide your current CBH contracted provider with previous treatment records, if requested, as well as provide accurate and complete medical information to CBH and any other health care professionals involved in the course of your treatment.
  • Be on time for all appointments and notify your provider’s office as far in advance as possible if you need to cancel or reschedule an appointment.
  • You have the right at any and all times to contact CBH for assistance with issues regarding your behavioral health plan. It is your right to have all the above rights apply to the person you have designated with legal authority to make decisions regarding your health care.

  Filing a Claim

  CBH and your care providers and facilities take care of claim forms when you receive services from CBH providers. Payment is made directly to the provider. If you received approved services from a provider who is not contracted with CBH, you will need to file your claims directly with CBH.

  Appeals and Grievances

  To submit an appeal or grievance, call Carelon Behavioral Health’s Customer Service line at (866) 250-1555 or write to:

  Carelon Behavioral Health
  Attn: Appeals
  PO Box 1850
  Hicksville, NY 11802,1850

  Revised 07/2024