MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS

Mental health and substance abuse benefits are administered by Beacon Health Options (formerly ValueOptions). Beacon Health Options (formerly ValueOptions) has contracted with a comprehensive nationwide network of professionals, which includes psychiatrists, psychologists, clinical social workers, marriage, family and child counselors, treatment programs, hospitals and other clinical providers.

Privacy and confidentiality are basic rights of any individual who seeks counseling. Beacon Health Options (formerly ValueOptions) is dedicated to protecting your privacy, and all services are held confidential in accordance with state and federal laws.

Eligibility

Plan I
Plan I Earned, Self-Pay and Senior Performer participants and their eligible dependents are eligible for the mental health and substance abuse benefits.

Plan II
Plan II Earned and Self-Pay participants are not eligible for these benefits. This includes mental health/substance abuse prescriptions and emergency care.

Benefits Available

The purpose of the program is to provide short-term, goal-focused treatment. Inpatient services and outpatient facility treatment are covered under the hospital benefit and limited to network providers only. These benefits also include alternative levels of care such as residential programs, partial hospital programs and intensive outpatient programs. Outpatient professional charges are covered under the major medical benefit at network and non-network providers.

Smoking cessation programs, weight loss programs and legal and financial counseling are not covered.

Deductibles, Co-Insurance, Co-Payments and Out-of-Pocket Maximums

Depending on the type of service, mental health and substance abuse charges fall under either the hospital or major medical coverages of your Plan I benefits.

How to Obtain Benefits

Using a Network Provider
When you use a Beacon Health Options (formerly ValueOptions) provider, payment is based on a pre-approved fee and benefits are subject to the lower network deductibles and participant co-insurance. Also, the provider will file your claims for you.

Once you decide to seek help, you may call Beacon Health Options (formerly ValueOptions) 24 hours a day, seven days a week. An experienced mental health professional will answer your questions and guide you in selecting a network provider who specializes in addressing your specific issues.

For network provider information:

Toll-free: (866) 277-5383
Hearing impaired: (800) 477-4624
website: www.achievesolutions.net/sag

After the initial visit, a mental health professional will assess your needs and support you by coordinating and clarifying your treatment plan with you and the network provider. If you are not fully satisfied after your initial visit with the recommended provider, call the Beacon Health Options (formerly ValueOptions) number. The staff will arrange a visit with a different provider.

Using a Non-Network Provider
It is important to note that hospital-based services are not covered for non-network providers.

When you use a provider outside of the network, payment is based on the Plan's Allowance or the fee actually charged, if less. If your provider's fees exceed the Plan's Allowance, you are responsible for the difference between the Plan's payment and the provider's actual charges. In addition, you will be responsible for the higher non-network deductibles and participant co-insurance Finally, your non-network provider may collect payment up front and may not be willing to file a claim form for you.

Emergencies

If you or your dependent experiences an acute mental health or substance abuse emergency, you should call 911 or go directly to a hospital emergency room for care. If you have Plan I coverage (Plan II participants are not covered), call Beacon Health Options (formerly ValueOptions) within 48 hours to report the emergency care. The Beacon Health Options (formerly ValueOptions) staff will review the care, authorize coverage if the treatment is clinically necessary, and assess your further needs. Hospital benefits are generally limited to network providers only. However, emergency mental health or substance abuse treatment within 24 hours of a sudden and serious illness will be covered at the network level of benefits.

Prescription Drugs

Your prescription drug benefit includes psychiatric medications (drugs used in the treatment of mental and nervous disorders). Simply follow the same procedures as for any other prescription drugs. Please remember that this only applies if you have Plan I benefits that make you eligible for mental health/substance abuse coverage.

Psychological Testing

Psychological testing is not covered under Beacon Health Options (formerly ValueOptions). Payment may be considered under the major medical benefits in certain circumstances when medically necessary. No benefits are payable for testing ordered by a child's school or for learning disabilities.

Claims Submission

Network providers will submit your claims directly to Beacon Health Options (formerly ValueOptions). If you use a non-network provider you and your provider must complete a claim form and submit it to Beacon Health Options (formerly ValueOptions):

Beacon Health Options (formerly ValueOptions) , Inc.
Latham Claims
P.O. Box 1290
Latham, NY 12110-8847

You can download claim forms here, request them through our automated system at
800-777-4013 or pick them up from the Plan Office.