Q. Do the POS II A and B options cover mental health and substance abuse treatment?
A. The Plan provides for mental health and substance abuse care through a nationwide mental health PPO (MHPPO) administered by Magellan Healthcare. The Aetna network is not used for mental health or substance abuse care. Magellan provides precertification for inpatient treatment and intensive outpatient treatment, provider referral, ongoing consultation and review, and case management for mental health and substance abuse treatment.
The POS II options include a number of provisions specific to mental health and substance abuse treatment.
When determining whether a service or supply is medically necessary, Magellan's utilizes written medical necessity criteria. Those criteria are available upon request, consistent with applicable law. You and your providers may contact Magellan at 800-442-4123 to request the medical necessity criteria applicable to your treatment or visit their website at Magellan Ascend.ed.
All inpatient and intensive outpatient mental health and substance abuse care must be precertified by Magellan. The health care provider is responsible for obtaining precertification for network care. The participant is responsible for obtaining required precertifications for non-network and out-of-network care; if precertification for inpatient care is not obtained, a $500 penalty will be assessed for failure to precertify inpatient non-network and out-of-network care.
Intensive outpatient programs provide planned, structured mental health services, for at least 2 hours per day and 3 days per week, consistent with Magellan’s published Medical Necessity criteria.
Precertification is required even if the Plan is secondary to other medical coverage. Whenever treatment for mental health or substance abuse is needed, call Magellan. The telephone numbers are shown in the Information sources section at the front of this SPD.
If emergency mental health or substance abuse care is needed:
- The patient (or a responsible adult, if the patient is incapable) should contact Magellan and indicate that there is an emergency. Magellan will direct the patient to the nearest MHPPO facility for treatment.
- If it is not feasible to contact Magellan in an emergency, the patient should seek treatment at the nearest emergency facility. However, seek to notify Magellan:
- Within 48 hours of treatment or admission, or
- Within 72 hours of a weekend or holiday treatment or admission.
Expenses for emergency care at a MHPPO facility will be reimbursed at the 80% benefit level for the POS II B or 75% for the POS II A.
If the patient is admitted and the emergency facility does not participate in the MHPPO, Magellan will work with the emergency care treatment team to arrange a transfer to a MHPPO facility as soon as possible after the patient is stabilized. Expenses for emergency care at a non-network MHPPO facility will be reimbursed at the 80% benefit level for the POS II B or 75% for the POS II A.
If you require mental health or substance abuse care in conjunction with a medical emergency, please notify Magellan within the time periods described above.
Mental Health PPO
The Mental Health PPO (MHPPO) is a nationwide network of providers who offer quality, cost-effective care. MHPPO providers work with Magellan to develop suitable treatment plans and provide needed services.
If you use mental health network providers
You pay the POS II A or B primary care copay for most outpatient office visits provided by a specialist, which does not apply to the annual deductible. If you need intensive outpatient or inpatient treatment, your covered expenses are reimbursed at 80% for the POS II B or 75% for the POS II A after the annual deductible is satisfied. There are no limits on the number of inpatient days or outpatient visits per year. The portion of expenses you pay for both inpatient and outpatient care is applied to the annual out-of-pocket limit with the exception of the $500 penalty for failure to precertify for inpatient non-network and out-of-network care.
For inpatient mental health and substance abuse treatment to be reimbursed at the network level, both the provider and the facility must participate in the MHPPO network. If either the provider or the facility is non-network, all expenses associated with the confinement will be reimbursed at the non-network level.
If you do not use mental health network providers
You should contact Magellan for precertification of non-network care. Remember, if you are referred, even in an emergency, by a POS II network provider to a mental health provider, you still must precertify with Magellan.
Example — payment of network and non-network expenses for inpatient mental health and substance abuse cases:
Assume you participate in the POS II B option and submit a claim for covered inpatient expenses to the Plan. Magellan determines that network charges for your treatment would be $15,000. Also assume that a non-network provider charged $19,000 for the same service. Assume that no deductibles have been met. Here is how payment of both network and non-network certified and non-certified expenses would compare:
|Certified Network Care||Certified Non-Network Care||Non-Certified Non-Network Care|
|Total Covered Charges:||$15,000.00||$15,000.00||$15,000.00|
|You Pay:||$200.00 (inpatient deductible)
|$600.00 (annual deductible)||$600.00 (annual deductible)|
|Certified Network Care – 20% of covered charges after the deductible, up to the remaining out-of-pocket limit of $3,000 ($15,000 - $500) = $14,500 X 20%) = $2,890||$2,890.00|
|Certified Non-network Care – 40% of covered charges after the deductible ($15,000-$600 = $14,400 x 40%):||$5,760.00|
|Non-certified, Non-network Care – 40% of covered charges after the deductible ($15,000-$600 = $14,400 x 40% + $500 penalty for no precertification = $6,260)||$6,260.00|
|Your Total Payment:||$3,390.00||$10,360.00||$10,860.00|
|Your Plan Pays:||$11,610.00||$8,640.00||$8,140.00|
Mental health care outside the United States
If you live or travel outside the United States and need treatment for a mental health or substance abuse condition, you should contact Magellan.
Currently, there are no network providers outside the United States. However, Magellan will recommend providers with whom it has experience. Treatment received is reimbursed at 80% for the POS II B or 75% for the POS II A after you satisfy the annual deductible. The same emergency care procedures apply inside and outside the United States.