| Inpatient Care |
| MHC Preferred Provider Facilities |
| Outpatient Care |
| What is covered |
| What is not covered |
| Maximum payments |
| Claim filing deadlines |
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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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| Mental, Nervous, Drug & Alcohol Benefits | |||||||||||||||||||||||||
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All eligible expenses are paid in full if you are
hospitalized for treatment of a mental or nervous disorder, drug addiction or
alcoholism provided you are admitted to an MHC preferred provider facility and
the admission is pre-certified and considered medically appropriate by MHC. Medical coverage under the Personal Choice Program does not include mental, nervous, drug or alcohol benefits. The Fund provides a separate benefit to cover such expenses. If you and your eligible dependents have medical coverage under the Keystone Point of Service Program, that plan is primary to coverage under this separate mental, nervous, drug & alcohol benefit, subject to the Fund’s general coordination of benefits provisions. If you and your eligible dependents are covered for mental, nervous, drug and alcohol benefits under any other plan, please check the section titled “Coordination of Benefits” to see how to submit your claims. Mental Health Consultants, Inc. (“MHC”) provides managed care and administrative services with respect to the Fund’s mental, nervous, drug and alcohol benefits. Benefits for covered services provided by MHC Preferred Providers are generally higher than benefits for services provided by non-preferred providers. Inpatient Care If you do not use one of the MHC Preferred Provider facilities for inpatient care, the plan will only pay 25% of the allowed charges. If you or your eligible dependents are hospitalized for treatment of a mental or nervous disorder, drug addiction or alcoholism, all eligible expenses are paid in full, provided you are admitted to an MHC Preferred Provider Facility and the admission is pre-certified and considered medically appropriate by MHC. MHC Preferred Provider Facilities are listed in the box below. The list of MHC Preferred Provider Facilities is subject to change without notice and will be updated periodically. Please call Mental Health Consultants to confirm your selection of an MHC Preferred Provider Facility prior to seeking admission If you do not use one of the MHC Preferred Provider Facilities for inpatient care, the Plan will pay 25% of the allowed charges of the facility (the provider’s reasonable charges, as determined by MHC), after you have satisfied a $100 calendar year deductible, and the Plan will pay 25% of the allowed charges of the inpatient professional fees (the provider’s reasonable charges, as determined by MHC) after you have satisfied a $100 calendar year deductible. Please note, the deductible and coinsurance are separate from any deductible and coinsurance requirements of your medical coverage under the Fund. You are responsible for paying the remainder of the charges, including any difference between the allowed charges (the provider’s reasonable charges, as determined by MHC) and the provider’s actual charges. Inpatient care is limited to 45 days per calendar year whether or not you are admitted to an MHC Preferred Provider Facility. Partial hospitalization and intensive outpatient treatment are considered inpatient care and are paid in accordance with the above benefit schedule. Each day of partial hospitalization and intensive outpatient treatment will be counted as 1/2 day toward the 45 day per calendar year maximum for inpatient care. Inpatient detoxification and/or substance abuse rehabilitation will be limited to two (2) stays per calendar year and four (4) stays per lifetime. MHC Preferred Provider Facilities Mental, Nervous, Drug & Alcohol admissions are covered at 100% in these facilities, subject to the limitations as described above:
Contact MHC for additional facilities. The list of Preferred Provider Facilities is subject to change without notice and will be updated periodically. Please call Mental Health Consultants to confirm your selection of an MHC Preferred Provider Facility prior to seeking admission. Outpatient Care The Plan offers a free and confidential information, referral and counseling service through MHC to help you and your family cope with a variety of problems or needs such as:  Drug and alcohol problems. Marital, family or other relationship problems. Counseling for grief or loss, catastrophic illness or post-traumatic stress. Stress-related problems. Anxiety or depression.If you or a dependent needs assistance with a personal or psychological problem, you simply call:
With this referral service, counselors are available from 9 a.m. to 5 p.m. Monday through Friday. In an emergency, you can call 24 hours a day. A counselor will briefly discuss the nature of the problem with you, evaluate the problem and make a recommendation for treatment or services. You may be: Scheduled for continued consultation with
MHC. Referred to a Preferred Provider through MHC such as a psychologist,
psychiatrist, or social worker, at
one of the centers located throughout
the area. Referred to another type of service provider, such as an attorney,
physician, or financial advisor, depending on
the nature of your problem.What is covered There is no charge for information and referral services through MHC. In addition, you pay only $10 per visit for counseling services when you use a Preferred Provider through MHC. There is a limit of 50 visits per calendar year when you use an MHC Preferred Provider. If you are not satisfied with the services you are receiving from the MHC Preferred Provider to whom you were referred, you may contact MHC for another referral. If you do not use a Preferred Provider through MHC, the Plan pays 50% of allowed charges up to $12.50 per visit after you have satisfied a $100 calendar year deductible.( Please note, the deductible and coinsurance are separate from any deductible and coinsurance requirements under your medical coverage.) You are responsible for paying the remainder of the charges. Benefits for intensive outpatient treatment are combined with the inpatient benefit and are subject to the maximum 45 day per calendar year limit and benefit schedule set forth under the Inpatient Care section above. IMPORTANT: Your claim for benefits may be denied if you have failed to complete a prescribed course of treatment. You should receive a claim denial letter in such event. You (or a member of your family) has the right to appeal any such denial in writing in accordance with the claim appeal procedure set forth herein within 60 days of your receipt of the claim denial letter on the basis that (1) despite your best efforts, you were unable to comply with the prescribed course of treatment, or (2) you failed to complete your treatment based on the medical advice of another mental health provider or a physician. The other provider does not have to be an MHC Preferred Provider. What is not covered
Psychological TestingMaximum payments Whether you use an MHC Preferred Provider or a non-preferred provider, the benefits for treatment of mental, nervous, drug and alcohol disorders for both inpatient and outpatient care are applied toward the lifetime maximum of $1,000,000 for medical coverage. Claim filing deadlines All claims for both inpatient and outpatient care must be filed within 1 year of the date of service. Otherwise, the Plan will not pay your claim. |