Open Choice PPO

Mental and Nervous and Substance Abuse Benefits (Behavioral Health)

A. In-patient benefits

All hospitalization for mental and nervous and substance abuse conditions (behavioural health) is subject to review by Aetna Behavioral Health. Staff members are assured that the Aetna Behavioral Health programme is conducted in the strictest confidence.

Prior to a non-emergency hospital admission, Aetna must be informed of the intended admission. This is accomplished by placing a telephone call to a toll-free Aetna number (800-424-1601) that connects directly to Aetna Behavioral Health. The telephone call may be placed by the subscriber, the attending physician, a family member, or any other person acting for the patient to be hospitalized.

The initial information required by Aetna in order to pre-certify the admission includes the subscriber's identification number (payroll index number), the reason for the admission, the physician's name, address and telephone number, the hospital name, address and telephone number, and the scheduled admission date.

The Aetna Behavioral Health specialist then contacts the attending physician to review the information prior to certification of the admission. If the attending physician makes the original call to the 800 number, this step will be accomplished at that time. The Aetna Behavioral Health specialist certifies a certain number of in-patient days, if appropriate, and develops a plan of regular follow-up visits with the attending physician.
An emergency admission, which cannot be pre-certified before the confinement begins, must be called in to the Aetna Behavioral Health number within 48 hours of the emergency admission.

B. In-patient mental and nervous and substance abuse care (behavioural health)

Coverage includes:

• The full cost (semi-private accommodation) of 90 days of hospitalization per calendar year for the treatment of mental and nervous disorders (behavioural health).
  
• The full cost (semi-private accommodation) of 30 days of hospitalization for substance (alcohol and/or drug) abuse detoxification and rehabilitation, limited to two 30-day benefit periods in a lifetime. Continuous confinement of up to 30 days beyond this 30-day limit is subject to the provision under the paragraph below.
  
• Coverage for up to 30 days of hospitalization for substance abuse (alcohol and/or drug) rehabilitation after the 30-day hospitalization benefit described in the paragraph above has been exhausted. This benefit is available twice in a lifetime and is applicable only as a continuation of each of the two 30-day hospitalization periods provided under the preceding paragraph.

C. Out-patient behavioral health and substance abuse care

• A maximum of 50 out-patient visits per year to a medical doctor engaged in the practice of psychiatry (and, depending on the state in which the provider is licensed, for the services of a psychologist and psychiatric social worker). If treatment is obtained from a network provider, the plan pays 100 per cent of the cost. If the provider does not participate in the PPO network, reimbursement will be at 80 per cent of the reasonable and customary fee level for the area in which the services are rendered, and will be subject to the annual deductible. The 50-visit annual maximum is for network and non-network treatment combined. Co-insurance payments made in respect of out-of-network treatment will not be applied to the $1,000 annual co-insurance maximum.
  
• Sixty out-patient visits per calendar year for the treatment of alcoholism or drug abuse diagnosed by a physician. Of these 60 annual visits, 20 may be utilized for the counselling of the patient's family if directly related to the patient's alcoholism or drug abuse.