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Service Employees 32BJ North Health Fund
Tri-State Preferred North Summary Plan Description (SPD)
>> Employee Assistance Program (EAP)
EAP stands for the Employee Assistance Program. It provides you
and your family with confidential, professional counseling, and benefits
for behavioral and substance abuse treatment. The EAP’s staff of health
professionals, counselors, psychologists, social workers and psychiatrists
can help you deal with stress, depression, gambling, drinking or drug
abuse, domestic violence, family or relationship issues and other personal
problems.
This EAP is administered by Managed Health Network (MHN), an
independent organization that manages a network of behavioral health
specialists and also arranges consultations, assessments and referrals.
This network is separate from and not part of the Empire Direct POS
network.
These benefits for behavioral and substance abuse treatment are
payable for in-network care only. You must use a participating MHN
network provider to get benefits. If you use an out-of-network facility
or provider, no benefits are payable.
All services, including counseling, behavioral and substance abuse
treatment, both inpatient and outpatient, require referral from MHN (see
below for how emergency treatment is handled). If you need services or
want to discuss a problem, call MHN at 1-800-798-2150.
When you call MHN at their toll free number, an MHN representative
will assess your problem and refer you to a trained EAP counselor. The EAP counselor will discuss your problem with you, assess your individual
needs and outline a plan of action for you to consider. You may talk to
an EAP counselor by phone, through scheduled telephone appointments,
or be referred to see an EAP counselor in his or her office. For each
problem you call about, you can get up to eight office-based sessions with a
counselor. There is no limit on counseling by telephone.
For many people, talking to an EAP counselor, by telephone or in the
office, is all the help they need. However, if you need more specialized or
extensive behavioral or substance abuse treatment, the EAP counselor will
refer you to a MHN specialist or inpatient facility. This benefit is described
in the following text.
If you know that you do not want to use the EAP services when you
first call MHN, an MHN representative can provide you with a referral
directly to an MHN participating specialist near where you work or live.
All these services, including counseling, behavioral and substance
abuse must be in-network and must be arranged through MHN. Call
MHN toll-free at 1-800-798-2150. You can call directly anytime day
or night to speak with a trained EAP counselor.
Behavioral and Substance Abuse Treatment
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Inpatient. As long as you go to an in-network facility and the stay
has been pre-certified (see below), the Plan pays the allowed amount for up to 30 days per year, including partial hospitalization and day
programs. If you use an out-of-network facility and/or do not pre-certify
care, no benefits are payable unless it is an emergency. If there is an
emergency, the patient should first go to the nearest emergency room,
then call MHN (a provider or relative may make the call for the patient).
As long as MHN is contacted within 48 hours of admission, the Plan
will pay benefits for charges that are determined to be emergency care
charges. If the facility is not an MHN network provider, the patient may
be transferred to a network facility once the emergency has passed.
Benefits for inpatient substance abuse rehabilitation are payable only
once in each person’s lifetime. This limit does not apply when the only
care provided is for detoxification.
Outpatient. For outpatient treatment from a network provider,
you pay $15 per visit. If you use an out-of-network therapist or do
not pre-certify care, no benefits are payable. Outpatient treatment may
include individual and group psychotherapy, couples and family treatment,
psychiatric and medication evaluations, and ongoing medication
management, depending on the patient’s needs. This is subject to a limit
of 40 visits per year.
Psychological testing is covered as long as it is clinically indicated and
pre-certified. Psychological testing for educational purposes is not covered.
Electro-convulsive therapy (ECT) is covered on either an inpatient
or outpatient basis, subject to the applicable limits and/or co-payments described above, as long as it is pre-certified and received from a network provider.
Confidentiality
MHN is committed to protecting your privacy, and all contact with
them is strictly confidential as required by Federal and state laws. If
anyone else requests information, MHN must first get your approval
before they can release it. All services are kept confidential in accordance
with Federal, state and local laws, and professional standards of
confidentiality. Among the situations where the provider is required by
law to notify authorities are instances of child abuse, elder abuse or a
professional determination that the patient is a threat to personal safety.
Pre-Certifying Behavioral or Substance Abuse Treatment
To pre-certify care, call MHN toll-free at 1-800-798-2150. If you
are unable to make the call yourself, your MHN network provider,
EAP counselor, treatment facility or a family member can call instead.
As part of the pre-certification process, your MHN case manager will
determine eligibility and help make arrangements for required admissions,
transportation to and from facilities, and ongoing case management during
and after hospitalization.
Eligible Providers
For behavioral health care purposes, “providers” include psychiatrists,
psychologists and certified social workers with six or more years of postdegree
experience, who are certified by the New York State Board for
Social Work or a comparable organization outside New York to provide
psychiatric or psychological services within the scope of their practice,
including the diagnosis and treatment of mental and behavioral disorders.
Conditions for Coverage
In order to be covered, any expenses you incur for behavioral and
substance abuse treatment must be in-network, medically necessary and:
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the requested services must provide for the diagnosis and/or active
treatment of a current substance-abuse–related disorder or a
condition listed as an Axis I disorder in the most recent edition of
the “Diagnostic and Statistical Manual of Mental Disorders” by the
American Psychiatric Association
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• the proposed treatment plan must represent an active, necessary and
appropriate intervention for the timely resolution of the patient’s
symptoms and the restoration to baseline level of functioning
(proposed services cannot be custodial in nature)
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• the type, level and length of the proposed services and setting must be
consistent with MHN’s level-of-care criteria and guidelines, and must
be rendered in the least restrictive level of care in which the patient
can be safely and effectively treated
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• the proposed treatment must not be experimental in nature (that is,
safety and efficacy must have been clearly demonstrated and widely
accepted in the modern psychiatric literature)
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• the proposed treatment plan must be shown in peer-reviewed journals
to be at least equally effective in bringing about a rapid resolution
of symptoms when compared to possible alternative treatment
interventions, and
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the proposed treatment plan must utilize clinical services in
an efficient manner when compared to alternative treatment
interventions and must contribute to effective management of the
patient’s benefits.
What Is Not Covered
Your EAP does not include coverage for any of the services, supplies
or charges listed below. However, some of these items are covered under
medical/hospital; check the medical/hospital section of this booklet (see the "Hospital and Medical Benefits" section).
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services received or expenses incurred before the patient’s coverage
began or after the patient’s coverage ended, except as specifically
stated herein
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outpatient treatment for any medically treated illness
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treatment or services for mental retardation or autism
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more than eight EAP counseling sessions per problem per year
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services by counselors who are not in the EAP network
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testing, treatment or counseling required by law or court
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formal psychological evaluations and fitness-for-duty opinions
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legal advice (although this is not covered under the Health Benefit
Fund, it may be covered under the Service Employees 32BJ North Legal
Services Fund or the Building Service 32BJ Legal Services Fund if your
collective bargaining agreement requires contributions to either Legal
Services Fund; see the Legal Services Fund booklet for information)
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long-term hospitalization for residential or chronic care
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treatment of detoxification in newborns
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treatment of congenital and/or organic disorders (this includes,
without limitation, Alzheimer’s disease, mental retardation (other
than the initial diagnosis), organic brain disease, delirium, dementia,
amnesic disorders and other cognitive disorders as defined in the
“Diagnostic and Statistical Manual of Mental Disorders”)
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treatment for chronic pain and other pain disorders, smoking
cessation, nicotine dependence, nicotine withdrawal and nicotinerelated
disorders
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treatment of obesity and eating disorders—other than the diagnosis
of anorexia and bulimia nervosa as defined in the “Diagnostic and
Statistical Manual of Mental Disorders”—unless otherwise required by
law
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private hospital rooms and/or private duty nursing, unless medically necessary and authorized by MHN
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ancillary services such as:
- vocational rehabilitation
- behavioral training
- speech or occupational therapy
- sleep therapy
- employment counseling
- training or educational therapy for reading or learning disabilities
- other education services
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testing, screening or treatment for:
- learning disorders, expressive language disorders, mathematics
disorder, phonological disorder and communication disorder
- motor skills disorders and development coordination disorder
- all disorders of infancy and early childhood, and development
disorders including, but not limited to, communication disorders,
pervasive developmental disorders, autistic disorder, Rett’s
disorder, Asperger’s disorder (except as otherwise required by law)
- disorders resulting from general medical conditions, including, but
not limited to, catatonic disorder due to general medical condition,
personality change due to general medical disorder, narcolepsy,
stuttering, stereotypic movement disorders, sleep disorders, tic
disorders, elimination disorder and sexual dysfunctions
- personality disorders
- pedophilia
- primary sleep disorders, including primary hypersomnia,
dyssomnia and insomnia
- age-related cognitive decline
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treatment of conditions that are medical in nature, even when such
conditions may have been caused by a mental disorder
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treatment by providers other than those within licensing categories
that are recognized by MHN as providing medically necessary
services in accordance with applicable medical community standards
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treatment rendered for conditions not listed as an Axis I disorder
(V Code diagnoses listed as Axis I disorders are also excluded unless
otherwise specified in the Plan)
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services beyond what is authorized by MHN’s pre-certification and
concurrent review procedures -
psychological testing (except as conducted by a licensed psychologist
for assistance in treatment planning, including medication
management or diagnostic clarification) and specifically excluding all
educational, academic and achievement tests, psychological testing
related to medical conditions or to determine surgical readiness, and
automated computer-based reports
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all prescription or non-prescription drugs and laboratory fees, except
for drugs and laboratory fees prescribed by a provider in connection
with inpatient treatment (if prescribed in the course of outpatient
treatment, these may be covered under the prescription drug
program—see the "Prescription Drug Benefits" section)
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inpatient services, treatment or supplies rendered in a non-emergency
situation by a non-participating provider, unless
authorized by MHN
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inpatient stays in excess of 30 days per year for behavioral and
substance abuse treatment combined
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inpatient stays in excess of 30 days lifetime for substance abuse
treatment
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outpatient care in excess of 40 visits per year for behavioral and
substance abuse combined
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emergency behavioral or substance abuse hospital admissions that
have not been pre-certified within 48 hours of admission
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emergency room services not provided by a psychiatrist directly
related to the treatment of a mental disorder in accordance with the
limitations listed above
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damage to a hospital or facility caused by the patient
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health care services, treatment or supplies determined to be
experimental by MHN in accordance with accepted behavioral
standards, except as otherwise required by law
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health care services, treatment or supplies:
- provided as a result of Workers’ Compensation law or similar
legislation (see the "Coordination of Benefits" section)
- obtained through, or required by, any governmental agency or
program
- caused by the conduct or omission of another party for which the
patient has a claim for damages or relief or has been reimbursed
(for information about subrogation of benefits, see the "Subrogation and Reimbursement" section)
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health care services, treatment or supplies for military service
disabilities for which treatment is reasonably available under
governmental health care programs
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treatment for biofeedback, acupuncture or hypnotherapy
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health care services, treatment or supplies rendered to the patient
that are not medically necessary (this includes, but is not limited
to, services, treatment or supplies primarily for rest or convalescence,
custodial or domiciliary care as determined by MHN)
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services for which:
- the person is not legally obligated to pay
- no charge is made to the person
- no charge would have been made to the person in the absence of
insurance
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services in connection with conditions caused by an act of war
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conditions caused by release of nuclear energy, whether or not the
result of war
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professional services received from a person who lives in the patient’s
home or who is related to the patient by blood or marriage
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any services or supplies to the extent they are covered and primary
under Parts A or B of Medicare if the patient is either enrolled in
Part A of Medicare (whether or not the patient is enrolled in Part B
of Medicare), or is entitled to enroll in Medicare and has made the
required number of quarterly contributions to the Social Security
System (whether or not the patient has actually enrolled in Medicare
or claimed Medicare benefits)
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all other services, confinements, treatments or supplies not provided
primarily for the treatment of the specific conditions described in the
EAP section of this booklet, and/or
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all other services, confinements, treatments or supplies specifically
included as covered services elsewhere in this Plan.
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