The following benefit is being added: Behavioral health treatment applied behavior analysis (ABA)
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1 <April 25, 2012> Customer No.: <XXXXXXX> <Group name> <Address line 1, Address line 2> <City, State, ZIP code> Dear <group name>, Thank you for your business. We re writing to let you know of changes to your Blue Shield of California Evidence of Coverage (EOC) for you and/or your employees, effective July 1, The following benefit is being added: Behavioral health treatment applied behavior analysis (ABA) Due to a new California law, effective July 1 mandating certain mental health benefits, behavioral health treatment benefits have been added to your plan. Coverage is provided for professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder, or autism. Treatment is covered when prescribed, authorized, and rendered by designated providers. Please distribute the enclosed amendments to your employees for their respective plan to retain for their records. If you have any questions, feel free to contact Group Services at (800) If your employees have any questions, please have them contact the number on the back of their ID card. Thank you for choosing Blue Shield for your employees and their families. T9573 (4/12) Sincerely, Blue Shield Account Management Enclosure(s): Amendment(s) to the Evidence of Coverage (EOC) Blue Shield of California 50 Beale Street, San Francisco, CA blueshieldca.com
2 Blue Shield of California Amendment to HMO Plans This amendment should be attached to, and is made part of, your Blue Shield of California HMO Evidence of Coverage. 1. In the Summary of Benefits, in the Mental Health and Substance Abuse Benefits section, a new section is added for Behavioral Health Treatment which is provided in an office location. The Member s Copayment for this Benefit will be the same as the Copayment paid for Outpatient Rehabilitation Benefits provided in an office location as set forth in the Summary of Benefits. 2. In the Summary of Benefits, in the Mental Health and Substance Abuse Benefits section, a new section is added for Behavioral Health Treatment which is provided in the home or other setting (non-institutional). The Member s Copayment for this Benefit will be the same as the Copayment paid for Home Health Care as set forth in the Summary of Benefits. 3. In the Plan Benefits section, subsection Mental Health Benefits and Substance Abuse Benefits a new Item 5, Behavioral Health Treatment, is added as follows: 5. Behavioral Health Treatment Behavioral Health Treatment is covered when prescribed by a Physician or licensed psychologist who is a Plan Provider and the treatment is provided under a treatment plan prescribed by an MHSA Participating Provider. Behavioral Health Treatment must be prior authorized by the MHSA and obtained from MHSA Participating Providers. 4. In the Definitions section, a definition for Behavioral Health Treatment is added as follows: Behavioral Health Treatment professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism. 1 of 1 SGHMOBHTAMEND (7-12)
3 Blue Shield of California Amendment to the POS Plans This amendment should be attached to, and is made part of, your Blue Shield of California POS Evidence of Coverage. 1. In the Summary of Benefits, in the Mental Health section, a new section is added for Behavioral Health Treatment which is provided in an office location. The Member s Copayment for this Benefit will be the same as the Copayment paid for Outpatient Rehabilitation Benefits provided in an office location as set forth in the Summary of Benefits. 2. In the Summary of Benefits, in the Mental Health section, a new section is added for Behavioral Health Treatment which is provided in the home or other setting (non-institutional). The Member s Copayment for this Benefit will be the same as the Copayment paid for Home Health Care as set forth in the Summary of Benefits. 3. In the Benefits Authorization Requirements section and the Prior Authorization subsection, Item 16 is revised to add Behavioral Health Treatment as follows: 16. Behavioral Health Treatment, Outpatient psychiatric Partial Hospitalization and Outpatient electroconvulsive therapy (ECT) Services for the treatment of mental illness. 4. In the Benefits Authorization Requirements section and the Prior Authorization subsection, Item 17 is revised to add Behavioral Health Treatment as follows: 17. Medically Necessary dental and orthodontic services that are an integral part of Reconstructive Surgery for cleft palate procedures. Failure to contact Blue Shield as described above or failure to follow the recommendations of Blue Shield for: PKU Related Formulas and Special Food Products Benefits, Special Transplant Benefits, all bariatric Surgery, Outpatient speech therapy services, Hospital and Skilled Nursing Facility admissions, Behavioral Health Treatment, Outpatient psychiatric Partial Hospitalization and Outpatient ECT Services, and Dental and orthodontic services that are an integral part of Reconstructive Surgery for cleft palate procedures as described above will result in a reduced payment as described in the Additional and Reduced Payments for Failure to Use The Benefits Management Program section or may result in non-payment if Blue Shield determines that the service is not a covered Service. Other specific services and procedures may require prior authorization as determined by Blue Shield. A list of services and procedures requiring prior authorization can be obtained by your provider by going to or by calling the Member Services telephone number indicated on the back of the member s identification card. 1 of 2 SGPOSBHTAMEND (7-12)
4 5. In the Plan Benefits section, Mental Health and Substance Abuse Benefits subsection Level I (HMO) Benefits a new Item 6, Behavioral Health Treatment, is added as follows: 6. Behavioral Health Treatment Behavioral Health Treatment is covered when prescribed by a Physician or licensed psychologist who is a Plan Provider and the treatment is provided under a treatment plan prescribed by an MHSA Participating Provider. Behavioral Health Treatment must be prior authorized by the MHSA and obtained from MHSA Participating Providers. 6. In the Plan Benefits section the Mental Health and Substance Abuse Benefits subsection, the second paragraph under Level II (MHSA Non-Participating) Benefits is replaced as follows: All Inpatient Mental Health and substance abuse Services, Outpatient Partial Hospitalization Services and Behavioral Health Treatment, except for Emergency and Urgent Services, must be prior authorized by the MHSA. For prior authorization, Subscribers should contact the MHSA at (See the Benefits Management Program section for complete information.) 7. In the Plan Benefits section the Mental Health and Substance Abuse Benefits subsection, the fourth paragraph under Level II (MHSA Non-Participating) Benefits is replaced as follows: Note: For all Inpatient Hospital care except for Emergency and Urgent Services, failure to contact the MHSA prior to obtaining Services will result in the Subscriber being responsible for an Additional Payment as outlined in the Preadmission Review Hospital Admissions paragraphs of the Benefits Management Program section. For Outpatient psychiatric Partial Hospitalization Services, Behavioral Health Treatment, failure to contact Blue Shield or the MHSA or failure to follow the recommendations of Blue Shield will result in non-payment of services by Blue Shield. 8. In the Plan Benefits section the Mental Health and Substance Abuse Benefits subsection, Item 5 Behavioral Health Treatment is added as follows: 5. Behavioral Health Treatment Behavioral Health Treatment is covered when prescribed by a physician or licensed psychologist and treatment is provided under a treatment plan approved by the MHSA. Behavioral Health Treatment must be prior authorized by the MHSA and Behavioral Health Treatment delivered in the home or other non-institutional setting must be obtained from MHSA Participating Providers. 9. In the Definitions section, a definition for Behavioral Health Treatment is added as follows: Behavioral Health Treatment professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism. 2 of 2
5 Blue Shield of California Amendment to Baja Plans This amendment should be attached to, and is made part of, your Blue Shield of California HMO Evidence of Coverage. 1. In the Summary of Benefits, in the Mental Health section, a new section is added for Behavioral Health Treatment which is provided in an office location. The Member s Copayment for this Benefit will be the same as the Copayment paid for Outpatient Rehabilitation Benefits provided in an office location as set forth in the Summary of Benefits. 2. In the Summary of Benefits, in the Mental Health section, a new section is added for Behavioral Health Treatment which is provided in the home or other setting (non-institutional). The Member s Copayment for this Benefit will be the same as the Copayment paid for Home Health Care as set forth in the Summary of Benefits. 3. In the Plan Benefits section, subsection Mental Health Benefits a new Item 4, Behavioral Health Treatment, is added as follows: 4. Behavioral Health Treatment Behavioral Health Treatment is covered when prescribed by a Physician or licensed psychologist who is a Plan Provider and the treatment is provided under a treatment plan authorized by the Access Baja HMO Personal Physician. 4. In the Definitions section, a definition for Behavioral Health Treatment is added as follows: Behavioral Health Treatment professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism. 1 of 1 SGBAJABHTAMEND (7-12)
6 Blue Shield of California Amendment to the Shield Spectrum PPO and Shield Savings Plans This amendment should be attached to, and is made part of, your Blue Shield of California Evidence of Coverage. 1. In the Summary of Benefits, in the Mental Health and Substance Abuse Benefits section, a new section is added for Behavioral Health Treatment which is provided in an office location. The Member s Copayment for this Benefit will be the same as the Copayment paid for Outpatient Rehabilitation Benefits provided in an office location as set forth in the Summary of Benefits. 2. In the Summary of Benefits, in the Mental Health and Substance Abuse Benefits section, a new section is added for Behavioral Health Treatment which is provided in the home or other setting (non-institutional). The Member s Copayment for this Benefit will be the same as the Copayment paid for Home Health Care as set forth in the Summary of Benefits. 3. In the footnotes to the Summary of Benefits, the footnote which reads, All Inpatient Mental Health Services, Outpatient Partial Hospitalization Services, Intensive Outpatient Care and Outpatient electroconvulsive therapy Services (except for Emergency and urgent Services) must be prior authorized by the MHSA, is replaced in its entirety with the following: All Behavioral Health Treatment, Inpatient Mental Health Services, Outpatient Partial Hospitalization Services, Intensive Outpatient Care and Outpatient electroconvulsive therapy Services (except for Emergency and urgent Services) must be prior authorized by the MHSA. 4. In the Benefits Management Program section, the Prior Authorization subsection, Item 16 is revised to add Behavioral Health Treatment as follows: 16. Behavioral Health Treatment, Outpatient psychiatric Partial Hospitalization and Outpatient electroconvulsive therapy (ECT) Services for the treatment of mental illness. 5. In the second to last paragraph of the Benefits Management Program section and Prior Authorization subsection, Behavioral Health Treatment is added to the list of services which will be subject to reduced payment, or possible nonpayment, for failure to obtain prior authorization. 6. In the Principal Benefits and Coverages (Covered Services) section and the Mental Health Benefits subsection, the introduction (all paragraphs before the list of benefits identified as Items 1-5) is replaced as follows: Mental Health and Substance Abuse Benefits Blue Shield of California s Mental Health Service Administrator (MHSA) administers and delivers the Plan s Mental Health and substance abuse care Services. Prior authorization is not required for Inpatient Mental Health and Substance Abuse Services when obtained outside of California. See the Out-Of-Area Program: The BlueCard Program section of this booklet for an explanation of how payment is made for out of state Services. All Non-Emergency Inpatient Mental Health Services and Outpatient Partial Hospitalization, Behavioral Health Treatment, and Outpatient ECT Services must be prior authorized by the MHSA. For prior authorization, Subscribers should contact the MHSA at (See the Benefits Management Program section for complete information.) Benefits are provided for the following Medically Necessary covered Mental Health and substance abuse Services, subject to applicable Deductibles, Copayments and charges in excess of any Benefit maximums, MHSA Participating Provider provisions and Benefits Management Program provisions. Coverage for these Services is subject to all terms, conditions, limitations and exclusions of the Contract, to any conditions or limitations set forth in the benefit description below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this booklet. 1 of 2 SGPPOBHTAMEND (7-12)
7 Benefits are provided, as described below, for the diagnosis and treatment of Mental Health and substance abuse conditions. All Non-Emergency Inpatient Mental Health Services and all Outpatient Partial Hospitalization, Behavioral Health Treatment, and Outpatient ECT Services must be prior authorized by the MHSA. The Copayments for covered Mental Health and substance abuse Services, if applicable, are shown on the Summary of Benefits. Note: For all Inpatient Hospital care, except for Emergency Services, failure to contact the MHSA prior to obtaining Services will result in the Subscriber being responsible for an additional payment, as outlined in the Hospital and Skilled Nursing Facility Admissions paragraphs of the Benefits Management Program section. For Outpatient psychiatric Partial Hospitalization, Behavioral Health Treatment, and Outpatient ECT Services, failure to contact Blue Shield or the MHSA as described above or failure to follow the recommendations of Blue Shield will result in non-payment of services by Blue Shield. 7. In the Principal Benefits and Coverages (Covered Services) section and Mental Health Benefits subsection, a new Item 6, Behavioral Health Treatment, is added as follows: 6. Behavioral Health Treatment Behavioral Health Treatment is covered when prescribed by a physician or licensed psychologist and treatment is provided under a treatment plan approved by the MHSA. Behavioral Health Treatment must be prior authorized by the MHSA and Behavioral Health Treatment delivered in the home or other non-institutional setting must be obtained from MHSA Participating Providers. 8. In the Definitions section, a definition for Behavioral Health Treatment is added as follows: Behavioral Health Treatment professional services and treatment programs, including applied behavior analysis and evidence-based intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism. 2 of 2
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