Association for Los Angeles Deputy Sheriffs Insurance Trust (ALADS)
Managed Behavioral Health Care Plan
Effective Date: January 1st to December 31st
Members on CaliforniaCare HMO Plan
Please note: The following is a brief summary intended for informational purposes only. Please consult your Evidence of Coverage booklet for complete benefit details. Information found in the Evidence of Coverage booklet supersedes any information found on this website.
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CA & FEDERAL PARITY COMPLIANT PLAN
MENTAL HEALTH AND SUBSTANCE USE
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| MENTAL HEALTH SUBSTANCE ABUSE6 |
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| In-Network |
Out-of-Network |
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| Outpatient |
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| SUBACUTE-100 DAYS/CALENDER YEAR2 |
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| Inpatient1 |
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| EMERGENCY ROOM5 |
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Deductible
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| Annual Maximum |
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| Lifetime Maximum |
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| Out-of-pocket Maximum3 |
| $500/INDIVIDUAL & $1,500/FAMILY |
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| Ambulance |
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1 Holman uses RBRVS (professional) and DRGs (hospital) to calculate reimbursement for Non-Contracted providers. Any disputes are to be negotiated directly with Holman Professional Counseling Centers. Every effort will be made to ensure that Enrollees of Holman Professional Counseling Centers are not subject to balance billing practices for covered services.
RBRVS and DRGs are government approved reimbursement calculations for the reasonable and customary value of healthcare services rendered. They are based upon statistically credible information that is updated at least annually and takes into consideration:
(i) The provider’s training, qualifications, and length of time in practice
(ii) The nature of services provided
(iii) The fees usually charged by the provider
(iv) Prevailing provider rates charged in general geographic areas in which services were rendered
(v) Other aspects of the economics of the medical provider’s proactive that are relevant, and
(vi) any unusual circumstances in the case
• No Mental Health or Substance Abuse day limits or outpatient session limits; however, all treatment is subject to medical necessity & Lifetime Maximum.
• Combined in-network & out-of-network Mental Health Substance Abuse and medical all combined. Required pre-authorization subject to medical necessity. Holman is decider of medical necessity, subject to DMHC review.
• Any co-payments made for the treatment of mental and nervous disorder or substance abuse will be applied toward satisfying the out of pocket maximum and deductible.
• Waived if admitted.
• Preauthorization and concurrent review is required for in and out of network. Emergency Hospitalization must notify Holman within 48 hours of admission.
