Prudent Buyer (PPO Member)

Association for Los Angeles Deputy Sheriffs Insurance Trust (ALADS)

 

Managed Behavioral Health Care Plan
Effective Date: January 1st to December 31st

Prudent Buyer (PPO Member) 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.

COINSURANCE:
10% per session		 COINSURANCE:
30% per visit
COINSURANCE:
10% per session		 COINSURANCE:
30% per visit
COINSURANCE:
10% per session		 COINSURANCE:
30% per visit
FEDERALLY COMPLIANT PLAN
MENTAL HEALTH AND SUBSTANCE USE PARITY PLAN
Mental Health & Substance Abuse
Prudent Buyer PPO Plan
In-Network Out-of-Network
Outpatient
10% CO-PAY/VISIT 30% CO-PAY/VISIT
SUBACUTE
10% CO-PAY/VISIT 30% CO-PAY/VISIT
In-Patient1
10% CO-PAY/DAY 30% CO-PAY/VISIT
Deductible
$300 MEMBER/YEAR
$900 FAMILY/YEAR
Annual Maximum
NONE
Lifetime Maximum
UNLIMITED
Annual Out-of-Pocket
$450 MEMBER/YEAR
$1,350 FAMILY/YEAR		 $6,000 MEMBER/YEAR
$18,000 FAMILY/YEAR
Ambulance
BENEFIT THROUGH MEDICAL
Emergency Room
10% Copay

 

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.

 

• After $6,000 in out of pocket payments for covered expenses, for NON participating providers, 100% of covered expenses are paid.

 

• 30% for non-emergency

 

• Preauthorization and concurrent review is required for in and out of network. Emergency Hospitalization must notify Holman within 48 hours of admission.

 

• Emergency room is covered as In-Network