District Council #21 – Health & Welfare Office
2980 Southampton Road
Philadelphia, PA 19154
|
Common Medical Event |
Services You May Need |
Your Cost If You Use a Network Provider |
What Will be Covered if You Use an Out of Network Provider |
Limitations & Exceptions |
|---|---|---|---|---|
|
If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
$20 copay per visit |
70% of allowance, after deductible * |
Out of pocket maximum |
|
Mental/Behavioral health intensive outpatient services |
$20 copay per visit |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Mental/Behavioral health partial services |
$20 copay per visit |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Mental/Behavioral health inpatient services |
No charge |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Mental/Behavioral health inpatient miscellaneous facility charges |
Included in room and board facility charges |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Substance use disorder outpatient services |
$20 copay per visit |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Substance use disorder intensive outpatient services |
$20 copay per visit |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Substance use disorder partial services |
$20 copay per visit |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Substance use disorder inpatient services |
No charge |
70% of allowance, after deductible * |
Out of pocket maximum |
|
|
Substance use disorder miscellaneous facility charges |
Included in room and board facility charges |
70% of allowance, after deductible * |
Out of pocket maximum |
* 70% of allowance refers to 70% of ATAP’s usual and customary charges. As a member, if the provider does not accept this as full payment, you can be balance billed anything above this and what you pay will not count toward your out of pocket maximum.
|
Important Questions |
Answers |
Why this Matters: |
|---|---|---|
|
What is the plan year? |
The plan year is calendar year, January 1 – December 31. |
The plan year impacts the way your benefit plan will cover your treatment costs. |
|
What is the overall deductible? |
For each calendar year: |
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. |
|
What is the overall lifetime maximum? |
Network: Unlimited |
The lifetime maximum refers to the total amount of money you can put out over the time you are covered by these benefits. |
|
Is there an out of pocket maximum on my expenses? |
Yes |
The out of pocket maximum is the most you could pay during a coverage period for your share of the cost of covered services. This limit helps you plan for health care expenses. |
|
Does this plan use a network of providers? |
Yes. For a list of network providers, see www.alliedtrades-online.com or call 1-800-258-6376 |
If you use an in network provider, this plan will pay some or all of the costs of covered services. Be aware, your in network doctor or hospital may use an out of network provider for some services. Plans use the term in network, preferred, or participating for providers in the network. |
|
Do I need authorization/precertification to see a Mental/Behavioral health or Substance use provider? |
Yes |
Authorization is required for all Mental/Behavioral health and Substance use treatment services. Authorization can be obtained by calling ATAP at 1-800-258-6376. (Typically, the provider calls for this information). |
|
Provider Frequently Asked Questions |
Answers |
Additional Information |
|---|---|---|
|
What is the effective date of the policy? |
SPDs are effective the 1st of each year & benefits are based on a calendar year |
N/A |
|
Is there any pre-existing? |
No |
N/A |
|
Are the mental health and substance abuse benefits combined? |
No |
N/A |
|
Is accreditation required? |
Yes |
Both state license and JACHO accreditation are required |
|
Are prescriptions covered by this plan? |
No |
Prescription medications are covered by the client’s prescription plan |
|
Do intensive outpatient programs and partial hospitalization programs come from the inpatient or outpatient benefit? |
Outpatient |
N/A |
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What type of plan is this (PPO, HMO, etc.)? |
Self funded |
N/A |
|
Are all levels of care authorized based on medical necessity? |
Yes |
N/A |
|
Where do providers send claims? |
Claims address will be provided when pre-certification is requested |
Eligibility and potential benefit term date will also be explained at this time. Provider can call 800-258-6376 at the time of pre-certification to obtain this information |
|
Is there an electronic payer ID? |
Not at this time |
N/A |
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Are there any limitations on this policy? |
Yes |
See above SPD for information about deductibles, out-of-pocket maximums, and other benefit limitations |