Mental Health & Substance Abuse

 
 

Benefits Summary Plan Description

Mental Health & Substance Abuse

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Mental Health & Substance Abuse

The Leidos medical plans include mental health and substance abuse benefits. These benefits are administered by Aetna or Anthem. For more information on how the mental health and drug or alcohol treatment works, visit the sections below.


How Mental Health and Substance Abuse Benefits Work

The mental health and substance abuse benefits are network-based and give participants a choice when it comes to receiving mental health and substance abuse treatment:

  • For outpatient care, the participant pays a coinsurance. When the participant uses a network provider, the plan pays 80% after deductible. If a participant uses an out-of-network provider, the plan pays 50% after deductible.
  • For inpatient care, the participant pays a coinsurance. When the participant uses a network provider, the plan pays 80% after deductible. If a participant uses an out-of-network provider, the plan pays 50% after deductible.

Participants must call Aetna or Anthem (depending on their state of residence) to receive information and guidance on how to locate a network provider or participants can search for a provider on the Aetna or Anthem web site. If a participant elects to use an out-of-network provider, the participant will be responsible for additional out-of-pocket costs.


Inpatient and Emergency Pre-admission Certification

When inpatient care is necessary, the participant must notify Aetna or Anthem and obtain authorization in advance, whether he or she is using Aetna or Anthem or an out-of-network provider.

If an emergency occurs, and it is not possible to get advance authorization, the participant must notify Aetna or Anthem of all inpatient treatment within 48 hours of the admission (or the next business day if the patient receives treatment on a weekend or holiday). The participant must contact Aetna or Anthem regarding an emergency admission, regardless of whether he or she is in a Aetna or Anthem or non-contracting facility.


Network Benefits

Participants receive the highest plan benefits for mental health and substance abuse treatment by using network providers:

  • For outpatient care, the plan pays as follows:
    • Healthy Focus Essential Plan: 65% after deductible in-network
    • Healthy Focus Advantage Plan: 80% after deductible in-network
  • For inpatient care, the plan pays a percentage of the cost and the participant pays the remaining amount (the coinsurance).

Deductibles and coinsurance for mental health and substance abuse services received through Aetna or Anthem count toward the annual out-of-pocket maximums for the Healthy Focus Essential and Healthy Focus Advantage plans.


Out-of-Network Benefits

If a participant chooses to use an out-of-network provider to obtain outpatient services, the plan pays a percentage of the cost as follows:

  • Healthy Focus Essential Plan: 50% after deductible out-of-network
  • Healthy Focus Advantage Plan: 50% after deductible out-of-network

The participant pays the remaining amount (the coinsurance).

Deductibles and coinsurance for mental health and substance abuse services received through Aetna or Anthem count toward the annual out-of-pocket maximums for the Healthy Focus Essential and Healthy Focus Advantage plans.


What is Covered

Services or supplies must be considered medically necessary by the Claims Administrator, be delivered for the treatment of illness or injury, and be performed or prescribed by a licensed physician to be covered by the Leidos self-insured medical plans. The services are subject to any applicable annual deductibles, coinsurance, and co-payments. See Comparing the Leidos Medical Plans for more detail.

In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:

  • There is a written treatment plan prescribed and supervised by a behavioral health provider;
  • This Plan includes follow-up treatment; and
  • This Plan is for a condition that can favorably be changed.

What is Not Covered

No payment will be made by Aetna or Anthem for the following care, services or supplies:

  • Educational rehabilitation or treatment of learning disabilities, regardless of the setting in which such services are provided;
  • Educational/academic testing and services;
  • Residential Coverage for Wilderness Programs or Military Schools;
  • Residential treatment facilities, that do not meet Aetna or Anthem medical necessity requirements;
  • Custodial care;
  • Treatment for personal or professional growth development, or training or professional certification;
  • Evaluations, consultations or therapy for educational or professional training or for investigational purposes relating to employment;
  • Therapies which do not meet national standards for mental health professional practice;
  • Experimental or investigational therapies;
  • Court-ordered psychiatric or substance abuse treatment, except when certified by Aetna or Anthem as medically necessary;
  • Psychological testing, except when considered medically necessary by Aetna or Anthem;
  • Services, supplies or treatment that are covered for benefits under the medical portion of this plan;
  • Prescription drugs;
  • Private duty nursing, except when precertified by Aetna or Anthem as medically necessary;
  • Treatment of congenital and/or organic disorders;
  • Non-abstinence-based or nutritionally-based treatment for substance abuse;
  • Treatment or consultations provided via telephone;
  • Services, treatment or supplies:
    • Provided as a result of Worker's Compensation laws or similar legislation;
    • Obtained through, or required by, any governmental agency or program whether federal, state or any subdivision thereof (exclusive of Medicaid/Medi-Cal); or
    • Caused by the conduct or omission of a third-party for which the Member has a claim for damages or relief, unless the participant provides Aetna or Anthem with a lien against such claim for damages or relief in a form and manner satisfactory to Aetna or Anthem;
  • Treatment or consultations provided by the member's parents, siblings, children or current or former spouse or domiciliary partner;
  • Sexual therapy programs;
  • Remedial education beyond evaluation and diagnosis of learning disabilities, education rehabilitation, academic education, and educational therapy for learning disabilities;
  • Marital therapy;
  • Treatment for caffeine or nicotine intoxication, withdrawal or dependence; or
  • Treatment in a convalescent facility for drug addiction, chronic brain syndrome, alcoholism, senility, mental retardation and any other mental disorder.