What the Program Covers for NAP Members
Eligible Expenses
All benefits are based on "Eligible Expenses," which are:
  • expenses for Covered Health Services that are covered by the plan,
  • those expenses that ValueOptions considers medically necessary for diagnosis or treatment; and
  • those that do not exceed the "Usual and Customary" rate, as determined by ValueOptions.
Any costs not meeting this definition are the responsibility of the member. For additional information or questions, call ValueOptions.
Network Benefits
Mental health and chemical dependency expenses covered under the Program include:
  • Outpatient treatment;
  • Alternate Levels of Care
    • Partial hospitalization,
    • Residential treatment programs,
    • Intensive or structured outpatient treatment;
  • Inpatient hospitalization; and
  • Detoxification, medically necessary (medical detoxification may be covered under your Company-sponsored medical plan).
You receive network benefits only if:
  • you have obtained care from a network provider;
  • your treatment plan is medically necessary (see "Medically Necessary"); and
  • the primary diagnosis is not excluded and is found within the Diagnostic and Statistical Manual of Mental Disorders (DSM V).
Mental Health
To receive network benefits for any covered mental health treatment (both inpatient and outpatient), you must obtain care from a ValueOptions network provider.
Inpatient
For network inpatient mental health benefits, after the annual deductible has been satisfied, the Program pays 100% of the cost of authorized inpatient hospitalization. If treatment is not authorized within 48 hours of the beginning of confinement, a $300 penalty will apply. There is no maximum on the number of stays.
Alternate Levels of Care
For network mental health Alternate Levels of Care, after the annual deductible has been satisfied, the Program pays 100% of the cost of partial hospitalization programs, residential treatment programs, intensive outpatient services and structured outpatient services. If treatment is not authorized within 48 hours of the beginning of confinement or treatment, a $300 penalty will apply. There is no maximum on the number of stays, programs, or services.
Outpatient
For network outpatient mental health treatment, after the annual deductible has been satisfied, you pay $10 a visit for outpatient individual therapy or $5 a visit for group therapy. There is no copayment for an initial visit to a psychiatrist for medication evaluation. There is no maximum on the number of visits.
Substance Abuse Treatment
To receive network benefits for any covered substance abuse treatment (both inpatient and outpatient), you must obtain care from a ValueOptions network provider.
Inpatient
For inpatient substance abuse treatment, after the annual deductible has been satisfied, the Program pays 100% for authorized treatment. A $300 penalty applies if you fail to obtain authorization within 48 hours of the beginning of confinement. There is no limit on the number of stays.
Alternate Levels of Care
For network substance abuse treatment Alternate Levels of Care, after the annual deductible has been satisfied, the Program pays 100% of the cost of partial hospitalization programs, residential treatment programs, intensive outpatient services and structured outpatient services. If treatment is not authorized within 48 hours of the beginning of confinement or treatment, a $300 penalty will apply. There is no maximum on the number of stays, programs, or services.
Outpatient
For outpatient substance abuse treatment, after the annual deductible has been satisfied, you pay $10 a visit for individual therapy or $5 a visit for group therapy. There is no maximum on the number of visits.
Non-Network Benefits
Mental Health
For mental health treatment, you will receive lower non-network benefits when you do not obtain care from a network provider for outpatient treatment.
Covered services for non-network mental health treatment include:
  • Outpatient treatment
  • Inpatient hospitalization
  • Alternate Levels of Care
    • Partial hospitalization
    • Residential treatment
    • Intensive or structured outpatient programs
Your mental health non-network treatment will be covered only if:
  • your treatment provider is an independently-licensed mental health practitioner. California licenses the following mental health providers to practice independently: psychiatrists; psychologists; licensed clinical social workers (LCSW); licensed marriage and family therapists (LMFT); and psychiatric nurses (MSN);
  • your treatment plan is medically necessary (see "Medically Necessary"), as verified by VO throughout your treatment; and
  • your primary diagnosis is not excluded and is found within the Diagnostic and Statistical Manual of Mental Disorders (DSM V).
When you receive covered non-network mental health treatment, the Program pays 70% of the usual and customary charges for inpatient hospitalization or Alternate Levels of Care (partial hospitalization, residential treatment, intensive or structured outpatient care) after the annual deductible has been satisfied. There is a $300 penalty for not obtaining authorization within 48 hours of the beginning of confinement or treatment. There is no maximum on the number of stays, programs, or services.
The Program also pays 70% of the usual and customary charges for outpatient treatment after the annual deductible has been satisfied. There is no maximum on the number of visits.
If you are hospitalized for a non-emergency condition on a non-network basis, benefits for your entire hospital stay will be paid at the non-network level — 70% of the usual and customary charges for medically necessary treatment — and the $300 penalty for not obtaining authorization will apply.
Substance Abuse Treatment
Your substance abuse treatment will be covered only if:
  • your treatment provider is an independently-licensed mental health practitioner. California licenses the following alcohol and drug care providers to practice independently: psychiatrists; psychologists; licensed clinical social workers (LCSW); licensed marriage and family therapists (LMFT); and psychiatric nurses (MSN);
  • your treatment plan is medically necessary (see "Medically Necessary"), as verified by VO throughout your treatment; and
  • your primary diagnosis is an alcohol or drug dependency condition.
For substance abuse treatment, you will receive lower non-network benefits when you do not obtain care from a network provider for outpatient treatment.
For covered outpatient substance abuse treatment, after the annual deductible has been satisfied, the Plan pays 70% of usual and customary charges. There is no limit on the number of visits.
For covered inpatient substance abuse treatment or Alternate Levels of Care ( partial hospitalization, residential treatment programs, and intensive or structured outpatient services), after the annual deductible has been satisfied, the Plan pays 70% of usual and customary charges for authorized treatment at a non-network facility. A $300 penalty applies for inpatient or Alternate Levels of Care if you fail to obtain authorization within 48 hours of the beginning of confinement or treatment. There is no limit on the number of stays, programs, or services.