What the Program Covers for HMO and Kaiser EPO 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.
Benefits
Substance abuse care expenses covered under the Program include:
  • Outpatient treatment (except for Kaiser Permanente EPO and Kaiser Permanente Senior Advantage);
  • Alternate Levels of Care
    • Partial hospitalization,
    • Residential programs
    • Intensive and structured outpatient treatment,
  • Inpatient hospitalization; and
  • Detoxification, medically necessary (medical detoxification may be covered under your Company-sponsored medical plan).
You receive benefits only if:
  • you have obtained a referral to a network provider through a VO care manager (800-562-3588) or an EAP on-site counselor;
  • your treatment plan is medically necessary (see "Medically Necessary") and is approved by a VO care manager or by one of the Company's on-site EAP counselors; and
  • the primary diagnosis is alcoholism or drug dependency.
All benefits require referrals or authorization from ValueOptions.
Mental Health
Mental health benefits for HMO or EPO members are provided through the plan — not through ValueOptions. For details on the benefits provided by your HMO, refer to the HMO's Evidence of Coverage (EOC), which is provided to all HMO members. For details on the benefits provided by the Kaiser EPO, refer to your Kaiser EPO Summary Plan Description. To receive benefits that are provided through your HMO or EPO, you must go through the processes of your HMO or EPO.
Substance Abuse
If you are eligible to receive benefits for any outpatient substance abuse treatment through this Program, you must obtain authorization from ValueOptions. Authorization for inpatient or Alternate Levels of Care (partial hospitalization, residential treatment, and intensive or structured outpatient care) is required. Except for outpatient benefits for Kaiser Permanente Senior Advantage members, HMO members are eligible for substance abuse treatment through ValueOptions. Members enrolled in Health Net Seniority Plus also have the option of seeking care through Health Net Seniority Plus. Kaiser Permanente EPO and Kaiser Permanente Senior Advantage members receive any outpatient care and medical detoxification services through their plan, not through ValueOptions, but they are eligible to receive inpatient care and Alternate Levels of Care through the program administered by ValueOptions.
Inpatient
For inpatient substance abuse care, after your HMO's deductible, if any, has been satisfied, the Program pays 100% for authorized treatment. Authorization from VO is required. There is no limit on the number of stays.
Alternate Levels of Care
For substance abuse 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, and intensive or structured outpatient services. Authorization from VO is required. There is no maximum on the number of stays, programs, or services.
Outpatient
For outpatient substance abuse care through ValueOptions, after any deductible has been satisfied, if applicable, you pay $10 a visit for individual therapy or $5 a visit for group therapy. There is no maximum on the number of visits. Kaiser Permanente EPO and Kaiser Permanente Senior Advantage members receive outpatient care through Kaiser — not through ValueOptions. Members of Health Net Seniority Plus have the option of receiving outpatient substance abuse treatment through ValueOptions of directly through their HMO.
Autism Applied Behavior Analysis (ABA)
Applied Behavioral Analysis (ABA) is a type of treatment for autism that emphasizes behavioral training and management through positive reinforcement, self-help, and social skills training. ABA is used to help improve behavior, communication, and overall function. ABA for the treatment of autism is fully covered under both administrators. The ABA benefit is fully covered and requires authorization by plan.