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OPERATING ENGINEERS
TRUST FUNDS

Mental Health and Substance Abuse Benefits

Provided by Managed Health Network (MHN)

All mental health and substance abuse care, both inpatient and outpatient, is covered through MHN. There is no prior authorization requirement.

Mental health and substance abuse care are covered the same as all other medical care:

  • 90% coverage when a MHN Network provider is used
  • 70% for non-Network providers after satisfaction of the deductible

If You Are Admitted to a Hospital in an Emergency

If you are admitted to a hospital or treatment center in an emergency, you or someone acting on your behalf should notify MHN at (800) 327-0577, as soon as possible to ensure maximum benefits and coverage are available to you.

Mental Health Benefits

  • Outpatient visits are covered at 90% of the contracted rate, after a $20 co-payment for MHN participating providers, subject to the annual in-network deductible of $250. If you use mental health providers who are not contracted with MHN, the Plan pays a maximum benefit of $15 after satisfaction of the $500 non-network calendar year deductible.
  • Inpatient care is covered at an approved mental health facility. When you obtain services from an MHN contracted provider, you pay only 10% of the contract rate and the in-network calendar year deductible applies. If you are admitted to a facility that is not contracted with MHN, you must pay 30% of the Reasonable and Customary Charge plus any amount that exceeds the Reasonable and Customary Charge, as determined by MHN. The non-network calendar year deductible also applies.

Substance Abuse Benefits

  • Outpatient (including detoxification) visits are covered at 90% of the contracted rate, after a $20 co-payment for MHN participating providers, subject to the annual in-network deductible of $250. If you use providers who are not contracted with MHN, the Plan pays a maximum benefit of $15 after satisfaction of the $500 non-network calendar year deductible.
  • Inpatient treatment (including detoxification and residential treatment) is covered at an approved substance abuse treatment facility. When you obtain services from an MHN contracted provider, you pay only 10% of the contract rate and the in-network calendar year deductible applies. If you are admitted to a facility that is not contracted with MHN, you must pay 30% of the Reasonable and Customary Charge plus any amount that exceeds the Reasonable and Customary Charge, as determined by MHN. The non-network calendar year deductible also applies.
  • Alternate Levels of Care: (including partial hospitalization, day, and intensive outpatient treatment). Alternate levels of care are covered at an approved facility. When you obtain services from an MHN contracted provider, you pay 10% of the contract rate and the calendar year deductible applies. If you are admitted to a facility that is not contracted with MHN, you must pay 30% of the Reasonable and Customary Charge plus any amount that exceeds the Reasonable and Customary Charge, as determined by MHN. The non-network calendar year deductible also applies.

Exclusions and Limitations

No benefits are payable for:

  • Treatment of intellectual disability, developmental or learning disabilities other than the initial diagnosis
  • Court-ordered testing, counseling and treatment, including detention under Welfare and Institutional Code, Section 5150
  • Ancillary services such as psychological testing, neuropsychiatric testing, vocational rehabilitation, behavioral training, sleep therapy, speech therapy, employment counseling, training or educational therapy for learning disabilities or other education services
  • Services, treatment or supplies which are not Medically Necessary or Clinically Appropriate, such as those primarily for rest, custodial care, Domiciliary Care or convalescent care
  • Charges for smoking cessation or weight loss programs (however, there is coverage for smoking cessation treatments under the Comprehensive Medical Plan and prescription drug program)
  • Services, treatment or supplies provided as a result of any Workers’ Compensation law or similar legislation or obtained through or required by any governmental agency or program, whether federal, state or any subdivision thereof (exclusive of Medi-Cal)
  • Benefits, services, treatment or supplies that exceed the maximums allowed by the Fund

Definitions

For purposes of this section:

  • Domiciliary Care means inpatient institutional care provided not because it is Medically Necessary but because care in the home setting is not available, is unsuitable or members of the patient’s family are unwilling to provide the care. Institutionalization because of abandonment constitutes domiciliary care.
  • Clinically Appropriate means that the health care services, treatment or supplies meet all of the following conditions:
    • Are rendered for the purpose of diagnosis or treatment of a mental disorder or chemical dependency;
    • Are non-experimental treatments that can be reasonably expected to improve the patient’s condition or level of functioning;
    • Are not mainly for the convenience of the patient or the patient’s health care provider;
    • Are rendered in an environment in which services are performed at the least restrictive level of care providing effective treatment;
    • Are “appropriate,” that is:
      1. Consistent with the symptoms and diagnosis
      2. The type, level, length and setting to provide safe and adequate care and treatment; and
      3. In keeping with generally accepted standards for good medical practice within the organized medical community

    Rights and Responsibilities

    Dignity and Respect

    You have the right to be treated with consideration, dignity and respect and the responsibility to respect the rights, property, and environment of all providers and other health care professionals, Employees and other patients. You have the right to access your own treatment records and have the privacy and the confidentiality of those records maintained. You are also entitled to exercise these rights regardless of gender, age, sexual orientation, marital status or culture; or economic, educational, or religious background.

    Member Accountability/Autonomy

    As a partner in your own health care, you have the right to refuse treatment providing you accept responsibility and the consequences of such a decision and the right to refuse to participate in any medical research projects. You also have the responsibility to:

    • Identify yourself as an MHN member when receiving services.
    • Provide your current MHN contracted provider with previous treatment records, if requested, as well as provide accurate and complete medical information to MHN and any other health care professionals involved in the course of your treatment.
    • Be on time for all appointments and notify your provider’s office as far in advance as possible if you need to cancel or reschedule an appointment.
    • You have the right at any and all times to contact MHN for assistance with issues regarding your behavioral health plan. It is your right to have all the above rights apply to the person you have designated with legal authority to make decisions regarding your health care.

    Filing a Claim

    MHN and your care providers and facilities take care of claim forms when you receive services from MHN providers. Payment is made directly to the provider. If you received approved services from a provider who is not contracted with MHN, you will need to file your claims directly with MHN.

    Complaint and Grievance Process

    Participants are required to follow MHN grievance procedures.

    If you have a complaint or grievance, call MHN at: (888) 466-2219, or online at www.mhn.com, or write:

    MHN
    Grievance & Appeals Unit
    P.O. Box 10697
    San Rafael, CA 94912

    The MHN staff will fill out a Grievance Report Form. If the grievance involves quality of care, it will be investigated and resolved by MHN’s Quality Management staff. MHN Quality Management will acknowledge receipt of your form in writing within five calendar days.

    MHN will resolve most grievances within 30 days of receipt of the Grievance Report Form. However, if additional time is required, you will be notified within 30 days and you will be given the reason for the delay. You will be notified of the resolution of the grievance, in writing if appropriate. If you are dissatisfied with the outcome, you can appeal by writing to the Quality Management Clinical Manager at the address above. If the Quality Management Clinical Manager upholds the original decision, you will receive a letter informing you of your right to appeal.

    Appeal Process: Level I: Internal Review

    If you are still in treatment or have an imminent need for treatment, you or your MHN provider can request an expedited appeal by telephone by calling MHN at (888) 466-2219. An appeal determination via telephone will be made as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the request for review. The reviewer will not be the one who issued the initial denial.

    If treatment is completed, appeals are processed within 30 days of a request. The appeal request should include a complete copy of relevant hospital information or clinical records and be sent to:

    MHN
    Grievance & Appeals Unit
    P.O. Box 10697
    San Rafael, CA 94912

    Revised 01/2020

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