Citi Benefits Handbook
Mental Health/Substance Abuse In and Out of Network
The Choice Plan provides confidential mental health and substance abuse coverage through a network of participating counselors and specialized practitioners.
When you call the Claims Administrator at the telephone number on your ID card, you will be put in touch with an intake coordinator who will gather information from you and help find the right provider for you. In an emergency, the intake coordinator will also provide immediate assistance, and, if necessary, arrange for treatment in an appropriate facility.
You must call your Claims Administrator before seeking treatment for mental health or substance abuse treatment.
Mental health and substance abuse treatment benefits are subject to the same medical necessity requirements, coverage limitations and deductibles that are required under the Choice Plan.
Mental health benefits include, but are not limited to:
- Assessment, diagnosis and treatment;
- Medication management;
- Individual, family and group psychotherapy;
- Acute inpatient care;
- Partial hospitalization programs;
- Facility-based intensive outpatient program services; and
- Psychological testing that is not primarily educational in nature.
No benefit will be paid for services that are not considered to be medically necessary.
Aetna: In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
- There is a written treatment plan supervised by a physician or licensed provider;
- The treatment plan is for a condition that can favorably be changed; and
- Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office.
The Choice Plan pays benefits at the in-network level (80% of the negotiated rate contracted with the Claims Administrator) if you call the plan, you use an in-network provider, and the treatment is medically necessary and occurs in the appropriate level-of-care setting. If you do not use an in-network provider, you will be reimbursed at 60% of MAA after the deductible is met, provided that the treatment is medically necessary and occurs in the appropriate level-of-care setting.
In general, inpatient services are covered only if they are determined to be medically necessary and there is no less intensive or more appropriate level of care in lieu of an inpatient hospital stay. If it is determined that a less intensive or more appropriate level of treatment could have been given, no benefits will be payable.
Generally, inpatient services must be rendered in the state in which the patient resides, unless approved by the Claims Administrator in advance of the admission.
Aetna: Benefits are payable for charges incurred in a hospital, psychiatric hospital or residential treatment facility. Covered expenses include charges for room and board at the semiprivate room rate, and other services and supplies. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting.
Covered expenses also include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically directed intensive treatment of a mental disorder. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting.
If you use an in-network provider, you will be reimbursed at 80% of covered expenses after the deductible is met. If you do not use an in-network provider, you will be reimbursed at 60% of MAA for covered services after the deductible is met.
Aetna: Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility. The plan covers partial hospitalization services (more than four hours but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically directed intensive treatment. The partial hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility.
Emergency care for mental health or substance abuse treatment does not require a referral. However, you are encouraged to call the Claims Administrator within 48 hours after an emergency admission. The Choice Plan's behavioral health providers are available 24/7 to accept calls.