Specialized mental and behavioral health services are provided under a single program available to employees enrolled in the state’s medical plan. This program is administered by Optum Behavioral Solutions. Optum provides 24-hours-a-day, seven-days-a-week phone assessment and referral services for a variety of behavioral health issues, such as:
- Anger management
- chemical dependency
- Compulsive disorders
- Marital and family issues
- Serious mental illnesses
Also, the following services are available to members with a medical diagnosis of Autism Spectrum Disorder.
- Clinical Therapeutic Intervention administered by or under the supervision of a qualified/approved provider, in accordance with an approved applied behavioral analysis (ABA) treatment plan.
- Mental and behavioral outpatient services performed by a psychologist, psychiatrist, physician or board-certified behavior analyst who is licensed/qualified/approved provider for consultation/assessment/development/oversight of treatment plans.
- ABA services must be pre-certified. Treatment that is not pre-certified may result in no coverage.
The amount the plan pays for covered services is based on the contracted allowed amount. If an out-of-network provider charges more than the contracted allowed amount, you may be responsible for the difference between the billed amount and plan contracted allowable amount.
Example: If an out-of-network hospital (facility) charges $1,500 for an overnight stay and the contracted allowed amount is $1,000, you may have to pay the $500 difference, which is called balance billing.
Contact Optum before receiving services to ensure the highest level of benefits or review the Behavioral Health Benefits Summary Plan Document tab for more information on the benefits.
About Behavioral Health Insurance
Using my Behavioral Health Insurance:
- There are no limits on the number of clinically necessary visits or inpatient days under the program.
- There are no annual or lifetime monetary maximums;
- Patients should obtain pre-approval for the services that require pre-approval;
- Patients should utilize providers, hospitals and other facilities that participate in the Optum network to obtain the highest level of benefits; and
- The Optum behavioral health care system is coordinated through the Ohio Employee Assistance Program (Ohio EAP).
For questions, call Ohio EAP at 1-800-221-6327 or 1-614-644-8545.
All enrolled employees and their families have access to both in-network and out-of-network behavioral health benefits. However, if a member opts to use an out-of-network provider and facility, the member will pay more for services. See the Behavioral Health Benefits Plan Benefits Chart in the Costs tab.
Out-of-Network Provider Charges
If the medical plan provides out-of-network benefits, you may have access to out-of-network benefits through Optum Behavioral Solutions, but at a higher cost to you.
The amount the plan pays for covered services is based on the contracted allowed amount. If an out-of-network provider charges more than the contracted allowed amount, you may have to pay the difference.
Example: If an out-of-network hospital charges $1,500 for an overnight stay and the contracted allowed amount is $1,000, you may have to pay the $500 difference. This is called balance billing.
If the plan provides a benefit for out-or-network inpatient facility services (e.g., hospitalization, partial hospitalization, residential, day or structured outpatient treatment facilities), you must obtain pre-authorization before obtaining medical care. If you do not obtain pre-authorization before obtaining medical care, you will be required to pay a $350 penalty.
To receive benefits under the plan, you should contact Optum Behavioral Solutions before inpatient and outpatient behavioral health services are provided.
For example, you or your provider of service must obtain pre-authorization from Optum for any non-routine outpatient services (e.g., office visits longer than 60 minutes and all psychological testing). This helps to ensure that the covered person receives the highest level of benefits.
Note: For routine outpatient services (i.e., office visits less than 45 minutes), pre-authorization is not required.
For some services, Optum may perform a Utilization Review to determine whether the service or supply is a covered service. The covered person and his/her provider decides which behavioral health services are needed.
Effective Coverage Dates
Coverage is effective on the same date that your health care plan becomes effective, which is the first day of the month following the month in which you enroll in the plan, or the first day of the new benefit period.
In addition, Optum provides various classes on mental health, substance abuse and wellness to State of Ohio employees. Classes are provided at your worksite; however, the classes must be requested through the Ohio Employee Assistance Program by your agency human resources office or management. See the OEAP website to access the training request form to request the Optum Behavioral Solutions seminars.
What is Covered
The following are included in your coverage:
- Individual and group outpatient mental health and substance abuse treatment;
- Inpatient psychiatric and chemical dependency treatment;
- Family and marital counseling
- Services for lifestyle management counseling; and
- Mental health and substance abuse disorders and conditions, including, but not limited to:
- Individual and group psychotherapy;
- Inpatient treatment;
- Intensive outpatient services;
- Medication management;
- Preventive services; and
- Treatment planning.
You should call Optum Behavioral Solutions at 800-852-1091 before seeking services to ensure you will receive the highest level of benefits.
Visit the Optum Behavioral Solutions website at liveandworkwell.com and enter access code 00832 to find:
- Participating providers;
- Health and wellness information;
- Mental health conditions;
- Online assessments; and
- Educational tools.
What is not Covered
Some conditions that may be perceived as mental health or substance abuse related problems are not covered by Optum Behavioral Solutions.
*These include, but are not limited to:
- Conditions requiring long term care in custodial settings such as nursing homes;
- Conditions for which treatment is court-ordered but not medically necessary, such as weekend programs for driving under the influence of alcohol or drugs;
- Examinations for employment, licensing, school, camp, sports, insurance, adoptions or other non-medically necessary reasons;
- Food supplements, liquid diets, diet plans or any related education requirement;
- Herbal medicine;
- Nicotine replacement products;
- Nutritional counseling, membership costs for health clubs and weight loss clinics, and similar programs;
- Report preparation and presentation;
- Services provided in an institution that is mainly a school, camp or other training institution;
- Services that are considered investigational;
- Sex change therapy or transsexualism;
- Some organic conditions such as chronic organic brain syndrome; and
- Treatment given in connection with mental retardation, pervasive development disorders and learning disabilities.
*Note: This list is not all inclusive; contact Optum Behavioral Solutions before receiving services.
In-Network and Out-of-Network Costs
For in-network hospital care, you must pay 100 percent of the charges until your deductible has been met and then 20 percent of the charges until your annual out-of-pocket maximum has been met. For out-of-network hospital care, you must pay 100 percent of the charges until your deductible has been met and then 40 percent of the charges until your out-of-pocket maximum is met and you may be subject to balance billing over the allowed amounts. For out-of-network providers, you must have your services pre-authorized or you may be assessed a $350 penalty. Coinsurance amounts made for mental health and substance abuse services count toward your health plan deductible and out-of-pocket maximums. Once you have reached your annual out-of-pocket maximum, all charges will be covered in full.
Employees and dependents are required to pay a $30 copayment for each in-network outpatient visit. For out-of-network visits, a $50 per visit copayment applies and then the plan pays 60 percent of the allowed amount. You may be subject to balance billing for amounts above the allowable amount. You should contact Optum Behavioral Solutions before seeking care to ensure the highest level of benefits. Office visit copayments do not count toward your deductible.
Routine Care for Outpatient Services
You may obtain assistance in locating a participating provider experience in dealing with your specific issues. If you have a previously-established relationship with a counselor, or if one has been recommended by your physician, call Optum at 1-800-852-1091 and ask to if the provider participates in the Optum network.
Optum calls are answered by master’s degree-level, licensed clinicians who are trained to assist members with emergency, urgent or routine issues as well as assist in locating an appropriate provider within the network.
You may access a list of participating providers by visiting the Optum website at liveandworkwell.com and select Search for a Clinician. Enter the State of Ohio access code number: 00832 to enter the site or register as a user by creating a user name and password.
If a member or dependent family member experiences a life threatening emergency that requires immediate attention, go to the nearest emergency room. It is best if you can contact Optum before you arrive at the hospital. If you are unable, call Optum at 1-800-852-1091 within 24 hours. In most cases, emergency care is covered by the State of Ohio medical plan. If the emergency room visit is going to result in an admission to the hospital for a behavioral health or chemical dependency condition, the member of the facility must contact Optum for authorization. You may be directed to a more appropriate inpatient or outpatient facility for treatment.
Care While Traveling
Optum has a nationwide network of providers and hospitals. Call 1-800-852-1091 for assistance in obtaining services when outside of the Ohio service area.
In most cases, there are no forms to complete. Employees and dependents simply attend appointments and pay the required copayments, deductibles, and coinsurance. In rare situations, such as emergency care, claim forms may be necessary. You must file your claim within 15 months of the date services occurred.
Explanation of Benefits
Optum will send you an explanation of benefits form which explains how each claim was paid or why it was denied. You may review your explanation of benefits forms online by visiting liveandworkwell.com and registering on the site. Requests for reviews of denied claims must be made within 90 days of the date the claim was processed.
Questions or Disputed Claims
If you have any questions or disagree with an Optum benefit decision, call the Optum Member Relations Department at 800-852-1091, Monday through Friday between 9 a.m. and 8 p.m. Eastern Time. A representative will assist you with your request and inform you of your options for further review if you remain dissatisfied.
Ohio Employee Assistance Program (OEAP)
The State of Ohio offers support services through the OEAP for various behavioral health issues, which includes mental health referrals and consultations for employees and their family members. Other services include education and training, critical incident stress management, mediation and organizational transitional services.
Optum Disability Solutions Program
Optum's Disability Solutions Program involves early identification of employees who have applied for or may be on short-term mental health disability. Employees undergo a special assessment by a disability specialist who is an Optum network provider trained in disability management. The provider provides the employee with an intensive-focused treatment plan to assist in the employee’s return to work. There is no cost to the employee for the assessment.
The Disability Solutions team partners with the State of Ohio’s Disability Services Unit to support employees while on mental health disability. This program goal is to assist you in obtaining an appropriate treatment plan as soon as possible. Optum provides the State of Ohio’s Disability Services team with progress updates to help with the management of mental health disability claims.
Optum Training Offerings
Optum provides various classes on mental health, substance use, and wellness to State of Ohio employees. Classes are provided at your worksite; however, the classes must be requested through the OEAP by your agency human resources office or management. See the OEAP website to access the training request form to request the Optum Behavioral Solutions seminars.
Family Support Program
The Family Support Program gives you phone access to licensed clinicians who will assess, educate, support and manage cases of children or adult dependents with substance use disorders (alcohol or drugs).