The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
What Is Not Covered
The following mental health and substance abuse services are specifically not covered:
• Services to hold or confine a person under chemical influence when no medical services are
required, except as required by law.
• Marriage counseling or training services.
• Interpersonal relationship counseling.
• Treatment of codependency.
• Custodial and supportive care.
• Court-ordered services that are not medically necessary.
• Special education, therapy, counseling or care for learning disorders or behavioral problems
whether or not associated with a manifest mental disorder, mental retardation or other
disturbance.
• Services related to mental illness that are not listed in the most recent edition of the
International Classification of Diseases.
• Biofeedback.
Preventive Care
As required by law, you are not responsible for paying for eligible preventive care services
received from an in-network/participating provider. These eligible preventive care services
will be paid by the plan at 100%, no deductible. Such services include:
• Evidence-based recommended items or services of the United States Preventive Services
Task Force (USPSTF) with a rating of "A" or "B";
• Immunizations recommended from the Advisory Committee on Immunization Practices
(ACIP) of the Centers for Disease Control (CDC); and
• Evidence-informed preventive care and screenings provided for in the comprehensive
guidelines supported by the Health Resources and Services Administration (HRSA) for
infants, children, adolescents and women.
Note: Recommended ages and populations vary for the services listed above. Refer to the charts in
this section for more detailed information about eligible preventive care services. In addition,
eligible preventive care services received from an out-of-network/non-participating provider
will not be covered.
Providers are legally required to code and bill accurately for services they provide to patients.
Covered services are paid based on the billing codes used by your provider on the claim
submitted to BCBS for payment. Therefore, you may be responsible for a portion of the
preventive care visit when:
– the service is not billed as preventive care (including those that may have been received
at the same time as your preventive care visit);
– you do not meet the criteria (based on age or population) for the recommendation or
guideline for the preventive care service; or
– the preventive care service was received from an out-of-network/non-participating
provider.
Please call BCBS if you have questions about coverage. Telephone numbers are listed in the
“Important Resources” section in this SPD.
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