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Metropolitan and Suburban Plan SPD >> Employee Assistance Program (EAP)
“EAP” stands for the Employee Assistance Program. It provides you and your family with confidential, professional counseling, and benefits for behavioral and substance abuse treatment. The EAP’s staff of health professionals, counselors, psychologists, social workers and psychiatrists can help you deal with stress, depression, gambling, drinking or drug abuse, domestic violence, family or relationship issues and other personal problems.
This EAP is administered by Mental Health Network (MHN), an independent organization that manages a network of behavioral health specialists and also arranges consultations, assessments and referrals. This network is separate from and not part of the Empire Direct POS network.
Unlike our medical and hospital benefits, benefits for behavioral and substance abuse treatment are payable for in-network care only. You must use a participating HMC network provider to get benefits. If you use an out-of-network facility or provider, no benefits are payable.
When you call, an EAP counselor will discuss your problem with you, assess your individual needs and outline a plan of action for you to consider. For each problem you call about, you can get up to eight sessions per year with an EAP counselor. There is no charge for these EAP counseling sessions.
For many people, talking to the EAP counselor is all the help they need. However, if you need more specialized or extensive treatment, the EAP counselor may refer you to an HMC specialist or inpatient facility that can give you more care.
Call HMC toll-free at 1-800-798-2150. You can call directly anytime day or night to speak with a trained EAP counselor.
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Behavioral and Substance Abuse Treatment
Inpatient. As long as you go to an in-network facility and the stay has been pre-certified (see below), the Plan pays the allowed amount for up to 30 days per year, including partial hospitalization and day programs. If you use an out-of-network facility and/or do not pre-certify care, no benefits are payable unless it is an emergency. If there is an emergency, the patient should first go to the nearest emergency room, then call HMC (a provider or relative may make the call for the patient). As long as HMC is contacted within 48 hours of admission, the Plan will pay benefits for charges that are determined to be emergency care charges. If the facility is not an HMC network provider, the patient may be transferred to a network facility once the emergency has passed.
Benefits for inpatient substance abuse rehabilitation are payable only once in each person’s lifetime. This limit does not apply when the only care provided is for detoxification.
Outpatient. For outpatient treatment from a network provider, you pay $15 a visit. If you use an out-of-network therapist or do not pre-certify care, no benefits are payable. Outpatient treatment may include individual and group psychotherapy, couples and family treatment, psychiatric and medication evaluations, and ongoing medication management, depending on the patient’s needs. This is subject to a limit of 40 visits per year.
Psychological testing is covered as long as it is clinically indicated and pre-certified. Psychological testing for educational purposes is not covered.
Electro-convulsive therapy (ECT) is covered on both an inpatient and outpatient basis, as long as it is pre-certified and received from a network provider.
Confidentiality
HMC is committed to protecting your privacy, and all contact with them is strictly confidential as required by Federal and state laws. If anyone else requests information, HMC must first get your approval before they can release it. All services are kept confidential in accordance with Federal, state and local laws, and professional standards of confidentiality. Among the situations where the provider is required by law to notify authorities are instances of child abuse, elder abuse or a professional determination that the patient is a threat to personal safety.
Pre-Certifying Behavioral or Substance Abuse Treatment
To pre-certify care, call HMC toll-free at 1-800-798-2150. If you are unable to make the call yourself, your HMC network provider, EAP counselor, treatment facility or a family member can call instead. As part of the pre-certification process, your HMC case manager will determine eligibility and help make arrangements for required admissions, transportation to and from facilities, and ongoing case management during and after hospitalization.
Eligible Providers
For behavioral health care purposes, “providers” include psychiatrists, psychologists and certified social workers with six or more years of post-degree experience, who are certified by the New York State Board for Social Work or a comparable organization outside New York to provide psychiatric or psychological services within the scope of their practice, including the diagnosis and treatment of mental and behavioral disorders.
Conditions for Coverage
In order to be covered, any expenses you incur for behavioral and substance abuse treatment must be in-network, medically necessary and:
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the requested services must provide for the diagnosis and/or active treatment of a current substance-abuse–related disorder or a condition listed as an Axis I disorder in the most recent edition of the “Diagnostic and Statistical Manual of Mental Disorders” by the American Psychiatric Association
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the proposed treatment plan must represent an active, necessary and appropriate intervention for the timely resolution of the patient’s symptoms and the restoration to baseline level of functioning (proposed services cannot be custodial in nature)
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the type, level and length of the proposed services and setting must be consistent with HMC’s level-of-care criteria and guidelines, and must be rendered in the least restrictive level of care in which the patient can be safely and effectively treated
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the proposed treatment must not be experimental in nature (that is, safety and efficacy must have been clearly demonstrated and widely accepted in the modern psychiatric literature)
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the proposed treatment plan must be shown in peer-reviewed journals to be at least equally effective in bringing about a rapid resolution of symptoms when compared to possible alternative treatment interventions, and
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the proposed treatment plan must utilize clinical services in an efficient manner when compared to alternative treatment interventions and must contribute to effective management of the patient’s benefits.
What Is Not Covered
Your EAP does not include coverage for any of the services, supplies or charges listed below. However, some of these items are covered under medical/hospital; check the medical/hospital section of this booklet (see the "Hospital and Medical Benefits" section).
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services received or expenses incurred before the patient’s coverage began or after the patient’s coverage ended, except as specifically stated herein
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outpatient treatment for any medically treated illness
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treatment or services for mental retardation or autism
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more than eight EAP counseling sessions per problem per year
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services by counselors who are not in the EAP network
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testing, treatment or counseling required by law or court
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formal psychological evaluations and fitness-for-duty opinions
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legal advice (although this is not covered under the Health Fund, it may be covered under the Building Service 32BJ Legal Services Fund; see the "Legal Services Fund" section for information)
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long-term hospitalization for residential or chronic care
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treatment of detoxification in newborns
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treatment of congenital and/or organic disorders (this includes, without limitation, Alzheimer’s disease, mental retardation (other than the initial diagnosis), organic brain disease, delirium, dementia, amnesic disorders and other cognitive disorders as defined in the “Diagnostic and Statistical Manual of Mental Disorders”)
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treatment for chronic pain and other pain disorders, smoking cessation, nicotine dependence, nicotine withdrawal and nicotine-related disorders
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treatment of obesity and eating disorders—other than the diagnosis of anorexia and bulimia nervosa as defined in the “Diagnostic and Statistical Manual of Mental Disorders”—unless otherwise required by law
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private hospital rooms and/or private duty nursing, unless medically necessary and authorized by HMC
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ancillary services such as:
- vocational rehabilitation
- behavioral training
- speech or occupational therapy
- sleep therapy and employment counseling
- training or educational therapy for reading or learning disabilities
- other education services
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testing, screening or treatment for:
- learning disorders, expressive language disorders, mathematics disorder, phonological disorder and communication disorder
- motor skills disorders and development coordination disorder
- all disorders of infancy and early childhood, and development disorders including, but not limited to, communication disorders, pervasive developmental disorders, autistic disorder, Rett’s disorder, Asperger’s disorder (except as otherwise required by law)
- disorders resulting from general medical conditions, including, but not limited to, catatonic disorder due to general medical condition, personality change due to general medical disorder, narcolepsy, stuttering, stereotypic movement disorders, sleep disorders, tic disorders, elimination disorder and sexual dysfunctions
- personality disorders
- pedophilia
- primary sleep disorders, including primary hypersomnia, dyssomnia and insomnia
- age-related cognitive decline
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treatment of conditions that are medical in nature, even when such conditions may have been caused by a mental disorder
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treatment by providers other than those within licensing categories that are recognized by HMC as providing medically necessary services in accordance with applicable medical community standards
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treatment rendered for conditions not listed as an Axis I disorder (V Code diagnoses listed as Axis I disorders are also excluded unless otherwise specified in the Plan)
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services beyond what is authorized by HMC’s pre-certification and concurrent review procedures
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psychological testing (except as conducted by a licensed psychologist for assistance in treatment planning, including medication management or diagnostic clarification) and specifically excluding all educational, academic and achievement tests, psychological testing related to medical conditions or to determine surgical readiness, and automated computer-based reports
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all prescription or non-prescription drugs and laboratory fees, except for drugs and laboratory fees prescribed by a provider in connection with inpatient treatment (if prescribed in the course of outpatient treatment, these may be covered under the prescription drug program—see the "Prescription Drug Benefits" section)
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inpatient services, treatment, or supplies rendered in a non-emergency situation by a non-participating provider, unless authorized by HMC
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inpatient stays in excess of 30 days per year for behavioral and substance abuse treatment combined
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outpatient care in excess of 40 visits per year for behavioral and substance abuse combined
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emergency behavioral or substance abuse hospital admissions that have not been pre-certified within 48 hours of admission
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emergency room services not provided by a psychiatrist directly related to the treatment of a mental disorder in accordance with the limitations listed above
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damage to a hospital or facility caused by the patient
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health care services, treatment or supplies determined to be experimental by HMC in accordance with accepted behavioral standards, except as otherwise required by law
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health care services, treatment or supplies:
- provided as a result of Workers’ Compensation law or similar legislation (see the "Coordination of Benefits " section)
- obtained through, or required by, any governmental agency or program
- caused by the conduct or omission of another party for which the patient has a claim for damages or relief or has been reimbursed (for information about subrogation of benefits, see the "Subrogation and Reimbursement " section)
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health care services, treatment or supplies for military service disabilities for which treatment is reasonably available under governmental health care programs
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treatment for biofeedback, acupuncture or hypnotherapy
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health care services, treatment or supplies rendered to the patient that are not medically necessary (this includes, but is not limited to, services, treatment or supplies primarily for rest or convalescence, custodial or domiciliary care as determined by HMC)
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services for which:
- the person is not legally obligated to pay
- no charge is made to the person
- no charge would have been made to the person in the absence of insurance
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services in connection with conditions caused by an act of war
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conditions caused by release of nuclear energy, whether or not the result of war
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professional services received from a person who lives in the patient’s home or who is related to the patient by blood or marriage
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any services or supplies to the extent they are covered and primary under Parts A or B of Medicare if the patient is either enrolled in Part A of Medicare (whether or not the patient is enrolled in Part B of Medicare), or is entitled to enroll in Medicare and has made the required number of quarterly contributions to the Social Security System (whether or not the patient has actually enrolled in Medicare or claimed Medicare benefits)
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all other services, confinements, treatments or supplies not provided primarily for the treatment of the specific conditions described in the EAP section of this booklet, and/or
- all other services, confinements, treatments or supplies specifically included as covered services elsewhere in this Plan.
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