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Mental Health and Substance Abuse Benefits

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Outpatient benefit overview

Visits to mental health providers have a $10 copay per visit for members of the MIT Traditional and MIT Choice Plans with a PCP at MIT Medical. Members of the MIT High Deductible Health Plan will pay full price until meeting the deductible. 

Members of all three health plans will be covered for visits to both in- and out-of-network mental health providers in the community, though out-of-pocket costs will be lower if you see an in-network provider. You do not need an authorization or referral to begin necessary outpatient mental health care. 

Out-of-pocket cost

• MIT Traditional Health Plan…
  • In-network provider: You pay $10 copay for each visit.
  • Out-of-network provider: You pay the difference between the provider’s actual fee and the per-visit payment from Blue Cross Blue Shield. For example, if the provider’s fee is $250 and the Blue Cross Blue Shield per visit payment is $60, you pay $190 ($250 – $60).
• MIT Choice Plan with MIT Medical PCP…
  • In-network provider: You pay $10 copay for each visit.

  • Out-of-network provider: Once you have satisfied your annual deductible, you pay 25 percent of the Blue Cross “allowed amount” for each visit. In addition, the provider may choose to bill you for the difference between his or her usual fee and the Blue Cross allowed amount.

    For example, if the provider’s usual fee is $250 and the Blue Cross Blue Shield allowed amount for that type of visit is $150, and you have satisfied your plan’s deductible for the year, you will pay $37.50 (25 percent of $150) and Blue Cross Blue Shield will pay $112.50 (75 percent of $150). After that, the provider may choose to bill you for an additional $100—the difference between his or her usual fee ($250) and the Blue Cross allowed amount ($150). If the provider chooses to bill you for this difference, your total cost for the visit would be $137.50. Note that the additional $100 billed by the provider will not count toward Blue Cross Blue Shield’s calculation of your annual out-of-pocket costs.

    Once your coinsurance payments reach your health plan’s maximum out-of-pocket costs for the year, Blue Cross Blue Shield will begin paying the full allowed amount for each visit to any out-of-network provider. However, out-of-network providers can still bill you for the difference between their usual fees and the Blue Cross Blue Shield allowed amount for the service they provide. 

• MIT High Deductible Health Plan 
  • In-network provider: You pay full price until your deductible is met. After that, you will be responsible for 10 percent of the allowed amount until you satisfy your in-network out-of-pocket maximum; then services will be covered in full.

  • Out-of-network provider: Once you have satisfied your annual, separate out-of-network deductible, you pay 25 percent coinsurance for any out-of-network visits until you satisfy your out-network out-of-pocket maximum, then services will be covered will be covered without any coinsurance. However, you may still be responsible for the difference between the allowed amount and the full charge.

Finding or verifying in-network providers

You can use the Blue Cross Blue Shield of Massachusetts (BCBSMA) website (see chart above) to find behavioral health providers who participate in the network for your plan. To find out if a specific provider is part of your plan’s network, choose the appropriate subspecialty, and sort providers by name from the top drop-down menu item on the right. 

If you have any questions about a specific provider’s network participation, please contact Claims and Member Services at 617-253-5979 or mservices@med.mit.edu.

Filling Prescriptions

You may fill prescriptions from an outside mental health provider at any Express Scripts retail pharmacy or at the MIT Pharmacy. To take advantage of the lower copayments at the MIT Pharmacy, we must have a referral for your clinician on file, but this is easy to do. Just contact MIT Medical’s Mental Health and Counseling Service at 617-253-2916, and ask to speak with someone about getting a referral for your outside treatment. They’ll submit a referral that will let you fill your prescriptions here.

Submitting Claims

Make sure your clinician knows that you are covered for mental health services through Blue Cross Blue Shield. If you are seeing an in-network clinician, you don’t have to worry about dealing with the insurance company; your provider will take care of submitting claims to Blue Cross Blue Shield.

If you are seeing an out-of-network provider, you should ask the provider to submit claims to Blue Cross Blue Shield for you. If he or she refuses to do so, you will have to pay the clinician’s full fee up front, and then submit a claim for reimbursement using the Blue Cross Blue Shield Subscriber Claim Form. Be sure to get the clinician’s information and an itemized record of the services provided, including date(s) of visit(s), procedure code(s), diagnosis, and charges. You must submit all claims within one year of the date of service.

Inpatient Care

With prior authorization, admissions to an in-network hospital, mental health facility, or inpatient substance abuse treatment program are covered for as many days as medically necessary. You will have no out-of-pocket cost unless you are covered by the MIT High Deductible Health Plan (HDHP). With the MIT HDHP, you will pay 10 percent coinsurance for in-network care or 25 percent for out-of-network care after you reach your deductible. Please note that the in-network deductible and out-of-network deductible are not combined.

MIT Choice Plan members who admit themselves to facilities without prior authorization, or who choose to admit themselves to out-of-network facilities, will pay 25 percent coinsurance (25 percent of the Blue Cross Blue Shield allowed amount for such treatment facilities) after the annual deductible is met. The facility may also choose to bill the patient for any difference between the Blue Cross Blue Shield allowed reimbursement and the facility’s actual fee.