FEP: Residential Treatment Center Benefit Changes for 2016

Beginning January 1, 2016, Blue Cross and Blue Shield of North Carolina’s Federal Employee Program (FEP) will provide benefits for inpatient residential treatment for short-term transitional services designed to achieve predicted outcomes focused on fostering improvement or stability in functional, physical, and/or mental health relating to the FEP patient’s individual medical, physical, mental health, and/or substance abuse therapy needs.

Requirements:

• Facilities must be accredited by a nationally recognized organization relevant to the type of care being provided.
• The facility must be licensed in the state of North Carolina as a residential treatment center that provides 24-hour residential evaluation, treatment, and comprehensive specialized services relating to the FEP patient’s medical, physical, mental health, and/or substance abuse therapy needs.
• Members must be enrolled in and participating in case management prior to, during, and following his or her stay in the accredited facility. Signed consent must be returned to the member’s FEP Plan prior to services being received.
• Preliminary treatment plan and discharge plan, including goals, must be developed, agreed upon by member, provider/facility, and case manager prior to admission. The facility/provider must agree to collaborate with the case manager.
• Precertification is required, even if Medicare is primary. Retrospective approvals will not be granted.
• The inpatient stay must be medically necessary for treatment of a medical, mental health, or substance abuse condition.

What Is Covered:

• Room and board, nursing care, meals, special diets, ancillary charges, and covered therapy services billed by the accredited facility when precertification requirements are met.

What Is Not Covered:

• Admissions that begin prior to receipt of case management consent, preliminary treatment, and discharge plan agreed to by provider, member, and case manager, as well as determination of medical necessity. This includes weekends, provider or family request, court orders, emergency psychiatric assessments, emergency commitments, 72- hour evaluations, etc. Members requiring immediate treatment should be evaluated at the nearest acute-care facility.
• Group home, half-way house, or similar setting
• Respite care
• Care that is primarily domiciliary
• Other noncovered services include:
  • Services provided outside of the provider’s scope of practice
  • Recreational therapy
  • Educational therapy and/or classes
  • Bio-feedback
  • Outward-bound programs
  • Equine therapy
  • Personal comfort items, guest meals, television, etc.

To verify the FEP member’s benefits, please call the number on the back of the member’s FEP ID card. For precertification needs, please contact Magellan at 1-800-288-3976.