UniCare State Indemnity Plan/Medicare Extension

Behavioral Health Benefits-at-a-Glance

This chart is an overview of your Beacon Health Options (Beacon) plan benefits. It is not a complete description. All mental health and substance use disorderbenefitsare administered by Beacon, not your medical plan. For more detailed information, contact Beacon (see below) or consult your member handbook.

COVERAGE
Provider / Beacon Health Options
Telephone / 855-750-8980 (TTY: 711)
Website / Beaconhealthoptions.com/gic
BENEFITS / IN-NETWORK / OUT-OF-NETWORK
Inpatient Care1
General hospital or psychiatric/substance use disorder facility / $50 inpatient care copay per quarter / $150 inpatient care copay per quarter, then 80% coverage of the allowed amount.
Intermediate Care1
Including, but not limited to, 24-hour intermediate care facilities, such as crisis stabilization, day/partial hospitals, and structured outpatient treatment programs / $50 inpatient care copay per quarter / $150 inpatient care copay per quarter, then 80% coverage of the allowed amount.
Outpatient Care1,2
  • Individual and Family therapy, including Autism Spectrum Disorder services
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  • Medication management
  • Group therapy
/ First 4 visits: no copay
Visits 5 and over:
$10 copay
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First 4 visits: no copay
Visits 5 and over:
$5 copay / First 15 visits: 80% coverage of the allowed amount
Visits 16 and over: 50% coverage of the allowed amount
Enrollee Assistance Program (EAP)3
Including, but not limited to, depression, marital issues, family problems, alcohol and drug use/misuse, and grief. Also includes referral services – legal, financial, family mediation, and elder/child care. / No copay
Up to 4 visits per member, per year / N/A
Deductible / None / None
Out-of-Pocket Limit
Separate from the medical out-of-pocket limit / $1,000 / $3,000
Provider Eligibility / All providers licensed by the relevant licensing board in their state. Examples include: MD Psychiatrist, PhD,EdD, PsyD, MSW, LICSW, LMHC, LMFT,MSN, MA, RNCS, BCBA. / All providers licensed by the relevant licensing board in their state. Examples include: MD Psychiatrist, PhD,
EdD, PsyD, MSW, LICSW, LMHC, LMFT, MSN, MA,
RNCS, BCBA.

1 Failure to obtain prior authorization for care that is not covered by Medicare may result in no coverage. Please call Beacon for assistance in determining if your care requires prior authorization.

2For non-Medicare providers, prior authorization is required if more than 26 outpatient therapy visits are needed per member, per benefit year. Includes therapy done in conjunction with medication management.

3 Prior authorization is required.