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BCBS – South Carolina

One of the first questions many people have when they’re considering substance abuse, mental health, or behavioral health treatment is whether or not their insurance company will entirely or partially cover the cost. Blue Cross Blue Shield (BCBS) is accepted in all 50 states and covers more than 100 million Americans. BCBS is made up of more than 35 independent and locally operated agencies, and more than 96 percent of hospitals and 92 percent of healthcare providers work directly with a BCBS agency. Blue Cross Blue Shield is accepted, at least on some level, by most addiction treatment centers, although coverage can vary widely from state to state.

The Mental Health Parity Act stops discrimination so that mental health treatment and substance abuse/addiction treatments are considered equal to treatment for medical health issues. In the past, insurers could place higher co-pay prices on mental health services and employers could limit the number of days their employees were hospitalized and/or attending outpatient services. These historical moves have made it much easier to obtain care. Lower prices and better cooperation within the workplace can help clients get the help they need sooner.

Oftentimes only a portion of detox, addiction treatment, or mental health treatment will be covered by your insurance. It’s important to speak with your insurance company to determine your exact level of coverage and to understand what that translates to in terms of the amount you will pay out of pocket.

Let’s get started with some common terms and definitions:

Copayment: a fixed dollar amount you are required to pay for covered services at the time you receive care.

Deductible: a fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.

In-network: services provided by a physician or other health care provider with a contractual agreement with the insurance company and paid at a higher benefit level.

Out-of-network: services provided by doctors and hospitals who have not contracted with your health plan.

Out-of-pocket maximum: also called OOPM, this is the most you have to pay out of your own pocket for expenses under your insurance plan during the year. Deductibles, coinsurance, copays and other expenses for in-network essential health benefits (EHBs) apply to the OOPM.

Preauthorization: the process by which members or their primary care physicians (PCP) notify the health plan in advance of treatment plans, such as a hospital admission or a complex diagnostic test. Also called pre-notification.

Premium: the ongoing amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. The premium may not be the only amount you pay for insurance coverage. Typically, you will also have a copayment or deductible amount in addition to your premium.

Companion Benefit Alternatives, Inc. (CBA) is an independent company that manages and preauthorizes behavioral health and substance abuse benefits for most South Carolina BCBS members and their dependents.

CBA offers confidential guidance in getting referrals to outpatient professionals for diagnosis and treatment of sensitive behavioral health problems including depression, anxiety, substance abuse disorders, eating disorders, and more.

CBA can help make referrals to network health care professionals in South Carolina and across the country. You can get a higher level of coverage from a network provider than from someone outside the network. These health care professionals will file claims and get pre-certifications from CBA for your treatment.

Blue Cross and Blue Shield of South Carolina offers three levels of healthcare plans; Bronze, Silver, and Gold. All three plans cover essential health benefits, including mental health and substance abuse disorders, but the out of pocket costs for these benefits can vary depending on your plan.

Bronze Plans have the lowest premium costs but the highest out-of-pocket costs once you receive care. The plan pays about 60% while you pay about 40%.

Silver Plans have higher premium costs than Bronze plans, but lower out-of-pocket costs than Bronze plans. The plan pays about 70% while you pay about 30%.

Gold Plans have the highest premium costs and the lowest out-of-pocket costs, with the plan paying about 80% while you pay around 20%.

BCBS plans typically fall into two categories: an HMO (Health Maintenance Organization)  plan, or a PPO (Preferred Provider Organization) plan. An HMO plan gives its members access to certain doctors and facilities who have agreed to lower their rates for plan members. An HMO plan usually only covers doctors and facilities within their network. PPO plans have more options regarding the number of providers members can access.  With a PPO plan, covered individuals can be treated by a facility that is out-of-network, however, the expenses to the member will be considerably higher.

Is Residential Treatment Covered by BCBS South Carolina?

Residential Treatment Centers benefits include room and board, general nursing service, therapy services, and other ancillary services. Preauthorization is required. If Preauthorization is not obtained, benefits will be denied.

Is Mental Health Care Covered by BCBS South Carolina?

Yes, mental health care is considered an essential health benefit. Some mental health services may be excluded, so it’s important to check what your particular insurance plan covers.

Is Substance Abuse Treatment Covered by BCBS South Carolina?

Yes, substance abuse treatment is considered an essential health benefit. Some services may be excluded, so it’s important to check what your particular insurance plan covers.

Every insurance plan is different, so the amount your insurer is willing to cover will vary depending on your provider. There may be a limit on how much is covered, and certain therapies may be excluded. We will verify your insurance at no cost, and are happy to discuss your payment needs with you.


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