District Council #21

Claims address for District Council #21 claims:

District Council #21 – Health & Welfare Office
2980 Southampton Road
Philadelphia, PA 19154

Common Medical Event

Services You May Need

Your Cost If You Use a Network Provider

What Will be Covered if You Use an Out of Network Provider

Limitations & Exceptions

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$20 copay per visit

70% of allowance, after deductible *

Out of pocket maximum

Mental/Behavioral health intensive outpatient services

$20 copay per visit

70% of allowance, after deductible *

Out of pocket maximum

Mental/Behavioral health partial services

$20 copay per visit

70% of allowance, after deductible *

Out of pocket maximum

Mental/Behavioral health inpatient services

No charge

70% of allowance, after deductible *

Out of pocket maximum

Mental/Behavioral health inpatient miscellaneous facility charges

Included in room and board facility charges

70% of allowance, after deductible *

Out of pocket maximum

Substance use disorder outpatient services

$20 copay per visit

70% of allowance, after deductible *

Out of pocket maximum

Substance use disorder intensive outpatient services

$20 copay per visit

70% of allowance, after deductible *

Out of pocket maximum

Substance use disorder partial services

$20 copay per visit

70% of allowance, after deductible *

Out of pocket maximum

Substance use disorder inpatient services

No charge

70% of allowance, after deductible *

Out of pocket maximum

Substance use disorder miscellaneous facility charges

Included in room and board facility charges

70% of allowance, after deductible *

Out of pocket maximum

* 70% of allowance refers to 70% of ATAP’s usual and customary charges. As a member, if the provider does not accept this as full payment, you can be balance billed anything above this and what you pay will not count toward your out of pocket maximum.

Important Questions

Answers

Why this Matters:

What is the plan year?

The plan year is calendar year, January 1 – December 31.

The plan year impacts the way your benefit plan will cover your treatment costs.

What is the overall deductible?

For each calendar year:
Network: Individual $0/ Family $0.
Out of Network: Individual $300/ Family $600

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.

What is the overall lifetime maximum?

Network: Unlimited
Out of Network: $1,000,000

The lifetime maximum refers to the total amount of money you can put out over the time you are covered by these benefits.

Is there an out of pocket maximum on my expenses?

Yes
Network: $0
Out of Network: Individual $2000 / Family $4000

The out of pocket maximum is the most you could pay during a coverage period for your share of the cost of covered services. This limit helps you plan for health care expenses.

Does this plan use a network of providers?

Yes. For a list of network providers, see www.alliedtrades-online.com or call 1-800-258-6376

If you use an in network provider, this plan will pay some or all of the costs of covered services. Be aware, your in network doctor or hospital may use an out of network provider for some services. Plans use the term in network, preferred, or participating for providers in the network.

Do I need authorization/precertification to see a Mental/Behavioral health or Substance use provider?

Yes

Authorization is required for all Mental/Behavioral health and Substance use treatment services. Authorization can be obtained by calling ATAP at 1-800-258-6376. (Typically, the provider calls for this information).

Provider Frequently Asked Questions

Answers

Additional Information

What is the effective date of the policy?

SPDs are effective the 1st of each year & benefits are based on a calendar year

N/A

Is there any pre-existing?

No

N/A

Are the mental health and substance abuse benefits combined?

No

N/A

Is accreditation required?

Yes

Both state license and JACHO accreditation are required

Are prescriptions covered by this plan?

No

Prescription medications are covered by the client’s prescription plan

Do intensive outpatient programs and partial hospitalization programs come from the inpatient or outpatient benefit?

Outpatient

N/A

What type of plan is this (PPO, HMO, etc.)?

Self funded

N/A

Are all levels of care authorized based on medical necessity?

Yes

N/A

Where do providers send claims?

Claims address will be provided when pre-certification is requested

Eligibility and potential benefit term date will also be explained at this time. Provider can call 800-258-6376 at the time of pre-certification to obtain this information

Is there an electronic payer ID?

Not at this time

N/A

Are there any limitations on this policy?

Yes

See above SPD for information about deductibles, out-of-pocket maximums, and other benefit limitations

Member’s Quick Contact

All fields are required. The members quick contact portal should be utilized for basic questions regarding the Allied Trades Assistance Program's services. If this is a true emergency please contact 800-258-6376

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