Plan Limits
In-Network benefits payable under the Plan are unlimited
except for the annual limits explained below. A ComPsych
Behavioral Health Manager must determine if inpatient
days or outpatient visits are medically necessary or appropriate
based upon professional standards and protocols in
the geographic area in which the treatment is rendered.
Without this approval, the covered patient is responsible
for any additional charges.
- You have a 30-day inpatient annual maximum for
mental health and substance abuse services. Further,
there is a limit of two detoxification facility stays per
lifetime. These limits apply to all MILA Plans.
- Outpatient care has a separate 60-visit maximum each
calendar year.
Out-of-Network lifetime benefits in the Premier Plan and
in the MILA Medicare Wrap-Around Plan are limited to
$500,000 with no more than $50,000 for the treatment of
substance abuse. Your out-of-pocket expenses for care rendered
at 60% coinsurance (with your cost being 40%) will
be limited in a calendar year to $6,500 per individual or
$13,000 per family. (For Premier Plan Members who are
Out-of-Area and for Members in the MILA Medicare
Wrap-Around Plan, Member cost is 20% and limited to
$2,500/$5,000.) Non-certification penalties for failure to
obtain pre-authorization, copay expenses and any expenses
above the allowable expense, shall not be considered in
calculating this out-of-pocket limit.
