behavioral health benefits
mental health and substance use disorder
for expatriates on assignment in the U.S.
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telebehavioral health services
Talk with a mental health professional from home. Telebehavioral health services are available under the MHSUD:
the basics
The Mental Health and Substance Use Disorder (MHSUD) Plan for eligible expatriates on assignment in the U.S. provides confidential support for a wide range of personal issues – from everyday challenges to more serious problems.
- Carelon (formerly Beacon Health Options) is the claims administrator.
- You do not need to enroll. This benefit is automatically provided to you, as long as you’re eligible to participate.
- You do not pay a monthly cost for this coverage. Chevron currently pays the full monthly cost for coverage. However, you may need to share a portion of the costs when you receive benefits under the MHSUD Plan.
The MHSUD is a preferred provider organization (PPO) plan, so you can choose to see any provider you choose, network or out-of-network; you can also receive services under this plan outside the U.S. A network is a group of independent medical providers that have agreed with your medical plan claims administrators to charge contracted fees for services provided to plan members. Learn more about networks in the How To At-A-Glance section on this page.
Employees
- You are automatically covered by the MHSUD if you're an expatriate on assignment in the U.S. and you're eligible for the Global Choice Plan (Expatriates in the U.S.).
Dependents
- Eligible dependents generally include your spouse and children under the age of 26. You can enroll your domestic partner only if your domestic partner is eligible for coverage under the Company-sponsored medical plan (or government-sponsored health plan, where provided) in your home country.
- Your eligible dependents are also covered, they are enrolled in the Global Choice Plan (Expatriates in the U.S.). If your eligible dependents are enrolled in the Global Choice Plan, they are also automatically enrolled in the MHSUD Plan. As a reminder, coverage under the Global Choice Plan is not automatic for your eligible dependents. You must enroll your eligible dependents in the Global Choice Plan when your expatriate assignment begins, during open enrollment, or within 31 days of a qualifying life event. If your dependent is not enrolled in the Global Choice Plan, then your dependent cannot participate in the MHSUD Plan.
- Special rules apply to dependents that are incapacitated or physically or mentally disabled. If you feel that your dependent may qualify to continue coverage beyond age 26 due to being incapacitated or physically or mentally disabled, contact the HR Service Center, in advance of your dependent turning age 26, for further assistance and instructions about how to certify your dependent to be eligible for coverage.
Dependent Verification Process
You are required to verify the eligibility of any new dependents you enroll in your Global Choice Plan in a dependent verification process. You have up to 60 days to obtain and submit requested documentation that verifies your dependent(s) are eligible to participate in Chevron’s medical benefits. If you don’t provide acceptable documentation by the deadline, your dependent(s) will be disenrolled from Global Choice coverage and will therefore also be ineligible for the MHSUD Plan. Learn more about this process.
The MHSUD covers treatment as a result of a diagnosis of a mental illness or substance abuse. It also covers treatment for mental health and substance abuse concerns including services for depression, stress and anxiety, family or relationship issues, personal or work concerns, drug and alcohol recovery, dealing with domestic violence, eating disorders, and others. Coverage features to note include:
- If you receive medical services inside the U.S., there are different levels of benefits for network providers and out-of-network providers.
- When you receive care for covered services from a network provider in the U.S. the plan pays 100 percent of charges.
- You always have the option of using an out-of-network provider, but plan will generally cover only 70 percent of charges for covered services and you are responsible for paying the remaining charges.
- See the How-To-At-A-Glance section on this page for more information about network providers and how to located them.
- There are no network providers outside the U.S., and the plan pays 100 percent of charges for covered services outside the U.S.
- The plan only pays benefits for covered charges for services, supplies, and treatment that are medically necessary and appropriate, as determined by the claims administrator.
- The plan doesn’t cover prescription drugs for outpatient office visit treatment. If you’re prescribed a drug as part of your outpatient treatment, you should check with your medical plan prescription drug administrator to find out if it can help pay for the drugs you need; otherwise, you’ll be responsible for paying the full cost of prescribed outpatient medication.
- In certain situations, to receive the full benefits, you have to follow certain notification or pre-certification procedures. If you do not follow notification procedures when required, you may pay a higher percentage for your care.
- The plan includes coverage for virtual visits - also called telebehavioral health services - as part of your benefit coverage. See the Telebehavioral Health Services section later on this page for more details.
- The MHSUD Plan includes coverage for Applied Behavior Analysis (ABA) treatment for those diagnosed with autism or pervasive development disorder (PDD). See the Applied Behavior Analysis (ABA) Coverage section later on this page for more information.
- Access to a behavioral health travel benefit to help cover the cost of travel for those who cannot access the care they need where they live.
- A temporary special provision is available for plan participants who maintain a permanent home address in one any of the specified zip codes in the Permian Basin. Learn about the special provision.
To see the current year out-of-pocket maximum amounts for this plan, reference the comparison or other plan documents posted on this page.
When you receive covered behavioral health care in the U.S. from an out-of-network provider or when from providers outside the U.S., you are responsible for sharing the cost of the service with the MHSUD Plan until you satisfy the annual out-of-pocket maximum amount. When you reach the out-of-pocket-maximum (OOP) your MHSUD Plan pays 100% of covered behavioral health services for the remainder of the calendar year.
- There is a combined annual out-of-pocket maximum for medical and prescription drugs (outside the U.S.) under the Global Choice Plan and behavioral health services you receive under the MHSUD from an out-of-network provider in the U.S. or a provider outside the U.S. You must satisfy your combined out-of-pocket maximum before the MHSUD Plan pays 100 percent of all covered behavioral health charges. When you reach the Global Choice combined out-of-pocket maximum amount, as applicable, you will also have met the MHSUD Plan’s annual out-of-pocket maximum and the MHSUD Plan pays 100 percent of all covered behavioral health charges until the end of the calendar year.*
Learn More
- You can review the plan's summary plan description, included in the Plan Documents section of this page, to understand more about how the out-of-pocket maximum works and what services do or do not apply toward meeting your annual out-of-pocket maximum.
* If you are covering dependents, each covered individual has a maximum out-of-pocket limit equal to the You Only network out-of-pocket maximum amount. This means no more than the You Only out-of-pocket maximum amount can be applied for any one person to satisfy the overall applicable out-of-pocket maximum amount when you're enrolled in the You + One Adult, You + Child(ren), and You + Family coverage tiers.
For employees in the Permian region
Access information about the temporary special provision available for plan participants who maintain a permanent home address in one of the specified zip codes in the Permian Basin.
how to at-a-glance
If you and/or your dependents are eligible to participate, you're automatically covered. Enrollment in not required.
- Your participation in the MHSUD Plan begins on your first day of your expatriate assignment.
- Dependents begin participation in the MHSUD Plan when they begin participation in the Global Choice Plan. As a reminder, your dependent's Global Choice enrollment is dependent upon your successful completion of the dependent verification process.
- If you add or drop Chevron medical coverage for a dependent during the year, MHSUD Plan coverage for that dependent will automatically be added or dropped, too.
If you're eligible to participate, you can verify the status of your coverage, including eligible dependents:
- On the BenefitConnect website.
- By calling the HR Service Center. Choose the option for Benefits, then Health coverage.
Tip: While your coverage starts the first day you are eligible, know that there is a slight delay before your coverage is activated with the claims administrators and for your coverage to display in the administrator's system. Please allow approximately 7 business days for BenefitConnect/HR Service Center to process your coverage eligibility with the claims administrators. If you have questions about your election, contact the HR Service Center. (Choose the option for Benefits, then Health coverage.)
ID cards for the Mental Health and Substance Use Disorder (MHSUD) Plan are not issued or necessary to receive care. Your Member ID/Subscriber ID is your Chevron Worker ID. Your Carelon Member ID is NOT on your health insurance ID card. This is a unique identifier that’s provided to all employees. You can call Carelon to get this number or, if you are an active employee, you can locate your Worker ID through Workday (generally requires Chevron intranet access).
Tip: While your coverage starts the first day you are eligible, know that there is a slight delay before your coverage is activated with the claims administrators and for your coverage to display in the administrator's system. Please allow approximately 7 business days for BenefitConnect/HR Service Center to process your coverage eligibility with the claims administrators. If you have questions about your election, contact the HR Service Center. (Choose the option for Benefits, then Health coverage.)
A network is a group of independent medical providers in the U.S. that have agreed with your medical plan claims administrators to charge contracted fees for services provided to plan members.
If you receive services outside the U.S. ...
The Carelon network is only available inside the U.S. So, if you go to a provider outside the U.S., you will be required to pay for the services when you receive them and submit a claim form to Carelon to be reimbursed. Generally, the plan pays 100 percent of covered services obtained outside the U.S. Benefit reimbursement is based on billed charges for services obtained outside the U.S. See the How to Submit a Claim section for further claims process instructions.
If you go to a network provider in the U.S. ...
- The plan generally pays 100 percent of covered charges when you use a provider in the Carelon network in the U.S.
- You do not have to file a claim form when you use a network provider in the U.S.
If you go to an out-of-network provider in the U.S. ...
- You always have the option of using an out-of-network provider, but plan will generally cover only 70 percent of charges for covered services, and you are responsible for paying the remaining charges. Chevron will not reimburse you for your portion of these charges.
Plan benefits are based on Allowed Charges. - You typically will be required to pay for the services when you receive them and submit a claim form to Carelon to be reimbursed. See the How to Submit a Claim section for further claims process instructions.
- If there are no Carelon providers near your home, Carelon can help you locate a qualified clinician or facility in your area and review their credentials for you. In cases like these, you may qualify for the network coverage level, even though the provider who treats you or your dependent isn’t a member of the Carelon network.
Temporary Special Provision for Permian Basin Participants
The Temporary Special Provision for Permian Basin Participants under the Chevron MHSUD applies to certain out-of-network services for plan participants who maintain a permanent home address in one any of the specified zip codes in the Permian Basin.
How to Locate a Network Provider
To locate a Carelon network provider:
- Call Carelon. (See contacts at the bottom of this page.)
- Access the Carelon website.
- Contact Chevron Employee Assistance and Work Life Services. (See contacts at the bottom of this page.)
Services From a Network Provider in the U.S.
If you go to a Carelon network provider for care, you generally don’t have to file a claim form for network benefits. However, before your benefits can be paid, you must sign an authorization to release medical information. Your provider may give you the authorization form, or you can request the form from Carelon. Your provider will make arrangements with you if you need to pay for part of your treatment.
Services From an Out-of-Network Provider in the U.S. or from a Provider Outside the U.S.
You will be required to pay for the services when you receive them (or you'll be billed by the provider later) and you will need to submit a claim form to Carelon to be reimbursed. To be reimbursed for treatment, you’ll have to file a claim form with Carelon.
- Claim form (U.S. out-of-network services)
- Claim form (international services)
- Claim forms are also available by contacting Carelon or going to the Carelon website.
To ensure timely payment, you should file your claim as soon as you can. If you don’t file a claim within 365 days from the date on which you incur a covered charge, no plan benefits will be payable for that covered charge.
Reimbursement for Behavioral Health Travel
If you need to request reimbursement of travel expenses for covered behavioral health services, learn about the requirements and the process here.
plan documents
The summary plan descriptions (SPD) provides specific details about your benefits, such as eligibility, covered services and participation rules. If there recent updates to the SPD since the last publication date, look for the summary of material modification (SMM) included in the very front of the book.
The documents listed below are called a summary of material modification (SMM). An SMM explains recent updates to your plan that are not yet captured or updated in your summary plan description (SPD) since the last publication date. Be sure to review the SMM for an understanding of important plan updates.
Mental Health and Substance Use Disorder Service Changes
- Expanded Travel Reimbursement Benefit (August 1, 2022)
- Elimination of advance notification/pre-certification for psychological testing and electroconvulsive therapy (January 1, 2021)
- Telebehavioral health (virtual visits): Coverage for non-MDLive providers March 18, 2020 | January 1, 2021 Update
- New Plan Name Established (January 1, 2020)
- Clarification Regarding Transcranial Magnetic Stimulation (TMS) Coverage (January 1, 2020)
- Applied Behavior Analysis (ABA) Coverage for Autism Spectrum Disorder (ASD) (January 1, 2018)
- Telebehavioral health (virtual visits) established (January 1, 2018)
Permian Basin Participants
- Temporary Special Provision for Permian Basin Participants (March 1, 2019)
Other General Plan Changes
- "Other dependent" legal guardian administrative clarification (January 1, 2021)
- New address for benefits correspondence (June 1, 2020)
- New dependent verification requirement (January 1, 2019) | Learn more
Review the Summary of Benefits and Coverage (SBC) to understand basic information about your plan, such as benefits, copayments, deductibles, and coinsurance.
- Go to the SBC section of this website to locate the document for your plan.
telebehavioral health services (virtual visits)
Telebehavioral health services (virtual visits) are available under the MHSUD Plan to employees eligible to participate in the plan. Where state laws allow, telebehavioral health services are available under the Mental Health and Substance Use Disorder (MHSUD) Plan to employees, retirees and covered dependents eligible to participate in the MHSUD Plan. Telebehavioral health services can be accessed in one of three ways:
- Directly through your provider.
- Through Carelon's telehealth service with TalkSpace
- Through Carelon's telehealth service with MDLIVE
To use telebehavioral health services directly with your provider:
- Speak to your provider about how it works and to get started.
To use telebehavioral health services through TalkSpace:
To use telebehavioral health services through MDLIVE:
- Step One: Register for an MDLIVE account.
- Step Two: Schedule a telehealth appointment from your MDLIVE account.
- Step Three: Access your MDLIVE account at your scheduled appointment time. Appointments can be done from your computer connected to the internet from the secure MDLIVE website, from your mobile device through the app, or by phone if necessary.
To be covered under the MHSUD Plan, telebehavioral health services:
- Directly through your provider or through Carelon's telehealth service with a TalkSpace or MDLIVE provider via telephone and/or secure video.
- Telebehavioral health services do not include email, text or fax consultations.
- Must be for a covered condition under the MHSUD Plan and be deemed medically appropriate by Carelon.
- Must be for a mental health and substance use disorder condition that Carelon has deemed appropriate for treatment through telebehavorial health services. Not all services, including the management of certain controlled medications, are appropriate for this type of remote treatment option.
- Must be allowed under state law.
Keep in mind that the MHSUD Plan’s pre-certification and/or notification rules – if any – continue to apply depending on the type of service you receive. In addition, telehealth/telemedicine visits that occur within behavioral health facilities will not be covered.
- The MHSUD Plan’s standard deductible, coinsurance or copayment, and out-of-pocket maximum plan rules and requirements are applied to your covered telebehavioral health services, as applicable.
- Telebehavioral health services are considered an outpatient treatment, so the MHSUD Plan’s standard Outpatient Office Visit schedule of benefits will apply.
No claim forms or other filing with Carelon is needed when you use MDLIVE or TalkSpace. The payment requested (if any) is your actual out-of-pocket cost for that service. - Carelon doesn’t cover prescription drugs for outpatient treatment – whether you’re visiting a provider in the office or through TalkSpace or MDLive. If you are prescribed a drug as part of your online visit, you should use your prescription drug plan with Express Scripts to fill prescribed medication.
applied behavior analysis (ABA) coverage
The plan only pays benefits for covered charges for services and treatment that are medically necessary and appropriate, as determined
by the claims administrator.
- Prior authorization or pre-certification with the claims administrator is required prior to services being delivered. You’re also required to obtain authorization on a recurring basis for continuing services, as required by the claims administrator.
- Based on an initial review and concurrent review of the case, a case-specific quantity of ABA therapy services will be allocated.
- Covered ABA services are paid according to the Outpatient Office Visit schedule of benefits. You will be responsible for any cost sharing that applies to you, including the deductible, copayments or coinsurance.
- You can visit any ABA licensed or certified provider, network or out-of-network*. But if you use of an out-of-network provider, covered services will be paid under the out-of-network portion of the MHSUD Plan, which means you’ll pay a larger share of the costs for service. Beacon Health Options can help you locate a network provider in your area.
- Review the MHSUD summary plan description for more information about how Outpatient Office Visit benefits are paid.
* As a reminder, if you are enrolled in a Chevron Medical HMO and want to use the benefits provided by the MHSUD Plan, you're required to use a provider in the Beacon Health Options network to be eligible for coverage.
Covered ABA services may include:
- Psychiatric evaluation to confirm the ASD diagnosis.
- Psychological testing, as necessary to confirm the ASD diagnosis.
- Individual, family, and group therapy.
- Medication management.
- Applied Behavior Analysis (ABA) treatment.
- Intensive Case Management for complex cases (individuals with extraordinary care needs).
The MHSUD Plan doesn’t cover prescription drugs for ABA treatment. If the covered individual is prescribed a drug as part of treatment, you
should check with your prescription drug plan to find out if it can help pay for the drugs you need; otherwise, you’ll be responsible for paying the full cost of prescribed outpatient medication.
Covered diagnoses include autism, which is a general term used to describe a group of complex developmental brain disorders known
as Pervasive Developmental Disorders (PDD) within the American Psychiatric Association Diagnostic and Statistical Manual 5 (DSM 5). Autism Spectrum Disorder (ASD) is a type of PDD. Your benefit covers Applied Behavior Analysis (ABA) treatment for ASD.
The other covered pervasive developmental disorders are:
- Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)
- Asperger Syndrome
- Rett Syndrome
- Childhood Disintegrative Disorder
Only these diagnoses, along with a diagnosis of being at risk of autism or PDD, will be covered.
Prior authorization or pre-certification will be required for benefits to be paid.
- Call the claims administrator - Beacon Health Options - to obtain prior authorization or pre-certification.
- Once authorization is complete, a Beacon Health Options representative will advise you that ABA therapy will be covered according to the MHSUD Plan’s benefits when provided or supervised by a ABA licensed or certified provider of services.
contacts
mental health and substance use disorder plan (expatriates in the U.S.)
- Plan Type Mental Health and Substance Use Disorder
- Eligibility Expatriates on assignment in the U.S.
- Enrollment Coverage automatic, if eligible. View eligibility on BenefitConnect or call the HR Service Center.
- Claims Administrator Carelon (formerly Beacon Health Options)
- Phone - Carelon 1-800-847-2438 (714-763-2420 outside the U.S.)
- Phone - TalkSpace For telebehavioral health services 1-800-847-2438
- Phone - MDLive For telebehavioral health services 1-888-430-4827
- Website www.achievesolutions.net/chevron
- Virtual Visits / Telehealth Access MD Live ǀ Access TalkSpace ǀ Learn more here
- Claim form Forms Library
employee assistance and worklife services (EAP-WL)
- Plan Type WorkLife program
- Eligibility All Chevron employees
- Enrollment Coverage automatic, if eligible. To use services, reach out to EAP-WL directly.
- Phone (Inside U.S.) 1-800-860-8205
- Phone (Outside U.S.) 925-842-3333 (CTN 842-3333)
- Website hr.chevron.com/health-wellness/eap/default.aspx (intranet only)
Chevron Corporation believes the Chevron Corporation Mental Health and Substance Use Disorder Plan (the MHSUD Plan) is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator by calling the HR Service Center. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.
This communication provides only certain highlights about benefit provisions. It is not intended to be a complete explanation. If there are any discrepancies between this communication and the legal plan documents, the legal plan documents will prevail to the extent permitted by law. Oral statements about plan benefits are not binding on Chevron or the applicable plan. Chevron Corporation reserves all rights, for any reason and at any time, to amend, change or terminate these plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision. Unless required by applicable law, there are no vested rights with respect to any Chevron health and welfare plan benefit or to any company contributions towards the cost of such health and welfare plan benefits. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to union-represented employees.
plan documentation
contact
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