mental health and substance use disorder plan
for U.S.-payroll employees

mental health matters

Supporting your mental health can help keep you thinking and feeling your best.

telebehavioral health with MDLIVE

Talk with a mental health professional from home.Telebehavioral health services through MDLIVE are available under the MHSUD Plan.

The Mental Health and Substance Use Disorder (MHSUD) Plan provides confidential support for a wide range of personal issues – from everyday challenges to more serious problems. The MHSUD Plan 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/anxiety, family or relationship issues, personal or work concerns, drug and alcohol recovery, dealing with domestic violence, eating disorders, and others.

the basics

  • You do not pay a monthly cost for this coverage. Chevron currently pays the full monthly cost for coverage. However, you do share a portion of the costs if you receive benefits under the MHSUD Plan.

  • You do not need to enroll. This benefit is automatically provided to you, as long as you’re eligible to participate. And you’re still covered by the MHSUD Plan even if you are not enrolled in a medical plan offered by Chevron.

  • Your eligible dependents are also covered, if they are enrolled in a medical plan to which Chevron contributes. 

  • 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 includes coverage for virtual visits - also called telebehavioral health services.

  • 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 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. 

  • How the plan works depends on which Chevron-sponsored medical plan you choose, if any. The plan's annual deductible(s), out-of-pocket maximum(s), network and out-of-network rules, and copayments or coinsurance may vary depending on your medical plan enrollment. What the plan covers and does not cover is the same for all participants. Reference the summary plan description (SPD) for further information.

if you are enrolled in a medical HMO ...

If you are enrolled in a Chevron Medical HMO Plan, you have the choice to use the mental health and substance abuse benefits provided by your HMO Plan, or to use the benefits provided under the MHSUD Plan. However, you cannot make a claim to both your HMO Plan and the MHSUD Plan for the same service.
  • If you choose to use the MHSUD Plan benefit, you must use a network provider to receive benefits. Out-of-network benefits are not covered, except for emergency services. If you use the MHSUD Plan benefit, there is no deductible to satisfy.
  • If you use the benefit provided by your Medical HMO, your HMO's deductible may or may not apply. Contact your HMO for additional information about this benefit, including additional plan rules that may apply.

plan facts at-a-glance

recent plan changes

Things change; be sure you're informed. The documents provided 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). Be sure to review the SMM for an understanding of important plan updates.

summary plan description (SPD)
summary of benefits and coverage (SBC)
ID cards for the Mental Health and Substance Use Disorder (MHSUD) Plan are not issued or necessary to receive care. If you need your Beacon Member ID number, contact Beacon Health Options directly.
services from a network provider
If you go to a Beacon Health Options 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 Beacon Health Options. Your provider will make arrangements with you if you need to pay for part of your treatment.  
 
services from an out-of-network provider
If your coverage permits you to see an out-of-network provider, or if you live in an area where there aren't any network providers, you may be billed directly by a provider. To be reimbursed for treatment, you’ll have to file a claim form with Beacon Health Options.  
  • Claim form (U.S. services)
  • Claim form (international services)
  • Claim forms are also available by contacting Beacon Health Options or going to their 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.  

network and out-of-network providers

When you're enrolled in a Chevron Medical HMO, the MHSUD plan pays benefits for covered treatment only when you use a provider in the Beacon Health Options network
  • Network providers charge discounted rates for covered services they provide to plan members and the plan benefits are based on these discounted rates. 
  • In addition, you do not have to file a claim form when you use a network provider.   
The MHSUD pays for covered services from an out-of-network provider only for emergency services. If you use an out-of-network provider for non-emergency care, the services are not covered by the MHSUD Plan. 
 
If there are no Beacon Health Options providers near your home, Beacon Health Options can help 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 covered dependent isn’t a member of the Beacon Health Options network.  
If you go to a network provider ...
  • Generally, the plan pays a higher level of reimbursement for care when you use a provider in the Beacon Health Options network.
  • Network providers charge discounted rates for covered services they provide to plan members and the plan benefits are based on these discounted rates.
  • You do not have to file a claim form when you use a network provider.   
 
If you go to an out-of-network provider ...  
  • Generally, the plan pays lower benefits for care when you go to an out-of-network provider and the plan benefits are based on Allowed Charges. For services provided outside the U.S., allowed charges means billed charges.
  • You typically will be required to pay for the services when you receive them and submit a claim form to be reimbursed.
  • If there are no Beacon Health Options providers near your home, Beacon Health Options 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 Beacon Health Options network. 

To locate a Beacon Health Options network provider:

If you're enrolled in a Chevron Medical HMO Plan and wish to use the mental health and substance use services provided by your HMO, contact your HMO directly to locate a provider near you.

annual deductible

There is no annual deductible for this plan if you are not enrolled in any of Chevron’s medical coverage options.
There is no annual deductible for this plan if you are enrolled in the Chevron Medical PPO Plan.
As a reminder, the Chevron HDHP has one combined annual deductible for medical, prescription drugs (both retail and mail-order), mental health and substance use disorder services. This means you’ll have to pay the full cost for covered services and supplies until you reach the deductible for the year.
  • The deductible amount for covered mental health and substance use disorder services is the same, regardless if you see a network or an out-of-network provider.
  • When you reach the HDHP network combined deductible amount, as applicable, you will also have met the MHSUD Plan’s annual deductible and the MHSUD Plan will share the cost of covered mental health or substance use disorder services with you.
January 1, 2020
Combined annual deductible
Network or Out-of-Network
  • You Only  $2,800
  • You + One Adult*  $5,600
  • You + Child(ren)*  $5,600
  • You + Family*  $5,600
* Each covered individual has a maximum deductible equal to the You Only amount. 
This means no more than the You Only deductible amount can be applied for any one person to satisfy the overall applicable deductible amount when you're enrolled in the You + One AdultYou + Child(ren), and You + Family coverage tiers.

For example: 
  • You + Family coverage tier in the HDHP 
  • Annual combined deductible is met when the family’s accumulation of covered services and supplies reaches $5,600
  • No more than $2,800 can be applied for each family member. 
  • This family could meet the $5,600 annual deductible with charges of $2,800 for one member, $1,200 for a second member, $1,400 for a third member and $200 for a fourth member.
As a reminder, the Chevron HDHP Basic has one combined annual deductible for medical, prescription drugs (both retail and mail-order), mental health and substance use disorder services. This means you’ll have to pay the full cost for covered services and supplies until you reach the deductible for the year.
  • The deductible amount for covered mental health and substance use disorder services is the same, regardless if you see a network or an out-of-network provider.
  • When you reach the HDHP Basic network combined deductible amount, as applicable, you will also have met the MHSUD Plan’s annual deductible and the MHSUD Plan will share the cost of covered mental health or substance use disorder services with you.
January 1, 2020
Combined annual deductible
Network or Out-of-Network
  • You Only  $5,000
  • You + One Adult*  $10,000
  • You + Child(ren)*  $10,000
  • You + Family*  $10,000
* Each covered individual has a maximum deductible equal to the You Only amount. 
This means no more than the You Only deductible amount can be applied for any one person to satisfy the overall applicable deductible amount when you're enrolled in the You + One Adult, You + Child(ren), and You + Family coverage tiers. 

For example: 
  • You + Family coverage tier in the HDHP Basic 
  • Annual combined deductible is met when the family’s accumulation of covered services and supplies reaches $10,000
  • No more than $5,000 can be applied for each family member. 
  • This family could meet the $10,000 annual deductible with charges of $5,000 for one member, $1,000 for a second member, $2,500 for a third member and $1,500 for a fourth member.
There is no annual deductible for this plan if you are enrolled in a Chevron Medical HMO Plan.
There is no annual deductible for this plan if you are enrolled in the Chevron Global Choice Plan (U.S.-Payroll Expatriates).

out-of-pocket maximum

You and the plan share the cost of covered charges until you reach the annual out-of-pocket maximum. When you reach your out-of-pocket maximum, the plan pays 100 percent of all covered charges until the end of the calendar year. 
 
January 1, 2020
Annual out-of-pocket maximum
Network or Out-of-Network
  • You Only  $2,300
  • You + One Adult  not eligible for coverage
  • You + Child(ren)  not eligible for coverage
  • You + Family  not eligible for coverage
 
The following expenses do not count toward the out-of-pocket maximum amount. They are also not part of the 100 percent coverage you receive after reaching your out-of-pocket maximum:
  • Charges in excess of covered charges.
  • Charges for services, supplies or treatments that are not covered under the MHSUD Plan.
  • Charges for services, supplies or treatments from a network provider that are in excess of the network provider charges.
  • Charges for services, supplies or treatments from an out-of-network provider that are in excess of the allowed charges, except for emergency services.
  • Charges resulting from the failure to meet the notification requirements.  
You and the plan share the cost of covered charges until you reach the annual out-of-pocket maximum. When you reach your out-of-pocket maximum, the plan pays 100 percent of all covered charges until the end of the calendar year. 
 
Your eligible out-of-pocket Medical PPO Plan expenses will be combined with your eligible out-of-pocket mental health and substance use disorder expenses under the MHSUD Plan to determine if your annual out-of-pocket maximum has been reached.
 
January 1, 2020
Annual out-of-pocket maximum
Network or Out-of-Network, combined with Medical PPO
  • You Only  $3,000
  • You + One Adult*  $6,000
  • You + Child(ren)*  $6,000
  • You + Family*  $9,000 
* Each covered individual has a maximum out-of-pocket amount equal to the You Only amount. 
 
This means no more than the You Only out-of-pocket amount can be applied for any one person to satisfy the overall applicable out-of-pocket maximum when you're enrolled in the You + One AdultYou + Child(ren), and You + Family coverage tiers. 
 
For example: 
  • You + Family coverage tier in the Medical PPO 
  • Annual out-of-pocket maximum is met when the family’s accumulation of covered out-of-pocket expenses reaches $9,000
  • No more than $3,000 can be applied for each family member. 
  • This family could meet the $9,000 annual out-of-pocket maximum with expenses of $3,000 for one member, $3,000 for a second member, $2,500 for a third member and $500 for a fourth member.
The following expenses do not count toward the out-of-pocket maximum amount. They are also not part of the 100 percent coverage you receive after reaching your out-of-pocket maximum:
  • Charges in excess of covered charges.
  • Charges for services, supplies or treatments that are not covered under the MHSUD Plan.
  • Charges for services, supplies or treatments from a network provider that are in excess of the network provider charges.
  • Charges for services, supplies or treatments from an out-of-network provider that are in excess of the allowed charges, except for emergency services.
  • Charges resulting from the failure to meet the notification requirements.
  • Charges that do not count toward the out-of-pocket maximum under the Chevron Medical PPO.
After you reach your deductible, you and the plan share the cost of covered charges until you reach the annual out-of-pocket maximum. When you reach your out-of-pocket maximum, the plan pays 100 percent of all covered charges until the end of the calendar year. 
 
There is a combined annual out-of-pocket maximum for medical, prescription drugs (both retail and mail order), and mental health and substance use disorder services with the Chevron HDHP and the MHSUD Plan.
 
January 1, 2020
Combined annual out-of-pocket maximum
Network or Out-of-Network, combined with HDHP
  • You Only  $5,000
  • You + One Adult*  $9,000
  • You + Child(ren)*  $9,000
  • You + Family*  $10,000 
* Each covered individual has a maximum out-of-pocket amount equal to the You Only amount. 
 
This means no more than the You Only out-of-pocket amount can be applied for any one person to satisfy the overall applicable out-of-pocket maximum when you're enrolled in the You + One AdultYou + Child(ren), and You + Family coverage tiers. 
 
For example: 
  • You + Family coverage tier in the HDHP 
  • Annual out-of-pocket maximum is met when the family’s accumulation of covered out-of-pocket expenses reaches $10,000
  • No more than $5,000 can be applied for each family member. 
  • This family could meet the $10,000 annual out-of-pocket maximum with expenses of $5,000 for one member, $3,000 for a second member, $1,500 for a third member and $500 for a fourth member.
The following expenses do not count toward the out-of-pocket maximum amount. They are also not part of the 100 percent coverage you receive after reaching your out-of-pocket maximum:
  • Charges in excess of covered charges.
  • Charges for services, supplies or treatments that are not covered under the MHSUD Plan.
  • Charges for services, supplies or treatments from a network provider that are in excess of the network provider charges.
  • Charges for services, supplies or treatments from an out-of-network provider that are in excess of the allowed charges, except for emergency services.
  • Charges resulting from the failure to meet the notification requirements.
  • Charges that do not count toward the out-of-pocket maximum under the Chevron HDHP.
After you reach your deductible, you and the plan share the cost of covered charges until you reach the annual out-of-pocket maximum. When you reach your out-of-pocket maximum, the plan pays 100 percent of all covered charges until the end of the calendar year. 
 
There is a combined annual out-of-pocket maximum for medical, prescription drugs (both retail and mail order), and mental health and substance use disorder services with the Chevron HDHP Basic and the MHSUD Plan.
 
January 1, 2020
Combined annual out-of-pocket maximum
Network or Out-of-Network, combined with HDHP Basic
  • You Only  $6,550
  • You + One Adult*  $13,100
  • You + Child(ren)*  $13,100
  • You + Family*  $13,100 
* Each covered individual has a maximum out-of-pocket amount equal to the You Only amount. 
 
This means no more than the You Only out-of-pocket amount can be applied for any one person to satisfy the overall applicable out-of-pocket maximum when you're enrolled in the You + One AdultYou + Child(ren), and You + Family coverage tiers. 
 
For example: 
  • You + Family coverage tier in the HDHP Basic 
  • Annual out-of-pocket maximum is met when the family’s accumulation of covered out-of-pocket expenses reaches $13,100
  • No more than $6,550 can be applied for each family member. 
  • This family could meet the $13,100 annual out-of-pocket maximum with expenses of $6,550 for one member, $3,000 for a second member, $1,500 for a third member and $2,050 for a fourth member.
The following expenses do not count toward the out-of-pocket maximum amount. They are also not part of the 100 percent coverage you receive after reaching your out-of-pocket maximum:
  • Charges in excess of covered charges.
  • Charges for services, supplies or treatments that are not covered under the MHSUD Plan.
  • Charges for services, supplies or treatments from a network provider that are in excess of the network provider charges.
  • Charges for services, supplies or treatments from an out-of-network provider that are in excess of the allowed charges, except for emergency services.
  • Charges resulting from the failure to meet the notification requirements.
  • Charges that do not count toward the out-of-pocket maximum under the Chevron HDHP Basic.
You and the plan share the cost of covered charges until you reach the annual out-of-pocket maximum. When you reach your out-of-pocket maximum, the plan pays 100 percent of all covered charges until the end of the calendar year.
 
Your eligible out-of-pocket Chevron Medical HMO Plan expenses will be combined with your eligible out-of-pocket mental health and substance use disorder expenses under the MHSUD Plan to determine if your annual out-of-pocket maximum has been reached. The out-of-pocket maximum in effect for you during a calendar year is the lowest out-of-pocket maximum amount under all the Chevron Medical HMOs in your corresponding group of plans. 
 
For participants in the following Medical HMO Plans: Hawaii Medical Service Association (HMSA), Kaiser Hawaii, Humana USW (Local 447), Kaiser USW Local 5 $15 HMO Plan, Kaiser USW Local 5 $500 Deductible HMO Plan 
January 1, 2020
Annual out-of-pocket maximum

Network, combined with Chevron Medical HMO
  • Individual  $
  • Family  $

For participants in all other Medical HMO Plans.
January 1, 2020
Annual out-of-pocket maximum
Network, combined with Chevron Medical HMO
  • Individual  $
  • Family  $
The following expenses do not count toward the out-of-pocket maximum amount. They are also not part of the 100 percent coverage you receive after reaching your out-of-pocket maximum:
  • Charges in excess of covered charges.
  • Charges for services, supplies or treatments that are not covered under the MHSUD Plan.
  • Charges for services, supplies or treatments from a network provider that are in excess of the network provider charges.
  • Charges resulting from the failure to meet the notification requirements.  
Tracking out-of-pocket expenses  
Out-of-pocket expenses will need to be tracked if you’re enrolled in a Medical HMO and using MHSUD Plan benefits. 
  • For claims submitted to Beacon Health Options, Beacon will track your eligible mental health and substance use disorder out-of-pocket expenses under the MHSUD Plan.
  • Chevron Medical HMO plans are not able to exchange medical out-of-pocket amounts with Beacon Health Options. When you’ve reached the annual out-of-pocket maximum under your Chevron Medical HMO, contact Beacon Health Options and provide proof by submitting the explanation of benefits (EOB) available from your Medical HMO.
You and the plan share the cost of covered charges until you reach the annual out-of-pocket maximum. When you reach your out-of-pocket maximum, the plan pays 100 percent of all covered charges until the end of the calendar year. 
 
Your eligible out-of-pocket Global Choice Plan expenses will be combined with your eligible out-of-pocket mental health and substance use disorder expenses under the MHSUD Plan to determine if your annual out-of-pocket maximum has been reached.

January 1, 2020
Annual out-of-pocket maximum
Network or Out-of-Network, combined with Global Choice Plan
  • You Only  $3,000
  • You + One Adult*  $6,000
  • You + Child(ren)*  $6,000
  • You + Family*  $9,000 
* Each covered individual has a maximum out-of-pocket amount equal to the You Only amount. 
 
This means no more than the You Only out-of-pocket amount can be applied for any one person to satisfy the overall applicable out-of-pocket maximum when you're enrolled in the You + One AdultYou + Child(ren), and You + Family coverage tiers. 
 
For example: 
  • You + Family coverage tier in the Global Choice Plan 
  • Annual out-of-pocket maximum is met when the family’s accumulation of covered out-of-pocket expenses reaches $9,000
  • No more than $3,000 can be applied for each family member. 
  • This family could meet the $9,000 annual out-of-pocket maximum with expenses of $3,000 for one member, $3,000 for a second member, $2,500 for a third member and $500 for a fourth member.
The following expenses do not count toward the out-of-pocket maximum amount. They are also not part of the 100 percent coverage you receive after reaching your out-of-pocket maximum:
  • Charges in excess of covered charges.
  • Charges for services, supplies or treatments that are not covered under the MHSUD Plan.
  • Charges for services, supplies or treatments from a network provider that are in excess of the network provider charges.
  • Charges for services, supplies or treatments from an out-of-network provider that are in excess of the allowed charges, except for emergency services.
  • Charges resulting from the failure to meet the notification requirements. 

telebehavioral health services (virtual visits)

Telebehavioral health services through MDLIVE are available under the MHSUD Plan to employees, retirees and covered dependents eligible to participate in the plan.

Ordinarily, to be covered under the MHSUD Plan, telebehavioral health services must be accessed through Beacon’s Telehealth service with an MDLIVE provider via telephone and/or secure video. Telebehavioral health service is not covered outside of the MDLIVE provider group.
 
In recognition of current physical distancing requirements and the heightened need for behavioral health care during the COVID-19 pandemic, effective March 18, 2020 the following temporary rules apply under the Mental Health and Substance Use Disorder (MHSUD) Plan:
  • The MHSUD Plan coverage rules for telebehavioral health services will be extended to include telebehavioral health services provided by a non-MDLIVE provider via telephone and/or secure video.
  • This temporary extension for telebehavioral health services provided by a non-MDLIVE provider will be in effect beginning on March 18, 2020 until the end of the COVID-19 emergency period. As of this writing, the emergency period ends June 16, 2020, but is subject to change. 
To be covered under the MHSUD Plan, telebehavioral health services:
  • Must be accessed through Beacon’s Telehealth service with an MDLIVE provider via telephone and/or secure video. Telebehavioral health services do not include consultations outside of the MDLIVE service. MDLIVE is a provider group that is formally contracted as a group provider with Beacon Health Options.
  • 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 Beacon Health Options.
  • Must be for a mental health and substance use disorder condition that Beacon 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 Beacon is needed when you use MDLIVE; the payment requested (if any) is your actual out-of-pocket cost for that service.
  • The MHSUD Plan doesn’t cover prescription drugs for outpatient treatment – whether you’re visiting a provider in the office or through Beacon’s telebehavioral health service. If you are prescribed a drug as part of your telebehavioral health service, you should check with your prescription drug plan 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.
When you call or access the MDLIVE secure website or app, you’ll answer questions about yourself and the service you require, and you’ll get to choose from a list of available providers. MDLIVE will use these answers and apply your MHSUD Plan rules to determine your personal out-of pocket cost for that telebehavioral health visit. You’ll see the cost for the visit, and you’ll need to provide a valid form of payment prior to proceeding with your telebehavioral health visit.
To use telebehavioral health services:
  • 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.  

who's eligible to participate

Except as described below, you’re generally eligible for this Plan if you’re considered by Chevron to be a common-law employee of Chevron Corporation or one of its subsidiaries that it has designated to participate in the Omnibus Health Care Plan and you meet all of the following qualifications:

  • You’re paid on the U.S. payroll of Chevron Corporation or a participating company.
  • You’re assigned to a regular work schedule (unless you’re on a family leave, disability leave,  short union business leave, furlough leave, military service leave or leave with pay) of at least 40 hours a week, or at least 20 hours a week if such schedule is an approved part-time work schedule under the corporation’s part-time employment guidelines.
  • If you’re a casual employee, you’ve worked (or are expected to work) a regular work schedule for more than four consecutive months.
  • If you’re designated by Chevron as a seasonal employee and you’re not on a leave of absence. 
  • You’re in a class of employees designated by Chevron as eligible for participation in the plan. 
However, you’re still not eligible if any of the following applies to you:
  • You’re not on the Chevron U.S. payroll, or you’re compensated for services to Chevron by an  entity other than Chevron — even if, at any time and for any reason, you’re deemed to be a  Chevron employee.
  • You’re a leased employee or would be a leased employee if you had provided services to Chevron for a longer period of time.
  • You enter into a written agreement with Chevron that provides that you won’t be eligible.
  • You’re not regarded by Chevron as its common-law employee and for that reason it doesn’t withhold employment taxes with respect to you — even if you are later determined to have been Chevron’s common-law employee.
  • You’re a member of a collective bargaining unit (unless eligibility to participate has been negotiated with Chevron).
  • You’re a professional intern. 
You may become eligible for different benefits at different times. Participation and coverage do not  always begin when eligibility begins. Chevron Corporation, in its sole discretion, determines your status as an eligible employee and whether you’re eligible for the plan. Subject to the plan’s administrative review procedures, Chevron Corporation’s determination is conclusive and binding. If you have questions about your eligibility for this plan, you should contact the Chevron Human Resources Service Center.

To be eligible to participate in the MHSUD, your dependents must meet all the requirements of an eligible spouse, domestic partner, child or other dependent, and you and your dependent must also satisfy these additional eligibility requirements or restrictions:

  • You must be eligible for and enrolled in the MHSUD Plan.
  • Your dependents must be eligible for and enrolled in a medical plan to which Chevron contributes. If your eligible dependents are enrolled in any of the medical plans offered by Chevron, they are also automatically enrolled in the MHSUD Plan. If your dependent is not enrolled in a medical plan to which Chevron contributes, then your dependent cannot participate in the MHSUD Plan.
An eligible spouse is a person to which you are legally married under the law of a state or other jurisdiction where the marriage took place. 
 
You can’t cover your spouse as a dependent if he or she is any of the following:
  • Enrolled in a Chevron medical plan as an eligible employee.
  • On active duty in the armed forces of any state, country or international authority. 
  • Enrolled in a Chevron medical plan as an eligible retiree.
To qualify for benefits available to eligible dependents of Chevron employees, you may be required to verify the eligibility of any new dependents you enroll in your Chevron health plans by completing the dependent verification process
You can’t cover your domestic partner as a dependent if he or she is any of the following:
  • Enrolled as an eligible employee. 
  • Enrolled as an eligible retiree. 
  • On active duty in the armed forces of any state, country or international authority. 
To qualify for benefits available to eligible dependents of Chevron employees, you may be required to verify the eligibility of any new dependents you enroll in your Chevron health plans by completing the dependent verification process. When you cover a domestic partner, you will be required to complete, sign and notarize the Chevron Affidavit of Domestic Partnership (F-6) form as part of the dependent verification process. By signing the affidavit, you certify that you and your partner meet the qualifications as identified on the Chevron Affidavit of Domestic Partnership (F-6) form. The form will be provided to you with your dependent verification materials or can be requested by contacting the HR Service Center
Your dependent child is eligible for coverage if he or she is all of the following:
  • Your or your spouse’s/domestic partner’s natural child, stepchild, legally adopted child, foster child, or a child who has been placed with you or your spouse/domestic partner for adoption.
  • Younger than age 26. Coverage continues until the end of the month in which your child turns age 26. 
Your other dependent is eligible for this coverage if he or she is all of the following:
  • Not married.
  • Younger than age 26. Coverage continues until the end of the month in which your other dependent turns age 26.
  • Is a member of your household.
  • Someone for whom you act as a guardian.
  • Dependent on you (or on your spouse/domestic partner) for more than 50 percent of his or her financial support. 
Your child or other dependent isn’t eligible for coverage if he or she is any one of the following:
  • Covered as a dependent by another eligible employee or eligible retiree.
  • Covered as an eligible employee. 
To qualify for benefits available to eligible dependents of Chevron employees, you may be required to verify the eligibility of any new dependents you enroll in your Chevron health plans by completing the dependent verification process.
Coverage can continue after the child reaches age 26, provided that your child meets both of the following requirements:
  • Enrolled in the plan.
  • Meets the Plan’s definition of incapacitated child.
Incapacitated child
An incapacitated child is a dependent child who is: 
  • Incapable of self-sustaining employment by reason of mental retardation or a mental or physical disability (proof of which must be medically certified by a physician).
  • Dependent on you, you and your spouse/domestic partner or your surviving spouse/domestic partner who is covered under the plan, for more than one-half of his or her financial support.
  • Your or your spouse/domestic partner’s qualifying child under section 152 of the Internal Revenue Code. This means that during the calendar year the individual is all of the following:
    • Is your child, brother, sister stepbrother, stepsister or a descendant of such person.
    • Lives with you for more than one-half the year.
    • Does not provide over one-half of his or her own support. 
The dependent child must be incapacitated under one of the following conditions: 
  • Immediately before turning age 26 while being covered under a Chevron health care plan.
  • Before turning age 26 if he or she had other health care coverage immediately before you became an eligible employee and is enrolled in a Chevron health care plan within 31 days after you become an eligible employee.
  • Before turning age 26 if he or she had other health care coverage immediately before the dependent child was enrolled in a Chevron health care plan. 

Application and ongoing recertification
  • If you need to certify an incapacitated dependent, contact the HR Service Center. You will be required to complete an application and provide documentation stating your dependent meets all the Plan's requirements of an incapacitated dependent.
  • For chronic disabilities, as determined by Chevron’s medical plan administrator, you must provide documentation every two years. 
  • If the disability is not chronic, Chevron’s medical plan administrator will determine how frequently you will need to provide such documentation.

If both you and your spouse/domestic partner are eligible employees and/or eligible retirees, only one of you can enroll all of your children for coverage. 

Pursuant to the terms of a qualified medical child support order (QMCSO), the plan also provides coverage for your child, even if you do not have legal custody of the child, the child is not dependent on you for support, and regardless of any enrollment season restrictions that might otherwise exist for dependent coverage. 
 
If you are not enrolled in a medical plan, you must enroll for coverage for yourself and your child. If the plan receives a valid QMCSO and you do not enroll the dependent child, the custodial parent or state agency can enroll the affected child. Additionally, Chevron can withhold any contributions required for such coverage. 
 
A QMCSO may be either a National Medical Support Notice issued by a state child support agency or an order or a judgment from a state court or administrative body directing Chevron to cover a child under the plan. Federal law provides that a QMCSO must meet certain form and content requirements to be valid. 
 
If you have any questions or if you would like to receive a copy of the written procedure for determining whether a QMCSO is valid, please contact the HR Service Center
 
You, a custodial parent, a state agency or an alternate recipient can enroll a dependent child pursuant to the terms of a valid QMCSO. A child who is eligible for coverage pursuant to a QMCSO cannot enroll dependents for coverage under the plan. 

enrollment & participation

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 work, provided you are eligible.
  • Dependents begin participation in the MHSUD Plan when they begin participation in a medical plan with Chevron.
  • If you add or drop medical coverage for a dependent during the year, MHSUD Plan coverage for that dependent will automatically be added or dropped, too. 
Your MHSUD Plan participation will end if any one of the following applies:
  • You’re no longer an eligible employee.
  • Chevron Corporation terminates the plan. 
Generally, dependent coverage will end when any of the following applies:
  • You’re no longer an eligible employee.
  • Your dependent’s coverage under the medical plan ends.
  • Your dependent is no longer eligible (for example, you become divorced or a child reaches age 26).  
As a reminder, to qualify for benefits available to eligible dependents of Chevron employees, you may be required to verify the eligibility of any new dependents you enroll in your Chevron health plans by completing the dependent verification process. If you do not complete the dependent verification process by your deadline, or it's determined your dependent is not eligible for Chevron medical coverage, your dependent will disenrolled from Chevron medical coverage, and, therefore, also be disenrolled from MHSUD Plan coverage.

If you commit fraud or make an intentional misrepresentation of a material fact about your participation in the health care plans, the plan has the right to terminate coverage permanently for you and all of your eligible dependents. Also, the plan may seek financial damages caused by the misrepresentations and may pursue legal action against you. Material misrepresentation includes, but is not limited to, adding a dependent who is ineligible (for instance, adding a spouse when you aren’t married or adding a child who doesn’t meet the plan qualifications of an eligible dependent). 

The MHSUD Plan ends the last day of the month in which your employment ends. This plan is available to certain retirees; you can elect COBRA coverage for you and your enrolled, eligible dependents for this plan. Please visit the Leaving Chevron section for more in-depth information about what happens to your coverage and what choices are available when you leave Chevron.

COBRA coverage
  • If you timely elect COBRA coverage, your MHSUD coverage will be retroactive to the date your coverage ended
  • If you wish to continue MHSUD coverage, you must make an election to continue it. 
  • You will receive an enrollment package from the COBRA administrator within 44 days of leaving Chevron.
retiree coverage
If you eligible for and enroll in retiree health benefits, coverage under the MHSUD plan continues only for the following participants:
  • Pre-65 or otherwise not eligible for Medicare.  
  • Enrolled in the Chevron Medical PPO, High Deductible Health Plan (HDHP) or the High Deductible Health Plan Basic (HDHP Basic).
If you or an eligible dependent are enrolled in Chevron Medical HMO Plan, mental health and substance use disorder coverage is provided by your HMO plan.
 
If you or an eligible dependent is post-65 and/or eligible for Medicare, mental health and substance use disorder coverage is provided by your Medicare coverage.

applied behavior analysis (ABA) coverage

When autism-related disorders are suspected, early diagnosis and intervention can have a positive effect on your child and your family. The MHSUD Plan includes coverage for Applied Behavior Analysis (ABA) treatment for those diagnosed with autism or pervasive development disorder (PDD). ABA includes many different techniques to increase useful or desired behaviors – such as communication and social skills – and reduce behaviors that may interfere with learning or may be harmful. 

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. 

support ABA therapy with rethink

Rethink is a service available to all U.S.-payroll employees eligible for Chevron health and welfare benefits. Parents caring for children with developmental disabilities or learning and behavior challenges can receive free, live teleconsultations with behavior experts to answer questions, and provide guidance and resources. Additionally, Rethink provides parents with over 1,500 easy-to-follow videos depicting behavior experts and educators teaching children skills such as language, socialization, self-help, academics, vocational, and more. Printable materials as well as on-demand web-based training complement these tools as parents support their children in reaching their top potential.

Rethink is not a health plan and does not provide diagnosis or health treatment, nor is the service a licensed ABA provider. Rethink only provides behavioral resources, tools and information, so a covered diagnosis is not required to take advantage of this service. While in-home ABA services directly impact your child's learning, Rethink is an online tool for you as a parent and caregiver to not only learn how to better address behavior challenges and communicate and interact with your child when the ABA provider is not there, but also supports you in collaborating with the ABA provider. Since they can use Rethink too, you can communicate more efficiently through the Rethink program, work on the same skills, and even share data if you wish.

understanding your ABA therapy coverage

Beacon Health Options explains ABA coverage available under the Chevron Mental Health and Substance Use Disorder Plan, including what’s available under the plan and how to request pre-certification to start receiving benefits. (Recorded from the March 13, 2018 webinar. 25 minutes)

rethink services

Rethink is a service available to eligible Chevron employees caring for children with developmental disabilities or learning and behavior challenges. Learn about the services and tools available through Rethink in this 2.5 minute video.  

Please note: Watching this video is only eligible to receive points toward Health Rewards for the "Watch a Rethink Video" activity; it is not eligible for points under the "Watch a Health Benefits Video" activity.

contact information

The HR Service Center manages your enrollment in and eligibility for this benefit plan. For all other questions regarding your coverage, contact the claims administrator. A claims administrator manages the administration of your plan — for example, claims, account balances, ID cards, what's covered and what's not, provider networks, phone numbers, the administrator's website or mobile app, and more. 

mental health and substance use disorder plan  (U.S.-payroll employees)
  • Plan Type   Mental Health and Substance Use Disorder 
  • Eligibility  U.S. Payroll Employees
  • Claims Administrator  Beacon Health Options 
  • Group Number  N/A
  • Phone (Inside U.S.) 1-800-847-2438
  • Phone (Outside U.S.) 714-763-2420
  • Website  www.achievesolutions.net/chevron
  • Mobile App   N/A
  • Email  N/A
  • Claim Form  Forms Library
  • Address  Beacon Health Options ǀ P.O. Box 1290 ǀ Latham, NY 12110

employee assistance and worklife services
  • Plan Type  WorkLife program
  • Eligibility  All Chevron employees
  • Claims Administrator  N/A 
  • Group Number  N/A
  • 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)
  • Mobile App   N/A
  • Email  N/A
  • Claim Form  N/A
  • Address  N/A

rethink
  • Plan Type  WorkLife program
  • Eligibility  U.S. Payroll Employees
  • Administrator  Rethink 
  • Group Number  N/A
  • Phone 1-800-714-9285 
  • Website  chevron.rethinkbenefits.com
  • Mobile App   Rethink App on Apple store or Google Play
  • Email  N/A
  • Claim Form  N/A
  • Address  N/A

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 web page provides only certain highlights about changes of 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. There are no vested rights with respect to Chevron health care plans or any company contributions towards the cost of such health care plans. Rather, 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. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to union-represented employees.