California ResidentsEMPLOYEE ASSISTANCE PROGRAM (EAP) Section
1: Definitions used in the document The Employee Assistance Program (EAP) is being offered by your employer to
provide you with confidential assistance from licensed mental health
professionals. There is no cost to you for EAP services. It is confidential;
your employer will not know you have accessed the Program. Your family
members (those living in your household, or financially dependent upon you)
can also access the EAP. The EAP maintains Provider locations throughout Program services are offered 24 hours a day, 365 days per year. When you contact the EAP, your call will be answered live by an EAP representative. Should your call require assistance with a clinical situation, you will immediately be connected to a licensed professional counselor. These EAP professionals can help with problems affecting your life at work as well as at home. Such problems the Program helps with are: marital issues, family relationships, job stress, adjustment concerns, grief, depression and anxiety, alcohol and drug assessment needs, problems within the workplace, etc. No matter what the concern, your Employee Assistance Program is available to you to assess, address and help you begin resolving your worries. The EAP Case Manager will conduct a thorough assessment of your concern and together with you will decide on an action plan that will either resolve the issue within the EAP sessions allowed or will refer you to appropriate providers and/or community resources that have been reviewed by the EAP. EAP services are overseen by a Clinical Director who reviews cases to ensure that a proper assessment and care plan developed meets the need of the client. The following terms have the following meanings for purposes of this Combined Evidence of Coverage and Disclosure Form. a. "Act" means the Knox-Keene Health Care Service Plan Act of 1975, as amended (California Health and Safety Code, Sections 1340 et seq.). b. "Benefits" means the Program services to which Members are entitled under an EAP Services Agreement, and which are described in Exhibit A to this Combined Evidence of Coverage and Disclosure Form. c. “Crisis Intervention” Crisis Intervention means any telephonic or in-person counseling EAP services resulting in a response to a request for immediate services in order to determine whether or not a medical-psychiatric emergency or urgent situation exists and to otherwise assess the needs for short term counseling, referrals to community resources and referrals to medical psychiatric emergency services d. "EAP Provider" means the licensed mental health professionals employed by, or under contract with, VMC Behavioral Healthcare Services to provide Benefits to Members. e. "EAP Services Agreement" means the Employee Assistance Program (EAP) Services Agreement between the EAP and a Group, which establishes the terms and conditions governing the provision of Benefits to Members by the EAP. f. “Emergency Services” means services which are needed immediately because of the sudden unexpected onset of an injury or condition affecting the care that manifests itself by acute symptoms of sufficient severity, including severe pain, that the condition requires immediate attention. g. “Exclusion” means any provision of an EAP Services Agreement whereby coverage for Benefits is entirely eliminated, and which is set forth in Exhibit A to this Combined Evidence of Coverage and Disclosure Form. h. "Group" means the company which has entered into an EAP Services Agreement with the EAP to provide Benefits to Members. i. "Limitation" means the number of sessions available (3,5,7,8,10,etc.) to a member per separate concern brought to the Program. Session model available is dependent upon an individual company's contract. j. "Member" means a Participant covered by Group, as defined below, and any person covered under Participant’s health benefit plan, residing with or dependent upon the Participant. k. “Participant” means any employee of Group who 1) resides in l. “Prepayment Fees” means the monthly/quarterly amounts due and payable to the EAP by a Group for providing Benefits to Members. m. “Qualified Health Care Provider” means is a counselor who is acting within his/her scope of practice and who possess the clinical background including training and expertise related to the members condition. n. "Service Area" means those areas of o. “Short-term Counseling” means a block of counseling sessions available under the Program. Short-term counseling sessions are intended to be applied to situations in which the EAP Case Manager believes that the presenting issues can be reasonably and appropriately resolved in the Program. Examples of these types of short-term issues can be, but are not limited to:
Unless otherwise provided herein, Members are entitled to Benefits from an EAP Provider. A Member must obtain Benefits by calling 1-800-342-8111 or 1-800-843-1327. Upon contacting the EAP, the Program will confirm eligibility for EAP services and arrange for needed resources and appointments. Covered family members of eligible employees are also able to access the benefit The EAP provides all EAP benefits. Services will be arranged by the EAP and will make such arrangements with an EAP Provider referred to by the EAP. Toll-free telephone numbers are available to access Benefits. Calls are taken 24 hours a day, 365 day per year. The phone is answered by a licensed mental health professional at all times. Appointments with EAP Providers are readily available and, depending on the Member's desire for a particular time and location, most appointments are offered within 72-120 business hours of contact. The EAP does not directly provide specialty services beyond assessment, brief counseling and/or referral. Member needs such as a psychiatric evaluation, medication management, and emergency admissions to a hospital, or longer term counseling are not a covered benefit under the EAP. The EAP’s role in the referral process is to function as an advocate for Members to obtain necessary and appropriate levels of care. In the event that the presenting problems cannot be reasonably resolved in the EAP short-term counseling model, the EAP will locate external resources in the community or under the group health plans. In all cases the Member’s EAP Case Manager and Provider will assist the Member in securing potential referral resources. During business hours, any Member with an emergency or urgent situation has immediate access to a licensed mental health professional for a telephone assessment. The EAP Case Managers may provide crisis intervention over the telephone, arrange a same-day appointment with an EAP Provider in the Member's area, or assist the Member in obtaining more intensive, acute care services. If you believe you are experiencing an emergency and need immediate medical attention, please use the “911” emergency response system in your area. After business hours, Members access the EAP by using the same telephone number: 1-800-342-8111 or 1-800-843-1327. If the situation is emergent, the EAP clinical call center will immediately provide crisis intervention over the telephone, arrange a same-day appointment with an EAP Provider in the Member's area, or assist the Member in obtaining more intensive, acute care services, as appropriate. 3. Prepayment Fees and other charges EAP services are free of charge to eligible Members and their covered family members. Your EAP program is provided for and paid for by your Employer. EAP bills your Employer Group for Periodic Fees and your Employer Group remits such fees to the EAP each month/quarter during the term of the EAP Services Agreement for Members entitled to receive Benefits during such month. The EAP may change the Periodic Fees and/or Benefits under the EAP Services Agreement, effective thirty (30) days after receipt by Group of written notice from the EAP setting forth any such change, but in no event during the then-existing twelve (12) month term of the EAP Services Agreement. There is no charge (co-payment) to the Member for Benefits. There is no charge (copayment) to the Member for Benefits. 5. CHOICE OF PHYSICIANS AND PROVIDERS: EAP PROVIDERS In order to best serve you, please read this section carefully so you know which EAP providers are available to serve you. Following your telephone contact with the EAP and brief assessment, you and your EAP Case Manager will determine what type of EAP services you need. S/he may identify for you an EAP Provider based on a number of factors: Your clinical needs, available appointment times, the location of the Provider’s office and the best place for you to be seen based on your needs. Members should call the EAP at 1-800-342-8111 or 1-800-843-1327 to initiate the EAP process and to determine the names and locations of EAP Providers in your geographic area. EAP Providers include licensed mental health providers authorized to provide services in the State of California including, but not limited to: Licensed Clinical Social Workers (LCSW), Marriage and Family Therapists (AAMFT), Psychologists (PhDs) and Doctors of Psychology (Psy.D). the EAP provider panel does not include medical doctors, including Psychiatrists. Continuity of Care:
Members should call the EAP at 1-800-342-8111 or 1-800-843-1327 to initiate the EAP process and to determine names and locations of EAP Providers in your geographic area. Please contact the EAP at anytime to request a copy of the list of providers in your area. The EAP shall cover the cost of the second opinion if the Member and the EAP Provider do not agree on a course of action, and the Member requests a second opinion. The EAP will make arrangement for the Member to meet with another EAP Provider at no cost. The Member will bear the financial responsibility for any self-directed second opinion. The EAP Clinical Director or designee shall review the request to determine whether there is an EAP Provider qualified to render a second opinion. If there is no EAP Provider available, the EAP shall pay for the cost for the second opinion by a qualified mental health professional of the Member’s choice. Requests for second opinions may be made by contacting the Clinical
Director at 1-800-342-8111 or 1-800-843-1327 or in writing
to: California Resident Second Opinion – In the rare case the Member is required to receive a covered benefit from a non EAP Provider and pays that Provider directly, the EAP will reimburse the member within 30 days of receipt of claim for services. 9. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE The EAP does not restrict access to the EAP benefit. All employees identified by any Group/employer are eligible for EAP services. In addition, dependent family members residing in the employee’s house, dependent children residing outside the home or spouses or children deemed eligible where a court has ordered coverage be provided can also use the EAP. If available from the Employer Group, eligibility information can be forwarded electronically to the EAP and regularly updated within the database. The Employer Group will notify the EAP as additional employees become eligible for services. If the EAP is unable to determine eligibility for a Member, the EAP will begin initiating EAP assessment services, obtain a Release of Information from the member and shall confirm with the Employer Group of the EAP’s determination to render services or provide resources to the ineligible caller outside the EA Program.
11. COMPLAINT AND APPEAL PROCEDURES The EAP seeks feedback from Members describing their satisfaction and overall experience with the EAP. The EAP conducts satisfaction surveys with all willing Members who have used the Program. Should a Member desire to register a complaint or grievance with the EAP concerning Benefits, he/she can either call the EAP at the toll-free telephone number 1-800-342-8111 or 1-800-843-1327 to report the complaint or grievance, or to request a copy of the EAP Complaint Form, or write directly to EAP Complaint Form at 9370 Sky Park Court, Suite 210, San Diego, CA 92123. If the complaint, grievance or appeal involves a delay, modification, or denial of service related to a clinically emergent or urgent situation, or, the urgent grievance includes cases in which there is a possibility of imminent and serious threat to the health of the member or family member, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function, or those situations in which the EAP Case Manager and Member believe that a serious threat to life, safety and well-being or health is present the review for urgent grievances will be expedited and a response provided in writing to the Member within three (3) days from receipt of the complaint or appeal. Members who are in an urgent or emergent situation should contact the EAP regarding their complaint immediately. Emergent and urgent situations are those that might result in imminent risk to seriously harm yourself or another person, or you believe that you are unable to care for your own basic needs or those of dependent persons you are responsible for. If you are significantly distressed, and are experiencing a reduced level of functioning resulting in an inability to function in key family/work roles, call the EAP to register your complaint immediately. The EAP will resolve each routine complaint and grievance within thirty (30) days of receipt. The Clinical Director, or her designee, will receive and investigate all Member complaints and grievances. Upon the conclusion of the investigation, the Clinical Director/designee will respond to the Member in writing stating the disposition and the rationale. Though health status is not an eligibility factor for EAP services, Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been canceled or not renewed because of his health status or requirement for services may request review by the California Department of Managed Health Care. Binding Arbitration All disputes that cannot be resolved informally or through the grievance
system, including claims of malpractice, must be brought to binding
arbitration by a single arbitrator through the commercial arbitration rules
of the American Arbitration Association. All arbitration hearings will be
held in the State of DEPARTMENT OF MANAGED HEALTH CARE The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-342-8111 or 1-800-843-1327 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. The EAP will not discriminate against any employee, independent contractor, enrollee/member or other party because of race, religion, color, sex, age, marital status, handicap status, veteran status or national origin.
COBRA. If the Group is subject to the Consolidated Omnibus Reconciliation Act (COBRA) of 1985, as amended, Members may be entitled to continuation of coverage. Members may qualify for continuation of coverage if they lose coverage for one of the following qualifying events:
The Employer Group is responsible for providing Members with notice of
their right to receive continuing coverage under COBRA. The Member must
provide the Employer Group with a written request for such coverage within
sixty (60) days of eligibility for continuing coverage or receipt of notice
of the qualifying event. Payment of Periodic Fees must be made to by the
Employer Group within forty-five (45) days of such written notice. The Group
shall notify the EAP in writing of any employee who has a qualifying event
within thirty (30) days of the qualifying event and the Group shall also
notify the EAP within 30 days of becoming subject to federal COBRA if that
event should occur. [Back
to Top] Employee Assistance Program Benefits The EAP is designed to assist Members with a variety of different types of personal concerns; these include, but are not limited to: individual and family assessment and counseling for personal, marital, family, relationship, and work-related stressors, as well as assessments and referrals for alcohol and substance treatment. The goal of the EAP is to either resolve the presenting issues within the EAP short-term counseling model, or align resources outside the EAP designed to provide longer term or more specific care. Community standards, standards of EAP practice and appropriate clinical guidelines help Members and EAP Providers make decisions about what care is needed. Each time you contact the EAP for a new issue, you have access to a maximum of (3,5,7,8,10,etc.) sessions which are dependent upon an individual company's contract. A "session" is usually defined as either an in person or telephone consultation with the Member, of no more than one hour in duration. Upon contacting the EAP, an initial authorization for sessions with the EAP Provider will be provided. Following the initial sessions, the Provider will review your needs with the EAP and request additional short-term counseling sessions as needed. There are no annual or lifetime maximums. If the EAP cannot resolve the problem, the EAP will locate resources outside the EAP and align a referral for you. EAP services are free to Members. Costs for resources outside the EAP may be no cost community resource agencies or may be resources covered under your primary health plan. Your Case Manager and EAP Provider will guide you. Referrals: The EAP Case Manager and Provider will identify resources, such as licensed and accredited mental health agencies, practitioners and programs, self-help organizations and other providers for any Member whose problem requires structured resources, professional diagnostic evaluation and/or consideration of medical intervention on an emergency or non-emergency basis. Referrals are designed after a complete assessment and treatment plan has been developed on collaboration with the Member. 1. Limitations: Each eligible Member is limited to the number of available EAP sessions as defined by the Group Subscriber Agreement (5, 7, 8, 10 sessions, etc.) for each problem the member presents. 2. Exclusions: The Benefits provided to Members by the EAP are limited in nature. If a Member requires medical care or a full range of mental health care, the Member should consult Group’s health plan summary of benefits, available through Group. The following are not applicable, or not a covered service under the EAP benefit. These include, but are not limited to: a. Prescription Drug Coverage Confidentiality Policy: Confidentiality is an essential element of EAP services. Records will not be released without your written consent. Employers sponsoring EAP benefits require that the EAP keep all records confidential. Situations that limit confidentiality and can result in disclosure to third parties can be: Plans to harm you or another person/property/identified victim, or, reports of child and/or elder abuse, including sexual abuse, physical abuse and neglect. A STATEMENT DESCRIBING THE EAP POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST. The EAP acknowledges that it may be a “covered entity” as that term is defined under the Health Insurance Portability and Accountability Act of 1996 and the regulations there under (“HIPAA”) and the Privacy Rule issued by the Department of Health and Human Services (45 CFR Subparts 160 and 164) (the “Privacy Rule”). In such event, the EAP acknowledges it has specified responsibilities to limit the uses and disclosures of protected health information (“PHI”), a term defined by the Privacy Rule (45 CFR Section 164.501, incorporated herein by reference as though set forth in full). The EAP represents that it will use and disclose PHI only as permitted by HIPAA and the Privacy Rule, subject to any additional limitations on the use and disclosure of that information as imposed by this Agreement, and the EAP will comply with all other applicable provisions of HIPAA, including the responsibility under HIPAA and the Privacy Rule to provide each Eligible Participant with access to his or her PHI (45 CFR Section 164.524); to allow that Eligible Participant to amend his or her PHI (45 CFR Section 164.526); and to provide an accounting of those disclosures identified under the Privacy Rule as reportable disclosures (45 CFR Section 164.528). In the event that the EAP is deemed to be a business associate of the Company, the EAP agrees to comply with the requirements relating to business associates in HIPAA, and enter into a business associate agreement with the Company in compliance with HIPAA. a. Member Consent. Under the EAP Services Agreement, Group makes Benefits available to Members. The EAP Services Agreement is subject to amendment, modification or termination, in accordance with the provisions thereof, or by mutual agreement between the EAP and Group, without the consent or concurrence of Members. By accepting Benefits hereunder, all Members legally capable of contracting, and the legal representatives of all Members incapable of contracting, agree to all terms, conditions and provisions of the EAP Services Agreement. b. Renewal Provisions. The initial term of the EAP Services Agreement is one year. Thereafter the Agreement may be renewed for successive twelve (12) month periods, subject to the termination provisions contained therein. The EAP may amend the renewal provisions no less than 90 days prior to renewal, reflecting Program or premium changes. c. Provider Compensation. The EAP compensates EAP Providers through an agreement by which they are paid a fixed amount of money based on hours worked, number of Members seen, or number of sessions provided. The EAP does not distribute financial bonuses or use any other incentive program to compensate its EAP Providers other than the methods of compensation defined above. Members may request further information about EAP Provider reimbursement policies and procedures by contacting EAP’ Manager, Provider Relations, at 1-800-342-8111 or 1-800-843-1327 or the Member's EAP Provider. d. Anti-Fraud. The EAP has established an anti-fraud plan designed to deal with false or fraudulent claims for health care benefits and otherwise deal with the prevention, detection and prosecution of suspected fraud by providers, vendors, members or anyone who might through improper activity harm the delivery of cost-effective health care services to the members. If you have any knowledge of fraudulent activity or you wish more information about our anti-fraud plan please call 1-800-342-8111 or 1-800-843-1327 or write to: Anti-Fraud
Plan Information Request PUBLIC POLICY COMMITTEE: The Public Policy Committee meets regularly to discuss issues and concerns about Employee Assistance Program services. We are particularly interested in matters that affect employees and their family members, identifying trends in areas of concerns, and becoming aware of special needs of any Group. You may call 1-800-342-8111 or 1-800-843-1327 regarding your interest in our Public Policy forum and Committee. You may submit your thoughts and concerns to the Public Policy Committee by writing to: Public
Policy Committee Notice of Organ Donation: Please be aware that organ donation is a serious public health issue: You may contact the Department of Motor Vehicles to arrange for Organ Donation and to place the sticker on driver's licenses as appropriate to participate in the Organ Donation Program. Please make certain to inform your family members of your decision to donate organs. For more information please go to www.organdonor.gov |
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