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Summary Plan Description (SPD)
Questions and Answers About the Program
The following Questions and Answers will be of assistance to you in understanding the Mental Health and Chemical Dependency Benefits Program, and in getting maximum benefits with the continuum of care management services provided by PBH.
Q.
What is continuum of care?
A.
Continuum of care means getting treatment which directs
you to a level of care and a provider appropriate for your treatment needs. As
you improve, PBH will progressively move you to a less restrictive level of care
that provides effective treatment until you complete
treatment.
Q. Show me how PBH uses the continuum of care treatment
option.
A.
Referring to the outline of benefits above for mental
health, an example of continuum of care would be if you had been hospitalized
for a mental disorder and had improved to the point that you no longer required
full-time hospitalization, but needed more intensive care than traditional
outpatient visits, you could be placed in alternate care such as residential or
partial treatment until you had recovered sufficiently to be placed in
outpatient treatment.
Q. Will PBH arrange for me to see a provider who is
convenient to where I live or work?
A.
Yes. PBH has a comprehensive network of providers
throughout the state of California. Your MAP counselor will assist you in making
certain that your provider is both convenient to where you live or work and is
the appropriate provider to treat you for your particular
problem.
Q. What if I use a provider for Inpatient/Alternate Care
Mental Health or Chemical Dependency that is not under contract with
PBH?
A.
This would be considered a Non-Network Provider. As
indicated on the above charts, no benefits are payable under the Program for
mental health or chemical dependency inpatient/alternate care services received
from a Non-Network Provider.
Q. If I have other group coverage, does coordination of
benefits apply?
A.
Yes. The benefits of the other plan would be taken into
consideration in computing the benefits which are payable under this Program.