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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.