CALIFORNIA - Pacificare Health Systems

CALIFORNIA
Behavioral Health
Schedule of Benefits
Mental Health and Chemical Dependency Services
Inpatient Deductible None
Inpatient per Admittance $250 per admission
Inpatient, Residential and Day Treatment $250 per admission
(up to 190 days per lifetime as defined by Medicare)
Outpatient Treatment $15 Copayment per visit – Unlimited visits
(based upon Medical Necessity)
Emergency and Urgently Needed Services $50 Copayment
(Copayment waived if admitted as inpatient)
If you would like to receive a Referral for
behavioral health services, please contact your
Primary Care Physician or Contracting Medical
Group/IPA. Authorized behavioral health
services will be provided for a specific number
of visits for a specific period of time.
If you change your Primary Care Physician to
one who is in a different Contracting Medical
Group/IPA, any Referrals for behavioral health
services that you previously received may
no longer be valid. In this situation, you will
need to ask your new Primary Care Physician
for a new Referral, which may require further
evaluation. In some cases, the request
for a new Referral will need to have Prior
Authorization from your Contracting Medical
Group/IPA or PacifiCare.
Since your Primary Care Physician is
responsible for the coordination of all of
your health care needs, it is important that
you notify him or her if you wish to continue
to receive behavioral health services from a
Provider who was affiliated with your previous
Primary Care Physician or Contracting Medical
Group/IPA.
If you continue to receive behavioral health
services without a new Referral from your new
Primary Care Physician, they may be financially
responsible for the cost of those services. In
certain circumstances, PacifiCare may authorize
continued care.
In the event of a Behavioral Health emergency,
go to the closest emergency room or call
911. PacifiCare will cover Emergency Services
whether they are in or out of the Service
Area. Ambulance Services dispatched through
911 are only covered if transportation in
any other vehicle could endanger your life.
Emergency Services are covered whether or
not a Contracting Medical Provider provides
them. It is important to notify your Primary
Care Physician or PacifiCare within forty-eight
(48) hours or as soon as is reasonably possible
of a Behavioral Health Medical Emergency, so
that your Primary Care Physician or PacifiCare
can be involved in the management of your
health care. (Please see Section 6 for more
information regarding Emergency and Urgently
Needed Services).
Note to all Secure Horizons Group Retiree
Medicare Advantage Plan Members in San
Francisco and Sonoma counties, Allcare
IPA Members in Stanislaus County and
Hill Physicians Medical Group Members
in Alameda, Contra Costa and Sacramento
counties: The description of the behavioral
health benefit referenced above applies to you.
You do not, however, access your behavioral
health benefits through your Primary Care
Physician or Contracting Medical Group/IPA.
You access your behavioral health benefit
directly through PacifiCare Behavioral Health
(PBH). To directly access your behavioral health
benefits, please call PBH 24 hours a day, 7
days a week. When you call, you will speak
with a representative who will check your
eligibility and gather basic information about
you and your situation. Depending on the
help you need, a clinician may then talk with
you about the problem you are experiencing
and assess what Provider and treatment would
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B