CALIFORNIA - Pacificare Health Systems

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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. 229 PART B
PART B 230 be appropriate for your situation. If you are Referred to a behavioral health Provider, you will be authorized for a specific number of visits for a specified period of time. You can also call to receive information about contracting practitioners, subspecialty care, and obtaining care after normal office hours. PBH maintains confidentiality so that you can be assured that what you discuss with its staff is kept strictly confidential.
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PacifiCare 5701 Katella Avenue P.O.
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Introducing PacifiCare’s HMO Plan
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Table of Contents Your Billing Prot
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PART A Section 1. Getting Started:
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PART A 6 Getting Started: Your Prim
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PART A Section 2. Seeing the Doctor
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PART A 10 Either you or your treati
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PART A Section 3. Emergency and Urg
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PART A 14 Emergency and Urgently Ne
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PART A 16 Changing Your Doctor or M
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PART A Section 5. Your Medical Bene
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PART A 20 Your Medical Benefits res
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PART A 22 Your Medical Benefits Net
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PART A 24 Your Medical Benefits 10.
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PART A 26 Your Medical Benefits If
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PART A 28 Your Medical Benefits n n
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PART A 30 Your Medical Benefits pro
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PART A 34 Your Medical Benefits X-r
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PART A 36 Your Medical Benefits exp
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PART A 40 Your Medical Benefits n n
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PART A Outpatient Prescription Drug
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PART A n n n 44 Outpatient Prescrip
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PART A 46 Outpatient Prescription D
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PART A Hearing Aid Benefits 48 50 p
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PART A Benefits Available While Hos
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PART A Benefits Available On an Out
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PART A 54 infertility provider(s).
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PART A UNIvERSITY OF CALIFORNIA Beh
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PART A n 58 under your Behavioral H
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PART A 60 How Your Behavioral Healt
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PART A 74 PBHC must provide the fol
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PART A 76 and the results of the re
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PART A Definitions 78 How Your Beha
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PART A 80 Family Member. The Subscr
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PART A Section 7. Payment Responsib
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PART A 86 Payment Responsibility fo
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PART A 88 Payment Responsibility If
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PART A 90 Payment Responsibility in
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PART A 92 Member Eligibility Retire
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PART A 94 Member Eligibility Adding
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PART A 96 Member Eligibility b. a m
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PART A This section describes how t
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PART A n n n 100 The Member no long
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PART A 102 Member Eligibility insta
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PART A A child who is born to or pl
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PART A 106 This coverage is subject
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PART A Extending Your Coverage: Con
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PART A 110 Member Eligibility 4. Yo
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PART A 112 Overseeing Your Health C
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PART A Quality of Care Review 114 O
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PART A Experimental or Investigatio
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PART A 124 General Information the
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PART A Section 11. Definitions 126
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PART A 128 Custodial Care includes
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PART A 130 Definitions i. Treating
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PART A 132 Definitions health care
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PART A Answering Questions 134 Answ
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PART B 136
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PART B Please fill this out for you
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PART B 140 Table of Contents Religi
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PART B 142 Welcome to the Secure Ho
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PART B Sponsorship and Administrati
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PART B 146 Contracting Medical Grou
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PART B 148 Section 1 - Health Care
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PART B 156 Section 2 - Eligibility,
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PART B n n n n 162 Section 2 - Elig
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PART B Your Secure Horizons Group R
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PART B 166 Section 5 - Working With
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PART B Section 5 - Working With You
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PART B Hospitalist When you are adm
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PART B 176 Services for which gover
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Page 199 and 200: PART B 194 Section 9 - Organization
Page 203 and 204: PART B n n n 198 Your request to ex
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Page 209 and 210: PART B If you have other health ins
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Page 215 and 216: PART B the agreed-upon budget. If t
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Page 219 and 220: PART B THIS NOTICE DESCRIBES HOW ME
Page 221 and 222: PART B 216 Section 14 - Notice of P
Page 223 and 224: PART B you in a designated record s
Page 225 and 226: PART B Addendum to the 2006 Secure
Page 227 and 228: PART B CALIFORNIA Vision Care Benef
Page 229 and 230: PART B CALIFORNIA Hearing Aid Benef
Page 231 and 232: PART B Benefits Available on an Out
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