Medi-Cal Member Handbook A helpful guide to getting services (Combined Evidence of Coverage and Disclosure Form) Benefit Year 2016
AS A HEALTH NET COMMUNITY SOLUTIONS MEMBER, YOU HAVE THE RIGHT TO Respectful and courteous treatment. You have the right to be treated with respect, dignity and courtesy from your Health Plan s Providers and staff. You have the right to be free from retaliation or force of any kind when making decisions about your care. Privacy and confidentiality. You have the right to have a private relationship with your Provider and to have your medical record kept confidential. You also have the right to receive a copy of, amend and request corrections to your medical record. If you are a minor, you have the right to certain services that do not need your parent s okay. Choice and involvement in your care. You have the right to receive information about your Health Plan, its services, its doctors and other Providers. You have the right to choose your Primary Care Provider (PCP) from the doctors and Clinics listed in your Health Plan s Provider Directory. You also have the right to get appointments within a reasonable amount of time. You have the right to talk with your doctor about any care your doctor provides or recommends, discuss all treatment options, and participate in making decisions about your care. You have the right to talk candidly to your doctor about appropriate or Medically Necessary treatment options for your condition, regardless of the cost or what your Benefits are. You have the right to information about treatment regardless of the cost or what your Benefits are. You have the right to say no to treatment. You have a right to decide in advance how you want to be cared for in case you have a Life-Threatening illness or injury. Voice your concerns. You have the right to complain about Health Net, the Health Plans and Providers we work with, or the care you get without fear of losing your Benefits. We will help you with the process. If you don t agree with a decision, you have the right to Appeal, which is to ask for a review of the decision. You have the right to Disenroll from your Health Plan whenever you want. As a Medi-Cal Member, you have the right to request a State Hearing and receive information on the circumstances under which an expedited fair hearing is possible. Service outside of your Health Plan s Provider Network. You have the right to receive emergency or urgent services, access to Federally Qualified Health Centers and Indian health service facilities, as well as Family Planning Services and sexually transmitted disease services outside of your Health Plan s Network. Service and information in your language. You have the right to request an interpreter at no charge and not use a family member or a friend to interpret for you. You have the right to get the Member Handbook and some Member informing materials in another language or format upon request and in a timely fashion appropriate for the format being requested. Know your rights. You have the right to receive information about your rights and responsibilities. You have the right to make recommendations about these rights and responsibilities.
AS A HEALTH NET COMMUNITY SOLUTIONS MEMBER, YOU HAVE A RESPONSIBILITY TO Act courteously and respectfully. You are responsible for treating your doctor and all Providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor s office at least 24 hours before the visit to cancel or reschedule. Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your Providers, and to our plan. You are responsible for getting regular check-ups and telling your doctor about health problems before they become serious. Follow your doctor s advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on. Use the Emergency Room only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your doctor. Emergency Care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate Diagnosis and treatment. Report wrong doing. You are responsible for reporting health care fraud or wrong doing to Health Net Community Solutions. You can do this without giving your name by calling the Health Net Fraud and Abuse Hotline toll-free at 1-800-977-3565.
TABLE OF CONTENTS Welcome to Health Net Community Solutions!... 1 When your care starts... 1 Using the Health Plan... 2 How we make coverage decisions... 2 How to change Health Plans... 3 This Member Handbook: Why Is It Important to You?... 3 Need this handbook in another language?... 3 Whom do I call and when?... 3 Helpful information at www.healthnet.com on the Internet... 4 Let s Get Started: How Do I Get Health Care?... 4 Your PCP... 5 PCP information for Members who have Medicare and Medi-Cal coverage... 5 Start getting your care now! Call your PCP for a check-up.... 6 How to see your PCP... 6 How to get care when your PCP s office is closed... 7 Triage and/or Screening nurse advice... 7 If you get a bill... 7 What is a second opinion?... 8 How to get a second opinion... 8 Are you pregnant? Call Health Net at 1-800-675-6110... 9 How to get health care that your PCP can t give you... 9 How to get a Standing Referral with a Specialist... 9 How to get a Standing Referral... 9 What happens if you don t get a Referral... 10 California Children s Services (CCS) Program Referrals... 10 What happens if you don t get a Referral through the CCS program... 10 Identification (ID) Cards: How Do I Use Them?... 10 What to do with your Health Net ID card... 10 What to do with your Medi-Cal card (also known as BIC card)... 11 Our Provider Network: Who Gives Me Health Care?... 11 Your PCP gives you most of your care... 12 How to change your PCP... 12 Kinds of PCPs... 12 Picking a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) as your PCP... 13 How to get care from a Specialist... 13 Our doctors professional qualifications... 13 Certified Nurse Midwives... 14 Certified Nurse Practitioners... 14 What care can you get from a Provider who is not your PCP?... 14 Access to services to which Provider has a moral objection... 14 How to keep seeing your doctor if your doctor leaves your Health Plan... 14 How to keep seeing your doctor if you are a new Member... 15 Continuity of Care for Seniors and Persons with Disabilities... 15
Continuity of Care for Members transitioning from Covered California... 16 Continuity of care for children receiving Behavioral Health Treatment for Autism Spectrum Disorder... 16 Care outside of your Network and Service Area... 16 What Is Covered: What Kind of Health Care Can I Get from Health Net?... 17 Alcohol/Drug Abuse... 18 Asthma Services... 18 Behavioral health treatment for Autism Spectrum Disorder... 18 Cancer Screening... 19 Child Health and Disability Prevention (CHDP)... 19 Diabetic Services... 19 Doctor Office Visits... 20 Drugs/Medications... 20 Durable Medical Equipment (DME)... 20 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services... 20 Enteral Nutrition Products... 21 Emergency Services... 21 Family Planning Services... 21 Health Education Services... 22 HIV Testing... 23 Home Health... 23 Hospice Care... 23 Hospital Care... 23 Incontinence Supplies... 24 Lab Services... 24 Maternity Care... 24 Mental Health Services... 25 Minor Consent Services... 26 Newborn Care... 26 Obstetrical/Gynecological (OB/GYN)... 27 Podiatry (services for the feet)... 27 Surgery... 27 Sexually Transmitted Disease (STD) Services... 27 Skilled Nursing Facility Services... 28 Temporomandibular Joint (TMJ) Disease... 28 Therapy Occupational, Physical and Speech... 28 Tobacco Cessation Services... 29 Transportation... 29 Vision... 30 X-ray Services... 30 More Benefits: What Other Services Can I Get?... 31 California Children s Services (CCS) program... 31 Women, Infants and Children (WIC) Program... 31 Special services for American Indians... 31 Dental Services... 32 Early Start/Early Intervention... 32
Local Education Agency (LEA) assessment services... 32 Members with developmental disabilities... 33 Community-Based Adult Services (CBAS)... 33 Specialty Mental Health Services... 33 Screening, Brief Intervention, Referral and Treatment Benefit (SBIRT)... 33 Alcohol and drug treatment (Outpatient)... 33 Childhood lead poisoning screening... 34 Direct observed therapy for the treatment of tuberculosis... 34 Major organ transplants... 34 Long Term Services and Supports (LTSS)... 35 Care coordination for Managed Long Term Services and Support (MLTSS) members... 36 Additional services provided as Medi-Cal Benefits but not covered by our plan... 36 Access to transgender services... 36 Non-Covered Services: What Does Medi-Cal Not Cover?... 37 Pharmacy Benefits: How Do I Get Prescription Drugs?... 38 What is a Pharmacy?... 38 How to get a Prescription filled at a Pharmacy... 38 How do I get my DRUG in an emergency if all the pharmacies in my area are closed?... 38 What is the Recommended Drug List, also called Formulary?... 38 Drugs not on the Recommended Drug List (RDL)... 39 What drugs are covered?... 39 What drugs are not covered?... 40 Emergency contraception... 40 What other drugs can I get?... 40 Medicare Part D: Prescription drug coverage for beneficiaries who get both Medicare and Medi- Cal... 41 If you are in Los Angeles County and you are assigned to a PCP through Molina Healthcare... 41 If you paid for your prescription... 41 How and where to send us your request... 41 Emergency Care: How do I get care in an emergency?... 42 How to get Urgent Care... 42 What is Emergency Care?... 42 What to do in an emergency... 43 Outside of your Service Area?... 43 What to do after an emergency... 43 How to get emergency transportation... 43 Not sure you have an emergency?... 43 Out of the country... 43 Help in Another Language and for the Disabled: How Can I Get Help?... 45 Information in other languages... 45 Interpreters for Members who don t speak English or are hearing or speech impaired... 45 If you need interpreter services... 45 Protection for people with disabilities... 46 Complaints... 46 Complaints: What Should I Do if I Am Unhappy?... 46 What is a Grievance?... 46
How to file a Grievance... 47 If you don t agree with the outcome of your Grievance... 48 How to file a Grievance for Health Care Services denied or delayed as not Medically Necessary... 48 If you don t agree with the outcome of your Grievance for Health Care Services denied or delayed as not Medically Necessary... 48 How to file a Grievance for urgent cases... 48 If you don t agree with the outcome of your Grievance for urgent cases... 49 Independent Medical Review... 49 When to File an Independent Medical Review (IMR)... 49 Contacting the California Department of Managed Health Care (DMHC)... 50 State Hearing... 51 Expedited State Hearing... 51 Ombudsman Office... 52 Medi-Cal: How Can I Make Sure I Don t Lose My Coverage?... 52 Share of Cost... 52 Keeping your Medi-Cal Eligibility... 52 If you move, you must tell us!... 52 Two types of Medi-Cal... 52 Mandatory Medi-Cal Managed Care Members... 52 Voluntary Medi-Cal Managed Care members... 53 Voluntary Disenrollment... 53 Involuntary Disenrollment... 53 Expedited Disenrollment... 54 Transitional Medi-Cal... 54 Getting Involved: How Do I Participate?... 54 Health Net regional Community Advisory Committees... 54 Communicating policy changes... 55 More Important Information: What Else Do I Need to Know?... 55 If you have other insurance... 55 If you travel outside of your Service Area... 55 How a Provider gets paid... 55 Workers Compensation... 55 Third-party Liability... 56 Disruption in services... 56 Organ donation... 56 What is an Advance Directive?... 56 New technology... 56 Glossary of Terms... 58 Important Phone Numbers and Addresses... 65 How to Stay Healthy... 67 Well-Care Guidelines... 67 Other topics to talk to your doctor about... 75 NOTICE OF PRIVACY PRACTICES... 77
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.... 77 For more information, contact:... 84
WELCOME TO HEALTH NET COMMUNITY SOLUTIONS! Thank you for joining Health Net Community Solutions, Inc. (Health Net). Health Net is a Managed Care Plan that has contracted with the California Department of Health Care Services (DHCS) to provide health care Benefits to people enrolled in the Medi-Cal program. A Managed Care Plan is a Health Plan that provides health care to its Members through a select group of doctors, hospitals, and pharmacies. Health Net arranges for the services of health care Providers to help you get health care. You and your doctor play an important role in your Managed Care Plan. Your doctor helps decide what care you need, so it is important you see your doctor and talk with him or her about your health. You can use the services of covered health care Providers AT NO COST TO YOU. This document explains your rights, responsibilities and Benefits as a Member of our plan. It explains how to get help through our Member Services Department (Member Services). Please read this document and keep it to use later. When this handbook says we, us, our, or our plan, it means Health Net Community Solutions. When this handbook uses you and your it means the Medi-Cal Member. Only the Member can get the Benefits talked about in this handbook. Your Member Handbook is also called the Combined Evidence of Coverage and Disclosure Form. It gives only a summary of Health Net policies and rules. You must look at the contract between Health Net and the California Department of Health Care Services (DHCS) to learn the exact terms and conditions of coverage. Call Member Services if you would like a copy of the contract. In this handbook, we capitalize important words that you can find in the Glossary of Terms for your reference. Member Services is available to help you understand how the Health Plan works. Contact the plan at 1-800-675-6110. Health Net Community Solutions 21281 Burbank Blvd, C-5 Woodland Hills, CA 91367 The following services are available by calling Member Services: Help choosing a Primary Care Provider (PCP) Help changing your PCP Help to arrange non-emergency transportation Help to arrange care with other programs such as the California Children s Services (CCS) program, Regional Center, County Mental Health Help filing a Grievance or Complaint. Help filing an Appeal if you received a denial letter for a pre-authorized service. Information on the health services that you can use. Member Services staff will talk to you in the language you prefer. To contact Member Services, call 1-800-675-6110 (TTY/TDD 1-800-431-0964). WHEN YOUR CARE STARTS To Enroll in the Medi-Cal program, call or visit the County Department of Public Social Services office (DPSS) near you. Once DPSS finds you Eligible, you can Enroll in a Health Plan of your 1
choice. Enrollment in a Health Plan can take between 15 to 45 days. While your Enrollment in a Health Plan is processed, you can access your Medi-Cal Benefits using the Benefits Identification Card ( BIC ) sent to you by the California Department of Health Care Services (DHCS). The Benefits you access during this time are covered by Medi-Cal. Your care through our plan starts when your Enrollment in a Health Plan is complete. You can start using your Medi-Cal Benefits through our plan on your effective date of coverage. Your effective date of coverage is the 1st day of the month following completion of Enrollment in a Health Plan. Check the Health Net Member ID card mailed to you for the effective date of coverage. Health Net Community Solutions is licensed with the State of California. The State of California has given us permission to serve you. The State of California pays for your health care. There is no cost to you when you get services that are covered by the Medi-Cal program. In order to Enroll in Health Net s Medi-Cal Program, you must live in one of the following counties: Kern, Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, or Tulare. Our plan is responsible for almost all of your Health Care Services. Some of the Medi-Cal Benefits are not provided by your Health Plan but we will help you to get these services. This is talked about in the section More Benefits: What other services can I get? in this handbook. Some services are coordinated by our plan, but provided by other county agencies, for example California Children s Services and Specialty Mental Health Services. USING THE HEALTH PLAN Health services are only paid for if They are Medically Necessary. You receive them from a Health Net contracted Provider. Your PCP arranged the services. They are Covered Services under the Medi- Cal program. The following services will be covered even if your PCP does not arrange for them. Emergency Services in the United States. (Please note: No services are covered outside of the United States, except for Emergency Services requiring hospitalization in Canada or Mexico.) Family Planning Services. Certified Nurse Midwife services. Sexually transmitted disease treatment. Immunizations (only if you get it in our plan s Network or through your local health department). HIV testing and counseling services. HOW WE MAKE COVERAGE DECISIONS Our plan strives to do what we can to help you and your family be healthy, secure and comfortable. As such, there should be no barriers to the care you need to be healthy and stay healthy. We believe that all decisions about your care should be based on Medical Necessity, medical appropriateness, safety and the Benefits of the Medi-Cal program. Our plan does not encourage or offer financial incentives to its contracting Physicians to deny any type of care or deny treatment to patients. Any doctor who fails to provide appropriate services to our plan s patients may be investigated and may have his or her contract terminated. If you wish to speak to our plan about a covered service or a denial of service, call Member Services at 1-800-675-6110. You can 2
ask for Case Management, or for an explanation of any health service you feel is necessary.. NEED THIS HANDBOOK IN ANOTHER LANGUAGE? HOW TO CHANGE HEALTH PLANS You can also leave our plan to Enroll with another Health Maintenance Organization (HMO) at any time and for any reason. To change your HMO, call Health Care Options (HCO). You can find HCO s phone number in the Important Phone Numbers and Addresses section of this handbook. When you change your HMO, you will get a new ID card and Member Handbook from your new HMO. Be sure to tear-up your old ID card. THIS MEMBER HANDBOOK: WHY IS IT IMPORTANT TO YOU? This Member Handbook has important information. New members will receive a Member Handbook no later than 7 calendar days following enrollment. Keep this handbook where you can find it easily. This handbook contains information on: how and from whom to get care, what types of care are and are not covered, whom to contact if you have problems, your rights regarding Medi-Cal and how you are treated. Call Member Services at 1-800-675-6110 if you would like this book in large print or an alternate format. WHOM DO I CALL AND WHEN? You can call your Primary Care Provider (PCP) when you: need an appointment, need a check-up, are sick, need Urgent Care services, have a health question, need follow up after a Hospital stay, need medical treatment for a Chronic illness such as diabetes or asthma, or 3
if the emergency room doctor or our plan s case manager has advised you to see the doctor. Your PCP s name and telephone number are on your ID card. Questions? Call Member Services at 1-800-675-6110 (TTY 1-800-431-0964). You can call Member Services when you: need a new ID card, want to change PCPs, have questions about services and how to get them, want to know what s covered or what is not covered, need help getting the care you need, get a bill from a doctor, are pregnant, have a problem you cannot solve, want to change Health Plans from Health Net Community Solutions to a different Health Plan, or are unsure whom to call. Our toll-free number is 1-800-675-6110. HELPFUL INFORMATION AT WWW.HEALTHNET.COM ON THE INTERNET Do you use the Internet? Our website, www.healthnet.com, is a great resource. You can: find a doctor, find a Hospital, learn about your Benefits, learn more about privacy rights, find out about your rights and responsibilities, or get a Complaint form (called a Grievance ). You can also check your Eligibility for medical coverage. Since this information is private, you will need to log on. Go to www.healthnet.com to find out what to do. (Be sure to have your ID card ready as we ask for your Member ID number. LET S GET STARTED: HOW DO I GET HEALTH CARE? In this handbook, we call your Primary Care Provider your PCP. Your PCP is responsible for making sure you get the medical care you need and are entitled to. You were asked to choose a Primary Care Provider (PCP) and a Health Plan when you filled out the Medi-Cal Enrollment form. Members have 30 days to select a PCP. Sometimes we cannot give you the PCP you choose. Some of the reasons are: the doctor is not taking new patients; the doctor does not work with the Molina Health Plan you chose; the doctor only sees patients of a certain age or only women (OB/GYNs); and the doctor does not work with our plan. 4
If you did not get the PCP or Health Plan you chose, call Member Services at 1-800-675-6110 to see if the PCP or Health Plan of your choice is available. Each Member has a PCP. A PCP can even be a Clinic. You can pick one PCP for all Members of your family in Medi-Cal. Or, you can pick a different PCP for each Member of your family in Medi-Cal. Women can choose an OB/GYN as their PCP. Members may choose to receive services from a non-physician medical practitioner. Non- Physician practitioners include: Certified Nurse Midwives (CNM), Certified Nurse Practitioners, and physicians assistants. However, Members will be linked to the supervising Primary Care Provider, but the Member will continue to receive services from their chosen non-physician practitioner. Members are allowed to change their choice of practitioner by changing the supervising Primary Care Provider. The Member s ID card will be printed with the name of the supervising Primary Care Provider. YOUR PCP Your PCP gives you primary, or basic, medical care. Health Care Services you can get from your PCP include: routine care Referrals to see a Specialist when Medically Necessary check-ups (also called well-visits ). This is when you see your PCP when you are not sick, like when you need shots. It is important to see your PCP even when you are not sick! Family Planning Services Sick care. These visits are when you see your PCP when you are not feeling well. care for most Chronic (long-term) conditions medical advice medication prescribing medication refills counseling on healthy living, weight management and how to stop smoking When you need a check-up or if you get sick, you need to go to your PCP. Call your PCP for all of your medical needs. The phone number is on your ID card. Los Angeles County Members only If you live in Los Angeles County, you can pick a PCP who is contracted with our plan or our subcontracting plan, Molina Healthcare of California (Molina). If you pick a PCP who works with Molina, you will get your drugs from pharmacies contracted with Molina and use Molina s Recommended Drug List. To get a copy of Molina s Recommended Drug List, call Member Services at 1-800-675-6110. If you need to see a Specialist, your PCP will refer you to a Molina contracting Specialist. Read the Molina Section of your Provider Directory to see which Pharmacies and vision Providers you may use. PCP INFORMATION FOR MEMBERS WHO HAVE MEDICARE AND MEDI-CAL COVERAGE If you have coverage from both Medicare and Medi-Cal, then you do not have to select a PCP from the Health Net Network. However, you can request a Medi-Cal PCP to help you coordinate your care and you can change the Medi-Cal PCP at any time. If you choose to not request a Medi- Cal PCP, you can continue to access care from Providers and hospitals in the same way you do today. This may include: 1. Selecting doctors and hospitals that accept Medicare payment if you are in Original Fee-for-Service Medicare or, 5
2. Selecting from the Provider Network of your Medicare Advantage (MA) plan, if you are enrolled in one. However, for certain Benefits and services, such as Managed Long Term Services and Supports (MLTSS), care must be received from within the Health Net Medi-Cal Network. For more information, see the If you have other insurance section in this handbook. START GETTING YOUR CARE NOW! CALL YOUR PCP FOR A CHECK-UP. It is important for a new Member to get a checkup even if you are not sick. Be sure to schedule this check-up soon after becoming a Health Net Member. Call your PCP today to make an appointment for a new Member check-up. This visit is also called a well-visit or initial health assessment. Your PCP s telephone number is on your Health Net ID card. This first visit is important. Your PCP looks at your medical history, finds out what your health is today, and can begin any new treatment you might need. You and your PCP will also talk about Preventive Care. This is care that helps prevent you from getting sick or keeps certain conditions from getting worse. And, remember, children need to get a check-up every year, even when they are not sick, to make sure they are healthy and growing properly. Make an appointment with your doctor or your child s doctor within 120 days after Enrollment.. If you do not choose a PCP, we will choose one for you within 30 days after your Enrollment in the Plan. We try to choose a PCP that is near your home and who speaks your primary language. Call Member Services if you want more help in choosing a PCP or if you want help changing PCPs. HOW TO SEE YOUR PCP 1. Call your PCP s office to schedule an appointment. Your PCP s phone number is on your Health Net ID card. Please call ahead as soon as possible. 2. When you make an appointment, identify yourself as a Health Net Medi-Cal Member, and tell the receptionist when you would like to see your doctor. Your doctor s office will do their best to make your appointment at a time that works best for you. 3. This is a general idea of how many Business Days you may need to wait to see your doctor. ( Business Days is the number of working days, typically Monday through Friday, before your appointment. Business Days do not include weekends and holidays.) Wait times for an appointment depend on your condition and the type of care you need. You should get an appointment to see your PCP: PCP appointments within 10 Business Days of request for an appointment Urgent Care appointment with PCP within 48 hours of request for an appointment First pregnancy visit within 10 Business Days of request for an appointment Well-child visit with PCP within 10 Business Days of request for an appointment Routine check-up/physical exam within 30 calendar days of request for an appointment The doctor may decide that it is okay to wait longer for an appointment as long as it doesn't harm your health. 4. If you cannot go to your appointment, call the PCP s office right away. By canceling your appointment, you let someone else be seen by the doctor. 6
5. If you miss your appointment, call right away to make another appointment. 6. Show the PCP s office your ID card when you are there. Sometimes your doctor will tell you that you need ancillary services such as lab, X-ray, therapy, and medical devices, for treatment or to find out more about your health condition. Here is a general idea of how many Business Days you may need to wait for the appointment: Ancillary service appointment within 15 Business Days of request for an appointment Urgent Care appointment for services that need Approval in advance within 96 hours of request for an appointment Important! You can still get services without your ID card. If you need to see your PCP, your PCP (or Hospital or Pharmacy) can call us so you can get care. HOW TO GET CARE WHEN YOUR PCP S OFFICE IS CLOSED If you need care when your PCP s office is closed, call your PCP s office. Most offices will have a person to answer the phone when the office is closed. Ask to speak to your PCP or to any available doctor. A doctor will call you back. If you call when your doctor s office is closed and hear a recording, listen carefully and follow the instructions given in the recording. If you are calling to schedule an appointment, you should call back during office hours. If you are calling because you are sick and your doctor s office does not leave instructions, call Member Services at 1-800-675-6110. A representative will connect you to a health care professional who will be able to help you and answer your questions. If you speak a language other than English or Spanish, we will help get an interpreter to assist with the phone call at no charge. As our Member, you have access to Triage and/or Screening services, 24 hours per day, 7 days per week. For Urgent Care (this is when a condition, illness or injury is not Life-Threatening, but needs medical care right away), call your PCP office to find out where your nearest Urgent Care center is. Many of our plan s doctors have Urgent Care hours in the evening, on weekends or during holidays. TRIAGE AND/OR SCREENING NURSE ADVICE As our Member, when you are sick and can t reach your doctor, like on the weekend or when the office is closed, you can call Member Services at 1-800-675-6110, to access Nurse Advice and Triage or Screening services. A representative will connect you to a registered nurse or other qualified health care professional who will be able to help you and answer your questions. As our Member, you have access to Triage or Screening services, 24 hours per day, 7 days per week. If you have a Life-Threatening emergency, call 911 or go immediately to the closest emergency room. Use 911 only for true emergencies. IF YOU GET A BILL Our plan pays for all Medically Necessary and covered medical services approved by your PCP according to plan rules or for Emergency Services. Please note: No services are covered outside of the United States, except for Emergency Services requiring hospitalization in Canada or Mexico. Bills for services covered by our plan should be submitted directly to the Health Plan for reimbursement. If you receive a bill for Medically Necessary or approved services, please submit those bills to us. You may get a bill if: 7
you go to a Provider outside of your Network or outside of your Service Area and the services are not for Emergency Care, Family Planning Services, HIV testing and counseling, pregnancy termination or for Sexually Transmitted Disease (STD) services. there is no Prior Authorization for the services provided and the services provided are not for Emergency Care, Family Planning Services, HIV testing and counseling, pregnancy termination or for STD services. If you have services provided to you that are NOT Emergency Care, Family Planning Services, HIV testing and counseling, pregnancy termination, Sexually Transmitted Disease (STD) services or there is no Prior Authorization for the services, you may receive a bill from the doctor and may be required to pay for those services. If you submit payment for those services please keep a copy of your payment, along with the bill for the services and send to Health Net for review. If the services are for covered or Authorized services, you may receive a reimbursement from Health Net. You should not be billed for Emergency Care, Family Planning Services, HIV testing and counseling, pregnancy termination or for STD services at a Clinic. If you receive a bill, do not pay it. Call Health Net right away to take care of the bill for you. WHAT IS A SECOND OPINION? You have the right to ask for and get a second opinion. You also have the right to ask for a timely response to your request for a second opinion. A second opinion is a visit with another doctor when: You question a Diagnosis for a Chronic condition or for a condition that endangers your life or body. (A Diagnosis is when a doctor identifies a condition, illness or disease.) You receive a Diagnosis and a recommended treatment plan that you are not satisfied with. (A treatment plan is what the doctor says is best for you, based upon the doctor s Diagnosis.) You are not satisfied with the result of the treatment provided Your condition is not diagnosed or test results are conflicting. The clinical indications are hard to understand. The second opinion must be from a qualified health care professional in our plan s Network. (A qualified health care professional is an individual who has the training and expertise to treat or review a specific medical condition.) HOW TO GET A SECOND OPINION To get a second opinion: 1. Talk to your PCP, Specialist or our plan, and let them know you would like to see another doctor and the reason why. 2. Your PCP, Specialist or our plan will refer you to a qualified health care professional. If you are requesting a second opinion about a Diagnosis that your PCP made, the second opinion shall be from another PCP within our plan s Network of Physicians, or a specialty Physician who is familiar with the medical problem you have. If you are requesting a second opinion about a Diagnosis that your Specialist made, a second opinion must come from any Independent Physician Association (IPA) or Medical Group within our plan s Network for the same specialty. If there is no qualified health care professional within your plan s Network, we will Authorize (approve) a second opinion by a qualified Provider outside the Network. 3. Call the second opinion doctor to make an appointment. 4. Show the doctor s office your ID card. 8
Members must continue treatment and visits with their original doctor unless they receive Authorization to continue to see the second opinion doctor. You may file a Complaint if your Health Plan denies your request for a second opinion or you do not agree with the second opinion. This is also called filing a Grievance. This is talked about in the Complaints: What should I do if I am unhappy? section in this handbook. ARE YOU PREGNANT? CALL HEALTH NET AT 1-800-675-6110 Call our plan right away if you are pregnant or become pregnant. This is because we want you and your baby to be healthy. Then, call your PCP or OB/GYN to make an appointment. You should get an appointment to see the PCP or OB/GYN within 10 Business Days from the date of your call. When you are pregnant, it is important to get care right away and throughout your pregnancy. HOW TO GET HEALTH CARE THAT YOUR PCP CAN T GIVE YOU Sometimes you need care your PCP can t give you. You may need care from a Specialist or a Hospital. To see a Specialist or for treatment at a Hospital, your PCP must approve (Authorize) the care and give you a Referral. A Referral is a request from your PCP to another doctor or to the Hospital for Health Care Services or treatment you may need. Your PCP will start the Referral process. Your PCP will know whether you need an Authorization or whether you can make the appointment directly. If you have any questions about whether care from a Specialist or from a Hospital needs approval, you can call Member Services at 1-800-675-6110 (Remember, Emergency Care, Urgent Care or care with an OB/GYN in your Network, Family Planning Services, HIV testing and counseling, pregnancy termination, Sexually Transmitted Disease (STD) services do not require a Referral). Routine Referrals take up to 5 working days to process ( working days are Monday through Friday), but may take up to 28 calendar days (14 days from the date of the original request plus an additional 14 days if an extension is requested) if more information is needed from your PCP. In some cases, your PCP may ask to rush your Referral. Expedited (rush) Referrals may not take more than three calendar days. Please call our plan if you do not get a response by these times. If a Referral is not approved, your PCP or Health Net will tell you why. You will receive a letter explaining why the Referral was denied or not Authorized. If you do not agree with the explanation given, you may file an Appeal. For information on how to file an Appeal, this is talked about in the Complaints: What should I do if I m not happy? section in this handbook. HOW TO GET A STANDING REFERRAL WITH A SPECIALIST A Standing Referral to a Specialist means that you don t need to get approval every time you see that doctor. You would need a Standing Referral if you have a condition or disease that needs special medical care for several visits over a year. You will also need a Standing Referral for expert treatment if you have a condition or disease that is life threatening or disabling. A Specialist will manage the care for your condition or disease. HOW TO GET A STANDING REFERRAL To get a Standing Referral, call your PCP. You, your PCP, a Specialist and our plan s medical director decide whether you need a Standing Referral to a Specialist. You, your PCP, a Specialist and our plan s medical director decide on the treatment plan that is right for you. 9
Your PCP, a Specialist and our plan s medical director decide on the number of visits and how often you can see the Specialist. Your Specialist may also need to give regular reports to your PCP and our plan on the health care they are giving you. If you have any problems getting a Standing Referral, call Member Services at 1-800-675-6110 (TTY/TDD for the hearing impaired at 1-800-431-0964). If your Standing Referral is denied or you did not get the help you needed with your Standing Referral, read about our Grievance and Appeals process in the section Complaints: What Should I Do if I Am Unhappy? in this handbook. WHAT HAPPENS IF YOU DON T GET A REFERRAL If you see a Specialist before you get a Referral, you may have to pay for the cost of the treatment. If our plan denies the request for a Referral, we will send you a letter explaining the reason. The letter will also tell you what to do if you don t agree with this decision. This notice does not give you all the information you need about our plan s Specialist Referral policy. To get more information about our Specialist Referral policy, please contact Member Services at 1-800-675-6110. CALIFORNIA CHILDREN S SERVICES (CCS) PROGRAM REFERRALS If you or your dependent child is under the age of 21, Specialist care may be provided by the California Children s Services (CCS) Program. The CCS program will Authorize care with a CCS paneled Specialist Provider or CCS certified special care center. Our plan will help you coordinate the Referral to the CCS program and to the Specialist. WHAT HAPPENS IF YOU DON T GET A REFERRAL THROUGH THE CCS PROGRAM You may be referred to the CCS program by your PCP, a Specialist, a Hospital or our plan. The CCS program will help you find the appropriate Specialist. If you have a CCS Eligible condition, and see a Specialist before you get a Referral, you may have to pay for the cost of the treatment. If our plan denies the request for a Referral, we will send you a letter explaining the reason. The letter will also tell you what to do if you don t agree with this decision. This notice does not give you all the information you need about our Specialist Referral policy. To get more information about our Specialist Referral policy, please contact Member Services at 1-800-675-6110. IDENTIFICATION (ID) CARDS: HOW DO I USE THEM? WHAT TO DO WITH YOUR HEALTH NET ID CARD Along with this handbook, you received a Health Net ID card for every family member covered by our plan. If you did not receive an ID card for a family member who is covered by our plan, call Member Services right away. Your Health Net ID card has important information on it, including: 10
Your PCP s name (or the name of your Clinic or Medical Group). This information does not appear on ID cards for Members who have both Medicare (Part A and Part B) and Medi-Cal coverage. Your PCP s address and phone number. This information does not appear on ID cards for Members who have both Medicare (Part A and Part B) and Medi-Cal coverage. Here s what to do with your ID card: Check to make sure the information on your ID card is correct. Is your name spelled right? If anything on your ID card is wrong, call Member Services at 1-800-675-6110 right away. We will connect you to your county Department of Public Social Services office to get it fixed. Keep your ID card in a safe place. If you lose or damage your ID card, call Member Services at 1-800-675-6110 for replacement. Show your ID card whenever you: have a doctor s appointment, go to the Hospital, need Urgent Care/Emergency Services, or pick up a Prescription. WHAT TO DO WITH YOUR MEDI-CAL CARD (ALSO KNOWN AS BIC CARD) The State of California sent you another ID card, your Medi-Cal Benefits Identification Card (also called a BIC card). You need to show your Medi- Cal Card whenever you get services you don t get from our plan. These services are talked about in the section More Benefits: What other services can I get? in this handbook. Call your county Department of Public Social Services office if you need a new Medi-Cal Card. You can find the phone number for your county under Important Phone Numbers and Addresses in this handbook. Never let anyone use your Health Plan ID card or Medi-Cal Card. This is called fraud. You can lose your Medi-Cal Benefits if someone else uses your ID cards to get care. If you lose your Medi-Cal Benefits, Health Net will not be able to give you care. OUR PROVIDER NETWORK: WHO GIVES ME HEALTH CARE? Please read the following information so you will know from whom or what group of Providers you can get health care. Our plan works with a large group of doctors, Specialists, pharmacies, Hospitals and other health care Providers. This group is called a Network. You can get a copy of our plan s Network by calling Member Services and asking for a Provider Directory. Please see our Provider Directory for information on the physical accessibility of Provider offices. Our Provider Directory also has accessibility indicator definitions to help you. We cannot promise that every doctor will always have the access that you may need for a Disability. You should call the doctor's office to talk about your access needs for your Disability. You may call Member Services at 1-800-675-6110 for help in finding a doctor to meet your needs. In most cases, you need to get care within your Network and within your Service Area. As a Member, you receive most of your medical care from participating Providers within your assigned Network. All services that are outside of your Network require Prior Authorization from your assigned Network, except for Emergency Care, 11
Family Planning Services, HIV testing and counseling, pregnancy termination and STD services. You have the right to request out-of-network care when in-network providers are not reasonably accessible. YOUR PCP GIVES YOU MOST OF YOUR CARE Your PCP is responsible for making sure you get the health care Benefits you need and should receive from Medi-Cal. HOW TO CHANGE YOUR PCP If you didn t choose a PCP when you enrolled in Medi-Cal, a PCP was chosen for you by our plan. Your PCP was chosen for you based on: the language you speak, your age, and how close you live to the PCP s office. It is best to keep the same PCP. Your PCP gets to know your health history and health needs. But sometimes you cannot stay with your PCP. You can choose a PCP from our Network shown in the Provider Directory mailed to you with this handbook. Call us for another copy of the Provider Directory or to help you choose another PCP. You can change your PCP for any reason if you are not happy. To change your PCP, call Member Services. You may choose a PCP within the first 30 calendar days of Enrollment and change at least monthly after that. Things to remember if you choose a new PCP: Some doctors work within a group of doctors with certain Specialists, Hospitals and other health care Providers (this is called a Medical Group ). If you need a Specialist, your PCP may send you to these Providers. If you are going to a Specialist already or want to use a specific Hospital, talk with the PCP you are choosing to make sure you can continue to see your Specialist and keep going to the same Hospital. A PCP is a doctor or a Clinic. You can pick one PCP for all members of your family in Medi- Cal, or you can pick a different PCP for each member of your family in Medi-Cal. Women are able to choose an OB/GYN as their PCP. Ask about office access if you or a family member has a Disability. The PCP you choose may not agree to treat you and may ask our plan to make a change. This can happen if: you are disruptive or disrespectful to your doctor or your doctor s office staff; you do not follow your doctor s treatment plan that you agreed to; or KINDS OF PCPS You can pick your PCP from our Provider Directory that came with this handbook. The kinds of Physicians that can be PCPs are: family practice, general practice, internal medicine, pediatricians, and OB/GYNs (for female Members only). For religious or ethical reasons, some Hospitals and other Providers do not provide one or more of the following services that may be covered under our plan and that you or your family member 12
might need. These services are available to you from other Providers or Hospitals: Family Planning Services Contraceptive services, including emergency contraception Sterilization, including tubal ligation at the time of labor and delivery Abortion If you need help finding a Provider, call Member Services at 1-800-675-6110. PICKING A FEDERALLY QUALIFIED HEALTH CENTER (FQHC) OR RURAL HEALTH CLINIC (RHC) AS YOUR PCP An FQHC or a RHC is a Clinic and can be your PCP. These are health centers that are located in areas without a lot of Health Care Services. Call Member Services for the names and addresses of the FQHCs and RHCs that work with our plan or look in the Provider Directory. HOW TO GET CARE FROM A SPECIALIST Your PCP is the doctor who makes sure you get the care you need when you need it. Sometimes your PCP will send you to a Specialist. A Specialist is a type of doctor who is an expert in some kind of health care. These Specialists are within your PCP s Network (also called a Medical Group ) and Health Net s Network. If you need care from a Specialist, your PCP must approve these services before you receive them. Routine Referrals to a Specialist take up to 5 working days (but may take up to 28 calendar days - 14 days from the date of the original request plus an additional 14 days if an extension is requested) and rush Referrals cannot take more than 3 calendar days (for example, when you need medical care right away or have an urgent condition). Once you get approval to receive the Specialist services: 1. Call the Specialist s office to schedule an appointment. Please call ahead as soon as possible. 2. When you make an appointment, identify yourself as a Health Net Medi-Cal Member, and tell the receptionist when you would like to see the Specialist. The Specialist s office will do their best to make your appointment at a time that works best for you. 3. This is a general idea of how many Business Days you may need to wait to see the Specialist. ( Business Days is the number of working days, typically Monday through Friday, before your appointment. Business Days do not include weekends and holidays.) Wait times for an appointment depend on your condition and the type of care you need. You should get an appointment to see the Specialist: Specialist appointments within 15 Business Days of request for an appointment. Urgent Care appointment with a Specialist or other type of Provider that needs approval in advance within 96 hours of request for an appointment. Female Members who need OB/GYN care don t need their PCP s okay to go to an OB/GYN doctor that is in Health Net s Network. Female Members may get Family Planning Services from any health care Provider licensed to provide these services in or out of our plan s Network, and can be provided outside of your county of residence. OUR DOCTORS PROFESSIONAL QUALIFICATIONS We are proud of our doctors and their professional training. If you have questions about the 13
professional qualifications of Network doctors and Specialists, call Member Services. We can tell you about their medical training or qualifications. CERTIFIED NURSE MIDWIVES Certified Nurse Midwife services are available both inside and outside of our plan s Network. Members may see a Certified Nurse Midwife, who accepts Medi-Cal patients without a PCP s okay. To find out more, ask your PCP or call Member Services. CERTIFIED NURSE PRACTITIONERS Some of the PCPs who work with our plan use Certified Nurse Practitioners to see patients. Members may see a Certified Nurse Practitioner who accepts Medi-Cal patients out of Network. To see a Certified Nurse Practitioner, or for more information, ask your PCP or call Member Services. WHAT CARE CAN YOU GET FROM A PROVIDER WHO IS NOT YOUR PCP? There are some kinds of care that you can get from someone other than your PCP: Emergency Care In an emergency, dial 911. Emergency Services do not need a Referral or an okay from your PCP or our plan before you get them. Urgent Care For non-emergency medical problems when your PCP office is closed or the PCP is unable to provide the service, you may go to an Urgent Care center that works with your PCP. Family Planning Services and sexually transmitted disease testing You may get these services from any health care Provider licensed to provide these services. You do not need to get your PCP s approval to get these services. You should not be billed for Family Planning Services and for sexually transmitted disease testing. This is talked about in the section If you get a bill in this handbook. Specialist care A Specialist is a type of doctor who is an expert in some kind of health care. Your PCP will send you to a Specialist if you need one. In most cases, you cannot see a Specialist without your PCP s okay. Members may see an in-network OB/GYN for OB/GYN services without their PCP s approval. ACCESS TO SERVICES TO WHICH PROVIDER HAS A MORAL OBJECTION Some health care Providers may not perform certain services covered under our plan. This may be for religious or ethical reasons. When this happens, the Provider or our plan will find other Providers who are willing to perform these services for you. HOW TO KEEP SEEING YOUR DOCTOR IF YOUR DOCTOR LEAVES YOUR HEALTH PLAN Sometimes our plan stops working with a doctor or Hospital. If this happens, we will let you know as soon as we can. You can ask to keep seeing your doctor (including Specialists and Hospitals) if that doctor agrees and has been treating you for any of the following conditions, also known as Qualifying Conditions: Acute condition (a serious and sudden condition that lasts a short time like a heart attack, pneumonia or appendicitis) For the time the condition lasts. Serious Chronic (long-term) condition For a period of time of up to 12 months necessary to complete a course of treatment and arrange for a safe transfer to another Provider. Pregnancy During the pregnancy and immediate postpartum care (six weeks after giving birth). Terminal illnesses/conditions For the length of the illness up to 12 months. 14