Member Handbook A helpful guide to getting services (Combined Evidence of Coverage and Disclosure Form)

Transcription

1 CALVIVA HEALTH MEDI-CAL (Serving Fresno, Kings and Madera Counties) Member Handbook A helpful guide to getting services (Combined Evidence of Coverage and Disclosure Form) Benefit Year

2 IMPORTANT If your child has moved to Medi-Cal as a result of a program change and you would like information about your child s Medi-Cal services and benefits, call Member Services at (TTY/TDD ). They can tell you who your child s Primary Care Provider (PCP) is or help you find a new PCP. They can also answer your questions about CalViva Health. If you have been told you have to pay a premium, you may visit your county office or call for more information. If you have questions about your child s Medi-Cal eligibility or about when your child has to renew his or her eligibility, please call the Medi-Cal office in your area. The phone numbers are listed in the Important Phone Numbers and Addresses section of this booklet under County Offices. Mental Health Benefit Starting 1/1/2014, Medi-Cal managed care plans will now cover some of your mental health services that you get in Fee-For-Service Medi-Cal, and will also cover some substance use disorder services. Substance Use Disorder Benefits You will receive the following Substance Use Disorder Benefits through CalViva Health. Alcohol misuse screening and counseling for persons 18 and older We do not cover treatment for major alcohol problems, but if you need services for major alcohol problems you may be referred to the County Alcohol and Drug Program. Mental Health Benefits If you qualify, you will receive the following mental health services through CalViva Health. Individual and group mental health testing and treatment (psychotherapy); Psychological testing to evaluate a mental health condition; Outpatient services that include lab work, drugs, supplies and supplements; Outpatient services to monitor drug therapy; and Psychiatric consultation To find out more information about the expanded benefits or to find a new doctor, call CalViva Health Member Services at (TDD ). Notice of Privacy Practices (NPP) Due to changes in federal laws, CalViva Health has revised the NPP in this handbook. CalViva Health is following the new NPP as of September 1, 2013.

3 AS A CALVIVA HEALTH 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 provider about any care your provider provides or recommends, discuss all treatment options, and participate in making decisions about your care. You have the right to talk candidly to your provider 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 CalViva Health, the health plans and providers we work with, or the care you get without fear of losing your benefits. CalViva Health 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. Service outside of your health plan s provider network. You have the right to receive emergency or urgent services as well as family planning and sexually transmitted disease services outside of your health plan s network. No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico 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 other information in another language or format. 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.

4 AS A CALVIVA HEALTH MEMBER, YOU HAVE A RESPONSIBILITY TO Act courteously and respectfully. You are responsible for treating your PCP and all providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your PCP 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 CalViva Health. You are responsible for getting regular checkups and telling your PCP about health problems before they become serious. Follow your PCP s advice and take part in your care. You are responsible for talking over your health care needs with your PCP, 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 PCP. 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 CalViva Health. You can do this without giving your name by calling the CalViva Health Fraud and Abuse Hotline toll-free at

5 Table of contents WELCOME TO CALVIVA HEALTH!... 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?... 4 Whom do I call and when?... 5 Helpful information at on the internet... 5 LET S GET STARTED: HOW DO I GET HEALTH CARE?... 6 Your PCP... 6 Start getting your care now! Call your PCP for a check-up How to see your PCP... 7 How to get care when your PCP S office is closed... 8 Triage and/or screening/nurse advice... 9 If you get a bill... 9 What is a second opinion?... 9 How to get a second opinion Are you pregnant? Call CalViva Health at How to get health care that your PCP can t give you How to get a standing referral with a specialist How to get a standing referral What happens if you don t get a referral California Children s Services (CCS) program referrals What happens if you don t get a referral through the CCS program IDENTIFICATION (ID) CARDS: HOW DO I USE THEM? What to do with your CalViva Health ID card What to do with your Medi-Cal card (also known as BIC card) OUR PROVIDER NETWORK: WHO GIVES ME HEALTH CARE? Your PCP gives you most of your care How to change your PCP Kinds of PCP Picking a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) as your PCP How to get care from a specialist Our doctors professional qualifications Certified Nurse Midwives Certified Nurse Practitioners What care can you get from a provider who is not your PCP? Access to services to which a provider has a moral objection How to keep seeing a provider if your provider leaves your health plan How to keep seeing your provider if you are a new member Continuity of Care for Seniors and Persons with Disabilities Continuity of Care for Transitioning Healthy Families members for primary care... 19

6 Care outside of your network and service area WHAT IS COVERED: WHAT KIND OF HEALTH CARE CAN I GET FROM CALVIVA HEALTH? Alcohol/Drug abuse Alcohol misuse screening services Asthma services Cancer screening Community Based Adult Services (CBAS) Dental services Diabetic services Doctor office visits Drugs/medications Durable Medical Equipment (DME) Emergency services Family planning services Health education services HIV testing Home health Hospice care Hospital care Lab services Maternity care Mental health services Minor consent services Newborn care Obstetrical/Gynecological (OB/GYN) Podiatry (services for the feet) Perinatal care Sexually Transmitted Disease (STD) services Skilled Nursing Facility services Surgery Temporomandibular Joint (TMJ) disease Therapy Occupational, Physical and Speech Transportation Vision X-ray services MORE BENEFITS: WHAT OTHER SERVICES CAN I GET? California Children s Services (CCS) Child Health and Disability Prevention (CHDP) Women, Infants and Children (WIC) program Special services for American Indians Early Start/Early Intervention Local Education Agency (LEA) assessment services Members with developmental disabilities Specialty mental health services Alcohol and drug treatment (outpatient) Childhood lead poisoning screening... 38

7 Direct observed therapy for the treatment of tuberculosis Major organ transplants Additional services provided as Medi-Cal benefits but not covered by CalViva Health: NON-COVERED SERVICES: WHAT DOES MEDI-CAL NOT COVER? PHARMACY BENEFITS: HOW DO I GET PRESCRIPTION DRUGS? What is a pharmacy? How to get a prescription filled What is the Recommended Drug List, sometimes called a formulary? Drugs not on the the Recommended Drug List sometimes called a formulary What drugs are covered? What drugs are not covered? Emergency contraception What other drugs can I get? Medicare Part D: Prescription drug coverage for beneficiaries who get both Medicare and Medi-Cal EMERGENCY CARE: HOW DO I GET CARE IN AN EMERGENCY? How to get urgent care What is emergency care? What to do in an emergency Outside of your service area? What to do after an emergency How to get emergency transportation Not sure you have an emergency? Out of the country HELP IN ANOTHER LANGUAGUE AND FOR THE DISABLED: HOW CAN I GET HELP? Information in other languages Interpreters for members who don t speak English or are hearing or speech impaired If you need interpreter services Protection for people with disabilities Complaints COMPLAINTS: WHAT SHOULD I DO IF I AM UNHAPPY? What is a grievance? How to file a grievance If you don t agree with the outcome of your grievance How to file a grievance for health care services denied or delayed as not medically necessary If you don t agree with the outcome of your grievance for health care services denied or delayed as not medically necessary How to file a grievance for urgent cases If you don t agree with the outcome of your grievance for urgent cases Independent Medical Review When to File an Independent Medical Review (IMR ) IMRs for Experimental and Investigational Therapies(IMR-EIT) Contacting the California Department of Managed Health Care (DMHC) State Hearing Expedited State Hearing... 54

8 Ombudsman Office Office of the patient advocate MEDI-CAL: HOW CAN I MAKE SURE I DON T LOSE MY COVERAGE? Keeping your Medi-Cal eligibility If you move, you must tell us! Two types of Medi-Cal Mandatory Medi-Cal managed care members Voluntary Medi-Cal managed care members Voluntary disenrollment Involuntary disenrollment Expedited disenrollment Transitional Medi-Cal GETTING INVOLVED: HOW DO I PARTICIPATE? CalViva Health Public Policy Committee Communicating policy changes MORE IMPORTANT INFORMATION: WHAT ELSE DO I NEED TO KNOW? If you travel outside of your service area How a provider gets paid If you have other insurance Workers Compensation Third-party liability Disruption in services Organ donation What is an advance directive? Estate recovery New technology GLOSSARY OF TERMS IMPORTANT PHONE NUMBERS AND ADDRESSES HOW TO STAY HEALTHY Other topics to talk to your PCP about: NOTICE OF PRIVACY PRACTICES NURSE ADVICE... 87

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10 WELCOME TO CALVIVA HEALTH! Thank you for joining CalViva Health. CalViva Health is a health 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. CalViva Health offers Medi-Cal Managed Care services and utilizes various contracted third parties to help provide these services. Certain administrative and support services are provided to CalViva Health under contractual arrangements with various third parties. CalViva Health s service area is Fresno, Kings, and Madera Counties. CalViva Health arranges for the services of health care providers to help you get health care. Doctors and hospitals are some of the health care providers that are available to serve you. 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 CalViva Health. It explains how to get help through CalViva Health s Member Services Department. Please read this document and keep it to use later. The Member Services Department is available to help you understand how the health plan works. The following services are available by calling the Member Services Department. Help choosing a PCP Help changing your PCP Help to arrange transportation Help to arrange care with other programs such as California Children s Services (CCS), Regional Center and County Mental Health Help filing a grievance or complaint Help filing an appeal if you received a denial letter Information on the health services that you can use. Member Services staff will talk to you in the language you prefer. To contact the Member Services Department, call (TDD ). 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 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. 1

11 Your care through CalViva Health starts when your enrollment in a health plan is complete. You can start using your Medi-Cal benefits through CalViva Health 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 CalViva Health member ID card mailed to you for the effective date of coverage. CalViva Health is licensed with the State of California. The State of California has given CalViva Health 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. CalViva Health 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 CalViva Health, 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 CalViva Health contracted provider. Your PCP arranged the services. They are covered 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. Nurse midwife services. Sexually transmitted disease treatment. Immunizations. (Only if you get it in CalViva Health s network or through your local health department). HIV testing and counseling services. How we make coverage decisions CalViva Health 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. CalViva Health does 2

12 not encourage or offer financial incentives to its contracting physicians to deny any type of care or treatment to patients. Any doctor who fails to provide appropriate services to CalViva Health s patients may be investigated and may have his or her contract terminated. If you wish to speak to CalViva Health about covered service or a denial, call the Member Services Department at You can ask for Case Management, or for an explanation of any health service you feel is necessary. How to change health plans You can also leave CalViva Health to enroll with another health plan for any reason. To change your health plan, 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 health plan, you will get a new ID card and Member Handbook from your new health plan. Be sure to tear up your old ID card. THIS MEMBER HANDBOOK: WHY IS IT IMPORTANT TO YOU? This Member Handbook has important information. 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, and Your rights regarding Medi-Cal and how you are treated. In this handbook, we use you and your to mean 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 (CalViva Health) policies and rules. You must look at the contract between CalViva Health and the California Department of Health Care Services (DHCS) to learn the exact terms and conditions of coverage. Call CalViva Health if you would like a copy of the contract. In this handbook, we explain certain important words. You can find the words in the Glossary of Terms for your reference. 3

13 Need this handbook in another language? Call CalViva Health if you would like your handbook in this language. (English) Call CalViva Health at if you would like this book in large print or an alternate format. 4

14 Whom do I call and when? You can call your PCP when you: Need an appointment, Need a checkup, 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 If the emergency room doctor or CalViva Health s case manager has advised you to see a doctor. Your PCP s name and telephone number are on your ID card. Questions? Call CalViva Health Member Services at (TTY ). You can call CalViva Health when you: Need a new ID card, Want to change PCP, 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 CalViva Health to a different health plan, or Are unsure whom to call. CalViva Health s toll-free number is Helpful information at on the internet Do you use the Internet? Our website, is a great resource. You can: Find a doctor, Find a Hospital Learn about your benefits, 5

15 Learn more about privacy rights, Find out about your rights and responsibilities, or Get a complaint form (called a grievance ). LET S GET STARTED: HOW DO I GET HEALTH CARE? Your PCP is responsible for making sure you get the medical care you need and are entitled to. You were asked to choose a PCP and a health plan when you filled out the Medi-Cal enrollment form. 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 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 CalViva Health. If you did not get the PCP or health plan you chose, call CalViva Health at to see if that PCP or health plan 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 select a non-physician medical practitioner as their primary care provider. Nonphysician practitioners include: certified nurse midwives, certified nurse practitioners, and physicians assistants. 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 identification (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. 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. 6

16 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 checkup 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. Start getting your care now! Call your PCP for a check-up. It is important for a new member to get a check-up even if you are not sick. Be sure to schedule this checkup soon after becoming a CalViva Health member. Call your PCP today to make an appointment for a new member checkup. This visit is also called a well visit or initial health assessment. Your PCP s telephone number is on your CalViva Health 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 checkup every year, even when they are not sick, to make sure they are healthy and growing properly. Make an appointment with your child s PCP within 60 days of becoming a CalViva Health member if your child is under the age of 18 months. Make an appointment with your PCP or your child s PCP within 120 days after enrollment for every other family member 18 months and older. If you do not choose a PCP, we will choose one for you. We try to choose a PCP that is near your home and who speaks your primary language. Call the Member Services Department 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 CalViva Health ID card. Please call ahead as soon as possible. 2. When you make an appointment, identify yourself as a CalViva Health Medi-Cal member, and tell the receptionist when you would like to see your PCP. Your PCP 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 PCP. ( 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: o PCP appointments within 10 business days of request for an appointment. 7

17 o Urgent care appointment with PCP within 48 hours of request for an appointment. o First pregnancy visit within 10 business days of request for an appointment. o Well-child visit with PCP within 10 business days of request for an appointment. o Routine checkup/physical exam within 30 calendar days of request for an appointment. The PCP 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. 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 PCP 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 CalViva Health 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 PCP 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 PCP s office does not leave instructions, call CalViva Health s Member Services Department at A representative will connect you to a health care professional who will be able to help you and answer your questions. As a CalViva Health member, you have access to triage 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 CalViva Health s doctors have urgent care hours in the evening, on weekends or during holidays. 8

18 Triage and/or screening/nurse advice As a CalViva Health Member, when you are sick and can t reach your PCP, like on the weekend or when the office is closed, you can call CalViva Health s Member Services Department at , 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 answer your questions. As a CalViva Health 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 CalViva Health pays for all medically necessary and covered medical services approved by your PCP according to plan rules or for an emergency. Please note: No services are covered outside of the United States, except for emergency services requiring hospitalization in Canada or Mexico. You should not get a bill for any services covered by CalViva Health. Please call CalViva Health right away if you receive a bill for medical services. CalViva Health will make sure the doctor stops sending you a bill for covered services. You may get a bill if: you go to a provider outside of your network or outside of your service area and the service requested is not for emergency care, family planning, HIV testing and counseling, pregnancy termination or for sexually transmitted disease (STD) services. there is no prior-authorization for the service requested and the service requested is not for emergency care, family planning, HIV testing and counseling, pregnancy termination or for STD services. If this happens, you may be billed by the doctor and may have to pay. If you pay the bill, keep a copy or record of your payment. Send a copy of your payment to CalViva Health for review. If the bill is for covered or authorized services, you may receive a reimbursement from CalViva Health. You should not be billed for emergency care, urgent 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 CalViva Health 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. You will not have a cost 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.) 9

19 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 CalViva Health 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 CalViva Health, and let them know you would like to see another doctor and the reason why. 2. Your PCP, specialist or CalViva Health 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 CalViva Health 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 the network for the same specialty. If there is no qualified health care professional within your plan s network, CalViva Health 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. 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 CalViva Health at Call your health 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 an appointment directly. If you have any questions about whether care from a specialist or treatment 10

20 from a hospital needs approval, you can call Member Services at (Remember emergency care, urgent care or care with an OB/GYN in your network does 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 CalViva Health if you do not get a response by these times. If a referral is not approved, your PCP or CalViva Health 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. Emergency services anywhere in the United States or urgently needed services outside of your service area do not need a referral. Please note: No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico 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 CalViva Health s medical director decide whether you need a standing referral to a specialist. You, your PCP, a specialist and CalViva Health s medical director decide on the treatment plan that is right for you. Your PCP, a specialist and CalViva Health 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 your health plan on the health care they are giving you. If you have any problems getting a standing referral, call CalViva Health at (TDD/TTY for the hearing impaired at ). 11

21 If your standing referral is denied or you did not get the help you needed with your standing referral, read about CalViva Health's 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 CalViva Health denies the request for a referral, CalViva Health 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 CalViva Health s specialist referral policy. To get more information about our specialist referral policy, please contact Member Services at 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 Program (CCS). The CCS program will authorize care with a CCS paneled specialist provider or CCS certified special care center. CalViva Health will help you to 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 CalViva Health. 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 CalViva Health denies the request for a referral, CalViva Health 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 CalViva Health s specialist referral policy. To get more information about our specialist referral policy call Member Services at

22 IDENTIFICATION (ID) CARDS: HOW DO I USE THEM? What to do with your CalViva Health ID card You should have received or currently have a CalViva Health ID card for every family member covered by CalViva Health Medi-Cal. If you did not receive or have an ID card for a family member who is covered by CalViva Health Medi-Cal, call Member Services right away. Your CalViva Health ID card has important information on it, including: Your PCP s name (or the name of your clinic or medical group). Your PCP s address and phone number. 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? Is your birth date right? If anything on your ID card is wrong, call CalViva Health at right away. CalViva Health 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 CalViva Health at for a 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 CalViva Health. 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, CalViva Health will not be able to give you care. 13

23 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. CalViva Health 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 CalViva Health s network by calling CalViva Health and asking for a provider directory. Please see your provider directory for information on the physical accessibility of provider offices. The CalViva Health provider directory also has accessibility indicator definitions to help you. CalViva Health 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 for help in finding a doctor to meet your needs. In most cases, you need to get care within CalViva Health s network. That is not the case if you need emergency care or need urgent care outside of your service area. This is talked about more in the section Emergency care: How Do I Get Care in an Emergency? in this handbook. 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 CalViva Health. 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 the CalViva Health network shown in the provider directory mailed to you with this handbook. Call CalViva Health 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 CalViva Health. You may choose a PCP within the first 30 calendar days of enrollment and change at least monthly after that. 14

24 Things to remember if you choose a new PCP: Some PCP s 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 CalViva Health to make a change. This can happen if: You are disruptive or disrespectful to your PCP or your doctor s office staff; or You do not follow your doctor s treatment plan; or The service or care you need are not within the doctor s scope of care (like a highrisk pregnancy). Kinds of PCP You can pick your PCP from the CalViva Health 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 your plan contract and that you or your family member might need. These services are available to you from other providers or hospitals: Family planning 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

25 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 CalViva Health for the names and addresses of the FQHCs and RHCs that work with CalViva Health 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 CalViva Health 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 three 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 CalViva Health 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 Urgent care appointment with a specialist or other type of provider that does not need approval in advance within 48 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 CalViva Health s network. Female members may get family planning services from any health care provider licensed to provide these services in or out of CalViva Health s network, and can be provided outside of your county of residence. 16

26 Our doctors professional qualifications We are proud of our doctors and their professional training. If you have questions about the professional qualifications of network doctors and specialists, call CalViva Health. CalViva Health can tell you about their medical training or qualifications. Certified Nurse Midwives Certified Nurse Midwife services are available outside of CalViva Health s network. Members may see a Certified Nurse Midwife without a PCP s approval. To find out more, ask your PCP or call CalViva Health. Certified Nurse Practitioners Some of the PCPs who work with CalViva Health use Certified Nurse Practitioners to see patients. Members may see a Certified Nurse Practitioner. To see a Certified Nurse Practitioner, or for more information, ask your PCP or call CalViva Health. 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 CalViva Health 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. 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 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 approval. Members may see an in-network OB/GYN for OB/GYN services without their PCP s approval. Access to services to which a provider has a moral objection Some health care providers may not perform certain services covered under your health plan. This may be for religious or ethical reasons. When this happens, the provider or CalViva Health will find other providers who are willing to perform those services for you. 17

27 How to keep seeing a provider if your provider leaves your health plan Sometimes CalViva Health 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 provider (including specialists and hospitals) if that provider agrees and has been treating you for any of the following 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 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. Children ages birth to 36 months For up to 12 months. You have surgery or other procedures authorized by CalViva Health as part of a documented course of treatment. This treatment was set to occur within 180 days of the time the provider stops working with CalViva Health or within 180 days of the time you began coverage with CalViva Health. How to keep seeing your provider if you are a new member Members who have just joined CalViva Health may ask to keep seeing their out-of-network provider (including PCP and Specialist) if they are in the middle of treatment or have scheduled treatments or procedures. This is called a continuity of care benefit. In order for CalViva Health to approve your request for continuity of care: You must have one of the conditions listed under the above section How to keep seeing a provider if your provider leaves your health plan in this handbook, You must have seen the out-of-network provider at least once during the twelve (12) months prior to the date of your enrollment with CalViva Health, for a non-emergency visit, The out-of-network provider must agree to the health plan s usual payment rate or the Medi- Cal payment rate, and The out-of-network provider must meet CalViva Health s professional standards. The continuity of care benefit includes only those services covered by CalViva Health. In addition, the continuity of care benefit does not include services provided by the following providers: Durable medical equipment Transportation Other ancillary services, and Services provided by Fee-For-Service Medi-Cal program. 18