For TDD Users, call To the addressee or guardian of:

Transcription

1 121X131C For TDD Users, call To the addressee or guardian of: 121X131C M-M u X - *140921FWDX041014* t X FWD-04/10/14 JOHN SAMPLE 1234 SAMPLE STREET SAMPLE CITY, CA TDD/TTY MU_ _ENG1_0311

2 121X131C For TDD Users, call u X - *140921FWDX041014* t X FWD-04/10/14 MU_ _ENG2_1204

3 State of California-Health and Human Services Agency Department of Health Care Services P.O. Box West Sacramento, CA *140921FWDX041014* t April 10, 2014 To the addressee or guardian of: u X- X FWD-04/10/14 JOHN SAMPLE 1234 SAMPLE STREET SAMPLE CITY CA Welcome to Medi-Cal Managed Care! We re happy to welcome you and your family member(s) to Medi-Cal Managed Care. We look forward to working with you to keep your entire family healthy. That s our number one concern. The beneficiary(ies) listed on the enclosed choice form must choose a health plan and doctor. You have until May 10, 2014 to complete and return the choice form. You can make a plan choice at any time before the date listed above. The effective date of your plan enrollment will depend on when we receive your plan choice. Your plan choice could be effective as early as the first of the next month. After your plan choice has been received and processed, you will receive a letter with your chosen health plan s name and start date. Your new health plan will also send you some information once you are enrolled. If you have any questions or want to enroll over the phone, call Health Care Options, toll-free, at, between the hours of 8:00 a.m. and 5:00 p.m., Monday through Friday. If you need personal assistance, take a look at the presentation schedule in the packet for site locations near your home or visit us on-line. Go to For TDD/TTY users, call Take the first step toward providing yourself and your family with health care by completing a choice form today! Get a good start on the road to health! 121X131C M MA_IA_ENG_0311

4

5

6

7 JOHN SAMPLE * FWD-X* 1234 SAMPLE STREET SAMPLE CITY JOHN SAMPLE *M E-X* E-X 079 KP Cal, LLC 068 Health Net Comm Solutions 167 Care1st Partner Plan, LLC 131 Molina Healthcare Partner 029 Community Hlth Grp Partner 079 KP Cal, LLC 068 Health Net Comm Solutions 167 Care1st Partner Plan, LLC 131 Molina Healthcare Partner 029 Community Hlth Grp Partner 000 Regular Medi-Cal (FFS) 079 KP Cal, LLC 068 Health Net Comm Solutions 167 Care1st Partner Plan, LLC 131 Molina Healthcare Partner 029 Community Hlth Grp Partner 000 Regular Medi-Cal (FFS) MU_ _ENG_0707

8

9 JOHN SAMPLE 1234 SAMPLE JOHN SAMPLE * FWD-X* * FWD-X* FWD-X STREET SAMPLE CITY *M E-X* *M E-X* M E-X 079 KP Cal, LLC 068 Health Net Comm Solutions 167 Care1st Partner Plan, LLC 131 Molina Healthcare Partner 029 Community Hlth Grp Partner 079 KP Cal, LLC 000 Regular Medi-Cal (FFS) 068 Health Net Comm Solutions 167 Care1st Partner Plan, LLC 131 Molina Healthcare Partner 029 Community Hlth Grp Partner 079 KP Cal, LLC 000 Regular Medi-Cal (FFS) 068 Health Net Comm Solutions 167 Care1st Partner Plan, LLC 131 Molina Healthcare Partner 029 Community Hlth Grp Partner MU_ _ENG_0707

10

11 Health Information Form You are receiving this form because you are eligible to enroll in a new Medi-Cal health plan. Your new plan will use this form to make sure you get needed care. Please fill in the circle with black or blue pen for the answers that apply to you. Complete one form for each person in your family who is enrolling in a new Medi-Cal health plan. If you have questions, please call Health Care *1010* 1010 Options, toll free at Monday through Friday, between 8:00 a.m. and 5:00 p.m. TDD/TTY users should dial Please return completed form with your Medi-Cal Choice Form or mail separately to: CA Department of Health Care Services Health Care Options - PO Box West Sacramento, CA Filling out this form is voluntary. You will not be denied care based on your confidential answers. JOHN SAMPLE Born In: 2007 *140921FWD * FWD Name of Person Completing Form: 1. Do you need to see a doctor within the next 60 days?... Yes No 2. Do you take 3 or more prescription medicines each day?... Yes No 3. Do you see a doctor regularly for a mental health condition such as depression, bipolar disorder, or schizophrenia?... Yes No 4. Have you been to the emergency room two or more times in the last 12 months?... Yes No 5. Have you been admitted to the hospital in the last 12 months?... Yes No 6. Have you needed help with personal care, such as bathing, getting dressed, or changing bandages in the last 6 months?... Yes No IMAGE 7. Are you using medical equipment or supplies, such as a hospital bed, wheelchair, walker, oxygen, or ostomy bags?... Yes No 8. Do you have a condition that limits your activities or what you can do?... Yes No 9. Are you pregnant?... Yes No 9a. If Yes, are you currently seeing a doctor for this pregnancy?... Yes No MISSING 10. Do you see a doctor regularly for a chronic medical condition?... Yes No If Yes, fill in all that apply: Asthma Cancer Cystic Fibrosis Diabetes Heart Problems Hepatitis High Blood Pressure HIV or AIDS Kidney Disease Seizures Sickle Cell Anemia Tuberculosis Other When you become a health plan member, If you think you need to see a doctor before your DHCS will send this information to your Medi-Cal Medi-Cal health plan contacts you, you should go to health plan. the doctor or hospital at that time. I understand that this information will be disclosed to Health Care Options and my new plan. Signature: Date Signed: If not signed by beneficiary, specify relationship:.parent of minor CONFIDENTIAL Guardian.Other representative MU_ _ENG_0912

12

13 MU_ _ENG1_0707A

14

15 MU_ _ENG3_0707A

16

17 1OZ_ _ENG1_0211a

18 1OZ_ _ENG2_1012 Do not put more than 4 forms in this envelope

19

20 Medi-Cal Managed Care Comparison Chart The information is being provided for INFORMATION purposes only. To order an enrollment package, or for assistance filling one out, call. Translators are available. For TDD/TTY users, call Care 1st Partner Plan Community Health Group Partnership Plan (Community Health Group) Standard Benefits Medi-Cal Covered Services Medi-Cal Covered Services Plan Network Hospitals* Fallbrook Hospital Paradise Valley Hospital Palomar Medical Center Pomerado Hospital Rady Children s Hospital San Diego Scripps Green Hospital Scripps Memorial Hospital-Encinitas Scripps Memorial Hospital-La Jolla Scripps Mercy Hospital Scripps Hospital-Chula Vista Sharp Chula Vista Medical Center Sharp Coronado Hospital Sharp Gossmont Hospital Sharp Memorial Hospital Sharp Mary Birch Hospital for Women and Tri City Medical Center Alvarado Hospital Fallbrook Hospital Green Hospital of Scripps Clinic Grossmont Hospital Palomar Medical Center Paradise Valley Hospital Pomerado Hospital Promise Hospital of San Diego Rady Children s Hospital of San Diego Scripps Memorial Hospital Encinitas Scripps Memorial Hospital La Jolla Scripps Mercy Hospital Chula Vista Scripps Mercy Hospital Hillcrest Sharp Chula Vista Medical Center Sharp Coronado Hospital Sharp Mary Birch Hospital for Women Sharp Memorial Hospital Tri-City Medical Center Doctors you can go to Please call Member Services at for a directory or assistance in choosing a doctor, or you can go online to for all network information. We have over 500 Primary Care Physicisans who work directly with over 1,200 Specialists. Please look in Community Health Group s Provider Directory for a doctor near your home. Urgent Care Centers Call your provider during business hours. After hours, call Community Health Group offers after-hours access to urgent care. Pharmacies The Care1st Health Plan pharmacy network includes most of the large chains such as CVS, Rite Aid and Walgreens along with many neighborhood pharmacies. Our network includes 400 pharmacies, many chain and independent pharmacies. Please look in Community Health Group s Provider Directory for a pharmacy near your home. Vision Plan Care1st Health Plan offers access to vision services through March Vision. Vision Service Plan for your vision benefits. If you are 21 years of age or older, some limitations may apply. Assistance with Public Transportation Free transportation to your doctor s appointments. Some restrictions may apply. Call from 8:00 am to 6:00 pm, Monday - Friday. 24-hour emergency transportation services. For non-emergent transportation, contact Community Health Group. Health Education Care1st Health Plan offers Asthma Management, Healthy Start (Comprehensive Prenatal and Post Partum), Quitting Smoking and Weight Management programs. Health Education Classes and Community Events in your area; Member Newsletters Languages Spanish, Russian, Mandarin, Vietnamese, Armenian, Hmong, Cantonese. Other languages available through the language line services. Call Member Services: Our Member Services staff speaks English, Spanish, Vietnamese and Arabic and many more through the use of the Language Line. Member Services Hotline Member Servcie Department TTY ; 24 hours a day, 7 days a week. Telephone Advice Nurse *In the event of an emergency, call 911 SD_ _ENG2_0312

21 Medi-Cal Managed Care Comparison Chart The information is being provided for INFORMATION purposes only. To order an enrollment package, or for assistance filling one out, call. Translators are available. For TDD/TTY users, call Health Net Community Solutions, Inc. (Health Net) KP Cal, LLC (Kaiser Permanente) Molina Healthcare of California Partner Plan, Inc. (Molina) Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services. Bridge2AccessSM Program-to help members access care. Alvarado Hospital Medical Center Rady Children s Hospital Scripps Green Hospital Scripps Memorial Hospital - Encinitas Scripps Memorial Hospital - La Jolla Scripps Mercy Hospital Scripps Mercy Hospital - Chula Vista Tri-City Medical Center UCSD Medical Center - Hillcrest UCSD Medical Center - Thorton Kaiser Permanente Hospitals Hospital and Medical Offices: 4647 Zion Ave. Fallbrook Hospital Rady Children s Hospital San Diego Scripps-Mercy Hospital Scripps-Mercy Hospital-Chula Vista Sharp-Chula Vista Medical Center Sharp-Coronado Hospital Sharp-Grossmont Hospital Sharp-Mary Birch Hospital for Women Sharp Memorial Hospital Tri-City Medical Center Our provider directory can help you choose from several participating primary care providers and specialists or call Member Services at Per Kaiser Permanente Provider Directory/ EOC Primary Care Physician (PCP) Assignment and PCP Re-selection through Member Services Over 1,900 Primary Care Physicians and Specialists. Call for a directory or assistance in finding a doctor. Call Member Services Department 24 hours/7 days for assistance. Urgent Care is offered at most sites: 24-hour statewide emergency services Through most clinics (as identified in the at over 70 locations, as well as 24-hour Provider Directory) Through Medical Services Nurse Advice Line at ERs/EDs. Choose from a large selection of chain and independent pharmacies including CVS, K-Mart, Rite Aid, Target, Vons, Walgreens,Wal-Mart, and many others. Pharmacies at every Kaiser location: San Diego, Bonita, Carlsbad, Clairmont, Eastlake, El Cajon, Escondido, La Mesa, Mission Bay, Otay Mesa, Point Loma, Rancho Bernardo, San Marcos and Vista. Call ,000 pharmacies state-wide, including convenient neighborhood pharmacies like CVS, Rite Aid, and Walgreens. Our provider directory can help you find an eye care professional. Call us at Vision Services are available at all clinic locations. Phone numbers, appointments, and addresses are published in the Provider Directory. Members have access to March Vision s Provider Network, with many vision care service locations. Covers emergency services anywhere. 24-Hour Emergency Transportation is Directions, phone numbers and maps to all available. Call Health Net Member Services sites are in the Provider Directory. Directions at if you need assistance with are also available at non-emergency transportation. When medically necessary, Molina offers 24-hour emergency and pre-arranged nonemergency transportation. Materials on many health topics. Programs in weight management, nutrition, smoking cessation, asthma, diabetes and more. Call for more information. Health Education Centers are available at all clinic sites. Call Member Services at for the telephone numbers. Programs and materials available including: stop smoking, weight control, chronic diseases like diabetes and asthma, and Motherhood Matters Pregnancy Program. Our representatives speak Spanish, Hmong, and other languages. TDD/TTY: Call for assistance. Most languages are supported by clinic sites through Kaiser staff, contracted interpreter services or AT&T interpreter services (online). Multi-lingual staff available. We offer interpreters (including Sign Language) to meet you at doctor visits and telephone interpreter services in over 160 languages. Call our Member Services Department 24/7 at Call for answers about Medi-Cal Managed Care. Provided for all sites. Listed in the Provider Directory by location, hours and phone number (M-F, 7am 7pm). Deaf and hard of hearing members TDD/TTY or dial 711 (Calif. Relay Services). SD_ _ENG3_0312

22

23

24

25

26 Care1st Partner Plan, LLC Community Hlth Grp Partner Health Net Comm Solutions Kaiser Molina Healthcare Partner Getting needed care Children got the care they needed without problems. Getting care quickly Children got appointments and treatment without long waits. How well doctors communicate Doctors listened carefully, gave good explanations, and showed respect. Shared decision making Doctors talked with parents about treatment choices for the child and asked which was best for the child. Plan customer service Parents got the help they needed from plan customer service and plan written materials. Vaccines (shots) for children Children got all of the vaccines (shots) they were supposed to have to prevent illness. Check-ups for teenagers Teenagers got all of the check-ups they were supposed to have. Care for children with colds and flu Children with colds and flu got the right kinds of treatment.

27 This is what the symbols mean: = Scored higher than the average for Medi-Cal plans in California. = Scored about the same as the average for Medi-Cal plans in California. = Scored lower than the average for Medi-Cal plans in California. = Too few Medi-Cal plan members to report OR results were not available. Adults Care1st Partner Plan, LLC Community Hlth Grp Partner Health Net Comm Solutions Kaiser Molina Healthcare Partner Getting needed care People got the care they needed without problems. Getting care quickly People got appointments and treatment without long waits. How well doctors communicate Doctors listened carefully, gave good explanations, and showed respect. Shared decision making Doctors talked with patient about treatment choice and asked which was best for the patient. Plan customer service People got the help they needed from plan customer service and plan written materials. Pregnancy care Pregnant women got regular check-ups before their baby was born. Testing diabetics blood sugar level Adult diabetics (type 1 and 2) tested for the amount of sugar in their blood. Care for adults with bronchitis Adults with bronchitis got the right kinds of treatment. 5 For more information about Medi-Cal health plans call MU_ _ENG2_0412

28 Where to get answers if you have questions Questions about Medi-Cal sss Look in your enrollment booklet, called My Medi-Cal Choice for Healthy Care. Call to talk to someone at Health Care Options. It s a free call. The TDD/TTY number is This phone number is for people who have difficulties with hearing or speech. You need special equipment to use it. Medi-Cal holds meetings all over the state to help people understand the Medi-Cal program and how to sign up. You can come to one of these meetings if you want to hear about your choices and ask questions in person. To find out where and when meetings are held, look in the booklet My Medi-Cal Choice for Healthy Care or call Health Care Options at How to file a grievance If you have trouble getting an interpreter when you need one, or getting important written materials translated, you have the right to file a grievance. To file a grievance you may call your health plan or send them a letter. At the same time that you file a grievance with your health plan, you can ask for a State Hearing. Call (TDD/TTY: ) to ask for a State Hearing or send a letter to: California Department of Social Services State Hearing Division P.O. Box , MS Sacramento, CA Questions about the health plans If you have questions about how to use the plans and the programs or services they offer, you can call these phone numbers: Care1st Partner Plan, LLC TDD/TTY: Community Hlth Grp Partner TDD/TTY: Health Net Comm Solutions TDD/TTY: Kaiser TDD/TTY: Molina Healthcare Partner TDD/TTY: Funding for the development of this guide was provided by the California HealthCare Foundation. MU_ _ENG_1011

29

30

31 Health Care Options Presentations Attend an informative session at one of these convenient locations. California Health Care Options (HCO) Presentation Sites San Diego County June 2014 Schedule In-Person Medi-Cal Managed Care Information Appointment Necessary Free Help To Complete Forms Just ask for the "Health Care Options" Representative CITY LOCATION ZIP CODE ENROLLMENT COUNSELOR Chula Vista South Bay 690 Oxford Street El Cajon El Cajon 220 South First Street Escondido Escondido 620 East Valley Parkway Lemon Grove Lemon Grove 7065 Broadway Oceanside Oceanside 1315 Union Plaza Court You can call the HEALTHY SAN DIEGO Information Line at. Please leave a message with your name and telephone number and someone will return your call within 24 hours. Page 1 of 2 MSM-C-M61 SD_LTSS_PRES_ENG1_0614

32 Health Care Options Presentations Attend an informative session at one of these convenient locations. California Health Care Options (HCO) Presentation Sites San Diego County June 2014 Schedule In-Person Medi-Cal Managed Care Information Appointment Necessary Free Help To Complete Forms Just ask for the "Health Care Options" Representative CITY LOCATION ZIP CODE ENROLLMENT COUNSELOR Centre City 1255 Imperial Avenue Kearny Mesa 5055 Ruffin Road San Diego Northeast 7290 El Cajon Boulevard Southeast 4588 Market Street You can call the HEALTHY SAN DIEGO Information Line at. Please leave a message with your name and telephone number and someone will return your call within 24 hours. Page 2 of 2 MSM-C-M61 SD_LTSS_PRES_ENG2_0614

33

34

35

36

37

38

39

40

41 Report The Problem To The California Department Of Managed Health Care s Office Of Patient Advocacy Call , 24 hours a day, seven days a week. Ask For A State Fair Hearing With An Administrative Law Judge If you want a State Fair Hearing, you must ask for it within 90 days from the date of the Notice of Action or Grievance Resolution letter that you receive from your health plan, or from the date of the order or action you are complaining of. If the Notice of Action letter states that your requested treatment is terminated or reduced and you want to keep your treatment going, you must ask for a State Fair Hearing within 10 days from the date the letter was postmarked or personally delivered to you, or before the effective date of the action you re disputing, whichever is earlier. Complete the Form To File A State Fair Hearing that is included with your Notice of Action letter. You can also send a personal letter to ask for a State Fair Hearing. Be sure to include your name, address, phone number, Social Security Number, and the reason you want a State Fair Hearing. If someone is helping you ask for a State Fair Hearing, add his/her name, address, and phone number to the letter. If you want to keep your treatment going during the hearing process, be sure to state that in the Form To File A State Fair Hearing or in your personal letter. If you need a free interpreter, state that in the Form To File A State Fair Hearing or in your personal letter. Include the language that you speak. It takes up to 90 days after you ask for a hearing to get an answer. If you think waiting that long will threaten your health, ask your doctor or health plan for a letter. Make sure the letter explains how waiting will threaten your health. Then, ask for an expedited hearing and include the letter with the Form To File A State Fair Hearing or with your own personal letter. State Fair Hearing Write to: California Department of Social Services State Fair Hearing Division PO Box , MS Sacramento, CA Call: TDD/TTY: MV_ _ENG2_1011

42 How To Get An Exemption/Waiver You or a member of your family must choose a health plan if: You receive CalWorks benefits (cash aid, food stamps) You receive Medi-Cal only and you do not have a share of cost You or a member of your family cannot choose a health plan if: You are a member of a commercial health plan through private insurance You receive share of cost Medi-Cal You or a member of your family may not have to choose a health plan if: You receive health services from an Indian Health Provider You are being treated for a complex medical condition, such as: Pregnancy Cancer Organ transplant (or are scheduled for one) Renal disease and have dialysis at least two times a week A disease that affects more than one organ system (such as diabetes) You are HIV positive Other conditions may qualify How To Get An Exemption/Waiver You and your doctor must complete and sign the Medical or Non-Medical Exemption Form in this packet. Your doctor may not authorize your medical exemption, if he or she is part of a Medi-Cal Managed Care Health Plan in your area. You must return the form no later than 30 days after you receive this packet. If you do not return the form within 30 days, the State will choose a health plan for you. The State will review your request to change you to Regular Medi-Cal (Fee-For-Service). The State will send you a letter to let you know if your request has been approved or denied. If denied, you can call the State s Ombudsman at The call is free. MA_ _ENG_0712

43 *1* *SEPARATOR* MU_ _ENG1_0413

44 .

45

46

47 State of California - Health and Human Services Agency Department of Health Care Services Medi-Cal Managed Care Non-Medical Exemption Excepción Por Razones No Médicas Para Atención Médica Administrada de Medi-Cal Request for Non-Medical Exemption from Plan Enrollment American Indians and Beneficiaries with HIV/AIDS Each area of this non-medical exemption form must be completed or the form will be returned unprocessed. Please Print or Type (Ink Only) Dear Service Facility or Provider: If you currently provide or will be providing medical services to an individual who is receiving Medi-Cal benefits and that individual is required to enroll in a health plan, completion of this form will enable the individual to receive services through your facility as an alternative to enrollment in a Medi-Cal Managed Care health plan. The exemption form is valid until the individual chooses to enroll in a Medi-Cal Managed Care health plan. 1. Beneficiary Name 2. Beneficiary Medi-Cal I.D. Number (BIC) Last Name First Name M.I. 3. Name of Service Facility or Provider I certify that the information I have provided on this form is correct. I understand that the Department of Health Care Services may audit this form to determine if the information provided is accurate. 4a. Authorized signature of Medi-Cal Provider 4b. Date signed 4c. Printed name of Medi-Cal Provider 4d. NPI used to bill the Medi-Cal Program for this beneficiary. Last Name First Name 5. Telephone number of Medical Provider ( ) ( ) 10. Fax number of Medical Physician ( ) Mail completed form to: Health Care Options P.O. Box West Sacramento, CA Year 6. Fax number of Medical Provider 9. Telephone number of Medical Physician To be excused from plan enrollment you must have a service facility representative complete this form, certifying that you are or will be receiving services from a service facility or provider of your choice. The facility representative must submit this completed form to Health Care Options. Day M.I. Dear Medi-Cal Beneficiary: If you or a family member is receiving Medi-Cal benefits, you may be required to join a Medi-Cal Managed Care health plan. However, if you or a family member is a qualified individual for this exemption and you want to receive medical services through your choice of facility or provider, you may request to be excused from Medi-Cal Managed Care health plan enrollment in order to receive services through a service facility or provider of your choice. Month ( ) Estimado beneficiario de Medi-Cal: Si usted o un miembro de su familia está recibiendo beneficios de Medi-Cal, es posible que deba inscribirse en un Plan de Salud Administrado de Medi-Cal. Sin embargo, si usted o un miembro du su familia es de origen Indígena Americano, Nativo de Alaska o reúne los requisitos para personas de origen no indígena y desea recibir servicios medícos a través de un centro de Indian Health Service (IHS), puede solicitar que esté excluido de inscribirse en un plan de salud de Atención Médica Administrada de Medi-Cal para recibir los servicios a través del centro de Indian Health Service. Spanish Translation Here Para que esté excluido de inscribirse en el plan, debe solicitarle a un representante del centro de Indian Health Services que llene este formulario, en el que certifica que usted recibe o recibirá servicios a través de un centro de Indian Health Service. El representante del centro debe enviar este formulario completo al programa HCO. or Fax this form to: (916) If you have any questions regarding this form, please call HCO at ; TTY/TDD users, call LT_ _ENG_0314

48

49

50