Member Handbook and Evidence of Coverage

Transcription

1 Medi-Cal Member Handbook and Evidence of Coverage Last Updated 11/10/ 2015

2 Last Updated 11/10/ 2015

3 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. THIS NOTICE ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have questions about this Notice, please contact a Health Plan of San Mateo (HPSM) Member Services representative at or Why Am I Receiving this Notice? We understand that health information about you is personal. We are committed to protecting your health information. In general, health information is any information about your physical or mental health or about your payment for health services that can be identified with you as an individual. This information can be about your past, present, or future health. Examples of health information are your name, date of birth, diagnoses, medical treatments, and past medical claims, though this is far from a complete list. This notice contains a summary of HPSM s privacy practices and your rights relating to health information. This notice only covers HPSM s privacy practices. Your doctor may have different policies or notices regarding his or her use and disclosure of your health information created in the doctor s office. We Are Required by Law to: y Make sure that health information that identifies you is kept private; y Give you this notice of our legal duties and privacy practices about your health information; and y Follow the terms of the notice that is currently in effect. How May HPSM Use or Share My Health Information? The following are ways in which we may use your health information. The types of uses and disclosures of information listed below are allowed by state and federal law. Use refers to how we use information within HPSM. Disclosure means sharing information with someone outside HPSM. Following is a description of each type of use or disclosure and some examples. The list below does not include every possible allowable use and disclosure, and it is not intended to limit uses and disclosures that are permitted by law. However, all of the ways we are allowed to use and disclose your health information will fall within one or another of the following purposes: y For Payment. We use your health information to pay bills for the health services you receive as an HPSM Member. For Example: We may need to get information from your doctor about a treatment that the doctor is considering for you. We will review the information to make a decision about whether to approve payment for the treatment. Decisions are based on medical need. We may need to let the doctor know if the treatment is a covered benefit for you. y For Health Care Operations. We may use and disclose health information about you to carry out HPSM s operations. This is done in a confidential manner. These uses and disclosures are necessary to run the health plan and perform many of the services that you receive. For Example: We may use health information about you in our review of the doctors who provide your care. We check their performance to make sure you are receiving quality care. We may also use health information about you to compare the quality of our services to that of other health plans. This will help us check if there are ways we can improve the quality of care you receive. y For Treatment. We may use your health information in managing your care. We may share your health information with a provider for use in treating you. For Example: We may review your i 2016 Medi-Cal EOC Privacy Policy

4 health information, including medications that you are taking, to make sure that none of the treatments you receive will conflict. y Health-related Benefits and Services. We may use and share health information to tell you about HPSM s health benefits or services that may be of interest to you through HPSM s Health Education Programs. y To Contractors. We may disclose your health information to our contractors who assist us in our operations. Our contractors agree in writing to keep the health information provided to them confidential and secure, and not to use it except to assist us. For example, we contract with a company known as a Pharmacy Benefit Manager. This company processes claims for pharmacy services. We provide information that we have that is needed to pay the pharmacy claims for our Members. The Pharmacy Benefit Manager agrees to keep this information confidential. y To Health Insurance Program Sponsors. Employers and other organizations sponsor health insurance programs. These employers or sponsors contract with HPSM to provide services to you and pay claims. We may notify the plan sponsor if you are enrolled in, or disenrolled from the plan. We may also disclose your health information so the plan sponsor can audit HPSM s performance. The sponsor agrees to keep your health information confidential and secure. y To Family Members or Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a person who is responsible for paying for your health care, as necessary to enable that person to make payment. We may also disclose health information to family members and others who are involved in your health care. However, we may only disclose this information if you are present and agree to the disclosure. If you are not present, we may only disclose your health information to people involved in your care if you are unable to respond because of your medical condition and we believe that disclosing your information would be in your best interest. We may also disclose your health information to individuals involved in your care or payment for your care after your death, unless you tell us not to share your information with them. y To Schools Regarding Immunizations. We may provide a record of immunizations to a school about a student either enrolled or to be enrolled in the school if the school is required by the State or other law to have such proof of immunization. We will obtain your verbal authorization before disclosing this information. Special Situations y As Required by Law. We will disclose health information about you when required to do so by federal, state or local law. y To Avoid a Serious Threat to Health or Safety. We may use and disclose health information about you to prevent a serious threat to your health and safety or the health and safety of others. We would only give the information to someone who can help prevent the threat. y Military and Veterans. If you are a member of the armed forces or a veteran, we may release health information about you as required by military authorities or to assist in determining your eligibility for veterans benefits. y Correction Institutions. If you are in custody, release of health information may also be made to correction institutions in the course of coordinating your care. y Workers Compensation. We may release health information about you for Workers Compensation or similar programs. These programs provide benefits for work-related injuries or illness. ii 2016 Medi-Cal EOC Privacy Policy

5 y Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following: To prevent or control disease, injury or disability; To report child abuse or neglect; To report births or deaths; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease. To notify the appropriate government authority if we believe a Member has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when authorized by law. y Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. For example, we may disclose your health information to the public agency responsible for overseeing HPSM s operations. These activities are necessary for the government to monitor the health care system and government health benefit programs. y Lawsuits and Disputes. We may disclose health information about you if ordered to do so by a court or tribunal. We may also disclose health information about you in response to a subpoena, or other lawful process, but only if efforts have been made to notify you of the request or to obtain an order protecting the information requested. y Law Enforcement. We may release health information if required to do so by a law enforcement official or, in limited circumstances, if the official requests the information, or in order to report criminal conduct. Generally, this would have to be in connection with a criminal investigation and/or in response to a court order, warrant, or similar process. We also may release your health information to authorized federal officials for national security activities authorized by law. y Military Functions. We may release your information if it is requested to assist in a military mission or other governmental activity related to intelligence, national security, or protecting the President. y Coroners, Medical Examiners, and Funeral Directors. We may release the health information of Members who are deceased to coroners, medical examiners and funeral directors to enable them to perform their duties. y Organ Transplant Organizations. We may release your health information to organizations working on organ or tissue transplantation for the purposes of facilitating an organ transplant. y 50 Years after Death. We may release the health information of Members who are deceased to any agency if the Member has been deceased for at least 50 years. y Disaster Relief. We may release your health information in a disaster relief situation. However, if you prefer for us not to release your information for this type of situation, you have the right to make that choice. Limitations Other laws may limit or prevent the disclosures listed above. For example, there are special limits on the disclosure of health information relating to HIV/AIDS status, mental health treatment, developmental disabilities, and drug and alcohol abuse treatment. We comply with these restrictions in our use of your health information. We cannot sell your information. iii 2016 Medi-Cal EOC Privacy Policy

6 Authorization We will not allow uses and disclosures of your health information other than those described on the previous pages without your written permission or authorization. We must obtain your authorization before we use or disclose your information for any other reason. For Example: We may use and share health information about you for research purposes if we have your authorization. Your decision to grant us an authorization does not affect your medical treatment, health plan benefits, payment for treatment, or enrollment eligibility. You have the right to change your mind even after you have signed an authorization for use or release of your health information. If you decide to do this, we will not further use or disclose the information. Of course, we cannot take back any disclosures we had already made during the time we had your permission to do so. Your Rights Regarding Health Information about You You have the following rights regarding your health information that we store: y Right to Obtain a Copy of this Privacy Notice: You have the right to have a paper copy of this notice at any time. This notice is also available for your program on our website: y Right to Assign Someone to Represent You: You have the right to give someone medical power of attorney, which allows that person to act on your behalf and make choices about your health information. This right also applies if you have a legal guardian. We will make sure that anyone who represents you has this authority before we take any action. y Right to Request Restrictions. You have the right to request a restriction or limits on the use or disclosure of your health information. In your request, you must tell us: 1. What information you want to limit; 2. Whether you want to limit our use of information, disclosure of information, or both; and 3. To whom you want the limits to apply. To request restrictions, you must make your request in writing. See page v for instructions. Note: We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. y Right to Request Confidential Communications. You have the right to request that we contact you about medical matters privately and with special handling. For example, you can ask that we only contact you at work or by mail. We will not ask you for the reason for your request. We will make every effort to accommodate reasonable requests. Your request must specify how or where you wish to be contacted. To request special handling in the way you are contacted, you must make your request in writing. See page v for instructions. y Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a list of disclosures that we made of your health information. This list includes disclosures that we make for your treatment or our health plan operations, including payment for your care. It also includes most other disclosures that we are required or permitted to make without your authorization. For example, these include disclosures to governmental agencies that review our programs. To request this list, or accounting of disclosures, you must submit your request in writing. See page v for instructions. Your request must be for a period not longer than three (3) years prior to the date of your request and may not include dates before April 14, iv 2016 Medi-Cal EOC Privacy Policy

7 y Right to Access Your Health Information. You have the right to obtain a copy of certain health information that HPSM maintains in its records. In general, this includes health and billing records. You will have to contact your doctor for a copy of your medical record. To get a copy of health information that we maintain, you must submit your request in writing. See page v for instructions. We may deny your request to obtain a copy in certain cases. If you are denied access to health information, we will tell you the reason why in writing. If denied access, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. y Right to Receive Notice of a Breach. A breach occurs when protected health information is obtained, used or revealed in a way that violates relevant privacy laws. The health information must be unsecured, meaning that others could access the information. HPSM is required to inform you of any such incident within 60 days of discovering that the privacy of your information has been violated. The Secretary, U.S. Department of Health & Human Services, and in certain circumstances the media, may also have to be notified. The notice of the breach that you receive will include the following information: a description of what happened, the types of information that were involved in the breach, and the steps that you should take to protect yourself from potential harm. The notice will also tell you what HPSM is doing to investigate the situation and minimize harm to you, and to prevent breaches from occurring again. See Instructions on Page v about Your Right to Make a Complaint or File a Grievance y Right to Amend. You have the right to add a written comment that will be kept with your health information at HPSM. If you feel that health information we have about you is wrong or incomplete, you may ask us to amend the information. This is usually done if you disagree with the health information that we have on file for you. You have the right to request an amendment for as long as we maintain the information. To request an amendment, your request must be made in writing. See page v for instructions. We are not required to amend health information that: was not created by HPSM, unless the person that created the information is no longer available to make the amendment; is not part of the information we maintain; is not part of the information which you would be allowed to obtain a copy of; or is correct and complete. If HPSM denies your request to amend your health information, we will notify you in writing. You will also receive a written explanation of why your request was denied. Changes to this Notice This notice is effective as of November We reserve the right to change this notice. We reserve the right to make the revised notice effective for all health information we already have about you as well as any information we receive in the future. You can find the effective date of the Notice on the bottom of each page. In addition, each time there are changes to the notice, we will notify you through the mail within 60 days. We will also post a copy of the current notice on our website at v 2016 Medi-Cal EOC Privacy Policy

8 Instructions: (1) How to file a Grievance regarding your privacy rights: If you believe your privacy rights have been violated, you may file a grievance with the Health Plan of San Mateo. You may also contact the U.S. Department of Health and Human Services to file a complaint. Grievance Coordinator Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA or Secretary of the U.S. Department of Health and Human Services Office of Civil Rights Attn: Regional Manager 50 United Nations Plaza, Room 322 San Francisco, CA For additional information, call U.S. Office for Civil Rights at or TTY (OCR-PRIV) You will not be penalized for filing a Grievance. (2) For requests pertaining to your rights as listed in this notice, please send written requests to: Attention: Privacy Officer Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA ian.johansson@hpsm.org If you request a copy of your health information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We will notify you of the cost involved and you may choose to withdraw or change your request at that time before it is processed. If you have questions about this Notice, please contact Health Plan of San Mateo (HPSM) Member Services at or Members with hearing or speech impairments can call TTY: or dial California Relay Service (CRS). vi 2016 Medi-Cal EOC Privacy Policy

9 Notice of Privacy Practices... i Why Am I Receiving this Notice?... i We Are Required by Law to:... i How May HPSM Use or Share My Health Information?... i Special Situations... ii Limitations... iii Authorization...iv Your Rights Regarding Health Information about You...iv Changes to this Notice...v Instructions:...vi The Health Plan of San Mateo Medi-Cal Program 2015 Member Handbook and Evidence of Coverage...1 Welcome... 1 About the Health Plan of San Mateo... 1 Member Services... 1 Physical Access... 2 Access for the Hearing Impaired... 2 Access for the Vision Impaired... 2 The Americans With Disabilities Act of Disability Access Grievances... 2 How To Use This Member Handbook And Evidence Of Coverage... 2 Health Plan of San Mateo Service Area... 3 Disenrollment from HPSM... 3 How to contact the Nurse Advice Call Line... 3 Contact the Nurse Advice Call Line about:... 3 If You Have Questions... 3 Section 1 Definitions...5 Section 2 Member Rights and Responsibilities...9 As a Member of the Health Plan of San Mateo (HPSM) You Have the Right to:... 9 As a Member of the Health Plan of San Mateo (HPSM) You Have the Responsibility to:... 9 Section 3 Choice of Doctors and Facilities...11 Why Do I need a Primary Care Provider (PCP)? How to Pick Your Primary Care Provider (PCP) Changing Your PCP Special Members Continuity of Care for New Members Continuity of Care for Termination of Provider Federally Qualified Health Centers Native American Indian Health Care Services vii 2016 Medi-Cal EOC Contents

10 Section 4 How to Receive Health Care Services...15 Member Identification Card Timely Access to Non-Emergency Health Care Services Making Appointments Canceling Appointments Women s Services OB/GYN Services Referrals to Specialty Physicians Standing Referrals Treatment Authorization Request (TAR) Services Excluded from Prior Authorization Urgent Care and Night and Weekend Care Emergency Care Follow-up Care Post Stabilization and Follow-up Care After an Emergency Non-Qualifying Emergency Services Out-of-Area Care Obtaining a Second Opinion Medications Prescriptions Refills Over-the-Counter/Non-Prescription Drugs The Health Plan of San Mateo Drug Formulary Generic Equivalent Drugs Non-Formulary Drugs Availability of Drugs for Off-label Use Changes in Formulary Medications Submitting Prior Authorization Requests Evening, Weekend or Holiday Prior Authorization Requests (PAs) Deferred, Modified or Denied Medication Request Forms (MRFs) Prescription Drug Coverage for Members with Both Medicare and Medi-Cal Section 5 Member Payments, Co-payments, and Other Health Insurance Information...27 Member Payment Responsibilities (Billing) Claims Reimbursement Medi-Cal Co-payments Share-of-Cost Medi-Cal Transitional Medi-Cal (Medi-Cal for Working People) Medi-Cal with Medicare Medi-Cal and Other Health Insurance (not Medicare) Health Insurance Premium Payment (HIPP) Section 6 Covered Services and Benefits...31 Medi-Cal Program Detailed Description of Benefits, Conditions, and Exclusions Introduction Recommended Schedule for Well Child Visits Preventive Screening and Immunization Recommendations for Healthy Individuals* viii 2016 Medi-Cal EOC Contents

11 Health Plan of San Mateo Clinical Practice Guidelines Linkages to Other Programs Child Health and Disability Prevention (CHDP) Program Early Periodic Screening and Diagnostic Treatment (EPSDT) Program California Children s Services (CCS) Genetic Testing and Counseling Genetic Disease Treatment Genetically Handicapped Persons Program (GHPP) Other Available Benefits and Programs Not Covered by HPSM Section 7 Exclusions and Limitations on Benefits...57 General Exclusions and Limitations Specific Exclusions and Limitations Section 8 Member Complaint and Appeals...59 Grievance and Appeals Filing a Complaint or Appeal State Hearing Expedited State Hearing Independent Medical Reviews An IMR is available in the following situations: Independent Medical Review for Denials of Experimental / Investigational Therapies Review by the Department of Managed Health Care Mediation DHCS Medi-Cal Managed Care Ombudsman Section 9 Coordination of Benefits...63 Coordination Of Benefits (COB) Applicability Benefit Coordination with Other Coverage Recovery from Third-party Liability Medi-Cal Estate Recovery Program Section 10 General Provisions...65 Entire Contract Payment to Providers Durable Power of Attorney for Health Care or Advanced Directive Relationship Between Parties Privacy Practices Authorization for Release of Information Workers Compensation Not Affected Non-Discrimination Consumer Advisory Committee ix 2016 Medi-Cal EOC Contents

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13 The Health Plan of San Mateo Medi-Cal Program 2016 Member Handbook and Evidence of Coverage Welcome We are very pleased to welcome you to the Health Plan of San Mateo (HPSM). HPSM is your Medi-Cal managed care insurance plan. You automatically became an HPSM member when you were approved for Medi-Cal by the San Mateo County Human Services Agency or through the SSI (Supplemental Security Income) program. Your basic Medi-Cal benefits are the same as those of other Medi-Cal recipients in California, but you also have access to additional services. It is important that you understand how the Health Plan of San Mateo (HPSM) works so you can get the health care you need. This booklet, called a Member Handbook and Evidence of Coverage, explains your benefits and how to get care. It will also answer many of your questions. You will learn: y How to choose a doctor or change your doctor; y How to receive care; y What your benefits are; and, y What to do if you have a question or a problem. If you do not understand something in this Handbook, call and speak with an HPSM Member Service Representative. About the Health Plan of San Mateo The Health Plan of San Mateo is the health insurance plan for Medi-Cal recipients in San Mateo County. Since you now have Medi-Cal, you are a member of HPSM. This means that you will see doctors and other health care providers who are part of HPSM. HPSM will pay for your medical care, including your prescription drugs. Member Services The HPSM Member Services Department is here to help you. The Health Plan of San Mateo is located at 701 Gateway Blvd., Suite 400, South San Francisco, CA If you need help or want more information, call Member Services at or If you are hearing impaired you can use the California Relay Service at (TTY) or dial For California Relay services in Spanish call Member Services Representatives are available to speak with you Mondays through Thursdays from 8:00 a.m. to 6:00 p.m. and Fridays from 9:30 a.m. to 6:00 p.m. Our office hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. If you do not speak or read English well, you may get help in the following ways: y HPSM staff speaks several languages, including Spanish and Tagalog, and can answer questions, solve problems or help you choose a doctor Medi-Cal EOC Introduction

14 y Interpreter services are available by phone free of charge 24 hours per day at service sites. You do not have to use family members, friends, or children as interpreters. y You can see doctors who speak your language. HPSM s Provider List has information about languages spoken in each doctor s office, office locations and hours available for appointments, including evening and weekend hours. A Member Services Representative can help you choose a doctor if you need help or have questions. y HPSM documents are available in Spanish. Please call the Member Services Department if you would like information in Spanish. y Sign language interpreters are also available. You do not have to use family members, friends, or children as interpreters. Physical Access HPSM has tried to make our offices and the offices and facilities of HPSM providers accessible to the disabled. If you want help in finding an accessible provider, please call Member Services. Access for the Hearing Impaired If you are hearing impaired, you can use the California Relay Service at (TTY) or dial For California Relay Service in Spanish call HPSM also offers free sign language interpretation. We can arrange for a sign language interpreter to go with you to your appointments if you let us know at least two (2) days in advance. You do not need to use friends, family members, or children to interpret for you. Access for the Vision Impaired This booklet and other important HPSM materials are available in large print for the vision impaired. For other formats, or for help in reading this booklet and other materials, please call Member Services. The Americans With Disabilities Act of 1990 HPSM complies with the Americans with Disabilities Act of 1990 (ADA). This Act prohibits discrimination based on disability. The Act protects Members with disabilities from discrimination concerning program services. In addition, section 504 of the Rehabilitation Act of 1973 states that no qualified disabled person shall be excluded, based on disability, from participation in any program or activity which receives or benefits from federal financial assistance, nor be denied the benefits of, or otherwise be subjected to discrimination under such a program or activity. Disability Access Grievances If you believe HPSM or its providers have failed to respond to your disability access needs, you may file a Grievance with HPSM. See page [55] for more information. How To Use This Member Handbook And Evidence Of Coverage Please read this entire booklet. Many of the sections go together; so, if you read just one or two sections, you may not have complete information about the Health Plan of San Mateo. Many words used in this booklet have special meanings. These words are explained in Section 1, Definitions, and appear in this booklet with capital first letters. Refer to the Definitions to help you understand your benefits, rights and responsibilities under the Health Plan of San Mateo Medi-Cal EOC Introduction

15 Health Plan of San Mateo Service Area HPSM s service area includes all of San Mateo County. Disenrollment from HPSM You will be disenrolled from HPSM if: y You lose your Medi-Cal eligibility or y Your Medi-Cal changes to a category not covered by HPSM, or y You move out of San Mateo County. How to contact the Nurse Advice Call Line HPSM provides 24 hour 7 day per week access to Nurse Advice Line (NAL) services through its vendor. NAL services provide access to triage medical questions and facilitate appropriate follow up with member s provider. CALL This call is free. 24 hours a day, 7 days a week We have free interpreter services for people who do not speak English. TTY or dial This call is free. 24 hours a day, 7 days a week Contact the Nurse Advice Call Line about: Questions about your health care If You Have Questions The information in this booklet and New Member Packet should answer most of your questions about your health care benefits. If you have other questions about the Health Plan of San Mateo, your benefits, or your rights with HPSM, please call Member Services at or Situations When You Should Contact Member Services Choosing and changing your doctor You receive a bill to pay for a service y Find a doctor in your area y You prefer a female or male doctor y You want a doctor who speaks your language y You don t understand why a clinic or doctor s office has sent you a bill y You had to get urgent medical care from a non-network doctor when you were outside of HPSM s service area You need a new HPSM ID card y You lost your HPSM card y The PCP name on your card has to be changed Your home address or phone number has changed y You have moved or have changed your phone number Medi-Cal EOC Introduction

16 You have a complaint related to your doctor s office, your medical care, or HPSM y You do not like the way the staff at your doctor s office respond to you on the phone, or in person y You are not satisfied with your doctor s decisions about your medical care y You are not satisfied with a decision HPSM has made related to coverage for a service You have questions about HPSM s services y You want to know if a medical procedure or prescription will be covered y Your doctor ordered medical equipment for you and you want to know if it will be covered You cannot get a doctor s appointment y You have to wait too long to see your doctor because appointments are not available to be seen sooner Problems getting a prescription filled y The pharmacy told you that your prescription is not approved for coverage If you have questions about your Medi-Cal eligibility, call the San Mateo County Human Services Agency at Office hours are Monday through Friday 8:00 a.m. to 5:00 p.m. If you received your Medi-Cal eligibility through Social Security (Supplemental Security Income), please call Medi-Cal EOC Introduction

17 Section 1 Definitions Active Labor means labor when there is not enough time to safely transfer the member to another hospital before delivery or when transferring the member may be a threat to the health and safety of the member or the unborn child. Acute Condition means a condition that begins suddenly because of an illness, injury, or other medical problem and needs prompt medical attention. An acute condition continues for a limited time. Amendments mean changes to the services covered by the Medi-Cal Contract. You will receive a written description of an amendment when it causes a change in the Evidence of Coverage. You should read the amendment and then attach it to your Evidence of Coverage. Appropriately Qualified Health Care Professional A Primary Care Provider or Specialist who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to a particular illness, disease, condition, or conditions. Authorization means approval by your Primary Care Provider (PCP) or HPSM for a service. Auto Assignment means when a PCP is assigned to you because you do not make a choice or HPSM does not receive your PCP choice on time. Benefits or Coverage or Covered Service(s) means the health care services HPSM provides to Members. Benefits are described in this booklet. California Children s Services (CCS) is a program for children who have disabling medical conditions. This program provides insurance and case management for certain conditions. Case Management means a process to coordinate a Member s health care. It is a joint effort that includes the Member, his/her physician(s), provider staff, and the case manager. Clinics are places where doctors, nurses and other providers treat patients. Clinic care is sometimes called outpatient care, while hospital care is called inpatient care. Coverage Decision means the approval or denial of a service by HPSM or its providers. The coverage decision is based on whether or not the service is a medically necessary covered benefit. DMHC means the California State Department of Managed Health Care. Disputed Health Care Service means a covered health care service that is denied, modified, or delayed to a Member. The decision to deny, modify, or delay a service is based on a finding that the service is not medically necessary. A Member may dispute or disagree with a decision and file a Grievance. Emergency Care means care received right away for an illness or injury that puts your health in serious danger or for a medical condition that causes severe pain. An emergency is defined as an illness, injury, or medical condition that a careful or prudent person who has no medical training believes could: Medi-Cal EOC Section 1

18 put your health or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious danger. This includes active labor when there is not enough time to transfer to another hospital before delivery or when moving to another hospital would pose a threat to your health or your unborn child s health. result in serious harm to the way your body works, or result in serious damage of any body organ or part. Emergency care includes medical or psychiatric screening, examination, evaluation, and treatment by a physician or other personnel. Care and treatment for a medical or psychiatric emergency is covered to the extent permitted by the law. Such care may also be limited by the privileges and licensing of the facility. Established Patients Only (EPO) means doctors that will only see Members who received services from them in the past. Exclusion means any medical, surgical, hospital or other treatment for which Medi-Cal offers no coverage. Formulary means the list of medications covered by HPSM. The medications on the Formulary have been approved by HPSM and may be prescribed without Prior Authorization. Grievance means a written or oral expression of dissatisfaction regarding the Plan and/or Provider, including quality of care concerns, which includes a complaint, dispute, request for reconsideration or appeal made by a Member or the Member s representative. Where the plan is unable to distinguish between a Grievance and an inquiry, it shall be considered a Grievance. Health Plan or HPSM means the Health Plan of San Mateo. Identification (ID) Card means the card given by HPSM to each Member. This card should be presented whenever you need care. It is also called an ID Card. Investigational Services means drugs, equipment, and procedures that are now being tested in humans. Investigational services may be covered if the following conditions are met: You have a life-threatening or seriously debilitating condition, and Standard therapies have not been effective, or are not appropriate, or there is no standard therapy covered by HPSM that is more beneficial than the proposed therapy. Life Threatening means a disease or condition that is highly likely to cause death unless the disease or condition is promptly treated. Medical Emergency [See Emergency Care]. Medical Group means a group of doctors, clinics, hospitals, and other health care providers. A medical group in HPSM has a contract with HPSM to arrange for and provide health care services to Members. Medically Necessary Services means health care services that are needed to meet a person s basic health needs. The decision whether or not a service is medically necessary is based on many factors, including, but not limited to, the standards of the medical community. The fact that a doctor has Medi-Cal EOC Section 1

19 performed, prescribed or recommended a procedure or treatment does not mean that it is medically necessary. Medically Necessary Services must be: consistent with the diagnosis and prescribed course of treatment for the condition, or be generally accepted by the medical community as a preventive health service; required for reasons other than the convenience of the patient or his or her doctor; performed in the most cost efficient setting appropriate for the condition; and provided at a frequency which is accepted by the medical community as medically appropriate. Medically necessary services must not be required only for custodial, comfort, or maintenance reasons. If medically necessary services are not provided, the Member s condition or the quality of the medical care given will be adversely affected. Member means a person eligible for Medi-Cal and enrolled in HPSM. Out-of-Area Care means Emergency Care or Urgent Care provided outside of HPSM s Service Area that could not be delayed until the Member returned to the Service Area. Participating Hospital means a hospital that has a contract with HPSM to provide services. Participating Provider means a doctor, clinic, hospital, hospice, or other provider, which has a contract with HPSM to arrange for and provide health care services to Members. Pharmaceutical Benefits Manager (PBM) means a third party administrator of a health plan s prescription drug program that is mainly responsible for authorizing and paying prescription drug claims. PBMs assist the health plan with development and maintenance of drug formularies, contracts with pharmacies, and negotiate discounts and rebates with drug manufacturers. Primary Care Provider or PCP is the provider who provides your basic care. Your PCP is your regular doctor, nurse practitioner, or physician s assistant and knows your overall health situation. Your PCP is always the first provider you see and must set up referrals for Specialist care if you need it. You select or are assigned a PCP at the time you join HPSM. Prior Authorization means approval for a service. Before you receive a service, your PCP or HPSM must usually approve it. Provider List is a list of doctors, clinics, hospitals and other specialty providers who have a contract with HPSM to provide services to Members. Referral means that when you need special kinds of care, your PCP will refer or send you to a Specialist who is a Participating Provider. Serious Chronic Condition is due to a disease, illness, or other medical problem or disorder that is serious and will last, get worse over time, or require ongoing treatment to maintain remission or prevent deterioration Medi-Cal EOC Section 1

20 Service Area means the geographic area served by HPSM. The County of San Mateo is HPSM s Service Area. Special Member means you do not have a PCP assigned to you. You may see any HPSM doctor for health services. HPSM is listed as your PCP on your ID card. Specialist or Referral Provider means a doctor or other provider who only treats certain kinds of problems like broken bones or heart trouble. Your regular doctor will tell you if you need special care and will refer you to a Specialist. State means the State of California. Terminal Illness is a condition that is either incurable or irreversible and is expected to cause death within one year or less. Treatment Authorization Request (TAR) is a request from your doctor for a service/treatment that needs approval from HPSM. The TAR is reviewed by HPSM medical staff for approval. Urgent Care means services that need a quick diagnosis and/or treatment of a medical or mental condition. Urgent care is provided when a condition could become an emergency if not treated in a timely manner Medi-Cal EOC Section 1

21 Section 2 Member Rights and Responsibilities As a Member of the Health Plan of San Mateo (HPSM) You Have the Right to: y Get dignified, courteous, and considerate treatment regardless of race, religion, age, gender, national origin, disability, sexual identity or orientation, family composition or size, medical condition, or stage of illness. y Get up-to-date information about HPSM, HPSM s services and how to use them. y Get care from the Primary Care Provider (PCP) you choose from HPSM s network or change your PCP to another HPSM Network doctor. y Get appointments within a reasonable amount of time. y Access family planning services, Federally Qualified Health Centers, certified nurse practitioner services, Indian Health Service Facilities, sexually transmitted disease services and Emergency services outside HPSM s network according to federal law. You have a right to information from HPSM about how to access these services. If you are a minor, you have the right to access minor consent services. y Know and understand your medical problem. Receive information on available treatment. Obtain a second opinion from a different doctor. y Participate in decisions about your medical care. You also have the right to refuse or discontinue treatment and prepare advance directives. y Have your confidential health information protected. You also have the right to access your health information for reasons allowed by law and receive copies of, or add a statement to, your record. y Receive information and health care services in a manner that is easily understood in accordance with State and Federal laws and regulations. y Get information and services in a way that respects your language and culture. Receive information in your language or alternative formats and large size print upon request. y Not use family, friends, or children as interpreters, including as sign-language interpreters. y Use HPSM s free interpreter service, including during discussion of complex medical conditions and treatment options and after hours services, and file a Grievance if your language needs are not met. y File a Grievance about HPSM or the care you receive, either orally or in writing and to request a Medi-Cal State Hearing. y Be free from any form of restraint or seclusions used as a means of control, discipline, convenience, or retaliation. y Freely exercise these rights without adversely affecting how you are treated by HPSM, providers, or the State. As a Member of the Health Plan of San Mateo (HPSM) You Have the Responsibility to: y Carefully read all HPSM Member materials so you understand how to use your benefits and what procedures to follow when you need care. y Do your best to keep appointments; if you need to cancel or reschedule an Appointment, call your provider or clinic 24 hours in advance or as soon as possible Medi-Cal EOC Section 2

22 y Show your HPSM ID card or remember to tell your Provider (for example your doctor, hospital or pharmacy) you are an HPSM Member before receiving care. y Follow the treatment plan you and your provider have agreed upon. y Provide accurate and complete information about your health care needs when you see your provider. Let your provider know if you have a medical condition. y Ask your doctor questions if you do not understand something or aren t sure about the advice you are given. y See the Specialists to whom your Primary Care Provider (PCP) refers you. y Actively participate in health care programs that keep you well. y Work with your provider to build and maintain a good working relationship. y Use the emergency room only in cases of an emergency or as directed by your provider. y Follow-up with your Primary Care Provider (PCP) after getting care at an emergency facility. y Report lost or stolen ID cards to the Health Plan of San Mateo s Member Services Department and do not let anyone else use your card. y Contact the Health Plan of San Mateo s Member Services Department if you do not understand how to use your benefits or have any problems with the services provided. y Tell HPSM if you move or change your phone number. Call HPSM Member Services and your San Mateo County Medi-Cal Worker. If you receive SSI, call Social Security Administration. We all need to have your correct address and phone number. y Promptly follow the HPSM Grievance procedure if you believe you need to submit a Grievance. y Treat all HPSM personnel and health care providers respectfully and courteously Medi-Cal EOC Section 2

23 Section 3 Choice of Doctors and Facilities PLEASE READ THE FOLLOWING INFORMATION. THIS INFORMATION WILL EXPLAIN WHICH DOCTORS YOU CAN SEE FOR MEDICAL CARE. HPSM works to meet your health care needs through a network of qualified doctors, medical groups, clinics, hospitals, pharmacies, and other providers located in San Mateo County. Our network also includes some providers in San Francisco and Santa Clara counties. All your health care should be provided by network providers unless authorized by us or if the service does not require prior authorization. For a list of services and a description of those services that do not require prior authorization by law, please see pages [19]. The Health Plan of San Mateo Provider List, which you have received along with this booklet, lists the Primary Care Providers, clinics, hospitals, and other health care providers and facilities available to you. The List also has the doctors and other providers addresses, telephone numbers, languages spoken and the hospitals they work with. HPSM updates the list every three (3) months and shows which doctors are not accepting new patients. You can write or call the Member Services Department at or to request a Provider List or ask for specific information about a doctor, including board education, board certification, or specialty training. Why Do I need a Primary Care Provider (PCP)? Your PCP will provide most of your health care. Your PCP will give you regular check-ups and see you when you get sick. Your PCP will know your medical history and what medicines you take. A PCP may be a Pediatrician, a General Practitioner, a Family Practitioner, an Internist, or in some cases an OB/ GYN doctor. If you want to choose a specific nurse practitioner or physician assistant to be your PCP, select the primary care facility where he or she works. Your PCP will also refer you to other doctors such as Specialists you may need and will make arrangements if you need to be hospitalized. If you need to go to a hospital, you will usually be admitted to the hospital where your PCP is on staff or has made arrangements to admit you. The hospitals where HPSM doctors work or have arrangements with are listed in your Provider List. Each HPSM member in your family may choose a PCP. The name and telephone number of the PCP will be listed on each person s HPSM Member Identification (ID) Card. By the time you receive this booklet, we hope you will already have selected a PCP for yourself and any eligible family member. If you are returning as an HPSM Member and do not select a PCP, you will be automatically assigned to your previous doctor if you were assigned to that doctor in the previous four (4) months. If you have not yet selected your PCP or want to change your PCP, here are some ideas to help you choose a PCP. How to Pick Your Primary Care Provider (PCP) y You may choose the provider you already use if you see his or her name in the HPSM Provider List. y You may choose a new provider from the Provider List. The Provider List has helpful information about each provider and the offices and clinics where they work Medi-Cal EOC Section 3

24 Here are some things to think about when picking a doctor: Does the PCP take care of children? Does the PCP work at a clinic I like to use? Is the office close to my home, work or children s school? Is it easy to get to by public transportation? Do the doctors and nurses speak my language? Does the PCP work with a hospital that I like? Does the PCP provide the services I may need? What are the PCP s office hours? Some doctors and hospitals do not provide one or more of the following services that you or your family member may need: y Family Planning y Contraceptive services, including emergency contraception y Sterilization, including tubal ligation at the time of labor and delivery y Abortion You and your PCP are a team, working to keep you and your family healthy. It is best to stay with the same PCP, so she or he can get to know your health care needs. If you change your PCP often, your health care may not be as good as it could be. The PCP whom you choose will provide, authorize and coordinate your health care, except for emergency and out of area urgent care services and sensitive services if you choose to self-refer to another qualified provider in or out-of-network. Working with your PCP is the key to your health care. Your PCP will take care of most of your health care needs, including preventive care. Your PCP can refer you to Specialists when needed. Your PCP may want to see you at his/her office before authorizing your visit to a Specialist. If you do not choose a PCP for yourself and each family member within the first 30 calendar days of enrollment, we will assign each of you to a PCP based on your address, age and other available information to help us make a good choice for you. To receive more information before you select a PCP, you can call the provider s office. Member Services can also give you information to help you make a PCP choice. If you and your PCP are not able to establish a good relationship, either of you have the right to ask for a change. For example, if you miss too many appointments, do not follow your PCP s medical advice, or are disruptive or abusive, your PCP may request that you select a new PCP. If you are not satisfied with the treatment or service from your PCP, you may select a new doctor. A Member Services Representative may ask the reason for your PCP change. This information helps HPSM be sure our providers meet the needs of our Members. Changing Your PCP If you decide to change your PCP, we will do our best to meet your request. A PCP selection or choice may not be approved, in the following situations: (1) the PCP only accepts established patients (EPO) and you have not seen the PCP before; (2) the provider s practice is full; (3) you have been removed from the PCP s practice in the past; or (4) you have chosen a PCP who does not see Members in your age group. After you ask for a change, you should continue to see your current PCP until the end of the month. The PCP change will be effective the first day of the following month Medi-Cal EOC Section 3