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

28 If your request for continuity of care meets the conditions, the out-of-network provider meets the necessary requirements, including agreeing to the health plan s terms, CalViva Health will approve your continuity of care request and allow you to see the provider for the length of continuity of care as listed under section How to keep seeing a provider if your provider leaves your health plan in this handbook. You will not be eligible for the continuity of care benefit if EITHER: You are a new enrollee with CalViva Health and were offered an opportunity from your previous health plan to continue receiving care from an out-of-network provider; OR You had the option to continue care from your previous provider but still chose to change health plans. Doctors not contracted with CalViva Health may be required to agree to the same terms and conditions as contracted providers. If the doctor does not agree, CalViva Health is not required to provide the services through that doctor and you will be offered care with an in-network doctor. To request continuity of care please contact Member Services at Continuity of Care for Seniors and Persons with Disabilities Senior and Persons with Disabilities who have just joined CalViva Health may ask to keep seeing their doctor for Medically Necessary care for up to 12 months from the date you join CalViva Health. In order for CalViva Health to approve your request, you must have a qualifying condition and an ongoing relationship with the doctor. In addition, the doctor must agree to the health plan s usual payment rate or the Medi-Cal payment rate and also must have no quality of care issues. This continuity of care provision applies to physicians, surgeons and specialists only. To request continuity of care please contact Member Services at Continuity of Care for Transitioning Healthy Families members for primary care Healthy Families members who are transitioning to the CalViva Health Medi-Cal program may ask to keep seeing their Healthy Families program treating provider for up to 12 months from the time you came into the Medi-Cal program. In order for CalViva Health to approve your request to stay with your previous doctor, you must be undergoing treatment and the doctor must agree to accept the health plan's usual payment rate or the Medi-Cal payment rate. Also, the doctor must not have any quality of care issues. Once your continuity of care is approved, CalViva Health will need to Prior Authorize the services, and you will also be assigned to an in-network PCP during this 12 month period. To request continuity of care, contact Member Services at You can get a copy of CalViva Health s continuity of care policy by calling Please call CalViva Health and ask how to request continuity of care. 19

29 Care outside of your network and service area For routine (regular) care, all health care services are provided in your service area and within your network. Routine care outside of your service area is not covered. In most cases, you need to get care within your network and within your service area. As a member, you receive most of your medical care from participating providers within your assigned network. All services that are outside of your network require prior authorization from your assigned network, except for emergency care, family planning, HIV testing and counseling, pregnancy termination and STD services. You can always get emergency care anywhere in the United States. Please note: No services are covered outside the United States, except for emergency services requiring hospitalization in Canada and Mexico. If you get care from a non-contracted provider (a doctor or other provider that is not a part of CalViva Health s network) or outside of your service area, the provider may bill you and you may have to pay, except for emergency care, urgent care, family planning, HIV testing and counseling, pregnancy termination and for STD services. This is talked about in Emergency Care: How do I get care in an emergency in this handbook. WHAT IS COVERED: WHAT KIND OF HEALTH CARE CAN I GET FROM CALVIVA HEALTH? In order for you to get any health care service through CalViva Health, the service must be both: A covered benefit in Medi-Cal, and Medically necessary. A covered benefit means that you can get this service through Medi-Cal and CalViva Health. Medically necessary refers to all covered services that are reasonable and necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury. Many health care services are reviewed, modified (changed), approved or denied according to medical necessity. If you would like a copy of the policies and procedures CalViva Health uses to decide if a service is medically necessary, call CalViva Health. No doctor has to give you services that the doctor doesn t believe you need. Services are subject to all terms, conditions, limits and exclusions. These are talked about in the section Non-covered services: What does Medi-Cal not cover? in this handbook. All services may require prior authorization except for those listed below. 20

30 Prior authorization means that your PCP and CalViva Health agree that services and care are necessary. You must have an approved prior authorization from your PCP s network (the Medical Group ) or from CalViva Health before you get services or care, such as special scans, surgery, or services from a specialist. Services that do not require prior authorization are: PCP visits; Emergency services; Urgently needed services; Family planning services; Preventive service; Sexually transmitted disease services; HIV testing; Pregnancy Termination; Routine perinatal care from a doctor that works with CalViva Health; Certified Nurse Midwife; and OB-GYN, in-network visits. Call CalViva Health at if you have questions about: Your benefits, How or where to get benefits, or What is covered or not covered. Medi-Cal optional benefits that CalViva Health will continue to cover: Effective July 1, 2009, some optional Medi-Cal benefits were terminated by the Department of Health Care Services (DHCS) due to changes in state law. CalViva Health will continue to cover the following optional benefits for adult members ages 21 and over: Audiology services; Speech therapy services; Podiatry services; Incontinence creams, washes and related products; and Optometric examinations. CalViva Health is not providing coverage for the following optional benefits: Acupuncture, Eye appliances, and 21

31 Optical lenses and frames for Members over age 21 CalViva Health s coverage of the optional benefits is subject to change based on any decisions by the DHCS or other regulatory agency. All covered benefits are free. These benefits are covered: Alcohol/Drug abuse Health education and prevention counseling are covered as part of your PCP visits. CalViva Health provides health information materials. Contact for more information. For information on the benefits you can get through the county s alcohol and drug program, see section More Benefits: What Other Services Can I Get? in this handbook. Alcohol misuse screening services Alcohol misuse screening services for all members ages 18 and older. Services for alcohol misuse cover: one expanded screening for risky alcohol use per year and three 15-minute intervention sessions per year to talk about risky alcohol use (Screening, Brief Intervention, and Referral to Treatment (SBIRT)). Asthma services Nebulizers (including face mask and tubing), inhaler spacers and peak flow meters for management and treatment of asthma; and Member education on proper use of nebulizers, inhaler spacers and peak flow meters for asthma. Cancer screening All generally medically accepted cancer screening tests, including coverage for screening and diagnosis of prostate cancer; Mammography for breast cancer screening; and Cervical cancer screening test, including: Human Papilloma Virus ( HPV ) screening; Cancer clinical trials. If you have cancer, you may be able to be part of a cancer clinical trial. A cancer clinical trial is a research study with cancer patients to find out if a new cancer treatment or drug is safe and treats a member s type of cancer. The cancer clinical trial must meet certain requirements, when referred by your CalViva Health doctor or treating provider. The cancer clinical trial must have a meaningful potential to benefit you and must be approved by one of the following: the National Institute of Health (NIH), FDA, U.S. Department of Defense or the U.S. Veteran s Administration. If you are part of an approved cancer clinical trial, CalViva Health 22

32 will provide coverage for all routine patient care costs related to the cancer clinical trial. If you have a life-threatening or weakened condition or were eligible but denied coverage for a cancer clinical trial, you have the right to request an Independent Medical Review (IMR) on the denial. This is talked about in the section Complaints: What should I do if I am unhappy? in this handbook. Community Based Adult Services (CBAS) CBAS is a service you may qualify for if you have health problems that make it hard for you to take care of yourself and you need extra help. If you qualify to get CBAS, CalViva Health will send you to the center that best meets your needs. If there is no center in your county, CalViva Health will make sure you get the services you need from other providers. At the CBAS center you can get different services. They include: Skilled nursing care Social services Meals Physical therapy Speech therapy Occupational therapy CBAS centers also offer training and support to your family and/or caregiver. You may qualify for CBAS if: Your PCP refers you for CBAS and you are approved to get CBAS by CalViva Health You are referred for CBAS by a hospital, skilled nursing facility or community agency and you are approved to get CBAS by CalViva Health Dental services CalViva Health covers dental screenings performed by the PCP under the first health checkup and covers the following when medically necessary: topical fluoride varnish for children younger than six years old (topical fluoride varnish is also covered by the plan when provided by the PCP), Prescription drugs, lab or x-ray services, Outpatient surgical services, and Inpatient services. General anesthesia for dental work is covered when Medically Necessary for Members under seven years of age or for members that are developmentally disabled regardless of age, or 23

33 members whose health is compromised and for whom general anesthesia is Medically Necessary, regardless of age. Adults, children (under age 21) and regional center consumers (also known as DDS beneficiaries or consumers of DDS) age 21 and over, who have Medi-Cal and do not reside in a licensed health facility (Intermediate Care Facility or Skilled Nursing Facility) can get dental services from the Medi-Cal dental program (called Denti-Cal). For more information on the Medi-Cal dental program, please call the Denti-Cal Beneficiary Services Service Center at Diabetic services These services are covered for diabetics over the age of 21 when medically necessary: Medical equipment Prescription drugs Diabetes-related supplies: Blood glucose monitors and blood glucose testing strips; Blood glucose monitors designed to assist the visually impaired for insulin dependent, non-insulin dependent and gestational diabetes; Insulin pumps and all related necessary supplies; Ketone urine testing strips; Lancets and lancet puncture devices; Pen delivery systems for the administration of insulin; Podiatric devices of the feet to prevent or treat diabetes-related complications, such as special footwear or shoe inserts; Insulin syringes; and Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin. Patients under the age of 21 with diabetes are eligible for California Children s Services. The County CCS office will coordinate all services, testing, visits, medications and treatments related to the diagnosis of diabetes. Training and health education for self-management, and Family education for self-management. Doctor office visits All routine visits, exams, treatments, shots and Child Health Disability Prevention Program (CHDP) visits are provided by your PCP. Services received from a specialist. 24

34 Any CHDP services from school-based programs or the County Department of Health. There is more information about CHDP under the section More benefits: What other services can I get? in this handbook. You can also call CHDP at Drugs/medications Prescription drugs and over-the-counter drugs on the CalViva Health Recommended Drug List (RDL) are covered. This is talked about in the section Pharmacy benefits: How do I get prescription drugs? in this handbook. Durable Medical Equipment (DME) DME is medical equipment used repeatedly (over and over again) by a person who is ill or injured. These items are ordered by your PCP. Examples include: Apnea monitors; Wheelchairs; Wheelchair repairs Hearing aids; and Battery for hearing aids and/or pace makers. Members under the age of 21 with a CCS-eligible condition will receive DME from the California Children s Services (CCS) Program. CalViva Health will help coordinate the referral to the CCS program for you to make sure you receive the equipment that is necessary for your condition. See the section More Benefits: What other services can I get? for more information on the CCS program in this handbook. Emergency services Emergency services are covered 24 hours a day, seven days a week, anywhere in the United States. (Please note: No services are covered outside the United States, except for emergency services requiring hospitalization in Canada and Mexico). Emergency care is a service that a member reasonably believes is necessary to stop or relieve: Sudden serious illnesses or symptoms, and Injury or conditions requiring immediate diagnosis and treatment. Emergency services and care include ambulance, medical screening, exam and evaluation by a doctor or appropriate personnel. Emergency services include both physical and psychiatric emergency conditions, and active labor. These are talked about in Emergency care: How do I get care in an emergency? in this handbook. Family planning services Family planning services are provided to members of childbearing age to help them choose the number and spacing of children. These services include all methods of birth control approved by the Food and Drug Administration (FDA). You may receive family planning services and FDAapproved contraceptives from any health care provider licensed to provide these services. 25

35 Examples of family planning providers include: Your PCP; Clinics; Certified Nurse Midwives and Certified Nurse Practitioners; OB/GYN specialists (OB/GYNs are doctors who specialize in female reproductive health care); and Planned Parenthood clinics. Family planning services also include counseling and surgical procedures for the termination of pregnancy (called an abortion). Please call CalViva Health to find out more. Many of our doctors who provide family planning services are also OB/GYN specialists. Women may pick a OB/GYN as their PCP. Call CalViva Health for a copy of this list. Women have the right to family planning services given by a family planning provider who is not in CalViva Health s network. You do not need an okay from your PCP to do this. CalViva Health will pay that doctor or clinic for the family planning services you get. The California Department of Health Care Services (DHCS), Office of Family Planning, can also answer questions or give you a referral for family planning services. You may reach them at Health education services CalViva Health has health education materials, programs and services to help you stay healthy and take care of yourself. These programs are free. Health education services can help members by: Promoting health: Learn to develop life-long healthy habits. Preventing diseases: Learn how to prevent and care for life-threatening illnesses. Helping you manage chronic diseases. Learn more about these topics by talking to your PCP or through health education services: Asthma Breastfeeding Dental Health Diabetes Drug and Alcohol Programs Exercise/Fitness Family Planning/Birth Control HIV Healthy Eating/Nutrition 26

36 Heart Health Health Screenings High Blood Pressure How to Quit Smoking Immunization (Shots) Injury Prevention Medicine Safety Parenting Pregnancy Sexually Transmitted Diseases (STDs) Tuberculosis (TB) Weight Problems Violence and Abuse Health education services include: Written materials (booklets, flyers and cookbooks); Information in large fonts and audio formats (Tapes, DVDs, CDs or videos); Referrals to health education classes or programs; Online community resource and health education information; Medicines to help quit smoking; and Health promotion incentive programs. Ask your PCP for health education materials and classes. For health education services information, call CalViva Health s Health Education line at HIV testing You can get confidential HIV testing from any health care provider licensed to provide these services. You do not need a referral or an approval from your PCP or health plan for confidential HIV testing. Examples of where you can get confidential HIV testing include: Your PCP, County Department of Health, Family planning services providers, and Prenatal clinics. If you want to be tested, Please call Member Services at to request a list of testing sites. Home health These services are provided in the home by health care personnel for all of the following: 27

37 Short-term rehabilitation including physical, occupational and speech therapy; Nursing visits to monitor your illness Home IV antibiotics Wound Care Prenatal monitoring when you are placed on home bed rest by your OB/GYN doctor Home health services ordered by your PCP are provided by home health personnel such as: Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), Home Health Aides, and Medical Social Services. If a service can be provided in more than one location, CalViva Health will work with the provider to choose the location. Hospice care Care is limited to terminally ill members expected to live six (6) months or less, if the illness runs its normal course. Though hospice care is usually provided in a person s home, you can choose to be admitted to a nursing facility for hospice care. This is not considered long-term care and will not affect your eligibility. Hospice care services include, but are not limited to, the following: Nursing services, Physical, occupational, or speech-language pathology, Medical social services under the direction of a physician, Home health aide and homemaker services, Medical supplies and appliances, Drugs and biological, Physician services, Counseling services related to the adjustment of the member s approaching death; counseling, including bereavement, grief, dietary, and spiritual counseling, Continuous nursing services during periods of crisis and only as necessary to maintain the terminally ill member at home, Inpatient respite care for pain control or symptom management in a hospital, skilled nursing or hospice facility, Any other palliative item or service covered by the Medi-Cal program that is included in the hospice plan of care. 28

38 Hospital care Includes, but is not limited to: Inpatient services, Intensive care, Operating room and related facilities services, Outpatient services, Rehabilitative Services, Drugs, including discharge medication, and Discharge planning. Lab services Includes, but is not limited to: Blood tests Urine tests Throat cultures Services must be provided at a network: Doctor s office, Hospital, or Laboratory. Maternity care Maternity care includes: Regular doctor visits during your pregnancy (called prenatal visits); Comprehensive Perinatal Services Program (CPSP), including nutrition counseling, preparing for childbirth, advice about healthy lifestyles to have a healthy baby. Your OB/GYN doctor may be certified for CPSP, or if not, your OB/GYN doctor will refer you to a program near you for this education; Diagnostic and genetic testing; Nutrition counseling; Labor and delivery care in a hospital or birthing center; Health care for six weeks after delivery (called postpartum care); and Inpatient hospital care for at least 48 hours after normal vaginal deliveries, or for at least 96 hours after a cesarean section. Coverage for inpatient hospital care may be less than 48 hours, or 96 hours if: You and the doctor make the decision that you are healthy enough to go home early, and You agree to a post-discharge follow-up visit for the mother and newborn within 48 hours of discharge. 29

39 If you are pregnant, call CalViva Health Member Services at right away. We want to make sure you get the care you need. CalViva Health will help you choose your maternity care doctor from a doctor in your network. Your PCP can help you with any questions as well. We encourage breastfeeding as the healthiest food for your baby. The hospital will give you advice and counseling to make sure you have the support to breast feed if you want to. CalViva Health can provide additional support if you need. Breast pumps are a benefit of CalViva Health. Your PCP can order a breast pump for you, or you can call Member Services. Go to Women, Infants and Children (WIC) Program under More benefits: What other services can I get? for information about nutrition and food stamps. Mental health services Outpatient Mental Health care is covered by CalViva Health. (Outpatient is when you do not stay in the hospital.) This care is provided for the treatment of mild to moderate Mental Health conditions as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV)), which include: individual and group Mental Health evaluation and treatment (psychotherapy); psychological testing, when clinically indicated 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. If you are receiving mental health services through the County Mental Health Department, you should keep going there. If you are currently receiving mental health services, you may be able to keep your provider. Ask your provider if they work with CalViva Health. If the provider does, you will keep your provider. If your provider does not work with CalViva Health and you want to keep that provider, you can call Member Services for help. We will let you keep the doctor for up to 12 months, if the doctor agrees to work with us. If your doctor won t work with CalViva Health, you will need to find a new doctor. To find a CalViva Health mental health provider near you, ask your PCP for the name of one. Or, to find out more about covered mental health care, call Member Services at (TTY/TDD ). CalViva Health will coordinate and cover laboratory and x-ray services needed for the Diagnosis, treatment and monitoring of a mental health condition. CalViva Health or Fee-For- Service Medi-Cal covers mental health drugs listed on the CalViva Health Recommended Drug List (RDL) and prescribed by your PCP, or by a licensed mental health Provider Authorized to prescribe drugs. If Medically Necessary, you may also get a mental health drug not on the RDL. Go to a Network Pharmacy to fill your Prescription. This is talked about in the section Pharmacy benefits: How do I get Prescription Drugs? in this handbook. 30

40 Minor consent services There are some services adolescent members (children under the age of 18) can get without a parent s approval. Minors may choose to get some of these services through their PCP or from other qualified providers in or out of CalViva Health s network. Some of these services must be obtained in your PCP s network (also called a Medical Group ). The following services are covered: Counseling and surgical procedures to end pregnancy (abortion) from any qualified Medi-Cal provider, including providers not with CalViva Health s network; Drug and alcohol abuse services for children 12 years of age or older. This is provided by the County Mental Health Department. CalViva Health or your PCP can coordinate this for you, or you can call the County s hot line at any time. Please see the section More Benefits: What other services can I get? in this handbook for information on how to get these services; Family planning services from any qualified Medi-Cal provider including providers not with CalViva Health s network; Pregnancy related services in your PCP s network ( Medical Group ); Sexual assault services, including rape from any qualified Medi-Cal provider including providers not with CalViva Health s network; Sexually transmitted disease (STD) services for children 12 years of age or older from any qualified Medi-Cal provider, including providers not with CalViva Health s network; and Outpatient mental health treatment and counseling for minors (12 years of age or older) who are mature enough to participate in their treatment and where either (1) there is danger of serious physical or mental harm to themselves or to others, or (2) they are a victim of incest or child abuse. Newborn care Your newborn baby will be covered by CalViva Health for the month of birth and the following month. When you have a baby, it is important to do three things: 1. Please call CalViva Health at We want to make sure you and your baby get the care you need right away. 2. Contact your eligibility worker to enroll your baby in Medi-Cal. You can find the phone number for your county under Important Phone Numbers and Addresses in this handbook. This is important so that your baby can continue to receive Medi-Cal benefits! 3. Take your baby to the PCP. A CalViva Health PCP in your network should see your newborn baby within a few days after birth. Well baby checkups start within 1 week after birth, and sometimes within a few days. Call Member Services at if you have any questions. Newborn baby screenings for certain treatable genetic disorders are covered. These genetic disorders include: Phenylketonuria (PKU), 31

41 Galactosemia, Hypothyroidism, Hemoglobinopathies, Sickle cell disease, Thalassemia, Amino acid disorders, Organic acid oxidation disorders, Fatty acid oxidation disorders, Congenital adrenal hyperplasia (CAH), and Related blood disorders. Babies with these conditions will be referred to California Children s Services (CCS) for treatment. Treatment of PKU includes medically prescribed formulas and special food products. PKU cases are followed by a health care professional who consults with a provider specializing in PKU-related diseases. This is talked about in the section, More benefits: What other services can I get? in this handbook. Obstetrical/Gynecological (OB/GYN) Female members do not need a referral or approval from their PCP or CalViva Health to see an OB/GYN who works in their network. Please call CalViva Health if you have any questions. Podiatry (services for the feet) Podiatry services are limited and require prior authorization except when received on an emergency basis. Perinatal care Includes, but is not limited to: Regular doctor visits during your pregnancy (called prenatal visits). Health education assessment and information Prenatal vitamins Diagnostic and genetic testing Vaccines to prevent illness in yourself or your newborn baby Psychosocial assessment Postpartum services Sexually Transmitted Disease (STD) services STD services include: Preventive care, Screening, Testing, 32

42 Diagnosis, Counseling, Treatment, and Follow-up. You can get confidential STD services from any doctor or clinic. You do not need a referral or okay from your PCP. Skilled Nursing Facility services A facility licensed to provide medical services for non-acute conditions. Some services covered in a skilled nursing facility include room and board, physician and nursing services and medication. If you need long-term skilled nursing facility services, you will be disenrolled from CalViva Health and provided these services through Medi-Cal or another State program. Long-term care means that you are in the facility for longer than the month you were admitted plus one month. If you are disenrolled from CalViva Health, we will send you a letter that says when your coverage will end and why. You may file an appeal with the California Department of Managed Health Care (DMHC) if you think that your cancellation is because of your health status or need for services. This means you can ask DMHC to make sure we are allowed to disenroll you. You may also ask for a review from California Department of Health Care Services (DHCS). This is talked about in the section Complaints: What should I do if I am unhappy? in this handbook. You can also call CalViva Health to find out more. Surgery Surgery procedures inpatient or outpatient when medically necessary. Reconstructive surgery and prosthetic devices to restore the normal appearance after a breast mastectomy, including lumpectomy, or lymph node dissection. Any complications from a mastectomy, including treatment of lymphedema The amount of time you spend in the hospital after a mastectomy or lymph node dissection is the decision of your surgeon and Prior Authorization is not required for deciding how long you stay in the hospital. Reconstructive surgery means surgery performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumor or disease. Temporomandibular Joint (TMJ) disease TMJ disease is a disease of the temporomandibular joint (TMJ) that connects the lower jaw to the skull. Treatment of TMJ disease may include medication, splinting or surgery. This may be covered under the Denti-Cal program when provided by a dentist or may be covered by Medi- Cal if the treatment is provided by a medical doctor. Prior authorization is required. This may be covered under California Children s Services (CCS) for children under 21. See More Benefits: What other services can I get? in this handbook for more information on the CCS program. 33

43 Therapy Occupational, Physical and Speech Up to two (2) visits for Occupational Therapy, Speech Therapy, audiology, or podiatry (combined) are covered in any one calendar month. Members under age 21 have access to additional therapy visits when medically necessary, subject to prior authorization. Occupational therapy is used to improve and maintain a patient s daily living skills if there is a disability or injury. Physical therapy uses exercise to improve and maintain a patient s ability to function after an illness or injury. Physical therapy is a limited benefit under the Medi-Cal program. Physical therapy is allowed if the treatment will keep you out of the hospital, or shorten a hospital stay, and only if your provider thinks that your condition will improve significantly in a reasonable and generally predictable period of time or to establish an effective maintenance program in connection with a specific disease state. Speech therapy is used to treat speech problems. Transportation Includes emergency transportation, including ambulances, for a member who believes it is necessary to stop or relieve sudden serious illnesses or symptoms, or injury or conditions requiring immediate diagnosis and medical treatment. This also includes non-emergency transportation, such as ambulance, litter van and wheelchair van, for the transfer of a member from a hospital to another hospital or facility, or facility to home when the transportation is: Medically necessary, and Requested by the PCP, and Authorized in advance by CalViva Health. CalViva Health covers non-emergency medical transportation. We also provide assistance to Members in locating public transportation services including curb to curb transportation such as Dial A Ride, Access Services, Get a Lift, Handy Ride and other community resources. To receive transportation assistance, members must call the CalViva Health Member Services Department at least 7 business days in advance at CalViva Health Public Program Coordinators will help arrange transportation services when a member s medical and physical condition does not allow the member to travel by bus, passenger car or another form of public or private transportation system. Vision The following vision services are covered for Medi-Cal Members: Medically Necessary eye examinations for Diagnosis, treatment or prevention of eye disease or detection of ophthalmologic complications of medical disease. 34

44 Routine eye examination (refraction) every two years. Members may self-refer to obtain routine vision services from a participating optical Provider. Members may contact the CalViva Health Member Services Department at to obtain a directory of participating optometrists and ophthalmologists. Eye examination every year by an ophthalmologist or optometrist for Members with diabetes or other Chronic medical problems affecting the eye Medical eye exams by an ophthalmologist or optometrist for Acute or Urgent Care Contact lenses when Medically Necessary Optical lenses and frames (every two years) for Members under age 21, pregnant women if your provider says not having them will be harmful to your baby or pregnancy, and people living in a nursing home. Optical lenses are made by the California Prison Industry Authority (CALPIA) optical laboratories; however, CalViva Health or the delegated participating Medical Group, as applicable, will arrange for this service. Optical lenses and frames for Members over age 21 are not a covered benefit X-ray services Medically necessary services will be provided when ordered by your PCP from a network: Doctor s office Hospital Laboratory MORE BENEFITS: WHAT OTHER SERVICES CAN I GET? Medi-Cal members are entitled to other health care benefits and services that are not provided by CalViva Health. They are available through Medi-Cal or another state, regional, school or county program. Please call CalViva Health at if you have any questions. California Children s Services (CCS) CCS is for people under the age of 21 with a disability. If your child has a chronic (long-term) medical illness, or a sudden severe illness, your child may be eligible for services under CCS. CalViva Health will identify children with CCS-eligible medical conditions, arrange for a referral to the local CCS office and continue to provide Case Management until eligibility is established with the CCS program. Primary care services will continue to be provided by CalViva Health. CalViva Health does not cover services related to CCS-Eligible medical conditions. 35

45 Please call CalViva Health if your child is receiving CCS services. CalViva Health can arrange for those services to continue. Your child can continue getting routine services not related to the CCS medical condition as a member of CalViva Health. You can find contact information for CCS under the Important Phone Numbers and Addresses section in this handbook. Child Health and Disability Prevention (CHDP) Your child may receive preventive services through his or her PCP.CHDP services include the following services for children under the age of 21: regular checkups, immunizations (shots), education and counseling, and vision, dental, hearing and other tests. You can find contact information for CHDP under the Important Phone Numbers and Addresses section in this handbook. Women, Infants and Children (WIC) program The Women, Infants and Children (WIC) Supplemental Nutrition Program gives pregnant women and new mothers nutrition information and coupons to buy healthy foods. Ask your PCP, maternity nurse or midwife to find out more about WIC. WIC services are not covered by CalViva Health. However, CalViva Health will help to refer you to the WIC program and will work with your PCP to make sure your PCP also refers you to the WIC program. As part of the Referral process, your PCP will send the WIC program a current hemoglobin or hematocrit (blood test) laboratory value. As part of your initial health assessment, or, as part of the initial evaluation of a newly pregnant woman, your PCP will refer and document the Referral of a pregnant, breastfeeding, or postpartum woman, or a parent or guardian of a child under the age of five, to the WIC program, as required by law (Title 42 CFR ). You can find contact information for WIC under the Important Phone Numbers and Addresses section in this handbook. Special services for American Indians American Indians have the right to get health care services at Indian Health Centers and Native American Health Clinics. American Indians may stay with or disenroll from CalViva Health while getting health care services from an Indian Health Center or Native American Health Clinic. American Indians have a right not to enroll in a Medi-Cal managed care plan or may leave their health plans and return to Fee-For-Service Medi-Cal at any time and for any reason. Please call Indian Health Services at (916) to find out more. You may visit the Indian Health Services website at to find out more. 36

46 Early Start/Early Intervention Early Start/Early Intervention is for children ages 0 3. If your PCP tells you that your child is at risk for developmental delays, your child may be Eligible for the Early Start Program. Developmental delays include difficulty communicating, difficulty adjusting to different situations, and difficulty following directions or relating with others. For more information about Early Start/Early Intervention or a Referral to the regional center for Early Start/Early Intervention, talk to your PCP or to CalViva Health. Local Education Agency (LEA) assessment services The LEA provides certain health care assessment services through school programs. The LEA is your local public school. Children age 3 through 21 may get services without a Referral from their PCP. The PCP should coordinate needed medical services with the LEA. LEA services may include: physical and mental health evaluations education and psychosocial assessments health and nutrition education developmental assessments Physical and Occupational Therapy Speech Therapy and audiology (hearing tests) Counseling nursing services school health aide services medical transportation Members with developmental disabilities Developmental disabilities include difficulty learning or difficulty with motor skills. If your PCP tells you that you have a developmental Disability, you may be Eligible for services from the regional centers. For more information about, or for a Referral to, the Regional Centers, talk to your PCP or call CalViva Health. Specialty mental health services Specialty Mental Health Services may be needed for services beyond your PCP s training and practice. Specialty Mental Health Services are provided through your county Mental Health Department. You may receive services from the county Mental Health Department with or without a Referral from your PCP. If you are unable to obtain specialty mental health services for any reason, please contact the Health Plan for assistance in obtaining mental health benefits. Alcohol and drug treatment (outpatient) Inpatient treatment for Acute drug overdose or alcohol detoxification is covered by CalViva Health when Medically Necessary. However, most other alcohol and drug treatment services and Outpatient heroin detoxification services are not covered by CalViva Health. Members requiring 37

47 these services will be referred to their county alcohol and drug treatment program for treatment. CalViva Health will continue to work with your PCP to cover primary care and other services unrelated to the alcohol and substance abuse treatment and will coordinate services between your PCP and the treatment programs. For information on alcohol and drug treatment services covered by CalViva Health see Alcohol/Drug Abuse and Alcohol Misuse Screening Services in the What is covered: What kinds of health care can I get from CalViva Health? section in this handbook. Childhood lead poisoning screening CalViva Health covers a blood lead screening test for Members at ages 1 and 2 as part of the routine preventive care. Children that test above a certain blood lead level are referred to the Childhood Lead Poisoning Prevention Program (CLPPP), California Children s Services (CCS), and/or the Local Health Department for further evaluation and treatment. Direct observed therapy for the treatment of tuberculosis CalViva Health will refer Members identified with active tuberculosis who are at risk for noncompliance for the treatment of tuberculosis to the Local Health Department for direct observed therapy. Members at risk for non-compliance include, but are not limited to, Members with demonstrated multiple drug resistance, Members whose treatment has failed or who have relapsed after completing a prior regimen, children and adolescents, and individuals who have demonstrated non-compliance (such as those who failed to keep office appointments). CalViva Health will provide all Medically Necessary covered services to Members with tuberculosis on direct observed therapy and will ensure joint Case Management and coordination of care with the Local Health Department. Major organ transplants CalViva Health will refer Members identified as major organ transplant candidates to a Medi-Cal approved transplant center and will cover the evaluation performed by the Medi-Cal approved transplant center. If you are accepted as a transplant candidate and Medi-Cal approves your transplant, you will be disenrolled from CalViva Health and go back to Fee-For-Service Medi- Cal. CalViva Health will continue to cover all Medically Necessary services until you are disenrolled. CalViva Health does not Disenroll members over the age of 21 who need to receive a kidney or cornea transplant. CalViva Health will provide all services, including the transplant itself, for members who need these transplants. Members who are under the age of 21 for California Children s Services (CCS)-Eligible for a transplant are not disenrolled to Fee-For-Service Medi- Cal. CalViva Health will coordinate the Referral to the CCS program, and the CCS program will Authorize and pay for all needed evaluation and treatments, including the transplant and posttransplant follow up. Additional services provided as Medi-Cal benefits but not covered by CalViva Health: Long Term Care 38

48 Pediatric day health care. State laboratory services under the State Serum Alpha-fetoprotein Testing program. Targeted Case Management. NON-COVERED SERVICES: WHAT DOES MEDI- CAL NOT COVER? The following is a list of services not covered by CalViva Health or by the Fee-For-Service Medi-Cal program: Acupuncture All services excluded from Medi-Cal under state and/or federal law Routine circumcision, unless medically necessary Certain drugs as stated under the section What drugs are not covered? in this handbook Chiropractic services Cosmetic surgery (surgery performed to alter or reshape normal structures of the body in order to improve your appearance) Custodial care, which is a set of services that helps individuals with their activities of daily living, such as eating, bathing, grooming, going to appointments and dressing. Custodial care could also include help in preparing special food or drinks and taking medication with no assistance from a doctor or a nurse. Some custodial care may be covered under Fee-For- Service Medi-Cal. For more information about custodial care covered under Fee-For-Service Medi-Cal, call your eligibility worker. You can find the phone number for your county under Important Phone Numbers and Addresses in this handbook. Eye appliances Experimental and investigational services. This is talked about in IMRs for Experimental and Investigational Therapies (IMR-EIT) under Complaints: What should I do if I am unhappy? in this handbook. Infertility Immunizations (shots) for sports, work or travel Mental health care for relationship problems are not covered. This includes counseling for couples or families for conditions listed as relational problems (As defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV)). Optical lenses and frames for Members over age 21 Personal comfort items, (such as phones, television and guest tray) when in the hospital Treatment for major alcohol problems. If you need services for major alcohol problems, you may be referred to the county alcohol and drug program. 39

49 If you have questions about what is covered or not covered, please call CalViva Health at PHARMACY BENEFITS: HOW DO I GET PRESCRIPTION DRUGS? What is a pharmacy? A pharmacy is a place to get your prescriptions filled. CalViva Health works with pharmacies in many neighborhoods. You must get your prescribed medications (drugs) from a pharmacy in CalViva Health s network. A network is all of the pharmacies that work with CalViva Health. A pharmacy list is in the provider directory provided to you with this handbook. Or, you can call CalViva Health at for pharmacies in your neighborhood. How to get a prescription filled Sometimes when you are sick or have a health condition like asthma or diabetes, you may get a prescription. Your prescribing doctor will give you a prescription based on your health status. A pharmacy is the place to get the prescription filled. You must go to a pharmacy that works with your health plan. A list of pharmacies that work with your health plan is in the provider directory. You can also call CalViva Health at to find a pharmacy near you. Choose a pharmacy near you that works with CalViva Health. Bring your prescription to the pharmacy. Show the pharmacy your CalViva Health ID card. Make sure to give the pharmacy your correct address and phone number. Make sure the pharmacy knows any allergies you have to any medicine. You should not be asked to pay for covered prescription drugs. Call CalViva Health if a pharmacy asks you to pay. What is the Recommended Drug List, sometimes called a formulary? CalViva Health uses a list of approved drugs called a Recommended Drug List (RDL) A committee of CalViva Health practicing physicians and pharmacists reviews drugs to add or remove from the formulary every three months. Drugs can be added to the RDL when they are all of the following: Approved by the Food and Drug Administration (FDA), Generally accepted to be safe and effective, and Cost effective. 40

50 Your prescribing doctor usually prescribes drugs from the RDL. Your prescribing doctor will only prescribe a drug based on your health status. Just because a drug is on the RDL does not mean a doctor will prescribe it. The doctor may not think the drug is necessary for your symptoms or condition. You may call CalViva Health to ask for a copy of the RDL or if a specific drug is on the list. Drugs not on the the Recommended Drug List sometimes called a formulary Sometimes, your prescribing doctor may need to prescribe a drug not on the RDL. Your prescribing doctor must call to get an okay from CalViva Health. This is called a prior authorization. To decide if this drug will be covered, CalViva Health may ask your prescribing doctor or the pharmacist (or both) for more information. Within 24 hours or one business day after getting this information, CalViva Health will tell your prescribing doctor or the pharmacist if the drug will be covered. Your prescribing doctor or the pharmacist will then tell you. If the drug is approved, you can get the drug at a pharmacy that works with CalViva Health. If the drug is not approved, you have the right to appeal the decision. An appeal is when you want a decision to be reviewed. This is talked about in Complaints: What should I do if I am unhappy? in this handbook. What drugs are covered? Generally, you can only get up to a one month supply of a drug at any one time. Generic drugs will be given whenever they are available. Generic drugs are the same medication as the brandname drug, and they are approved by the Food and Drug Administration. They meet the same safety standards as brand-name drugs and work in just the same way as the brand-name drug. Very rarely, people have a problem with a generic drug. If this happens to you, your prescribing doctor can ask for authorization to use the brand-name drug. You can get the following drugs and other items when they are prescribed by the doctor and are medically necessary: Prescription drugs listed on the CalViva Health RDL; Prescription drugs you get from a pharmacy not in CalViva Health s network when you have an emergency; Non-prescription drugs or over-the-counter products (such as cough syrups, cough drops or aspirin) listed on the CalViva Health RDL; Diabetic supplies: insulin, insulin syringes, glucose test strips, lancets and lancet puncture devices, pen delivery systems, blood glucose monitors and ketone urine testing strips; FDA-approved birth control devices, birth control pills, diaphragms, condoms and contraceptive jellies on the CalViva Health RDL; Emergency contraception; Self-injectable epinephrine, peak flow meters to monitor asthma and inhaler spacer devices; 41

51 An additional 1 month vacation supply will be allowed for multiple medications, but limited to one instance per 12 months. What drugs are not covered? Drugs from a non-network pharmacy, except drugs needed because of an emergency or outof-area care; Non-formulary drugs, except with an approval from CalViva Health; Drugs that are experimental or investigational, except in certain cases of terminal illness. If you have been denied an experimental or investigational drug, you have the right to request an Independent Medical Review (IMR). This is talked about in Complaints: What should I do if I am unhappy? in this handbook; Cosmetic drugs, except as prescribed for medically necessary conditions; Any injectable drug that is not medically necessary and not prescribed by a doctor; Appetite suppressants, except as medically necessary for morbid obesity; Compounded medications with formulary alternatives or those with no FDA-approved indications; Over-the-counter cough and cold medications with antitussives or expectorants; Medications used to treat erectile dysfunction; and Emergency contraception You may get emergency contraceptive drugs from: Your provider; A pharmacy with a prescription from your provider; A pharmacy without a prescription if they participate in the Pharmacy Access Program in your health plan s network; or A pharmacy not in your health plan s network if they participate in the Pharmacy Access Program. If this is the case, you will be asked to pay for the service. Your health plan will reimburse you for this cost. Call your pharmacy and ask if they participate in the Pharmacy Access Program. What other drugs can I get? Some drugs are not covered by CalViva Health but are still Benefits. They are available through Fee-For-Service Medi-Cal or another state program. Please call Member Services at if you have any questions. California Children s Services (CCS) is a state program for children up to 21 years old with certain diseases or health problems. Certain drugs for CCS covered diseases or health problems are not covered by CalViva Health. Doctors that are approved by CCS need to write the Prescriptions. Pharmacies must bill CCS, and not CalViva Health, for drugs used to treat CCS covered conditions. If you are trying to fill your Prescription at the pharmacy and you are not yet in the CCS system, call Member Services at Member Services can 42

52 help refer you to the CCS program. They may also help you get an emergency supply of your drug if needed. CalViva Health s contract with the Department of Health Care Services (DHCS) excludes most antipsychotics, HIV-related medications, and alcohol, heroin detoxification and dependency treatment drugs. These medications are covered by Fee-For-Service Medi-Cal, not CalViva Health. You still get a Prescription from your provider and the Pharmacy will provide the drug. However, the Pharmacy bills the state directly for these drugs. Medicare Part D: Prescription drug coverage for beneficiaries who get both Medicare and Medi-Cal Medicare administers a federal prescription drug program called Medicare Part D. If you are a Medi-Cal beneficiary with Medicare, you will get most of your prescription drugs through the Medicare Part D benefit. There are some prescription drugs that are not covered by Medicare but that you can get through Medi-Cal. Please call CalViva Health for more information or talk to your pharmacist. To find out more about Medicare Part D and to choose a Medicare Prescription Drug Plan, call Medicare at or go to on the Internet or call CalViva Health. EMERGENCY CARE: HOW DO I GET CARE IN AN EMERGENCY? There is a difference between needing care urgently and an emergency. Urgent care is when a condition, illness or injury is not life-threatening, but needs medical care right away. Many of CalViva Health s doctors have urgent care hours in the evening and on weekends. How to get urgent care 1. Call your PCP. You may speak to an operator who answers calls for your PCP s office when closed. 2. Ask to speak to your PCP or the doctor on-call. Another doctor may answer your call if your PCP is not available. 3. Tell them about your condition and follow their instructions. You may receive same-day urgent care services; however, it should not take longer than 48 hours from the time you call to request an appointment to get urgent care services from your PCP. If you get urgent care services from another doctor when your PCP is not available, be sure to let your PCP know about this care. You may need follow-up care from your PCP. If you cannot reach your doctor or if you are outside your service area, call Member Services at to access Nurse Advice and Triage or Screening services. 43

53 What is emergency care? Emergency services are covered anywhere in the United States, 24 hours a day, seven days a week. Please note: No services are covered outside of the United States, except for emergency services requiring hospitalization in Canada or Mexico. Emergency care is a service that a member reasonably believes is necessary to stop or relieve: Serious illnesses or symptoms, or Injury or conditions requiring immediate diagnosis and treatment. Emergency services and care include ambulance, medical screening, exam and evaluation by a doctor or other medical personnel. Emergency services include both physical and psychiatric emergency conditions, and active labor. Examples of emergencies include but are not limited to: Having trouble breathing, Seizures (convulsions), Lots of bleeding, Unconsciousness/blackouts (will not wake up), In a lot of pain (including chest pain), Swallowing of poison or medicine overdose, Broken bones, Head injury, Eye injury, and Thoughts or actions about hurting yourself or someone else. If you think you have a health emergency, call 911. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine health care. What to do in an emergency Call 911 or go to the nearest emergency room if you have an emergency. Emergency care is covered at all times and in all places in the United States. Please note: No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico. Outside of your service area? If you have an emergency when you are not in your service area, you can get emergency services at the nearest emergency facility. Emergency services do not require a referral or an approval/authorization from your PCP. If you are admitted to a hospital not in CalViva Health s network or to a hospital your PCP or other provider does not work at, CalViva Health has the right to move you to a network hospital as soon as medically safe. 44

54 Your PCP must provide follow-up care when you leave the hospital. What to do after an emergency 1. Call CalViva Health at within 24 hours of receiving emergency care or as soon as you can. 2. Follow the instructions of the emergency room doctor. 3. Call your PCP to make an appointment for follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by your Health Plan. If your Emergency Care is provided by out-of-network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow. How to get emergency transportation Call 911 if you have an emergency. Ambulances for emergency medical conditions are paid for by CalViva Health. CalViva Health may refuse to pay if you use an ambulance when you do not have a real emergency condition. Not sure you have an emergency? If you are not sure, call your PCP. Do what your PCP tells you to do. You can also call the Nurse Advice and Triage or Screening services at any time your doctor is not available by calling Out of the country No services are covered outside the United States except Emergency Services requiring hospitalization in Canada or Mexico. You must call CalViva Health within 24 hours of your emergency. To call CalViva Health if you are in Canada or Mexico: 1. Dial the AT&T USADirect access number for the country you are calling from: Canada: CALLATT Mexico: After the prompts, dial toll-free to be connected to our main customer service system. ¹ ¹ Calling U.S. 800 numbers may be toll-free or AT&T USADirect charges may apply. 45

55 HELP IN ANOTHER LANGUAGUE AND FOR THE DISABLED: HOW CAN I GET HELP? Information in other languages You can get services and information in the language you understand and that is culturally appropriate for you. You have the right to receive all member materials in any of the following languages: Arabic, Armenian, Chinese (traditional characters), English, Farsi, Hmong, Khmer, Korean, Russian, Spanish, Tagalog and Vietnamese. Written member materials are also available in alternative formats, including Braille, large size print and audio format. Interpreters for members who don t speak English or are hearing or speech impaired We know doctors and other providers must understand you so that you can get the health care services you need. Laws like the Civil Rights Act of 1964 and the ADA Laws protect you if you do not speak English or have a disability and need help in communicating with your provider. Your PCP s office, clinic or hospital cannot deny services because you do not speak English or have a disability. You have the right to free interpreter services when getting health care service or other services that are paid for by your health plan, including after-hours interpreter services. An interpreter is a person who helps you understand what is being said by the person who is giving you care. An interpreter also tells the other person what you said, but in the language that person understands. This allows people who speak different languages to talk with each other and to understand. This is also more private because you are not telling your child, family member or friend to interpret for you. You may ask for a face to face interpreter for any doctor appointment. Interpreters are very helpful when your provider needs to talk about hard to understand medical information. You can get interpreter services from CalViva Health at no cost. Please call Member Services at (TTY/TDD ) to ask for a telephone face to face interpreter. Telephone interpreters are ready when you are even during the weekend and evening. We need at least 5 days before the doctor appointment to get a face to face interpreter for you. If you need interpreter services Interpreter services in your language are free, 24 hours a day, seven days a week. You should not use children or family members as interpreters. Call your provider or CalViva Health if you need interpreter services. We will work with you and your PCP to make sure that you can have services that you understand. California Relay Service. The California Relay Service (CRS) helps a person using a TTY to communicate by phone with a person who does not use a TTY. This service also works another way. CRS helps a non-tty user call a TTY user. Trained operators take phone calls and help hearing people and non-hearing people communicate. The phone numbers for CRS are: 46

56 1. AT&T: English voice, Spanish Voice, English TTY, Spanish TTY. 2. Hamilton: English voice/tty, Spanish voice/tty Members and providers can also dial 711 on their phones to directly call the California Relay Service. Protection for people with disabilities The Americans with Disabilities Act (ADA) of 1990 is a law that protects people with disabilities from being treated unfairly. A disability is a physical or mental condition that totally or seriously limits a person s ability in at least one major life activity. This law protects people who: Are any age, including seniors (65 years of age or older), who have disabilities; Have disabilities such as hearing, speech or vision loss, developmental disabilities, and other types of disabilities; or May not look like they have a disability, or had a disability in the past. The ADA law makes sure there are equal chances for people with disabilities in employment, state and local government services, including health care. The doctor s office, clinic or hospital cannot deny services simply because you are hearing impaired, or have other disabilities. Call your health plan right away if you don t get the services you need or services are hard to get. Here are some telephone numbers that can help you if you have a disability or want more information about the Americans with Disabilities Act (ADA): ADA Information Line: (Voice) or (TDD) Remember: Tell the doctor s office if you need an interpreter, require extra time during your visit, or need some help because of a disability. Complaints You can also file a complaint if: You can t get an interpreter; You couldn t get information in one of the languages listed on the previous page; or You feel that you were denied services because of a disability. This is talked about in the section Complaints: What should I do if I am unhappy? in this handbook. 47

57 COMPLAINTS: WHAT SHOULD I DO IF I AM UNHAPPY? If you are not happy, are having problems or have questions about the service or care given to you, you have the option of letting your PCP know. Your PCP may be able to help you or answer your questions. At any time, you or your Personal Representative may file a grievance with CalViva Health. A Member Representative is a person or persons appointed by the member, via written statement, to represent them in the State of California as a health care proxy, trustee named in a durable power of attorney or court appointed guardian. Also known as Personal Representative(s), a Member Representative may be a spouse, relative, legal guardian, friend, advocate or someone designated as a representative by the member under Durable Power of Attorney or as an Executor/Administrator of Estate. What is a grievance? A grievance is a complaint. This complaint is written down and tracked. You might be unhappy with the health care services you get or how long it took to get a service, and have the right to complain. Some examples of complaints are about: The service or care your PCP or other providers give you. The service or care your PCP s medical group gives you. The service or care your pharmacy gives you. The service or care your hospital gives you. The service or care CalViva Health gives you. What the federal and state agencies say about grievances If a member receives a Notice of Action from CalViva Health, the Member has three options. A Notice of Action is a formal letter telling you that a medical service has been denied, deferred or modified. Members have ninety (90) days from the date on the Notice of Action to file an appeal with their Plan. Members may request a State Hearing regarding the Notice of Action from the Department of Social Services (DSS) within ninety (90) days. Members may request an Independent Medical Review (IMR) regarding the Notice of Action from the Department of Managed Health Care (DMHC). Members may file an appeal with their Plan regarding a Notice of Action and request a State Hearing regarding that Notice of Action at the same time. However, an IMR may not be requested if a State Hearing has already been completed for that Notice of Action. 48

58 Members can also file a grievance that is not about a Notice of Action. Members must file a grievance within one hundred eighty (180) days from the date of the incident or action occurred which caused the member to be dissatisfied. How to file a grievance You have many ways to file a grievance. You can do any of the following: Write, visit, fax or call CalViva Health. CalViva Health Attention: Grievance and Appeals Department B Burbank Blvd. Woodland Hills, CA (fax) (TDD) You may get a grievance form online through CalViva Health s website at Call CalViva Health to get a grievance form in Braille, large print or other alternative format. Fill out a grievance form at your PCP s office. Your PCP will have grievance forms available in their office. You can ask for a State Hearing: You can ask for a State Hearing before, during or after filing a grievance with your health plan. You can file a grievance with your health plan and ask for a State Fair Hearing at the same time. CalViva Health can help you fill out the grievance form over the phone or in person. Or, we can send you a grievance form for you to fill out and send back to us. Within five calendar days of receiving your grievance, you will get a letter from CalViva Health saying we have your grievance and are working on it. Then, within 30 calendar days of receiving your grievance, CalViva Health will send you a letter explaining how the grievance was resolved. CalViva Health can provide notice of action letters, grievance and acknowledgement and resolution letters in another language. Filing a grievance or requesting a State Hearing does not affect your medical benefits. If you file a grievance or request a State Hearing, you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call CalViva Health. Grievances for Medi-Cal eligibility are not processed by CalViva Health. To file a grievance about Medi-Cal eligibility, call your eligibility worker. You can find the phone number for your county under Important Phone Numbers and Addresses in this handbook. 49

59 If you don t agree with the outcome of your grievance If you do not hear from CalViva Health within 30 calendar days, or you do not agree with the decision about your grievance, you may request a State Hearing and you may file a grievance with the Department of Managed Health Care (DMHC). For more information about State Hearings, go to the State Hearing section below in this handbook. For information on how to file a grievance with DMHC, go to Contacting the Department of Managed Health Care (DMHC) section in this handbook. How to file a grievance for health care services denied or delayed as not medically necessary If you believe a health care service has been wrongly denied, changed or delayed by CalViva Health because it was found not medically necessary, you may file a grievance. This is known as a disputed health care service. Within five calendar days of receiving your grievance, you will get a letter from CalViva Health saying we have received your grievance and that we are working on it. The letter will also let you know the name of the person working on your grievance. Then, within 30 calendar days, you will receive a letter explaining how the grievance was resolved. Filing a grievance or requesting a State Fair Hearing does not affect your medical benefits. If you file a grievance or a request for a State Hearing, you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call CalViva Health. If you don t agree with the outcome of your grievance for health care services denied or delayed as not medically necessary If you do not hear from CalViva Health within 30 calendar days, or you do not agree with the decision about your grievance, you may request a State Hearing and file a grievance with DMHC. For more information about State Hearings, go to the State Hearing section in this handbook. For information on how to file a grievance with DMHC, go to Contacting the Department of Managed Health Care (DMHC) section in this handbook. How to file a grievance for urgent cases Examples of urgent cases include: Severe pain; Potential loss of life, limb or major bodily function; and Immediate and serious deterioration of your health. In urgent cases, you can request an expedited review of your grievance. You will receive a call and/or a letter about your grievance within 24 hours. A decision will be made by CalViva Health within three calendar days (or 72 hours) from the day your grievance was received. You have the right to request an expedited State Hearing. You can request an expedited State Hearing and file a grievance with CalViva Health. For more information about State Hearings; go to the State Hearing section in this handbook. 50

60 You have the right to file an urgent grievance with DMHC without filing a grievance with CalViva Health. For information on how to file a grievance with DMHC, go to Contacting the Department of Managed Health Care (DMHC) section in this handbook. If you don t agree with the outcome of your grievance for urgent cases If you do not hear from CalViva Health within 3 calendar days, or you do not agree with the decision about your grievance, you may request a State Hearing and you may file a grievance with the Department of Managed Health Care (DMHC). For more information about State Hearings, go to the State Hearing section. For information on how to file a grievance with DMHC, go to the Contacting the Department of Managed Health Care (DMHC) section in this handbook. Independent Medical Review You may request an Independent Medical Review (IMR) from DMHC. You have up to six months from the date of the Plan s denial to file for an IMR. You will receive information on how to file an IMR request with your denial letter. You may reach DMHC toll-free at HMO-2219 or You may also request a State Hearing of the Plan s denial. However, an IMR may not be requested if you have already completed a State Hearing. Go to the State Hearing section in this handbook to find out how to file a complaint. There are no fees for an IMR. You have the right to provide information to support your request for an IMR. After the IMR application is submitted, a decision not to take part in the IMR Process may cause you to lose certain legal rights to pursue legal action against the plan. When to File an Independent Medical Review (IMR ) You may file an IMR request if you meet the following requirements: Your provider says you need a health care service because it is medically necessary and it is denied; or You received urgent or emergency services determined to be necessary and they were denied; or You have seen a network doctor for the diagnosis or treatment of the medical condition, even if the health care services were not recommended. The disputed health care service is denied, changed or delayed by CalViva Health based in whole or in part on a decision that the health care service is not medically necessary, and You have filed a grievance with CalViva Health and the health care service is still denied, changed, delayed or the grievance remains unresolved after 30 days. You must first go through the CalViva Health grievance process, before applying for an IMR. In special cases, the DMHC may not require you to follow the CalViva Health grievance process before filing for an IMR. In urgent or emergent cases, you are not required to participate in the CalViva Health expedited grievance process for more than three days before filing an IMR. 51

61 The dispute will be submitted to a DMHC medical specialist if it is eligible for an IMR. The specialist will make an independent decision on whether or not the care is medically necessary. You will receive a copy of the IMR decision from DMHC. If it is decided that the service is medically necessary, CalViva Health will provide the health care service. Non-urgent cases For non-urgent cases, the IMR decision must be made within 30 days. The 30-day period starts when your application and all documents are received by DMHC. Urgent cases If your grievance is urgent and requires fast review, you may bring it to DMHC s attention right away. You will not be required to participate in the health plan grievance process. For urgent cases, the IMR decision must be made within three calendar days from the time your information is received. Examples of urgent cases include: Severe pain; Potential loss of life, limb or major bodily function; and Immediate and serious deterioration of your health. IMRs for Experimental and Investigational Therapies(IMR-EIT) You can request an IMR-EIT through the DMHC when a medical service, drug or equipment is denied because it is experimental or investigational in nature. CalViva Health will notify you in writing that you may request an IMR-EIT within five days of the decision to deny coverage. You have up to six months from the date of denial to file an IMR- EIT. You may give information to the IMR-EIT panel. The IMR-EIT panel will give you a written decision within 30 days from when your request was received. If your provider thinks that the proposed therapy will be less effective if delayed, the decision will be made within seven days of the request for an expedited review. In urgent cases, the IMR-EIT panel will give you a decision within three business days from the time your information is received. You may file an IMR-EIT if you meet the following requirements: You have a very serious condition that is life-threatening or debilitating (for example, terminal cancer). Your provider must certify that: The standard treatments were not or will not be effective, or The standard treatments were not medically appropriate, or The proposed treatment will be the most effective. Your provider must certify in writing that: A drug, device, procedure or other therapy is likely to work better than the standard treatment; and 52

62 Based on two medical and scientific documents, the recommended treatment is likely to work better than the standard treatment. You have been denied a drug, equipment, procedure or other therapy recommended or requested by your provider. The treatment would normally be covered as a benefit, but CalViva Health has determined that it is experimental or investigational in nature. To find out more, get help with the IMR or IMR-EIT process, or ask for an application form, please call CalViva Health. You do not need to participate in CalViva Health s grievance process before asking for an IMR of a decision to deny coverage on the basis that the treatment is experimental or investigational in nature. Contacting the California Department of Managed Health Care (DMHC) The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at and use your health plan s grievance process before contacting the DMHC. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the DMHC for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The DMHC also has a toll-free telephone number (1-888-HMO-2219) and a TDD line ( ) for the hearing and speech impaired. The DMHC s website, has complaint forms, IMR application forms and instructions online. State Hearing A State Hearing is another way you can file a grievance. A hearing is a process where you can present your case directly to the State of California. All CalViva Health members have the right to ask for a State Hearing at any time before, during, or after CalViva Health s Grievance process, and within 90 days of the incident when a service has been denied, deferred, or modified. You can ask for a State Hearing regardless of whether or not a Grievance has been submitted. The State must reach its decision for a standard State Hearing within 90 days of the date of the request. 53

63 You may still request a State Hearing if you request an IMR. However, you will not be able to use the IMR process if you have completed a State Hearing. Go to the Independent Medical Review section in this handbook to find out more. If you ask for a State Hearing, you may choose to represent yourself or have another person represent you (such as an attorney, friend, or relative). You may get free legal help at your local legal aid office or welfare rights group. Look in your local phone book for the telephone numbers. You may ask for a State Hearing or ask for help with submitting a request by calling the Department of Social Services toll-free at (TDD) (English and Spanish), or by writing to: California Department of Social Services State Hearings Division P.O. Box , MS Sacramento, CA Fax: (916) or (916) Filing a Grievance or requesting a State Hearing does not affect your medical benefits. If you file a Grievance or a request for a State Hearing, you may be able to continue a medical service while the Grievance is being resolved. To find out more about continuing a medical service, call CalViva Health at Expedited State Hearing In cases of health services denials, you or your provider may ask for a faster decision through an Expedited State Hearing if your life, health or ability to attain, maintain or regain maximum function could be seriously risked by going through a standard State Hearing. For an Expedited State Hearing, the State must reach its decision with three (3) working days of receipt of the Expedited State Hearing request. An emancipated minor, a parent on behalf of his or her minor child, and a duly-appointed guardian or conservator of a member may also request an Expedited State Hearing. Requests for Expedited State Hearings should be directed to: Expedited Hearings Unit California Department of Social Services State Hearings Division P.O. Box , MS Sacramento, CA Fax: (916) or (916) If you ask for an Expedited State Hearing, you may choose to represent yourself or have another person represent you (such as an attorney, friend, or relative). You may get free legal help at your local legal aid office or welfare rights group. Look in your local phone book for the telephone numbers. 54

64 Filing a Grievance or requesting an Expedited State Hearing does not affect your medical Benefits. If you file a Grievance or a request for an Expedited State Hearing, you may be able to continue a medical service while the Grievance is being resolved. To find out more about continuing a medical service, call CalViva Health at Ombudsman Office You may call the Ombudsman Office of the California Department of Health Care Services (DHCS) for help with grievances. The Ombudsman Office was created to help Medi-Cal beneficiaries fully use their rights and responsibilities as a member of a managed care plan. To find out more, call toll-free Office of the patient advocate The Office of the Patient Advocate is an independent state office that informs and educates consumers about their rights and responsibilities as health plan enrollees and to teach them how to make the best use of the services offered by their health plans. You can request educational materials by calling toll-free MEDI-CAL: HOW CAN I MAKE SURE I DON T LOSE MY COVERAGE? Keeping your Medi-Cal eligibility To stay in Medi-Cal, you must be eligible for it. Eligible means that a person meets certain requirements to receive benefits from programs like Medi-Cal. If you lose Medi-Cal eligibility, you will not be able to keep your Medi-Cal benefits with CalViva Health. Be sure to fill out and return the Medi-Cal Annual Redetermination Form or any other information requested before the due date on the letter or form. If you have any questions about your Medi-Cal eligibility, call your eligibility worker. You can find the phone number for your county under Important Phone Numbers and Addresses in this handbook. If you move, you must tell us! Don t lose your Medi-Cal coverage if you move! Your eligibility worker must have your address so they can send you mail to renew and stay eligible. Call CalViva Health. We need to know your new address and phone number. Two types of Medi-Cal There are two types of Medi-Cal: Fee-For-Service and managed care. CalViva Health is a managed care health plan. 55

65 Managed care is when your health care is managed and coordinated by a health plan and a PCP. This makes it easier for you to get the care you need. It is CalViva Health s job to make sure you get the care you need. For example, if you need to see a specialist, it is your PCP s and our job to find a specialist that will see you. In Fee-For-Service Medi-Cal, you are not in a health plan and must find doctors and other providers who will accept payment from Medi-Cal. No one manages or coordinates your care for you. No one helps you find doctors and providers who will accept payment from Medi-Cal. This section explains why you are in managed care and the reasons why you can or cannot be enrolled in or disenrolled from a managed care health plan. To enroll means you become a member of a health plan. To disenroll means you leave a health plan and are no longer a member. Mandatory Medi-Cal managed care members The California Department of Health Care Services (DHCS) is in charge of Medi-Cal. DHCS says that most Medi-Cal members must enroll in a health plan and be in managed care. Members who must enroll in a health plan are called mandatory members. A mandatory member may disenroll from Medi-Cal managed care only if the member: Has a complex medical condition (such as HIV/ AIDS or cancer), and Has been in Medi-Cal managed care less than 90 days, and Is being treated by a doctor who does not work with any Medi-Cal managed care health plan. Otherwise, the member must choose a health plan like CalViva Health. For help with Fee-For- Service benefits outside of managed care, call CalViva Health. Voluntary Medi-Cal managed care members Some people with Medi-Cal can choose to enroll in a health plan. Members who choose to enroll in a health plan are called voluntary members. A voluntary member can choose to leave their health plan and return to Fee-For-Service Medi-Cal at any time. Voluntary members include: American Indians and their household, and others who are eligible to get services from an Indian Health Center or Native American Health Clinic; Children in foster care or the Adoption Assistance Program; and Disabled or elderly receiving Supplemental Security Income (SSI) Members with HIV/AIDS diagnoses. Voluntary disenrollment To disenroll means you leave a health plan and are no longer a member. To disenroll from CalViva Health, call Health Care Options at Health Care Options enrolls or disenrolls Medi-Cal beneficiaries in or out of a Medi-Cal managed care health plan. They will send you a disenrollment form. Your membership will end on the last day of the month in which Health Care Options approves your request. Disenrollment takes about 15 to 45 days. You must 56

66 continue to receive services through CalViva Health until you are disenrolled from CalViva Health. Involuntary disenrollment You will lose managed care coverage with CalViva Health, but not necessarily your Medi-Cal benefits, if any of the following happens: You move out of your service area permanently. You are in a long-term care or intermediate care facility beyond the month of admission and the following month. You require medical health care services not provided by CalViva Health (for example, some major organ transplants). You have other non-government or government sponsored health coverage. You are in prison or jail. If you are a mandatory or voluntary member you also can be disenrolled from CalViva Health, even if you don t want to leave, if: You take part in any fraud having to do with services, benefits or facilities of the plan. If you are disenrolled from CalViva Health, we will send you a letter that says when your coverage will end and why. You may file an appeal with the California Department of Managed Health Care (DMHC) if you think that your cancellation is because of your health status or need for services. This means you can ask DMHC to make sure we are allowed to disenroll you. You may also ask for a review from the California Department of Health Care Services (DHCS). This is talked about in the section Complaints: What should I do if I am unhappy? in this handbook. You can also call CalViva Health to find out more. Expedited disenrollment CalViva Health will process an Expedited Disenrollment if we are not able to provide you medical services due to your condition or situation which is indicated in CalViva Health s contract with the California Department of Health Care Services (DHCS). This may include a major organ transplant, long-term care service, Foster Care or Adoption Assistance Programs, or you move out of your current county. We will submit a disenrollment request to DHCS who will make a decision within 72 hours. When we receive the decision, we will notify you and your PCP of the effective date of disenrollment. Your health care for the condition will be covered by Fee-For-Service Medi-Cal. Transitional Medi-Cal Transitional Medi-Cal is also called Medi-Cal for working people. You may be able to get transitional Medi-Cal if you stop getting Medi-Cal because: You started earning more money; OR 57

67 Your family started receiving more child or spousal support. For example, if you are the person in your household who earns the most money, you might get transitional Medi-Cal. Even if you are a caretaker relative, you might get transitional Medi-Cal if you started earning more money or you are receiving more child or spousal support. Parents and caretaker relatives who get transitional Medi-Cal can get free Medi-Cal coverage for six to 24 months. If you have stopped getting Medi-Cal, you should ask your eligibility worker if you qualify for transitional Medi-Cal. Call your eligibility worker, or call CalViva Health tollfree at You can stay with CalViva Health if you are eligible for transitional Medi-Cal. GETTING INVOLVED: HOW DO I PARTICIPATE? CalViva Health Public Policy Committee CalViva Health maintains a Public Policy Committee, as one way for you to participate in establishing the public policy of the plan. Public policy means acts performed by the Plan or its employees and staff to assure the comfort, dignity, and convenience of members who rely on the Plan s facilities to provide health care services to them, their families, and the public. Public Policy Committee members: Talk about member issues Advise CalViva Health on how to make services better Educate and empower the community on health care issues Members who participate on the Public Policy Committee have access to plan information regarding public policy, including information about complaints received by the plan and how those complaints were handled. The recommendations and reports from the Public Policy Committee are sent to CalViva Health s governing board, the Fresno-Kings-Madera Regional Health Authority Commission (Commission) for action. It is also important to know that as a public agency, the Commission conducts its business in public. Attending the public meetings of the Commission is another way of participating in the policies that are proposed and adopted by the Commission. The Public Policy Committee meets four times a year. The Committee includes CalViva Health members, member advocates (supporters), a Commissioner and health care providers. To find out more about the Public Policy Committee please call Communicating policy changes As a CalViva Health member, you will get information on all policy changes that affect your health care. All important information will be included in your member newsletter, new member mailing or special mailings. This information is also on the CalViva Health website. 58

68 MORE IMPORTANT INFORMATION: WHAT ELSE DO I NEED TO KNOW? If you travel outside of your service area As a member of CalViva Health, your service area is the counties of Fresno, Kings, and Madera. If you travel outside of your service area, routine care is not covered. Only emergency care, urgent care, family planning, HIV testing and counseling, pregnancy termination and STD services are covered outside of your service area. Please note: No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico. You should not be billed for emergency care, urgent care, family planning, HIV testing and counseling, pregnancy termination, or for sexually transmitted diseases (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. How a provider gets paid Health care providers can be paid in several ways by the medical group or health plan they work with. Providers may receive: A fee for each service provided. Capitation (a flat rate paid each month per member). Provider incentives or bonuses. You can ask for more information about financial incentives or bonuses. Please call CalViva Health if you would like to know more about how your provider is paid or about financial incentives or bonuses. If you have other insurance Please call CalViva Health at to tell us about any other health insurance you have other than CalViva Health. We will send all bills to the correct place for payment. Workers Compensation CalViva Health does not pay for work related injuries covered by Workers Compensation. However, CalViva Health will provide the health care services you need while the injury is reviewed by the Workers Compensation insurance company and until the case is accepted by the insurance company. Third-party liability CalViva Health will not make any claim for recovery of the value of Covered Services provided to a Member when such recovery would result from an action involving the tort liability of a third party or casualty liability insurance, including Workers Compensation awards and uninsured motorist coverage. However, CalViva Health will notify the DHCS of such potential 59

69 cases, and will help the DHCS in pursuing the State s right to reimbursement of such recoveries. Members are obligated to assist CalViva Health and the DHCS in this regard. Disruption in services CalViva Health will use its best efforts to provide services in the event of a war, riot or other unusual event. If CalViva Health is not able to provide health services, we will send members to the nearest hospital for emergency services and pay for these services. Organ donation There is a need for organ donors in the United States. The California Department of Motor Vehicles (DMV) will give you a donor card if you wish to become an organ or tissue donor. The DMV will also give you a donor sticker to place on your driver s license or ID card. To find out more, call (Voice) or (TTY). What is an advance directive? An advance directive is a signed legal document that tells your health care provider what type of health care you want if you cannot decide or speak for yourself (such as if you are in a coma). It also lets you choose a person to make your health care choices. An advance directive must be signed when you are able to make your own decisions. If you want to use an Advance Directive to give your instructions, here is what to do: Get the form. If you want to have an Advance Directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. Downloadable forms can also be found on advance directive websites. You can also contact Member Services to ask for the forms. Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. Give copies to appropriate people. You should give a copy of the form to your provider and to the person you name on the form as the one to make decisions for you if you can t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an Advance Directive, take a copy with you to the Hospital. If you are admitted to the Hospital, they will ask you whether you have signed an Advance Directive form and whether you have it with you. If you have not signed an Advance Directive form, the Hospital has forms available and will ask if you want to sign one. It is your legal right to have an Advance Directive and to share this with your health care team, including doctors and hospitals. CalViva Health will tell you about any changes to state law 60

70 about advance directives as soon as possible but no later than 90 days after the date of the change. Ask your provider or call CalViva Health at to find out more about advance directives. Estate recovery The California Department of Health Care Services (DHCS) will decide whether or not the cost of services must be paid back when they receive notification regarding your death. DHCS will consider how much was paid by Medi-Cal and what is left in your estate. To learn more about the estate recovery program, call New technology CalViva Health follows changes and advances in health care. We study new treatments, medicines, procedures and devices. We call all of this new technology. We review scientific reports and information from the government and medical specialists. Then we decide whether to cover the new technology. Members and providers may ask CalViva Health to review new technology. 61

71 GLOSSARY OF TERMS This glossary will help you understand certain words used in this Member Handbook. Acute is a word used for a serious and sudden condition that lasts a short time and is not chronic. Examples include a heart attack, pneumonia or appendicitis. Advance Directive is a signed legal document that allows you to select a person to make your health care choices at a time when you cannot make them yourself and conveys your decision about your end of life care ahead of time. Americans with Disability Act (ADA) is a law that protects people with disabilities from being treated unfairly. The ADA law makes sure there are equal chances for people with disabilities in employment, and state and local government services, including health care. Authorize/Authorization is when a health plan approves treatment for covered health care services. Members may have to pay for non-approved treatment. Note: Emergency Services and out-of-area urgent care services do not require prior authorization. Benefits are the health care services, supplies, drugs and equipment that are medically necessary and covered by Medi-Cal. A Business Day is every official working day of the week. Typically, a business day is Monday through Friday, and does not include weekends and holidays. California Children Services Program (CCS) is the public health program which assures the delivery of specialized diagnostic, treatment and therapy services to financially and medically eligible children under the age of 21 who have CCS eligible conditions. California Department of Health Care Services (DHCS) is the state agency that is responsible for the Medi-Cal program. California Department of Managed Health Care (DMHC) is the state agency responsible for regulating health care service plans. Cancer Clinical Trial is a research study with cancer patients to find out if a new cancer treatment or drug is safe and treats a member s type of cancer. Case Management refers to doctors and nurses who make sure that you are getting the right health care services when you need them. This includes checkups, plans to make you better, getting you the right doctors, and coordinating care to meet your health care needs. Certified Nurse Midwife (CNM) is a registered nurse who has experience in labor and delivery, and at least one year hands-on training in midwifery. A CNM has completed an advanced course of study, and is certified by the American College of Nurse-Midwives. 62

72 Certified Nurse Practitioner is a registered nurse who has completed an advanced training program in a medical specialty. Child Health and Disability Prevention Program (CHDP) is a preventive program that delivers periodic health assessment and services. CHDP also provides care coordination to assist families with medical appointment scheduling, transportation and access to diagnostic and treatment services. Chronic is a word used for a condition that is long-term and ongoing, and is not acute. Examples include diabetes, asthma, allergies and hypertension. Clinic is a primary care facility that members can select as a Primary Care Provider (PCP). It is either a Federally Qualified Health Center (FQHC), community clinic, rural health clinic, Indian health facility or other primary care facility. Complain/Complaint is an oral or written expression of dissatisfaction, including any complaint dispute request for reconsideration or appeal. A complaint is also known as a grievance. Diagnostic/Diagnosis is when a doctor identifies a condition, illness or disease. Disability is a physical or mental condition that substantially limits a person s ability in at least one major life activity. Disenroll/Disenrollment is when a member leaves a health plan. Disputed health care service is a health care service eligible for coverage and payment under a plan that has been denied, modified or delayed based on the plan s decision that the service was not medically necessary. Durable Medical Equipment is medical equipment used in the course of treatment or home care including such items as crutches, knee braces or wheelchairs. Dual Eligible Member refers to a member that is eligible for Medi-Cal and Medicare. Eligible/Eligibility means that a person meets certain requirements to receive benefits from programs such as Medi-Cal, California Children s Services (CCS) and Child Health and Disability Prevention Program (CHDP). Enroll/Enrollment is when a member joins a health plan. Emergency Care/Emergency Services are covered anywhere in the United States 24 hours a day, seven days a week. Emergency care is a service a member reasonably believes is necessary to stop or relieve serious illness or symptoms, injury or conditions requiring immediate diagnosis and treatment, including physical and psychiatric emergency conditions and active labor. (Please 63

73 note: No services are covered outside the United States, except for Emergency Services requiring hospitalization in Canada or Mexico.) Evidence of Coverage and Disclosure Form (EOC) is the CalViva Health Member Handbook which has information about the benefits, services and terms available to members. Exclusions are any medical, surgical, hospital or other treatments or service for which the program offers no coverage. Expedited Review is a complaint that must be resolved as quickly as possible if it involves an imminent or serious threat, including but not limited to, severe pain, potential loss of life, limb or major bodily function. With an expedited review, the health plan will resolve the complaint as quickly as the medical condition requires but no later than 72 hours. Experimental or investigational in nature refers to new medical treatment that is still being tested, but has not been proven to treat a condition. Family planning services help people learn about and plan the number and spacing of children they want, through the use of birth control. Fee-For-Service Medi-Cal, is the component of the Medi-Cal Program which Medi-Cal providers are paid directly by the state for services. Federally Qualified Health Center (FQHC) is a community-based health organization that provides comprehensive primary health, oral and mental health/substance abuse services. Food and Drug Administration (FDA) is the U.S. government agency that enforces the laws on the manufacturing, testing and use of drugs and medical devices. Formulary is a list of approved drugs that is generally accepted in the medical community as safe and effective. Grievance is sometimes called a complaint. A grievance is the process used when a member is not happy with his or her health care. Grievances are about provision of care received or not received. Health care services prevent and treat disease, and keep people healthy. Examples include some of the following: Doctor services (includes one-on-one visits with a doctor and referrals); Emergency services (includes ambulance and out-of area coverage); Home health services; Hospital inpatient and outpatient services; Laboratory services; Pharmacy services; Preventive health services; and 64

74 Radiology services. Health Plan means an individual or group plan that arranges for the provision of, or pays the cost of, medical care. Hospice is the care and services provided to people who have received a diagnosis for a terminal illness. These services are given in a home or facility to relieve pain and provide support. Hospital provides inpatient and outpatient care from doctors or nurses. Human Immunodeficiency Virus (HIV) is the virus that affects the immune system and causes the disease known as AIDS (acquired immunodeficiency syndrome). Independent Medical Review for Experimental and Investigational Therapies (IMR-EIT) is a process where expert independent medical professionals are selected to review a denial by the health plan for a medical service, drug or equipment because it is experimental or investigational in nature. Independent Physician Association (IPA) is a company that organizes a group of doctors, specialists and other providers of health services to see members. Inpatient is when a person receives medical treatment in a hospital or other health care facility with an overnight stay. Involuntary/Involuntarily is when something is done without choice. Liable/Liability is the responsibility of a party or person according to law. Life-threatening is a disease, illness or condition that may put a person s life in danger if it is not treated. Local Education Agency is the school district or county office of education that will receive and disburse grant funds. Long Term Care means that you are in the facility for longer than the month you were admitted plus one month. Managed care is a health care system in which the health care provider, in return for a fixed fee per year from a health plan, manages the care of the individual, including decisions about whether a specialist is required. Medi-Cal is a California State health coverage program for low-income families. This program is funded by state and federal dollars. 65

75 Medi-Cal card, also known as the Beneficiary Identification Card (BIC), is the plastic card issued by the State of California to Medi-Cal recipients. The BIC is used by providers to verify Medi-Cal eligibility. Medical group is a group of PCPs, specialists and other health care providers that work together. Medically necessary/medical necessity refers to all covered services that are reasonable and necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury. Member is a person who has joined a health plan. Member Handbook is also called a Combined Evidence of Coverage/Disclosure Form is what you are reading right now. It has information about the benefits, services and terms offered by the health plan. Member Representative is a person or persons appointed by the member, via written statement, to represent them in the state of California as a healthcare proxy, trustee named in a durable power of attorney or court appointed guardian. Also known as Personal Representative(s), a Member Representative may be a spouse, relative, legal guardian, friend, advocate or someone designated as a representative by the member under Durable Power of Attorney or as an Executor/Administrator of Estate. Member Services Department is the health plan s department that helps members with questions and concerns. Mental or behavioral health services are given for the diagnosis or treatment of a mental or emotional illness. Network is a team of health care providers contracted with a health plan to provide services. The health care providers may be contracted directly with the health plan or through a medical group. Non-contracted provider is a doctor or provider that is not under contract with the health plan to provide services to members. Non-formulary drug is a drug that is not listed on the health plan s formulary and requires an authorization from the health plan in order to be covered. Notice of Privacy Practices (NOPP) informs the member how medical information may be used and distributed by the health plans. Occupational therapy is used to improve and maintain a patient s daily living skills because of a disability or injury. 66

76 Ongoing relationship with a doctor is determined by identifying whether the Member has seen the requested out of network provider at least once within the last 12 months. Orthotic is used to support, align, correct or improve the function of movable body parts. Outpatient is when a person receives medical treatment in a hospital or other health care facility without an overnight stay. Out-of-Area Care refers to medical services provided outside of the Member s service area that require Prior Authorization/approval unless they are Emergency services. Out-of-Network Providers are doctors and providers not under contract, either directly or indirectly, with the health plan. Pharmacy is a place to get prescribed drugs. Phenylketonuria (PKU) is a rare disease. PKU can cause mental retardation and other neurological problems if treatment is not started within the first few weeks of life. Physical therapy uses exercise to improve and maintain a patient s ability to function after an illness or injury. Physician is a licensed medical doctor. Prescription is a written order given by a licensed provider for drugs and equipment. Preventive care/ Preventive services consists of health checkups or services given at certain times due to a person s age, sex and medical history, in order to keep that person well. Primary care is a basic level of health care usually rendered in ambulatory settings by general practitioners, family practitioners, internist, obstetricians, pediatricians and midlevel practitioners. This type of care emphasizes caring for the member s general health needs as opposed to specialists focusing on specific needs. Primary Care Provider (PCP) is a doctor or clinic that takes care of a member s health care needs and works with the member to keep them healthy. The PCP will also make specialty referrals when medically necessary. Prior authorization/approval is a formal process requiring a health care provider to obtain advanced approval to provide specific services or procedures. Prior authorization is required for most services or care; however, for emergency services, prior authorization is not required or needed. Prosthetic/Prosthesis is used to replace a missing part of the body. 67

77 Providers are contracted with a health plan to provide covered health care services. Examples include: Doctors, Clinics, Hospitals, Skilled nursing facilities, Home health agencies, Pharmacies Laboratories, X-ray facilities, and Durable medical equipment suppliers. Provider directory is a list of providers contracted with a health plan. Provider network is a group of doctors, specialists, pharmacies, hospitals and other health care providers that is contracted by and works with the health plan. Qualifying Condition refers to conditions such as an acute condition, a serious chronic condition, a pregnancy, a terminal illness, care of a newborn child, and the performance of certain previously planned surgeries. Quality of Care Issue refers to when a health plan can document concerns with the provider s quality of care to the extent that the provider would not be eligible to provide services to any other health plan members. Referrals are when a doctor sends a member to another doctor, such as a specialist or providers of services including lab, X-ray, physical therapy and others. Rural Health Clinic are clinics that provide access to primary care services in rural areas. Service Area means a county or counties that CalViva Health serves. CalViva Health serves Medi-Cal beneficiaries who live in Fresno, Kings and Madera Counties. Skilled nursing facility (SNF) is a facility licensed to provide medical services for non-acute conditions that require skilled nursing services. Specialist is a physician or other health professional who has advanced education and training in a clinical area of practice and is accredited, certified or recognized by a board of physicians or like peer group, or an organization offering qualifying examinations (board certified) as having special expertise in that clinical area of practice. Specialty Mental Health Services are rehabilitative services that include mental health services, medication support services, day treatment intensive, day rehabilitation, crisis intervention, crisis 68

78 stabilization, adult residential treatment services, crisis residential services, and psychiatric health facility services such as: Psychiatric inpatient hospital services; Targeted Case Management; Psychiatric services; Psychologist services; and Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) supplemental specialty mental health services. Speech therapy is used to treat speech problems. Standing referral is a referral by a doctor for more than one visit by a specialist. Triage or Screening is the evaluation of a member s health concerns and symptoms by talking to a doctor, nurse, or other qualified health care professional to determine the member s urgent need for care. TTY/TDD is a telecommunications device for the deaf and speech impaired. Urgent care is any service required to prevent serious decline of health following the onset of an unforeseen condition or injury. Women, Infants and Children Program (WIC) is a State nutrition program that helps pregnant women, new mothers and young children eat well and stay healthy. 69

79 IMPORTANT PHONE NUMBERS AND ADDRESSES CALVIVA HEALTH CalViva Health Main Office (8am to 5pm Monday through Friday) 1315 Van Ness Ave, Suite 103 Fresno, CA CalViva Health Community Office Kings County (9am to 4pm Monday through Thursday, Friday by appointment) 315 West Lacey Hanford, CA CalViva Health Community Office Madera County (9am to 4pm Monday through Thursday, Friday by appointment) 525 East Yosemite Madera, CA CalViva Health Member Services: CalViva Health s 24-hour Nurse Advice Line: If you cannot reach your doctor during weekend or after office hours, please call our Member Services Department at and we will connect you with a nurse who will help you. CalViva Health Fraud and Abuse Hotline: DISABILITY SERVICES California Relay Service (CRS): TTY/TDD: 711 AT&T (Voice) Hamilton (Voice) Americans Disabilities Act (ADA) Information (Voice) (TDD) CHILDREN S SERVICES California Children s Services (CCS): (559) (Fresno County) (559) (Kings County) (559) (Madera County) Website: ( 70

80 Child Health and Disability Prevention (CHDP): (559) (Fresno County) (559) (Kings County) (559) (Madera County) Website: ( CALIFORNIA STATE SERVICES California State Department of Health Care Services (DHCS): (916) DHCS Ombudsman Office: Department of Social Services: Department of Managed Health Care (DMHC): (1-888-HMO-2219) Health Care Options: Armenian Cambodian/Khmer Cantonese English Farsi Hmong Lao Russian Spanish Tagalog Vietnamese Social Security Administration Supplemental Social Income (SSI): Women, Infants and Children (WIC): Website: ( COUNTY OFFICES Fresno County Department of Public Health: (559) Fresno County Department of Behavioral Health: (559)

81 Kings County Department of Public Health: (559) Kings County Department of Behavioral Health: (559) ex: 2376 Madera County Department of Public Health: (559) Madera County Department of Behavioral Health: (559)

82 HOW TO STAY HEALTHY Going to your PCP for regular checkups helps you stay healthy. The information on the following pages tells you when to go and what needs to be done during these checkups. Your PCP is always a good resource for counseling and education about health topics that are important to you and your family. WELL-CARE GUIDELINES If you are a new member, get your well care checkup within 120 days of joining CalViva Health. Babies 18 months or younger who are due for a checkup should get it within 60 days of joining CalViva Health. Remember to go for a checkup every year. Regular checkups help you stay healthy! 73

83 Shots/Immunization Schedule for Persons Aged 0 6 Years 1, 2 Vaccine Birth 1 month 2 months 4 months 6 months 12 months 15 months 18 months months 2-3 years 4-6 years Hepatitis B (HepB) X X X Rotavirus (RV) X X X Diphtheria, Tetanus, Pertussis (DTaP) X X X X X Haemophilus influenza Type B (Hib) X X X X Pneumococcal (PCV) X X X X Inactivated Poliovirus (IPV) X (PPSV, for high risk groups) X X X X Influenza X (Yearly) Measles, Mumps, Rubella (MMR) X X Varicella X X Hepatitis A (HepA) X (Dose 1 start at 12 months) X (As your doctor suggests) Meningococcal X (Start at 9 months for high risk groups) 74

84 Shots/Immunization Schedule for Persons Aged 7 18 Years 1, 2 Vaccine 7-10 years years years Tetanus, Diphtheria, Pertussis (TdaP) X (Catch-up immunizations) X X (Catch-up immunizations) Human Papillomavirus (HPV) Meningococcal Starting at age 9, as your doctor suggests X (For high risk groups) X (3 doses, as your doctor suggests) X X (Catch-up immunizations) X (Catch-up immunizations) Booster at age 16 Influenza X (Yearly) Pneumococcal X (For high risk groups) Hepatitis A (HepA) X (For high risk groups) Hepatitis B (HepB) X (Catch-up immunizations) Inactivated Poliovirus (IPV) X (Catch-up immunizations) Measles, Mumps, Rubella (MMR) X (Catch-up immunizations) Varicella X (Catch-up immunizations) 75

85 Shots/Immunization Schedule for Adults 1,2 Vaccine Age Age Age Age Age 65 and over Tetanus, Diphtheria, Pertussis (Td/Tdap) Human Papillomavirus (HPV) Varicella Substitute 1-time dose of Tdap for TD booster, then boost with Td every 10 years 3 doses or as your doctor suggests 2 doses if no history of prior vaccination or infection Td/Tdap if at risk Zoster Measles Mumps, Rubella (MMR) 1 or 2 doses if no history of prior vaccination or infection 1 dose As your doctor suggests Influenza Pneumococcal Hepatitis A (HepA) Every year As your doctor suggests As your doctor suggests 1 dose or as your doctor suggests Hepatitis B (HepB) As your doctor suggests Meningococcal As your doctor suggests 76

86 Screenings for Persons Aged 0 18 Years 1, 2, 3 Service Birth 6 months 9 months 12 months 15 months 18 months months 3 10 years years years Routine health exam 1,2,3 At birth, 3-5 days, and at 1, 2, 4, and 6 months Every 3 months Every 6 months Every year Lead testing At 12 months and 24 months or as your doctor suggests Dental visit Blood test Urine test Body Mass Index (BMI) Once between 0-2 months Every 6-12 months or as your dentist suggests Check during routine health exam if high risk or as your doctor suggests Every year for sexually active patients Starting at age 2, check BMI during routine health exam 77

87 Screenings for Adults 1,2,4 Service Age Age Age 65 and over Routine health exam 1,2,4 Every year Hearing screening n/a Every 10 years for age 40-49, after age 49 discuss with your doctor Vision screening Every 5-10 years Every 2 years for age 40-54; every 1-3 years for age Every 1-2 years Aspirin therapy n/a Discuss with your doctor in routine health exam Blood pressure Every 2 years Every 2 years or more often if high risk Body Mass Index (BMI) Cholesterol screening Colorectal cancer screening As your doctor suggests n/a Every year or during routine health exam If at increased risk, check every 5 years starting at age 35 for men and age 45 for women Every 2 years for age if high risk. Beginning at age 50, talk to your doctor about having one or more of these tests: 1. Fecal Occult Blood Test (FOBT) every year 2. FOBT every year with Sigmoidoscopy every 5 years or 3. Colonoscopy every 10 years Glucose screening Check if high risk Every 3 years starting at age 45 Human Immunodeficiency Virus (HIV) Every year if at increased risk As your doctor suggests 78

88 Health Screenings for Men 1,2,4 Service Age Age Age 65 and over Prostate-Specific Antigen (PSA/DRE) n/a As your doctor suggests Abdominal ultrasound n/a Once, for those age who have ever smoked Testicles self exam As your doctor suggests 79

89 Health Screenings for Women 1,2,4 Service Age Age Age 65 and over Pelvic exam with cervical smear Starting at age 21,screen every 2-3 years; starting at age 40, screen every 1-3 years Every 1-3 years, or as your doctor suggests Mammogram (an x ray of breast) n/a Every year or as your doctor suggests Breast exam by doctor Every 1-3 years Every year Self breast exam Monthly Chlamydia screening (a test for a sexually transmitted disease) Bone density test (to check for bone loss) Every year through age 24 for sexually active non-pregnant women, every year beginning at age 24 if high risk n/a Screening based on risk Every 2 years Hematocrit or hemoglobin test (to check for blood count) Every 5 years or as your doctor suggests n/a n/a 80

90 1 These guidelines may change. Please speak with your provider. 2 Doctor should follow proper series and current guidelines by the Centers for Disease Control and Prevention (CDC). 3 Routine health exams, counseling and education for children and adolescents should include: measuring the patient s height, weight, blood pressure, Body Mass Index (BMI), vision and hearing tests. Counseling and education could include but are not limited to: contraception/family planning substance abuse (e.g., alcohol and drug abuse prevention) dental health mental health (e.g. depression/eating disorders) sexually transmitted infections (STIs) screening Tuberculosis (TB) screening developmental/behavioral assessment tobacco use injury/violence prevention weight management nutrition/exercise 4 Routine health exams, counseling and education for adults should include: measuring the patient s height, weight, blood pressure, Body Mass Index (BMI), vision and hearing tests. Recommendations vary based on history and risk factors. Counseling and education could include: cancer screenings injury/violence prevention sexual practices contraception/pre-pregnancy maternity planning substance abuse (e.g., alcohol and drug abuse prevention) dental health menopause tobacco use drug abuse prevention/cessation mental health (e.g., depression/eating disorders) weight management family planning nutrition/exercise Tuberculosis (TB) screening 81

91 Other topics to talk to your PCP about: Asthma Dental Health Breastfeeding Diabetes Drug and Alcohol Problems Exercise/fitness Healthy eating (Nutrition) Heart Health Family Planning/Birth Control How to Quit Smoking Injury Prevention Medicine Safety Nutrition Parenting Pregnancy Staying Healthy Assessment STDs and HIV Tuberculosis (TB) Weight Problems Violence/Abuse 82

92 NOTICE OF PRIVACY PRACTICES Effective: 09/01/2013 THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. CalViva Health provides health care coverage to you and/or your family. We are required by state and federal law to protect your health information. We must give you this Notice that tells how we may use and share your information and what your rights are. Your information is personal and private. We receive information about you after you become eligible and enroll in our health plan. We also receive medical information from your doctors, clinics, labs and hospitals in order to pay for your health care. We are prohibited from using or disclosing genetic information for underwriting purposes. CHANGES TO NOTICE OF PRIVACY PRACTICES CalViva Health must obey this Notice. We have the right to change these privacy practices. If we do make changes, we will revise this Notice and send it to you. HOW WE MAY USE AND SHARE INFORMATION ABOUT YOU Your information may be used or shared by CalViva Health only for a reason directly connected to your health care. The information we use and share includes: Your name, Address, Personal information about your circumstances, Medical care given to you, and Your medical history. Some Examples For treatment: You may need medical treatment that requires us to approve covered care in advance. We will share information with doctors, hospitals and others in order to get you the care you need. For payment: CalViva Health reviews, approves and pays for health care claims sent to us for your medical care. When we do this, we share information with the doctors, clinics and others 83

93 who bill us for your care. And we may forward bills to other health plans or organizations for payment. For health care operations: We may use information in your health record to judge the quality of the health care you receive. We may also use this information in audits, fraud and abuse programs, planning and general administration. We also provide the names of members to county immunization reporting registries who report to CalViva Health whether members have received immunizations to assess their immunization status and to report related information to the California Department of Health Care Services. Members may instruct their health care provider that they do not consent to the provider s sharing of their immunization information with a county immunization registry. Actions we take when we act as a health care plan include checking your eligibility, enrollment and amount of medical aid, approving, giving and paying for covered health care services, and investigating or prosecuting cases (such as fraud). OTHER USES FOR YOUR HEALTH INFORMATION We may also send you information about free medical exams and food programs. We will also send your information when we are required or permitted to do so by law. Sometimes a court will order us to give out your health information. We will also give out information when legally required to do so for the operations of the health care program. This may involve fraud or actions to recover money from others, when another responsible party has paid your medical claims. You or your doctor, hospital and other health care providers may appeal decisions made about claims for your medical care. Your health information may be used to make these appeal decisions. WHEN WRITTEN CONSENT IS NEEDED If we want to use your information for the reasons listed below, we must get your written consent: For marketing purposes For disclosures that constitute the sale of your information For the use and disclosure of psychotherapy notes If we want to use your information for a purpose not listed above, we must get your written consent. If you give us your consent, you may take it back in writing at any time. WHAT ARE YOUR PRIVACY RIGHTS? You have the right to ask us not to use or share your personal health care information in the ways described above. We may not be able to agree to your request. 84

94 You have the right to receive notice whenever a breach of your information occurs. You have the right to ask us to contact you only in writing or at a different address, post office box or phone number. We will accept reasonable requests when necessary to protect your safety. You and your personal representative have the right to get a copy of your information. You will be sent a form to fill out and may be charged a fee for the costs of copying and mailing records. (We may keep you from seeing certain parts of your records for reasons allowed by law.) You have the right to ask that information in your records be changed if it is not correct or complete. We may refuse your request if the information is not created or kept by CalViva Health, or we believe it is correct and complete. If we don t make the changes you ask, you may ask that we review our decision. You may also send a statement saying why you disagree with our records and your statement will be kept with your records. When we share your health information for reasons other than treatment, payment or CalViva Health operations, you have the right to request a list of whom we shared the information with, when we shared it, for what reasons, and what information was shared. ****** IMPORTANT ****** CALVIVA HEALTH DOES NOT HAVE COMPLETE COPIES OF YOUR MEDICAL RECORDS. IF YOU WANT TO LOOK AT, GET A COPY OF, OR CHANGE YOUR MEDICAL RECORDS, PLEASE CONTACT YOUR DOCTOR OR CLINIC. HOW DO YOU CONTACT US TO USE YOUR RIGHTS? If you want to use the privacy rights explained in this Notice, please call or write us at: CalViva Health Privacy Office Attention: Chief Compliance Officer 1315 Van Ness Ave., Suite 103 Fresno, CA Phone: Fax: (559)

95 COMPLAINTS If you believe that we have not protected your privacy and wish to complain, you may file a complaint by calling or writing: Privacy Officer c/o Office of Legal Services California Department of Health Care Services 1501 Capitol Avenue P.O. Box Sacramento, CA (916) or TTY/TDD [email protected] OR Secretary of the U.S. Department of Health and Human Services Office for Civil Rights Attention: Regional Manager 50 United Nations Plaza, Room 322 San Francisco, CA For more information, call OR U.S. Office for Civil Rights at OCR-PRIV ) or TTY USE YOUR RIGHTS WITHOUT FEAR CalViva Health cannot take away your health care benefits or do anything to hurt you in any way if you choose to file a complaint or use the privacy rights in this Notice. QUESTIONS If you have questions about this Notice and want further information, please contact us at the address and phone number provided above. 86

96 NURSE ADVICE If you cannot reach your doctor during weekends or after office hours, please call our Member Services Department at and we will connect you with a nurse who will help you. For more information contact: CalViva Health 1315 Van Ness Ave., Suite 103 Fresno, CA Member Services: Telecommunications Device for the Hearing Impaired: To report suspected fraud or abuse: To call CalViva Health if you are in Canada or Mexico: Dial the AT&T USADirect access number for the country you are calling from: Canada: CALLATT Mexico: After the prompts, dial toll-free [ ] to be connected to our main customer service system.¹ ¹Calling U.S. 800 numbers may be toll-free or AT&T USADirect charges may apply CA (10/14) 87

97 Medi-Cal Member Handbook (Combined Evidence of Coverage and Disclosure Form) Benefit Year Important Information Please keep this with your CalViva Health Member Handbook Description: Behavioral Health Treatment for Autism Spectrum Disorder CalViva Health now covers behavioral health treatment (BHT) for autism spectrum disorder (ASD). This treatment includes applied behavior analysis and other evidencebased services. This means the services have been reviewed and have been shown to work. The services should develop or restore, as much as possible, the daily functioning of a Member with ASD. BHT services must be: Medically necessary; and Prescribed by a licensed doctor or a licensed psychologist; and Approved by the Plan; and Given in a way that follows the Member s Plan-approved treatment plan. You may qualify for BHT services if: You are under 21 years of age; and Have a diagnosis of ASD; and Have behaviors that interfere with home or community life. Some examples include anger, violence, self-injury, running away, or difficulty with living skills, play and/or communication skills. (continued) CA (10/14)

98 You do not qualify for BHT services if you: Are not medically stable; or Need 24-hour medical or nursing services; or Have an intellectual disability (ICF/ID) and need procedures done in a hospital or an intermediate care facility. If you are currently receiving BHT services through a Regional Center, the Regional Center will continue to provide these services until a plan for transition is developed. Further information will be available at that time. You can call CalViva Health if you have any questions or ask your Primary Care Provider for screening, diagnosis and treatment of ASD. Cost to member: There is no cost to the Member for these services.