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

Transcription

1 Medi-Cal Member Handbook A helpful guide to getting services (Combined Evidence of Coverage and Disclosure Form) Benefit Year 2014

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3 AS A HEALTH NET 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 doctor) from the doctors and Clinics listed in your Health Plan s Provider Directory. You also have the right to get appointments within a reasonable amount of time. You have the right to talk with your doctor about any care your doctor provides or recommends, discuss all treatment options, and participate in making decisions about your care. You have the right to talk candidly to your doctor about appropriate or Medically Necessary treatment options for your condition, regardless of the cost or what your benefits are. You have the right to information about treatment regardless of the cost or what your benefits are. You have the right to say no to treatment. You have a right to decide in advance how you want to be cared for in case you have a Life-Threatening illness or injury. Voice your concerns. You have the right to complain about Health Net, the Health Plans and providers we work with, or the care you get without fear of losing your benefits. Health Net 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. 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. AS A HEALTH NET MEMBER, YOU HAVE A RESPONSIBILITY TO Act courteously and respectfully. You are responsible for treating your doctor and all Providers and staff with courtesy and respect. You are responsible for being on time for your visits or calling your doctor s office at least 24 hours before the visit to cancel or reschedule. Give up-to-date, accurate and complete information. You are responsible for giving correct information and as much information as you can to all of your Providers, and to Health Net. You are responsible for getting regular

4 checkups and telling your doctor about health problems before they become serious. Follow your doctor s advice and take part in your care. You are responsible for talking over your health care needs with your doctor, developing and agreeing on goals, doing your best to understand your health problems, and following the treatment plans and instructions you both agree on. Use the Emergency Room only in an emergency. You are responsible for using the emergency room appropriately in cases of an emergency or as directed by your doctor. Emergency Care is a service that you reasonably believe is necessary to stop or relieve sudden serious illnesses or symptoms, and injury or conditions requiring immediate Diagnosis and treatment. Report wrong doing. You are responsible for reporting health care fraud or wrong doing to Health Net. You can do this without giving your name by calling the Health Net Fraud and Abuse Hotline toll-free at

5 TABLE OF CONTENTS Welcome to Health Net Community Solutions!... 1 When your care starts... 1 Using the Health Plan... 2 How we make coverage decisions... 2 How to change Health Plans... 2 This Member Handbook: Why Is It Important to You?... 3 Need this handbook in another language?... 3 Whom do I call and when?... 3 Helpful information at on the Internet... 4 Let s Get Started: How Do I Get Health Care?... 4 Your PCP doctor... 5 Start getting your care now! Call your PCP doctor for a check-up How to see your PCP or your main doctor... 6 How to get care when your PCP doctor s office is closed... 7 Triage and/or Screening nurse advice... 7 If you get a bill... 7 What is a second opinion?... 8 How to get a second opinion... 8 Are you pregnant? Call Health Net at How to get health care that your PCP doctor can t give you... 8 How to get a Standing Referral with a Specialist... 9 How to get a Standing Referral... 9 What happens if you don t get a Referral... 9 California Children s Services Program Referrals (CCS) 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 Health Net 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 doctor gives you most of your care How to change your PCP doctor Kinds of PCP Doctors Picking a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) as your PCP doctor 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 doctor? Access to services to which Provider has a moral objection How to keep seeing your doctor if your doctor leaves your Health Plan How to keep seeing your doctor 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... 15

6 Care outside of your Network and Service Area What Is Covered: What Kind of Health Care Can I Get from Health Net? Alcohol/Drug Abuse Asthma Services Cancer Screening 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) Prenatal Care Surgery Sexually Transmitted Disease (STD) Services Skilled Nursing Facility Services 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 Dental Services Early Start/Early Intervention Local Education Agency (LEA) assessment services Members with developmental disabilities Community-Based Adult Services (CBAS) Specialty Mental Health Services Screening, Brief Intervention, Referral and Treatment Benefit (SBIRT) Alcohol and drug treatment (Outpatient) Childhood lead poisoning screening... 30

7 Direct observed therapy for the treatment of tuberculosis Major organ transplants Additional services provided as Medi-Cal benefits but not covered by Health Net: 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 at a Pharmacy How do I get my medication in an emergency if all the pharmacies in my area are closed? What is the Recommended Drug List, also called Formulary,? Drugs not on the Recommended Drug List (RDL) 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 If you are in Los Angeles County and you are assigned to a PCP through Molina Healthcare 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 Language 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)... 43

8 State Hearing Expedited State Hearing 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? Health Net regional Community Advisory Committees 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? New technology Glossary of Terms Important Phone Numbers How to Stay Healthy Well-Care Guidelines Other topics to talk to your doctor about Notice of Privacy Practices For more information, contact:... 73

9 WELCOME TO HEALTH NET COMMUNITY SOLUTIONS! 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 doctor is or help you find a new doctor. They can also answer your questions about Health Net Community Solutions. 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 section of this booklet under County Offices. Thank you for joining Health Net Community Solutions, Inc. (Health Net). Health Net 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. Health Net 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 Health Net. It explains how to get help through Health Net 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 Primary Care doctor Help changing your Primary Care doctor Help to arrange transportation Help to arrange care with other programs such as California Children s Services (CCS), Regional Center, 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 (TTY/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. Your care through Health Net starts when your Enrollment in a Health Plan is complete. You can start using your Medi-Cal benefits through Health 1

10 Net on your effective date of coverage. Your effective date of coverage is the 1st day of the month following completion of Enrollment in a Health Plan. Check the Health Net member ID card mailed to you for the effective date of coverage. Health Net is licensed with the State of California. The State of California has given Health Net 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. Health Net 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 Health Net, but provided by other county agencies, for example California Children s Services and Specialty Mental Health Services. USING THE HEALTH PLAN Health services are only paid for if They are Medically Necessary. You receive them from a Health Net contracted Provider. Your Primary Care doctor arranged the services. They are covered under the Medi-Cal program. The following services will be covered even if your Primary Care doctor 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 (only if there is an in Network nurse midwife in your area who is credentialed by Health Net and is affiliated with a credentialed OB/GYN to provide obstetrical care if necessary). Sexually transmitted disease treatment. Immunizations (only if you get it in Health Net s Network or through your local health department). HIV testing and counseling services. HOW WE MAKE COVERAGE DECISIONS Health Net 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. Health Net does not encourage or offer financial incentives to its contracting Physicians to deny any type of care or deny treatment to patients. Any doctor who fails to provide appropriate services to Health Net s patients may be investigated and may have his or her contract terminated. If you wish to speak to Health Net about a 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 Health Net to Enroll with another Health Maintenance Organization (HMO) at any time and for any reason. To change your HMO, call Health Care Options (HCO). You can find HCO s phone number in the Important 2

11 Phone Numbers section of this handbook. When you change your HMO, you will get a new ID card and Member Handbook from your new HMO. Be sure to tear-up your old ID card. NEED THIS HANDBOOK IN ANOTHER LANGUAGE? 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, 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 Health Net Community Solutions (Health Net) policies and rules. You must look at the contract between Health Net and the California Department of Health Care Services (DHCS) to learn the exact terms and conditions of coverage. Call Health Net if you would like a copy of the contract. In this handbook, we capitalize important words that you can find in the Glossary of Terms for your reference. Call Health Net Community Solutions at if you would like this book in large print or an alternate format. WHOM DO I CALL AND WHEN? You can call your Primary Care Provider (PCP) your doctor 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 3

12 if the emergency room doctor or Health Net s case manager has advised you to see the doctor. Your doctor s name and telephone number are on your ID card. Questions? Call Health Net Member Services at (TTY ). You can call Health Net when you: need a new ID card, want to change PCP doctors, have questions about services and how to get them, want to know what s covered or what is not covered, need help getting the care you need, get a bill from a doctor, are pregnant, have a problem you cannot solve, want to change Health Plans from Health Net to a different Health Plan, or are unsure whom to call. Health Net 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, learn about your benefits, learn more about privacy rights, find out about your rights and responsibilities, or get a Complaint form (called a Grievance ). You can also check your Eligibility for medical coverage. Since this information is private, you will need to log on. Go to to find out what to do. (Be sure to have your ID card ready as we ask for your Member ID number.) LET S GET STARTED: HOW DO I GET HEALTH CARE? In this handbook, we call your Primary Care Provider your PCP doctor. Your PCP doctor is responsible for making sure you get the medical care you need and are entitled to. You were asked to choose a Primary Care Provider (PCP) doctor and a Health Plan when you filled out the Medi-Cal Enrollment form. Sometimes we cannot give you the PCP doctor you choose. Some of the reasons are: the doctor is not taking new patients; the doctor does not work with the Molina Health Plan you chose; the doctor only sees patients of a certain age or only women (OB/GYNs); and the doctor does not work with Health Net. find a Hospital, 4

13 If you did not get the PCP doctor or Health Plan you chose, call Health Net at to see if that PCP doctor or Health Plan is available. medical advice medication prescribing Each Member has a PCP doctor. A PCP doctor can even be a Clinic. You can pick one PCP doctor for all members of your family in Medi- Cal. Or, you can pick a different PCP doctor for each member of your family in Medi-Cal. Women can choose an OB/GYN or Family Planning Clinic as their PCP doctor. Members may select a non-physician medical practitioner as their Primary Care Provider (PCP). Non-Physician practitioners include: Certified Nurse Midwives (CNM), 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 ID card will be printed with the name of the supervising Primary Care Provider. YOUR PCP DOCTOR Your PCP doctor gives you primary, or basic, medical care. Health Care Services you can get from your PCP doctor include: routine care. check-ups (also called well-visits ). This is when you see your PCP doctor when you are not sick, like when you need shots. It is important to see your PCP doctor even when you are not sick! Family Planning Sick care. These visits are when you see your PCP doctor when you are not feeling well. care for most Chronic (long-term) conditions 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 doctor. Call your PCP doctor for all of your medical needs. The phone number is on your ID card. Los Angeles County Members only If you live in Los Angeles County, you can pick a PCP doctor who is contracted with Health Net or our subcontracting plan, Molina Healthcare of California (Molina). If you pick a PCP doctor who works with Molina, you will get your drugs from pharmacies contracted with Molina and use Molina s Recommended Drug List. To get a copy of Molina s Recommended Drug List, call Member Services at If you need to see a Specialist, your PCP doctor will refer you to a Molina contracting Specialist. Read the Molina Section of your Provider Directory to see which Pharmacies and vision Providers you may use. START GETTING YOUR CARE NOW! CALL YOUR PCP DOCTOR FOR A CHECK- UP. It is important for a new Member to get a checkup even if you are not sick. Be sure to schedule this checkup soon after becoming a Health Net Member. Call your PCP doctor today to make an appointment for a new Member checkup. This visit is also called a well-visit or initial health assessment. Your PCP doctor s telephone number is on your Health Net ID card. This first visit is important. Your PCP doctor looks at your medical history, finds out what your health is today, and can begin any new treatment 5

14 you might need. You and your PCP doctor 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 doctor within 60 days of becoming a Health Net Member if your child is under the age of 18 months. Make an appointment with your doctor or your child s doctor 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 OR YOUR MAIN DOCTOR 1. Call your PCP doctor s office to schedule an appointment. Your PCP doctor s phone number is on your Health Net ID card. Please call ahead as soon as possible. 2. When you make an appointment, identify yourself as a Health Net Medi-Cal Member, and tell the receptionist when you would like to see your doctor. Your doctor s office will do their best to make your appointment at a time that works best for you. 3. This is a general idea of how many Business Days you may need to wait to see your doctor. ( Business days is the number of working days, typically Monday through Friday, before your appointment. Business Days do not include weekends and holidays.) Wait times for an appointment depend on your condition and the type of care you need. You should get an appointment to see your PCP doctor: PCP appointments within 10 Business Days of request for an appointment Urgent Care appointment with PCP within 48 hours of request for an appointment First pregnancy visit within 10 Business Days of request for an appointment Well-child visit with PCP within 10 Business Days of request for an appointment Routine checkup/physical exam within 30 calendar days of request for an appointment The doctor may decide that it is okay to wait longer for an appointment as long as it doesn't harm your health. 4. If you cannot go to your appointment, call the PCP doctor 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 doctor s office your ID card when you are there. Sometimes your doctor will tell you that you need ancillary services such as lab, X-ray, therapy, and medical devices, for treatment or to find out more about your health condition. Here is a general idea of how many Business Days you may need to wait for the appointment: Ancillary service appointment within 15 Business Days of request for an appointment Urgent Care appointment for services that need approval in advance within 96 hours of request for an appointment 6

15 Important! You can still get services without your ID card. If you need to see your PCP doctor, your PCP doctor (or Hospital or Pharmacy) can call Health Net so you can get care. HOW TO GET CARE WHEN YOUR PCP DOCTOR S OFFICE IS CLOSED If you need care when your PCP doctor s office is closed, call your PCP doctor s office. Most offices will have a person to answer the phone when the office is closed. Ask to speak to your PCP doctor or to any available doctor. A doctor will call you back. If you call when your doctor s office is closed and hear a recording, listen carefully and follow the instructions given in the recording. If you are calling to schedule an appointment, you should call back during office hours. If you are calling because you are sick and your doctor s office does not leave instructions, call Member Services at A representative will connect you to a health care professional who will be able to help you and answer your questions. As a Health Net Member, you have access to Triage and/or Screening services, 24 hours per day, 7 days per week. For Urgent Care (this is when a condition, illness or injury is not Life-Threatening, but needs medical care right away), call your PCP office to find out where your nearest Urgent Care center is. Many of Health Net s doctors have Urgent Care hours in the evening, on weekends or during holidays. TRIAGE AND/OR SCREENING NURSE ADVICE As a Health Net Member, when you are sick and can t reach your doctor, like on the weekend or when the office is closed, you can call Health Net 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 and answer your questions. As a Health Net 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 Health Net pays for all Medically Necessary and covered medical services approved by your PCP doctor 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 Health Net. Please call Health Net right away if you receive a bill for medical services. Health Net 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 Health Net for review. If the bill is for covered or Authorized services, you may receive a reimbursement from Health Net. You should not be billed for Emergency Care, Family Planning services, HIV testing and 7

16 counseling, pregnancy termination or for STD services at a Clinic. If you receive a bill, do not pay it. Call Health Net right away to take care of the bill for you. WHAT IS A SECOND OPINION? You have the right to ask for and get a second opinion. You also have the right to ask for a timely response to your request for a second opinion. A second opinion is a visit with another doctor when: You question a Diagnosis for a Chronic condition or for a condition that endangers your life or body. (A Diagnosis is when a doctor identifies a condition, illness or disease.) You do not agree with your PCP doctor or Specialist s treatment plan. (A treatment plan is what the doctor says is best for you, based upon the doctor s Diagnosis.) You would like to make sure your treatment plan is right for you. The second opinion must be from a qualified health care professional in Health Net 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 doctor, Specialist or Health Net, and let them know you would like to see another doctor and the reason why. 2. Your PCP doctor, Specialist or Health Net will refer you to a qualified health care professional. If you are requesting a second opinion about a Diagnosis that your PCP doctor made, the second opinion shall be from another PCP doctor within Health Net 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, Health Net 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 HEALTH NET 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 doctor or OB/GYN to make an appointment. You should get an appointment to see the PCP doctor 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 DOCTOR CAN T GIVE YOU Sometimes you need care your PCP doctor 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 doctor must approve (Authorize) the care and give you a Referral. A Referral is a request from your PCP doctor to another doctor or to the Hospital for Health Care Services or treatment you may need. Your PCP doctor will start the Referral process. Your PCP 8

17 doctor will know whether you need an authorization or whether you can make the appointment directly. If you have any questions about whether care from a Specialist or from a Hospital needs approval, you can call Member Services at (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 doctor. In some cases, your PCP doctor may ask to rush your Referral. Expedited (rush) Referrals may not take more than three calendar days. Please call Health Net if you do not get a response by these times. If a Referral is not approved, your PCP doctor or Health Net will tell you why. You will receive a letter explaining why the Referral was denied or not Authorized. If you do not agree with the explanation given, you may file an appeal. For information on how to file an appeal, this is talked about in the Complaints: What should I do if I m not happy? section in this handbook. 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 of 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 Health Net s medical director decide whether you need a Standing Referral to a Specialist. You, your PCP, a Specialist and Health Net s medical director decide on the treatment plan that is right for you. Your PCP, a Specialist and Health Net 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 Member Services at (TTY/TDD for the hearing impaired at ). If your Standing Referral is denied or you did not get the help you needed with your Standing Referral, read about Health Net 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 Health Net denies the request for a Referral, Health Net 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. 9

18 This notice does not give you all the information you need about Health Net s Specialist Referral policy. To get more information about our Specialist Referral policy, please contact Member Services at CALIFORNIA CHILDREN S SERVICES PROGRAM REFERRALS (CCS) 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. Health Net 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 Health Net. 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 Health Net denies the request for a Referral, Health Net 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 Health Net s Specialist Referral policy. To get more information about our Specialist Referral policy, please contact Member Services at IDENTIFICATION (ID) CARDS: HOW DO I USE THEM? WHAT TO DO WITH YOUR HEALTH NET ID CARD Along with this handbook, you received a Health Net ID card for every family member covered by Health Net Medi-Cal. If you did not receive an ID card for a family member who is covered by Health Net Medi-Cal, call Member Services right away. Your Health Net ID card has important information on it, including: Your PCP doctor s name (or the name of your Clinic or Medical Group). Your PCP doctor 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 Health Net at right away. Health Net 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 Health Net at for replacement. Show your ID card whenever you: have a doctor s appointment, go to the Hospital, 10 need Urgent Care/Emergency Services, or pick up a Prescription.

19 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 Health Net. 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 in this handbook. Never let anyone use your Health Plan ID card or Medi-Cal Card. This is called fraud. You can lose your Medi-Cal benefits if someone else uses your ID cards to get care. If you lose your Medi-Cal benefits, Health Net will not be able to give you care. OUR PROVIDER NETWORK: WHO GIVES ME HEALTH CARE? Please read the following information so you will know from whom or what group of Providers you can get health care. Health Net 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 Health Net s Network by calling Health Net and asking for a Provider Directory. Please see your Provider Directory for information on the physical accessibility of provider offices. The Health Net Provider Directory also has accessibility indicator definitions to help you. Health Net 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 Health Net s Network. That is not the case if you need Emergency Care or need Urgent Care outside of your County. This is talked about more in the section Emergency Care: How Do I Get Care in an Emergency? in this handbook. YOUR PCP DOCTOR GIVES YOU MOST OF YOUR CARE Your PCP doctor is responsible for making sure you get the health care benefits you need and should receive from Medi-Cal. HOW TO CHANGE YOUR PCP DOCTOR If you didn t choose a PCP doctor when you enrolled in Medi-Cal, a PCP doctor was chosen for you by Health Net. Your PCP doctor was chosen for you based on: the language you speak, your age, and how close you live to the PCP doctor s office. It is best to keep the same PCP doctor. Your PCP doctor gets to know your health history and health needs. But sometimes you cannot stay with your PCP doctor. You can choose a PCP doctor from the Health Net Network shown in the Provider Directory mailed to you with this handbook. Call Health Net for another copy of the Provider Directory or to help you choose another PCP doctor. You can change your PCP doctor for any reason if you are not happy. To change your PCP doctor, call Health Net. You may choose a PCP doctor within the first 30 calendar days of Enrollment and change at least monthly after that. 11

20 Things to remember if you choose a new PCP doctor: Some doctors work within a group of doctors with certain Specialists, Hospitals and other health care Providers (this is called a Medical Group ). If you need a Specialist, your PCP doctor 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 doctor 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 doctor for all members of your family in Medi-Cal, or you can pick a different PCP doctor for each member of your family in Medi-Cal. Women may be able to choose an OB/GYN or Family Planning Clinic as their PCP doctor. Ask about office access if you or a family member has a Disability. The PCP doctor you choose may not agree to treat you and may ask Health Net to make a change. This can happen if: you are disruptive or disrespectful to your doctor or your doctor s office staff; you do not follow your doctor s treatment plan; or the service or care you need are not within the doctor s scope of care (like a high-risk pregnancy). KINDS OF PCP DOCTORS You can pick your PCP doctor from the Health Net Provider Directory that came with this handbook. The kinds of Physicians that can be PCP doctors 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 PICKING A FEDERALLY QUALIFIED HEALTH CENTER (FQHC) OR RURAL HEALTH CLINIC (RHC) AS YOUR PCP DOCTOR An FQHC or a RHC is a Clinic and can be your PCP doctor. These are health centers that are located in areas without a lot of Health Care Services. Call Health Net for the names and addresses of the FQHCs and RHCs that work with Health Net or look in the Provider Directory. HOW TO GET CARE FROM A SPECIALIST Your PCP doctor is the doctor who makes sure you get the care you need when you need it. Sometimes your PCP doctor 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 doctor s Network 12

21 (also called a Medical Group ) and Health Net s Network. If you need care from a Specialist, your PCP doctor must approve these services before you receive them. Routine Referrals to a Specialist take up to 5 working days (but may take up to 28 calendar days - 14 days from the date of the original request plus an additional 14 days if an extension is requested) and rush Referrals cannot take more than 3 calendar days (for example, when you need medical care right away or have an urgent condition). Once you get approval to receive the Specialist services: 1. Call the Specialist s office to schedule an appointment. Please call ahead as soon as possible. 2. When you make an appointment, identify yourself as a Health Net Medi-Cal Member, and tell the receptionist when you would like to see the Specialist. The Specialist s office will do their best to make your appointment at a time that works best for you. 3. This is a general idea of how many Business Days you may need to wait to see the Specialist. ( Business Days is the number of working days, typically Monday through Friday, before your appointment. Business Days do not include weekends and holidays.) Wait times for an appointment depend on your condition and the type of care you need. You should get an appointment to see the Specialist: Specialist appointments within 15 Business Days of request for an appointment. Urgent Care appointment with a Specialist or other type of Provider that needs approval in advance within 96 hours of request for an appointment. Female Members who need OB/GYN care don t need their PCP doctor s okay to go to an OB/GYN doctor that is in Health Net s Network. Female Members may get Family Planning services from any health care Provider licensed to provide these services in or out of Health Net s Network, and can be provided outside of your county of residence. OUR DOCTORS PROFESSIONAL QUALIFICATIONS We are proud of our doctors and their professional training. If you have questions about the professional qualifications of Network doctors and Specialists, call Health Net. Health Net can tell you about their medical training or qualifications. CERTIFIED NURSE MIDWIVES Certified Nurse Midwife services may be available outside of Health Net s Network. Members may see a Certified Nurse Midwife without a PCP doctor s okay. To find out more, ask your PCP doctor or call Health Net. CERTIFIED NURSE PRACTITIONERS Some of the PCP doctors who work with Health Net 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 doctor or call Health Net. WHAT CARE CAN YOU GET FROM A PROVIDER WHO IS NOT YOUR PCP DOCTOR? There are some kinds of care that you can get from someone other than your PCP doctor: Emergency Care In an emergency, dial 911. Emergency Services do not need a Referral or an okay from your PCP doctor or Health Net 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 13

22 go to an Urgent Care center that works with your PCP. Family Planning services and sexually transmitted disease testing You may get these services from any health care Provider licensed to provide these services. You do not need to get your PCP doctor s approval to get these services. You should not be billed for Family Planning services. 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 doctor will send you to a Specialist if you need one. In most cases, you cannot see a Specialist without your PCP doctor s okay. Members may see an in- Network OB/GYN for OB/GYN services without their PCP doctor s approval. ACCESS TO SERVICES TO WHICH PROVIDER HAS A MORAL OBJECTION Some health care Providers may not perform certain services covered under your plan. This may be for religious or ethical reasons. When this happens, the Provider or Health Net will find other Providers who are willing to perform these services for you. HOW TO KEEP SEEING YOUR DOCTOR IF YOUR DOCTOR LEAVES YOUR HEALTH PLAN Sometimes Health Net stops working with a doctor or Hospital. If this happens, we will let you know as soon as we can. You can ask to keep seeing your doctor (including Specialists and Hospitals) if that doctor agrees and has been treating you for any of the following conditions: 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 Health Net as part of a documented course of treatment. This treatment was set to occur within 180 days of the time the doctor or Hospital stops working with Health Net or within 180 days of the time you began coverage with Health Net. HOW TO KEEP SEEING YOUR DOCTOR IF YOU ARE A NEW MEMBER Members who have just joined Health Net 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 Health Net to approve your request for continuity of care: You must have one of the conditions listed under above section How to keep seeing your doctor if your doctor leaves your health plan, 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 Health Net, 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 14

23 The Out-of-Network Provider must meet Health Net s professional standards. The continuity of care benefit includes only those services covered by Health Net. 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 regular (Fee-for-Service) Medi-Cal progam. 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, Health Net 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 your doctor if your doctor leaves your health plan. You will not be Eligible for the continuity of care benefit if EITHER: You are a new enrollee with Health Net 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 Health Net may be required to agree to the same terms and conditions as contracted Providers. If the doctor does not agree, Health Net 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 Health Net may ask to keep seeing their doctor for Medically Necessary care for up to 12 months from the date you join Health Net. In order for Health Net to approve your request: you must have a Qualifying Condition, you must have an Ongoing Relationship with the doctor, the doctor must agree to the Health Plan's usual payment rate or the Medi-Cal payment rate, and the doctor 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 Health Net 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 Health Net to approve your request to stay with your previous doctor, you must be undergoing treatment, the doctor must agree to accept Health Net's usual payment rate or the Medi-Cal payment rate, and the doctor must not have any Quality of Care Issues. Once your continuity of care is approved, Health Net will need to Prior Authorize the services, and you will also be assigned to an in-network Primary Care doctor during this 12 month period. To request continuity of care, contact Member Services at You can get a copy of Health Net s continuity of care policy by calling Please call Health Net and ask how to request continuity of care. 15

24 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. As a Member of Health Net, your Service Area is your county with the following two exceptions: If you are a Los Angeles County resident, your Service Area is within a 30 mile radius of your PCP office; if you are a Tulare County resident, your Service Area may include part of Kern County. 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 of 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 Health Net 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 HEALTH NET? In order for you to get any health care service through Health Net, 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 Health Net. 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 Health Net uses to decide if a service is Medically Necessary, call Health Net. 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. Prior Authorization means that your PCP doctor and Health Net agree that services and care are necessary. You must have an approved Prior Authorization from your PCP doctor s Network (the Medical Group ) or from Health Net before you get certain services or care, such as special scans, surgery, or services from a Specialist. 16

25 Services that do not require Prior Authorization are: PCP doctor visits; Emergency Services; Urgently needed services Family Planning Services; preventive services; sexually transmitted disease services; HIV testing; pregnancy termination; routine prenatal care from a doctor that works with Health Net, and Certified Nurse Midwife / OB/GYN, in- Network visits. Call Health Net Community Solutions at if you have questions about: your benefits, how or where to get benefits, or what is covered or not covered. Speech Therapy services; podiatry services; incontinence creams, washes and related products; dental services (Available to Members who live in Los Angeles County or Sacramento County); and Optometric examinations. Health Net is not providing coverage for the following optional benefits: acupuncture, eye appliances, optical lenses and frames for Members over age 21, and Health Net s coverage of the optional benefits is subject to change based on any decisions by the DHCS or other regulatory agency. These benefits are covered: All covered benefits are free. ALCOHOL/DRUG ABUSE Health education and prevention counseling are covered as part of your PCP doctor visits. Medi-Cal optional benefits that Health Net will continue to cover: Health Net provides health information materials. Contact for more information. 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. Health Net will continue to cover the following optional benefits for adult Members, ages 21 and over: 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 the member handbook. audiology services; 17

26 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 papillomavirus ( 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 Health Net 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, Health Net 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. 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 selfmanagement, and family education for self-management. 18

27 DOCTOR OFFICE VISITS The following services are covered: All routine visits, exams, treatments, shots and Child Health Disability Prevention Program (CHDP) visits are provided by your doctor. Services received from a Specialist. Any CHDP services from school-based programs or the County Department of Health. There is more information about the 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 Health Net 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 doctor. 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. Health Net 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 More benefits: What other services can I get? for more information on the CCS program. 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 or 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 FDA-approved contraceptives from any health care Provider licensed to provide these services. Examples of Family Planning Providers include: your PCP doctor; Clinics; Certified Nurse Midwives (CNM) and Certified Nurse Practitioners; OB/GYN Specialists (OB/GYNs are doctors who specialize in female reproductive health care); and 19

28 Planned Parenthood Clinics. Family planning services also include counseling and surgical procedures for the termination of pregnancy (called an abortion). Please call Health Net to find out more. Many of our doctors who provide Family Planning services are also OB/GYN Specialists. Women may pick a PCP doctor from a list of Family Planning Clinics located near them. Call Health Net for a copy of this list. Women have the right to Family Planning services given by a Family Planning Provider who is not in Health Net s Network. You do not need an okay from your PCP doctor to do this. Health Net 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 (916) HEALTH EDUCATION SERVICES Health Net 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 lifelong 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 doctor or through Health Net health education services: asthma breastfeeding dental health diabetes drug and alcohol programs exercise/fitness Family Planning/birth control HIV healthy eating/nutrition 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 health education materials (booklets, brochures, flyers, cookbooks); health education information in large fonts and audio formats (DVDs, AudioHealth Library ); 20

29 counseling (one-on-one teaching, phone or group); health education classes; Referrals to health education classes or programs; medicines to help quit smoking; health promotion incentive programs; and online community resource and health education information including T2X (social media website for teens years old). Ask your doctor for health education materials and classes. For health education services information, call Health Net 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 doctor or Health Plan for confidential HIV testing. Examples of where you can get confidential HIV testing include: your PCP doctor, County Department of Health, Family Planning services Providers, and prenatal Clinics. If you want to be tested, 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: short-term rehabilitation including physical, Occupational and Speech Therapy; and 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 doctor are provided by home health personnel such as: Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), Home Health Aides, and Medical Social Services. 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. HOSPITAL CARE Includes, but is not limited to: Inpatient services, intensive care, operating room and related facilities services, Outpatient services, rehabilitative services, and discharge planning. LAB SERVICES Lab Services include: blood tests 21

30 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), up to 9 visits for a normal pregnancy; 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; You agree to a post-discharge follow-up visit for the mother and newborn within 48 hours of discharge. If you are pregnant, call Member Services at right away. We want to make sure you get the care you need. Health Net will help you choose your maternity care doctor from a doctor in your Network. Your Primary Care doctor 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. Health Net can provide additional support if you need. Breast pumps are a benefit of Health Net. Your doctor can order a breast pump for you, or you can call Member Services or your Medical Group. 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 Health Net. (Outpatient is when you do not stay in the hospital.) This care is provided for the treatment of mild to moderate Mental Health conditions, which include: 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 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 and supplies; Outpatient services to monitor drug therapy; and psychiatric consultation. 22

31 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 doctor. Ask your doctor if they work with Health Net. If the doctor does, you will keep your doctor. If your doctor does not work with Health Net and you want to keep that doctor, 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 Health Net, you will need to find a new doctor after 12/31/13. To find a Health Net mental health provider near you, ask your PCP doctor for the name of one. Or, to find out more about covered mental health care, call Member Services at (TTY/TDD ). Health Net will coordinate and cover laboratory and x-ray services needed for the Diagnosis, treatment and monitoring of a mental health condition. Health Net or regular (Fee-for-Service) Medi-Cal covers mental health drugs listed on the Health Net Recommended Drug List (RDL) and prescribed by your PCP doctor, 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. Los Angeles County Members only If you live in Los Angeles County, you can pick a PCP doctor who is contracted with Health Net or our subcontracting plan, Molina Healthcare of California (Molina). If you pick a PCP doctor who works with Molina, you will get your drugs from pharmacies contracted with Molina and use Molina s Recommended Drug List. Read the Molina Section of your Provider Directory to see which Pharmacies you may use. To get a copy 23 of Molina s Recommended Drug List, call Member Services at MINOR CONSENT SERVICES There are some services adolescent Members (children under the age of 18) can get without a parent s okay. Minors may choose to get some of these services through their PCP doctor or from other qualified Medi-Cal Providers, including Providers not with Health Net 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 Health Net s Network; drug and alcohol abuse services for children 12 years of age or older. This is provided by the County mental health department. Health Net or your doctor 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 Health Net s Network; pregnancy-related services in your PCP s Network ( Medical Group ); sexual assault services, including rape. These services may be accessed from any qualified Medi-Cal Provider, including Providers not with Health Net 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 Health Net s Network; and Outpatient mental health treatment and counseling for minors (12 years of age or older)

32 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. (Please see the section More benefits: What other services can I get? in this handbook for information on how to get Mental Health Services.) If you have questions or need help finding a qualified Medi-Cal Provider, call Health Net at NEWBORN CARE Your newborn baby will be covered by Health Net for the month of birth and the following month. When you have a baby, it is important to do three things: 1. Please call Health Net 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 in this handbook. This is important so that your baby can continue to receive Medi-Cal benefits! 3. Take your baby to the doctor. A Health Net doctor 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. Please call Health Net if you have any questions. Newborn baby screenings for certain treatable genetic disorders are covered. These genetic disorders include: Phenylketonuria (PKU), 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 doctor 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 doctor or Health Net to see an OB/GYN who works in their Network. Please call Health Net 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. PRENATAL CARE Includes, but is not limited to: regular doctor visits during your pregnancy (called prenatal visits). Up to 9 visits for normal pregnancy. 24

33 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 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. SEXUALLY TRANSMITTED DISEASE (STD) SERVICES STD services include: preventive care, screening, testing, 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 doctor. 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 longterm Skilled Nursing Facility services, you will be disenrolled from Health Net 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 Health Net, 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 Health Net to find out more. 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 25

34 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? for more information on the CCS program. THERAPY OCCUPATIONAL, PHYSICAL AND SPEECH Occupational Therapy is used to improve and maintain a patient s daily living skills if there is a Disability or injury. Up to two visits for Occupational Therapy, Speech Therapy, (combined) are covered in any one calendar month. 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 doctor thinks that your condition will improve significantly in a short period of time. Physical Therapy may be available from the school district, the California Children s Services (CCS) program or regional center if your condition is likely to last a long time. Health Net will help coordinate therapy with the other agencies if that is appropriate. Speech Therapy is used to treat speech problems. Up to two 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. 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 doctor, and Authorized in advance by Health Net. Health Net 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 Health Net Member Services Department at least 7 Business Days in advance at Health Net Public Programs 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. 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 Health Net Member Services Department at to obtain a directory of participating optometrists and ophthalmologists. 26

35 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 doctor 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, Health Net 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 doctor 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 Health Net. They are available through Medi-Cal or another state regional, school or county program. Please call Health Net 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. Health Net 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 Health Net. Health Net does not cover services related to CCS-Eligible medical conditions. Please call Health Net if your child is receiving CCS services. Health Net 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 Health Net. 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, vision, dental, hearing and other tests. If you have questions about CHDP services, ask your child s PCP. For non-emergency medical transportation to CHDP covered services, call CHDP at

36 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 doctor, maternity nurse or midwife to find out more about WIC. WIC services are not covered by Health Net. However, Health Net will help to refer you to the WIC program and will work with your doctor to make sure your doctor also refers you to the WIC program. As part of the Referral process, your doctor 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 doctor 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 ) 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 Health Net 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 regular (Fee-for- Service) Medi-Cal at any time and for any reason. Please call Indian Health Services at to find out more. You may visit the Indian Health Services website at to find out more. DENTAL SERVICES Health Net 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 members whose health is compromised and for whom general anesthesia is Medically Necessary, regardless of age. 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 Health Net offers a Medi-Cal dental plan for beneficiaries in Sacramento and Los Angeles Counties. Call for more information. 28 EARLY START/EARLY INTERVENTION Early Start/Early Intervention is for children ages 0 3. If your PCP doctor tells you that your child is

37 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 doctor or to Health Net. 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 doctor. The PCP doctor 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 doctor 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 doctor or call Health Net. COMMUNITY-BASED ADULT SERVICES (CBAS) CBAS is a program that delivers specific services at an Outpatient center to persons in Medi-Cal who qualify for the program. Services include skilled nursing care, social services, therapies, personal care, meals and transportation. The program also provides training and support to families and/or caregivers. If you qualify for the CBAS program, Health Net will send you to the center that best suits your needs. If there is no center near you, Health Net will help you get services from other Providers. SPECIALTY MENTAL HEALTH SERVICES Specialized Mental Health Services may be needed for services beyond your PCP doctor s training and practice. Specialized 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 doctor. 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. SCREENING, BRIEF INTERVENTION, REFERRAL AND TREATMENT BENEFIT (SBIRT) Services for adults (age 18 and older) who have alcohol or other substance use disorder conditions. This care is offered to you at no cost. The covered services for alcohol misuse are: One expanded screening for risky alcohol use per year (a screening tool that asks you 29

38 for more information about your alcohol use) Three 15-minute intervention sessions per year to talk about risky alcohol use ALCOHOL AND DRUG TREATMENT (OUTPATIENT) Inpatient treatment for Acute drug overdose or alcohol detoxification is covered by the Health Plan when Medically Necessary. However, all other alcohol and drug treatment services and Outpatient heroin detoxification services are not covered by the Health Plan. Members requiring these services will be referred to their county alcohol and drug treatment program for treatment. CHILDHOOD LEAD POISONING SCREENING Health Net 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 Health Net 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). Health Net 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 Health Net 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 Health Net and go back to regular (Fee-for-Service) Medi-Cal. Health Net will continue to cover all Medically Necessary services until you are disenrolled. Health Net does not Disenroll members over the age of 21 who need to receive a kidney or cornea transplant. Health Net 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 regular (Fee-for-Service) Medi-Cal. Health Net 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 post-transplant follow up. ADDITIONAL SERVICES PROVIDED AS MEDI-CAL BENEFITS BUT NOT COVERED BY HEALTH NET: Long Term Care Pediatric day health care. State laboratory services under the State Serum Alpha-fetoprotein Testing program. Targeted Case Management. 30

39 NON-COVERED SERVICES: WHAT DOES MEDI-CAL NOT COVER? The following is a list of services not covered by Health Net or by the regular (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 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) Mental Health services for relationship problems. This includes counseling for couples or families for conditions listed as relational problems. 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 regular (Fee-for-Service) Medi-Cal. For more information about custodial care covered under regular Medi-Cal, call your eligibility worker. You can find the phone number for your county under Important Phone Numbers 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 Optical lenses and frames for Members over age 21 Personal comfort items, (such as phones, television and guest tray) when in the Hospital Psychology services (psychology services are covered by regular (Fee-for-Service) Medi-Cal when provided by an FQHC or Rural Health Clinic Treatment for major alcohol problems. If you need services for major alcohol problems, you may be referred to the county alcohol and drug Program. If you have questions about what is covered or not covered, please call Health Net at PHARMACY BENEFITS: HOW DO I GET PRESCRIPTION DRUGS? WHAT IS A PHARMACY? A Pharmacy is a place to get your Prescriptions filled. Health Net works with pharmacies in many neighborhoods. You must get your prescribed 31

40 medications (drugs) from a Pharmacy in Health Net s Network. A Network is all of the pharmacies that work with Health Net. A Pharmacy list is in the Provider Directory provided to you with this handbook. You can also call Member Services at for pharmacies in your neighborhood. Los Angeles County Members only If you live in Los Angeles County, you can pick a PCP doctor who is contracted with Health Net or our subcontracting plan, Molina Healthcare of California (Molina). If you pick a PCP doctor who works with Molina, you will get your drugs from pharmacies contracted with Molina and use Molina s Recommended Drug List. Read the Molina Section of your Provider Directory to see which Pharmacies you may use. To get a copy of Molina s Recommended Drug List, call Member Services at HOW TO GET A PRESCRIPTION FILLED AT A PHARMACY Sometimes when you are sick or have a health condition like asthma or diabetes, your doctor may give you a Prescription. Your doctor will give you a Prescription based on your health status. A Pharmacy is the place to get the Prescription filled that was prescribed by your doctor. 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 Health Net Member Services tollfree at to find a Pharmacy near you. 1. Choose a Pharmacy near you that works with your Health Plan. 2. Bring your Prescription to the Pharmacy. 3. Give the Prescription to the Pharmacy with your Health Plan Member ID card. This will help the Pharmacy fill your Prescription. 4. Make sure you give the Pharmacy your correct address and phone number. 5. Make sure the Pharmacy knows any allergies you have to any medicine. Medi-Cal Members should not be asked to pay for Prescription drugs. Call your Health Plan if you are asked to pay for a Medi-Cal Prescription. HOW DO I GET MY MEDICATION IN AN EMERGENCY IF ALL THE PHARMACIES IN MY AREA ARE CLOSED? The Hospitals and emergency facilities that work with Health Net will be able to provide you with an emergency supply of a needed medication if no Pharmacy is available to fill your Prescription. You will receive enough of the medication to last until you are able to have a Pharmacy fill it for you. You may call Health Net to ask for more information. Please call the Member Services Department at the telephone number on your ID card. WHAT IS THE RECOMMENDED DRUG LIST, ALSO CALLED FORMULARY,? Health Net uses a list of approved drugs called a Recommended Drug List (RDL). A committee of Health Net practicing Physicians and pharmacists reviews drugs to add or remove from the RDL 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. Your doctor usually prescribes drugs from the RDL. Your doctor will only prescribe a drug 32

41 based on your health status. Just because a drug is on the RDL does not mean a doctor will prescribe it. Your doctor may not think the drug is necessary for your symptoms or condition. You may call Health Net to ask for a copy of the Health Net Medi-Cal RDL or to ask if a specific drug is on the list. Please call the Member Services Department at the telephone number on your ID card. DRUGS NOT ON THE RECOMMENDED DRUG LIST (RDL) Sometimes, your doctor may need to prescribe a drug not on the Health Net Medi-Cal Recommended Drug List (RDL). Your doctor must call to get an okay from Health Net. This is called a Prior Authorization. To decide if this drug will be covered, Health Net may ask your prescribing doctor or the pharmacist (or both) for more information. Within one Business Day after getting this information, Health Net will tell your doctor or the pharmacist if the drug will be covered. Your doctor or the pharmacist will then tell you. If the drug is approved, you can get the drug at a Network Pharmacy. 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 brand-name 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 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 your doctor and are Medically Necessary: Prescription drugs listed on the Health Net Medi-Cal Recommended Drug List (RDL) (Health Net closely follows the regular (Feefor-Service) Medi-Cal program quantity limitations for narcotic drugs); Prescription drugs you get from a Pharmacy not in Health Net s Network when you have an emergency; Non-Prescription drugs or over-the-counter products (such as aspirin or acid reflux drugs) listed on the Health Net Medi-Cal 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 Health Net Medi- Cal RDL; Emergency contraception; Self-injectable epinephrine, peak flow meters to monitor asthma and inhaler spacer devices; and 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 Health Net; 33

42 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. EMERGENCY CONTRACEPTION You may get emergency contraceptive drugs from: Your doctor; A Pharmacy with a Prescription from your doctor; 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 this program. WHAT OTHER DRUGS CAN I GET? Some drugs are not covered by Health Net but are still Benefits. They are available through regular (Fee-for-Service) Medi-Cal or another state program. Please call Member Services 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 Health Net. Doctors that are approved by CCS need to write the Prescriptions. Pharmacies must bill CCS, and not Health Net, 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 help refer you to the CCS program. They may also help you get an emergency supply of your drug if needed. Health Net 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 regular (Fee-for-Service) Medi-Cal, not Health Net. You still get a Prescription from your doctor 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. 34

43 Please call Member Services 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 Member Services. IF YOU ARE IN LOS ANGELES COUNTY AND YOU ARE ASSIGNED TO A PCP THROUGH MOLINA HEALTHCARE If your doctor wants you to take more than six (6) Prescription drugs per month, your doctor will need to fill out a form to approve more than six (6) in a month. This will help your doctor make sure the drugs you take make you healthy and do not cause any problems. If you have HIV, AIDS, cancer, or have had a transplant, you will not need this form. Molina will tell your doctor if a form needs to be filled out for you. Molina also uses a Pharmacy Home Program. If you get a controlled substance (narcotic) at more than one drug store, you may get a letter from Molina. This letter is to let you know that you may become a candidate for the Pharmacy Home Program. If you get a prescribed controlled substance at more than two (2) drug stores in a two- (2) month period, you may then be enrolled in the Pharmacy Home Program. The Pharmacy Home Program will allow you to choose a drug store to receive all non-emergency drugs. The drug store that you choose will provide your drugs for a twelve- (12) month period. You may request to change your selected drug store if you move or change workplaces. You may request to stop the Pharmacy Home Program if you qualify to be excluded. You may also request to stop this program at the end of the twelve- (12) month period. 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 Health Net s doctors have Urgent Care hours in the evening and on weekends. HOW TO GET URGENT CARE 1. Call your PCP doctor. You may speak to an operator who answers calls for your PCP doctor s office when closed. 2. Ask to speak to your PCP doctor or the doctor on call. Another doctor may answer your call if your PCP doctor 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 a PCP doctor. If you get Urgent Care services from another doctor when your PCP doctor is not available, be sure to let your PCP doctor know about the Urgent Care services you received. You may need follow-up care from your PCP doctor. If you cannot reach your doctor or if you are outside of your service area, call Member Services at to access Triage or Screening Services locations and telephone numbers. 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 the United States, except for Emergency Services 35

44 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 doctor. If you are admitted to a Hospital not in Health Net s Network or to a Hospital your PCP doctor or other Provider does not work at, Health Net has the right to move you to a Network Hospital as soon as medically safe. Your PCP doctor must provide follow-up care when you leave the Hospital. WHAT TO DO AFTER AN EMERGENCY 1. Call Health Net 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 doctor 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 Health Net. Health Net may refuse to pay if you 36

45 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 doctor. Do what your PCP doctor tells you to do. You can also reach a Health Net Nurse for Nurse Advice and Triage 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 Health Net within 24 hours of your emergency. To call Health Net 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. HELP IN ANOTHER LANGUAGE 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 doctor. Your doctor 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. 37 You may ask for a face to face interpreter for any doctor appointment. Interpreters are very helpful when your doctor needs to talk about hard to understand medical information. You can get

46 interpreter services from Health Net at no cost. Please call Member Services at (TTY ) to ask for a telephone or face to face interpreter. Telephone interpreters are ready when you are even during the weekend and evening. We need at least 5 days before your 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, 7 days a week. You should not use children or family members as interpreters. Call Member Services at or your doctor if you need interpreter services. We will work with you and your PCP doctor 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: AT&T: for voice ( in Spanish) or for TTY ( in Spanish). Hamilton: for voice or TTY ( in Spanish). 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. This law protects people with Disabilities, even if they do not look like they have a Disability, or if they had a Disability in the past. The ADA law makes sure there are equal chances for people with disabilities in employment, and 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 your 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. 38

47 This is talked about in the section Complaints: What should I do if I am unhappy? in this handbook. 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 doctor know. Your PCP doctor may be able to help you or answer your questions. At any time, you or your Personal Representative may file a Grievance with Health Net. 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 a 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 doctor or other Providers give you. The service or care your PCP doctor 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 Health Net gives you. What the federal and state agencies say about Grievances If a Member receives a Notice of Action from Health Net, 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 requested for that Notice of Action. 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 that 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, fax or call Health Net. 39

48 Health Net, Appeals & Grievances P.O. Box Van Nuys, CA (phone) (fax) (TDD) Visit Health Net at Burbank Blvd Woodland Hills, CA You may get a Grievance form online through Health Net s website at Call Health Net to get a Grievance form in Braille, large print or other alternative format. You can also fill out a Grievance form at your doctor s office. Your PCP doctor 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 Hearing at the same time. Health Net can help you fill out the Grievance form over the phone or in person at Burbank Blvd Woodland Hills, CA 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 Health Net saying we have your Grievance and are working on it. Then, within 30 calendar days of receiving your Grievance, Health Net will send you a letter explaining how the Grievance was resolved. 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 Health Net. Grievances for Medi-Cal Eligibility are not processed by Health Net. 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 in this handbook. IF YOU DON T AGREE WITH THE OUTCOME OF YOUR GRIEVANCE If you do not hear from Health Net 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. For information on how to file a Grievance with DMHC, go to Contacting the Department of Managed Health Care (DMHC) section. 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 Health Net 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 Health Net 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 Hearing does not affect your medical Benefits. If you file a Grievance or a request for a State Hearing, you 40

49 may be able to continue a medical service while the Grievance is being resolved. To find out more about continuing a medical service, call Health Net at 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 Health Net 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. For information on how to file a Grievance with DMHC, go to the Contacting the Department of Managed Health Care (DMHC) section. 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 Health Net 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 Health Net. For more information about a State Hearings, go to the State Hearing section. You have the right to file an urgent Grievance with DMHC without filing a Grievance with Health Net. For information on how to file a Grievance with DMHC, go to Contacting the Department of Managed Health Care (DMHC) section. IF YOU DON T AGREE WITH THE OUTCOME OF YOUR GRIEVANCE FOR URGENT CASES If you do not hear from Health Net 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. 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 sustained 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 sustained denial. However, an IMR may not be requested if you have already requested a State Hearing. Go to the State Hearing section 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: 41

50 Your doctor 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 Health Net 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 Health Net and the health care service is still denied, changed, delayed, or the Grievance remains unresolved after 30 days. You must first go through the Health Net Grievance process before applying for an IMR. In special cases, the DMHC may not require you to follow the Health Net Grievance process before filing for an IMR. In urgent or emergent cases, you are not required to participate in the Health Net expedited Grievance process for more than three days before filing an IMR. 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, Health Net 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. Health Net 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 doctor 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: 42

51 You have a very serious condition that is Life- Threatening or debilitating (for example, terminal cancer). Your doctor 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 doctor must certify in writing that: a drug, device, procedure or other therapy is likely to work better than the standard treatment; and 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 doctor. The treatment would normally be covered as a benefit, but Health Net 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 Member Services. You do not need to participate in Health Net 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 TTY/TDD line ( ) for the hearing and speech impaired. You can also call the DMHC Consumer Service toll-free telephone number at to submit a Grievance about your Health Plan. 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 Health Net Members have the right to ask for a State Hearing at any time before, 43

52 during, or after Health Net 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. 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 requested a State Hearing. Go to the Independent Medical Review section 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 PO 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 Health Net 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 PO Box , MS Sacramento, CA Fax: or If you ask for a 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. 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 Health Net 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 44

53 as Health Plan enrollees and to teach them how to make 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 Health Net. Be sure to fill out and return any 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 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 Health Net. 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. Health Net is a Managed Care Health Plan. Managed Care is when your health care is managed and coordinated by a Health Plan and a PCP doctor. This makes it easier for you to get the care you need. It is Health Net s job to make sure you get the care you need. For example, if you need to see a Specialist, it is your PCP doctor s and our job to find a Specialist that will see you. In regular (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 Health Net. For help with Fee-for-Service Benefits outside of Managed Care, call Health Net. 45

54 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 regular (Fee-for-Service Medi-Cal) at any time. Voluntary Members include: disabled or elderly receiving Supplemental Security Income (SSI); 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 Members with HIV/AIDS diagnoses. VOLUNTARY DISENROLLMENT To Disenroll means you leave a Health Plan and are no longer a Member. To Disenroll from Health Net, 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 continue to receive services through Health Net until you are disenrolled from Health Net. INVOLUNTARY DISENROLLMENT You will lose Managed Care coverage with Health Net, 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 Health Net (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 Health Net, 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 Health Net, 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 Health Net to find out more. EXPEDITED DISENROLLMENT Health Net 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 Health Net 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 doctor of the effective date of Disenrollment. Your health care for the condition will be covered by regular Medi-Cal. 46

55 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 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 6 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 Health Net toll-free at You can stay with Health Net if you are Eligible for transitional Medi-Cal. GETTING INVOLVED: HOW DO I PARTICIPATE? HEALTH NET REGIONAL COMMUNITY ADVISORY COMMITTEES Health Net maintains Community Advisory Committees or CACs in various California counties. Their purpose is to give input to Health Net that might affect policies, procedures, programs and practices. CAC members: Talk about Member issues. Advise Health Net on how to make services better. Educate and empower the community on health care issues. The CACs meet two to four times a year in each county. CACs include Health Net Members, Member advocates (supporters) and health care Providers. To join a CAC in your county or find out more about CACs, please call COMMUNICATING POLICY CHANGES As a Health Net 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 Health Net website. Many of the Health Net policies are decided by the California Department of Health Care Services (DHCS). Other policies are set by Health Net and Members like you. If you would like to ask for a copy of our non-proprietary clinical or administrative policies and procedures, call Health Net. 47

56 MORE IMPORTANT INFORMATION: WHAT ELSE DO I NEED TO KNOW? IF YOU TRAVEL OUTSIDE OF YOUR SERVICE AREA As a Member of Health Net, your Service Area is your county with the following two exceptions: If you are a Los Angeles County resident, your Service Area is within a 30 mile radius of your PCP office; if you are a Tulare County resident, your Service Area may include parts of Kern County. 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 Sexually Transmitted Disease (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, Family Planning, HIV testing and counseling, pregnancy termination, or for Sexually Transmitted Disease (STD) services at a Clinic. If you receive a bill, do not pay it. Call Health Net right away to take care of the bill for you. 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 Health Net if you would like to know more about how your doctor is paid or about financial incentives or bonuses. IF YOU HAVE OTHER INSURANCE Please call Health Net at to tell us about any other health insurance you have other than Health Net. We will send all bills to the correct place for payment. WORKERS COMPENSATION Health Net does not pay for work-related injuries covered by Workers Compensation. However, Health Net 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 Health Net 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, Health Net will notify the DHCS of such potential cases, and will help the DHCS in pursuing the State s right to reimbursement of such recoveries. Members are obligated to assist Health Net and the DHCS in this regard. DISRUPTION IN SERVICES Health Net will use its best efforts to provide services in the event of a war, riot or other unusual event. If Health Net is not able to provide health services, we will send Members to the nearest 48

57 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 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. 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. 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. Health Net will tell you about any changes to state law about Advance Directives as soon as possible but no later than 90 days after the date of the change. Ask your doctor or call Health Net to find out more about Advance Directives. NEW TECHNOLOGY Health Net 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 Health Net to review new technology. Give copies to appropriate people. You should give a copy of the form to your doctor 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. 49

58 GLOSSARY OF TERMS This glossary will help you understand words that appear capitalized 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 nonapproved 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. Business Day 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 ( Health 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. 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. 50

59 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), Los Angeles County clinic, 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 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 Health Net 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, also known as regular 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. 51

60 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 radiology services. Health Maintenance Organization (HMO) is an organization that, through a coordinated system of health care, provides or assures the delivery of an agreed-upon set of comprehensive health maintenance and treatment services for an enrolled group of persons through a predetermined periodic fixed prepayment. 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. 52

61 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. 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 and 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. Ongoing Relationship with a doctor is determined by identifying whether the Senior and Person with Disabilities has seen the requested out of network provider at least once within the last 12 months. 53

62 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 doctor) 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 doctor 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. 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. 54

63 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 Clinics (RHC) are clinics that provide access to primary care services in rural areas. Service Area means a county or counties, or a 30 mile radius from PCP office that Health Net serves. 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. 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 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. Specialized Mental Health Services are rehabilitative services that include mental health services, medication support services, day treatment intensive, day rehabilitation, crisis intervention, crisis stabilization, adult residential treatment services, crisis residential services, and psychiatric health facility services such as: psychiatric Inpatient Hospital services; 55

64 IMPORTANT PHONE NUMBERS Health Net Community Solutions Member Services and 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. Health Net Fraud and Abuse Hotline DISABILITY SERVICES California Relay Service (CRS): TTY/TDD: 711 Sprint (Voice) MCI (Voice) Americans Disabilities Act (ADA) Information (Voice) (TDD) CHILDREN S SERVICES California Children s Services (CCS): Child Health and Disability Prevention (CHDP): ( CHDP) CALIFORNIA STATE SERVICES Department of Health Care Services (DHCS): 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): COUNTY OFFICES Kern County Department of Human Services: Mental Health Services: Los Angeles County Department of Public Social Services (DPSS) Central Help Line (includes language services): DPSS Customer Service Center: Los Angeles County Department of Mental Health: Sacramento County Department of Human Assistance: Department of Health & Human Services (mental health):

65 San Diego County Department of Health & Human Services: San Diego Behavioral Health Division: San Joaquin County Department of Public Health: Behavioral Health: Social Services: or Stanislaus County Community Services Agency: Behavioral Health & Recovery Services: Tulare County Health & Human Services Agency: Department of Mental Health:

66 HOW TO STAY HEALTHY Going to your doctor 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 doctor 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 Health Net. Babies 18 months or younger who are due for a checkup should get it within 60 days of joining Health Net. Remember to go for a check-up every year. Regular check-ups help you stay healthy! 58

67 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 (PCV13) X X X X Inactivated Poliovirus (IPV) X (PPSV23, for high risk groups) X X X X Influenza X (Yearly) Measles, Mumps, Rubella (MMR) X X Varicella X X Hepatitis A (HepA) Meningococcal X X (For high risk groups) X (As your doctor suggests) 59

68 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 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 (PPSV 23) X (For high risk groups) Hepatitis A (HepA) X (As your doctor suggests) Hepatitis B (HepB) X (Catch-up immunizations) Inactivated Poliovirus (IPV) X (Catch-up immunizations) Measles, Mumps, Rubella (MMR) X (Catch-up immunizations) Varicella (VAR) X (Catch-up immunizations) 60

69 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 (VAR) 3 doses or as your doctor suggests Substitute 1-time dose of Tdap for TD booster, then boost with Td every 10 years 2 doses if no history of prior vaccination or infection Zoster 1 dose Measles Mumps, Rubella (MMR) 1 or 2 doses if no history of prior vaccination or infection As your doctor suggests Influenza Pneumococcal (PPSV23) 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 61

70 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 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 Starting at age 2, check BMI during routine health exam 62

71 Screenings for Adults 1,2,4 Service Age Age Age 65 and over Routine health exam 1,2,4 Every year Every year Every year Hearing screening (to check for hearing loss) n/a As your doctor suggests Vision screening (to check for eye problems) Every 5-10 years Every 2 years for age 40-54; every 1-3 years for age Every 1-2 years Aspirin therapy (to prevent heart disease) Blood pressure (to check for high blood pressure) Body Mass Index (BMI) (to check for obesity) n/a Discuss with your doctor in routine health exam Every 1-2 years Check during routine health exam Cholesterol screening (to check for blood fats) Colorectal cancer screening (to check for colorectal cancer) Glucose screening (to check for blood sugar) As your doctor suggests n/a If at increased risk, check every 5 years starting at age 35 for men and age 45 for women For age 40-49, as your doctor suggests. Beginning at age 50, talk to your doctor about 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 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 Dental checkup Every 6 months 63

72 Health Screenings for Men 1,2,4 Service Age Age Age 65 and over Prostate-Specific Antigen (PSA/DRE) (to check for prostate cancer) n/a As your doctor suggests Abdominal ultrasound (to check for abdominal aortic aneurysm, a swelling of a large blood vessel around the stomach area) n/a Once, for smokers age who have ever smoked Testicles self exam As your doctor suggests 64

73 Health Screenings for Women 1,2,4 Service Age Age Age 65 and over Pelvic exam with cervical smear (to check for cervical cancer) Starting at age 21,screen every 3 years; starting at age 30, screen every 3-5 years or as your doctor suggests As your doctor suggests Mammogram (an x ray of breast) Starting at age 35, as your doctor suggests Every year or as your doctor suggests Breast exam by doctor Every 1-3 years Every year Self breast exam (to check for breast changes) Chlamydia screening (a test for a sexually transmitted disease) Bone density test (to check for bone loss) Monthly 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 65

74 1 These guidelines may change. Please speak with your doctor. 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 OTHER TOPICS TO TALK TO YOUR DOCTOR ABOUT Asthma Breastfeeding Dental Health Diabetes 66

75 Drug and Alcohol Problems Exercise/Fitness Family Planning/Birth Control Healthy Eating (Nutrition) Heart Health How to Quit Smoking Injury Prevention Medicine Safety Parenting Pregnancy Staying Healthy Assessment STDs and HIV Tuberculosis (TB) Weight Problems Violence/Abuse 67

76 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice tells you about the ways in which Health Net* (referred to as we or the Plan ) may collect, use and disclose your protected health information and your rights concerning your protected health information. Protected health information is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. We are required by federal and state laws to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information, and notify you in the event of a breach of your unsecured protected health information. We must follow the terms of this Notice while it is in effect. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for your protected health information we already have as well as any of your protected health information we receive in the future. We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your rights, our legal duties, or other privacy practices stated in the notice. We will make any revised Notices available on our website, Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards. I. How We May Use and Disclose Your Protected Health Information We may use and disclose your protected health information for different purposes. The examples below are provided to illustrate the types of uses and disclosures we may make without your authorization for payment, health care operations and treatment. Payment. We use and disclose your protected health information in order to pay for your covered health expenses. For example, we may use your protected health information to process claims, to be reimbursed by another insurer that may be responsible for payment or for premium billing. Health Care Operations. We use and disclose your protected health information in order to perform our plan activities, such as quality assessment activities or administrative activities, including data management or customer service. Treatment. We may use and disclose your protected health information to assist your health care providers (doctors, pharmacies, hospitals, and others) in your diagnosis and treatment. For example, we may disclose your protected health information to providers to provide information about alternative treatments. Plan Sponsor. In addition, we may disclose your protected health information to a sponsor of the group health plan, such as an employer or other entity that is providing a health care program to you. We can disclose your protected health information to that entity if it has contracted with us to administer your health care program on its behalf. *This Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc. s affiliated covered entities: Health Net Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company, Health Net of Arizona, Inc., Health Net of California, Inc., Managed Health Network, Rev. 09/01/13 68

77 If the plan sponsor provides plan administration services, we may also provide access to identifiable health information to support its performance of such services which may include but are not limited to claims audits or customer services functions. Health Net will only share health information upon a certification from the plan sponsor representing there are restrictions in place to ensure that only plan sponsor employees with a legitimate need to know will have access to health information in order to provide plan administration functions. Person(s) Involved in Your Care or Payment for Your Care. We may also disclose protected health information to a person, such as a family member, relative, or close personal friend, who is involved with your care or payment. We may disclose the relevant protected health information to these persons if you do not object or we can reasonably infer from the circumstances that you do not object to the disclosure; however, when you are not present or are incapacitated, we can make the disclosure if, in the exercise of professional judgment, we believe the disclosure is in your best interest. II. Other Permitted or Required Disclosures As Required by Law. We must disclose protected health information about you when required to do so by law. Public Health Activities. We may disclose protected health information to public health agencies for reasons such as preventing or controlling disease, injury, or disability. Victims of Abuse, Neglect or Domestic Violence. We may disclose protected health information to government agencies about abuse, neglect, or domestic violence. Health Oversight Activities. We may disclose protected health information to government oversight agencies (e.g., California Department of Health Services) for activities authorized by law. Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request, or other lawful process. Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime. Coroners, Funeral Directors, Organ Donation. We may release protected health information to coroners or funeral directors as necessary to allow them to carry out their duties. We may also disclose protected health information in connection with organ or tissue donation. Research. Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy. To Avert a Serious Threat to Health or Safety. We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Rev. 09/01/13 69

78 Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities. Workers Compensation. We may disclose protected health information to the extent necessary to comply with state law for workers compensation programs. Fundraising Activities. We may use or disclose your protected health information for fundraising activities, such as raising money for a charitable foundation or similar entity to help finance its activities. If we do contact you for fundraising activities, we will give you the opportunity to optout, or stop, receiving such communications in the future. Underwriting Purposes. We may use or disclosure your protected health information for underwriting purposes, such as to make a determination about a coverage application or request. If we do use or disclose your protected health information for underwriting purposes, we are prohibited from using or disclosing your protected health information that is genetic information in the underwriting process. Other Uses or Disclosures that Require Your Written Authorization We are required to obtain your written authorization to use or disclose your protected health information, with limited exceptions, for the following reasons: Marketing. We will request your written authorization to use or disclose your protected health information for marketing purposes with limited exceptions, such as when we have face-to-face marketing communications with you or when we provide promotional gifts of nominal value. Sale of Protected Health Information. We will request your written authorization before we make any disclosure that is deemed a sale of your protected health information, meaning that we are receiving compensation for disclosing the protected health information in this manner. Psychotherapy Notes We will request your written authorization to use or disclose any of your psychotherapy notes that we may have on file with limited exception, such as for certain treatment, payment or health care operation functions. Other Uses or Disclosures. All other uses or disclosures of your protected health information not described in this Notice will be made only with your written authorization, unless otherwise permitted or required by law. Revocation of an Authorization. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan. III. Your Rights Regarding Your Protected Health Information You have certain rights regarding protected health information that the Plan maintains about you. 70 Rev. 09/01/13

79 Right to Access Your Protected Health Information. You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include enrollment, billing, claims payment, and case or medical management records. Your request to review and/or obtain a copy of your protected health information records must be made in writing. We may charge a fee for the costs of producing, copying, and mailing your requested information, but we will tell you the cost in advance. If we deny your request for access, we will provide you a written explanation and will tell you if the reasons for the denial can be reviewed and how to ask for such a review or if the denial cannot be reviewed. Right to Amend Your Protected Health Information. If you feel that protected health information maintained by the Plan is incorrect or incomplete, you may request that we amend, or change, the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by the Plan, as is often the case for health information in our records, or you ask to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision, and we have the right to rebut that statement. Right to an Accounting of Disclosures by the Plan. You have the right to request an accounting of certain disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, Your request should indicate in what form you want the list (for example, on paper or electronically). The first accounting that you request within a 12-month period will be free. For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance. Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply. Right to Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you about the Plan or that we send Plan information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Notice in the Event of a Breach. You have a right to receive a notice of a breach involving your protected health information (PHI) should one occur. 71 Rev. 09/01/13

80 Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy. Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our Privacy Office. See the end of this Notice for the contact information. IV. Health Information Security Health Net requires its employees to follow the Health Net security policies and procedures that limit access to health information about members to those employees who need it to perform their job responsibilities. In addition, Health Net maintains physical, administrative, and technical security measures to safeguard your protected health information. V. Changes to This Notice We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. We also post a copy of our current Notice on our website at Any time we make a material change to this Notice, we will promptly revise and issue the new Notice with the new effective date. VI. Complaints If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the U.S. Department of Health and Human Services. All complaints to the Plan must be made in writing and sent to the Privacy Office listed at the end of this Notice. We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint. VII. Contact the Plan If you have any complaints or questions about this Notice or you want to submit a written request to the Plan as required in any of the previous sections of this Notice, please contact: Address: Health Net Privacy Office Attention: Director, Information Privacy P.O. Box 9103 Van Nuys, CA You may also contact us at: Telephone: Fax: [email protected] 72 Rev. 09/01/13

81 FOR MORE INFORMATION, CONTACT: Health Net Community Solutions Burbank Blvd., C-5 Woodland Hills, CA Medi-Cal Member Services: Telecommunications Device for the hearing impaired: To report suspected fraud or abuse: To call Health Net 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. 73

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84 CA (3/2014) Health Net Community Solutions, Inc. is an affiliate of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved. 76