EVIDENCE OF COVERAGE MEMBER HANDBOOK. Medi-Cal SAN DIEGO COUNTY EVIDENCIA DE COBERTURA MANUAL PARA LOS MIEMBROS

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1 EVIDENCE OF COVERAGE MEMBER HANDBOOK Medi-Cal SAN DIEGO COUNTY EVIDENCIA DE COBERTURA MANUAL PARA LOS MIEMBROS

2 If you need this information in your language or in an alternative format (i.e. Braille, Large Print or Audio), please call our toll free number **ENGLISH** ا إذذاا كنت بحاجة ا إلى هھھھذهه االمعلوماتت بلغتك يیرجى االا تصالل بالهھاتف االمجاني ا أوو في شكل بديیل (برراايیلل ا أيي با حررفف كبيیررةة ا أوو االصووتت) **ARABIC** Si necesita esta información en español, o en formato alterno (por ejemplo, braille, letra grande o audio), por favor llame al Esta llamada es gratuita. **SPANISH** Nếu bạn cần thông tin này trong ngôn ngữ của bạn hoặc trong một định dạng khác (ví dụ như chữ nổi, lớn In hoặc Audio), xin vui lòng gọi số điện thoại miễn phí của chúng tôi số **VIETNAMESE** San Diego County_2014

3 MEMBER HANDBOOK Evidence of Coverage (EOC) SAN DIEGO GMC

4 Welcome This Member Handbook is also called the Combined Evidence of Coverage and Disclosure Form. It tells you how to get health care. It also has the terms and conditions of your health benefits coverage. You should read the Member Handbook completely and carefully. Words in bold can be found at the end of the book. Refer to the section titled GLOSSARY. The glossary will help you understand words used in this Member Handbook. If you or your child has special health needs, you should read the sections that apply to you. This Member Handbook and its Summary of Benefits Section are only a summary of the Care1st Health Plan policies and rules. You must look at the contract between Care1st Health Plan and the Department of Health Care Services (DHCS) to determine the exact terms and conditions of coverage. Call Care1st Health Plan if you have questions about covered services or specific provisions. CONTACTS Care1st Health Plan 3131 Camino Del Rio North Suite 1300 San Diego, CA Care1st Health Plan Member Services Department toll-free

5 IN YOUR LANGUAGE Dear Member, We know that it is important to communicate clearly so you can get the health care services you need. In the United States, there are laws, such as the Civil Rights Act of 1964, which protects you if you do not speak English. If you cannot hear or are hard of hearing (hearing impaired) or disabled, aged or blind, you are also protected by the Americans with Disabilities Act (ADA) of The ADA is a law that protects people with disabilities from discrimination The ADA makes sure that there is equal opportunity for persons with disabilities in employment, state and local government services. The doctor s office, clinic, or hospital cannot deny services because you do not speak English, are hearing impaired, or have other disabilities. You have the right to free interpreter services when getting health care or any related service through your health plan. An interpreter is a person who translates orally what is said in one language to another language. This allows persons of different languages to speak with each other and understand each other. If you would like to get this material in your language, please call Care1st Member Services Department at KNOW YOUR RIGHTS! You have the right not to be treated differently by health care providers (e.g., doctors, hospitals, clinics, and pharmacies) on the grounds of race, color, or national origin. Health care providers cannot leave you out or limit services to you. If you cannot speak English, or do not know English well, you have the right to get a FREE interpreter at the doctor s office. You should NOT be asked to bring your own interpreter or use a friend or family member. If you choose to use your own interpreter after a free interpreter is offered, you can do so. Ask your doctor or call Care1st Member Services Department at If you cannot read English, or do not know English well, you have the right to get important notices about your coverage, health advice and health education materials in your language. Ask your doctor or call Care1st Member Services Department at You have the right to file a complaint if your cultural and language needs are not met. Please call Care1st Member Services Department at Care1st Health Plan Member Services Department toll-free

6 Table of Contents IN YOUR LANGUAGE 3 YOUR RIGHTS AND RESPONSIBILITIES 7 What are your health care rights?... 7 What are your responsibilities as a health care member?... 8 Confidentiality... 9 Health Information Privacy... 9 HOW TO USE CARE1ST HEALTH PLAN 11 Your Identification (ID) Card Making an Appointment With Your Doctor Choosing a Primary Care Physician (PCP) Specialist Care Prior Authorizations and Referrals Getting a Second Medical Opinion Changing Your Primary Care Doctor How To Keep Seeing Your Doctor If Your Doctor Has Left The Plan or is not with the Plan Federally Qualified Health Centers (FQHCs) Preventive Care Programs To Keep You Well Emergency and Urgent Care Services Information In Other Languages, Hearing Impaired, Visually-Impaired and Disability Access How To Get Prescription Drugs Transportation Other Things You May Need To Know SUMMARY OF BENEFITS 26 Services Substance Use Disorder Preventive Services Cancer Screening Confidential HIV Testing Diabetic Services Doctor Office Visits Drugs /Medications Durable Medical Equipment (DME) Emergency Services Family Planning Health Education Services Hearing Aids Home Health Hospice Care Hospital Care Care1st Health Plan Member Services Department toll-free

7 Interpreter Services Lab Services Long Term Care Services...32 Mastectomy Maternity Care Newborn Care Nurse/Midwife and Nurse Practitioner Obstetrical/Gynecological (OB/GYN) Out of Service Area Coverage Outpatient Mental Health Services Prenatal Care Reconstructive Surgery Sexually Transmitted Disease (STD) Services Skilled Nursing Facility Therapy Occupational, Physical and Speech Vision Care X-ray Services CARVED OUT SERVICES 39 NON-COVERED SERVICES 40 SPECIAL SERVICES 41 California Children Services (CCS) Special Services for Native American Indians Women, Infants and Children (WIC) Program Minor Consent Services (Members 12 years and older) Important Things To Remember New Technology GRIEVANCES AND APPEALS 43 Grievances EXPEDITED APPEAL (Urgent review of denied services) Department of Managed Health Care (DMHC) Independent Medical Review of Grievances External Independent Review (EIR) State Fair Hearing ENROLLMENTS AND DISENROLLMENTS 49 Voluntary Medi-Cal Managed Care Members Disenrollments Expedited Disenrollments Mandatory Disenrollments PARTICIPATING IN PUBLIC POLICY MEETINGS 51 Care1st Health Plan Public Policy Committee Communicating Policy Changes OTHER INFORMATION 52 If You Move If You Get a Bill Care1st Health Plan Member Services Department toll-free

8 If You Have Other Insurance If You Are a Medical/Medicare Member How A Provider Gets Paid Third Party Liability Transitional Medi-Cal Organ Donation What is an Advance Directive? ARBITRATION DISAGREEMENTS 55 PREVENTING HEALTH CARE FRAUD 56 Prevention Tips Reporting Fraud Our Responsibilities Care1st Compliance Hotline GLOSSARY 57 IMPORTANT PHONE NUMBERS 66 Disability Services Children Services California State Services Care1st Health Plan Member Services Department toll-free

9 YOUR RIGHTS AND RESPONSIBILITIES What are your health care rights? You have the right to know. Know and receive information including all enrollment notices, information materials, and instructional material in all threshold languages. Know and receive your rights and responsibilities. Know about our services, doctors, and specialists and be informed when your doctor is no longer contracted with Care1st Health Plan. Know about all our other caregivers. Be able to see your medical records. You have to follow the State and Federal laws that apply. Know that if you are a recipient of In-Home Supportive Services (IHSS), you may give verbal consent to the IHSS provider to speak on your behalf. Know that you will not be balanced billed by a contracted provider. The Public Policy Committee at Care1st allows consumers with disabilities the right to participate in the committee. You have the right to be treated well. Always be treated with respect and recognition of your dignity. Have your privacy kept safe by everyone in our health plan. Know that we keep all your information private. Know that you will not face negative consequences for exercising your rights. Know that you have the right to be free from any form of abuse, such as being restraint or left secluded, as means of being disciplined or retaliated against. Care1st members are not discriminated against in the delivery of health care services based on; medical conditions (including physical and mental illness), claims experience, receipt of health care, medical history, and/or genetic information. You have the right to be in charge of your health care. Choose your primary care doctor. Say no to care from your primary care doctor or other caregivers. Be able to make choices and to participate with your provider about your health care. Make a living will (also called an Advance Directive). 7 Care1st Health Plan Member Services Department toll-free

10 Have an honest talk with your doctor about all treatment options for your condition, regardless of cost or benefit coverage. Voice complaints or appeals about Care1st or the care it provides including the right to file a grievance if you do not receive services in the language you request. You have the right to get a range of services. Get family planning services. Get preventative health care services. Get minor consent services. Be treated for sexually transmitted diseases (STDs). Get emergency care outside of our network. Get health care from a Federally Qualified Health Center (FQHC). Get health care at an Indian Health Center. Get a second opinion. Get interpreter services at no cost. This includes services for the hearing-impaired. Get informing information materials in alternative formats and large size print upon request. You have the right to get the Member Handbook and other information in another language or format (such as audio, large print, or Braille). You have the right to suggest changes to our health plan. Tell us what you don t like about our health plan. Tell us what you don t like about the health care you get. Question our decisions about your health care. Tell us what you don t like about our right and responsibilities policy. Ask the Department of Social Services for a Fair Hearing. Ask the Department of Managed Health Care for an Independent Medical Review. Choose to leave our health plan. What are your responsibilities as a health care member? Make an appointment with your doctor within 120 days of becoming a new member for an initial health assessment. Tell your doctors what they need to know to treat you. Learn as much as you can about your health. Follow the treatment plans you and your doctors agree to. Follow what the doctor tells you to do to take good care of yourself. Do the things that keep you from getting sick. Bring your ID card with you when you visit your doctor. 8 Care1st Health Plan Member Services Department toll-free

11 Treat your doctors and other caregivers with respect. Use the emergency room for emergencies only. Your doctor will provide most of the medical care that you need. Understand your health problems and participate in developing a mutually agreed-upon treatment goal(s), to the degree possible. Report health care fraud. We want you to understand your health plan. Know and follow the rules of your health plan. Know that laws guide our health plan and the services you get. Know that we can t treat you different because of, age, sex, race, national origin, culture, language needs, sexual orientation and/or health. Confidentiality You have the right to keep your medical records confidential. You can request a copy of our confidentiality policy. Just call Care1st Health Plan. Health Information Privacy At Care1st Health Plan, we value the trust you have in us. We want to keep you as a Care1st Health Plan member. That s why we want to share with you the steps Care1st Health Plan takes to keep health information about you and your family private. To keep health information about you and your family private, Care1st Health Plan: Uses secure computer systems Handles health information the same way, every time Reviews the way Care1st Health Plan handles health information Follows all laws about the privacy of health information All Care1st Health Plan staff that has access to your health information is trained on privacy laws. They also follow Care1st Health Plan s guidelines. They even sign a note that they will keep all health information private. Care1st Health Plan does not give out health information to any person or group who does not have a right to it by law. Care1st Health Plan needs some information about you so that we can give you good health care services. This information includes: Name Gender Date of birth Language you prefer to speak 9 Care1st Health Plan Member Services Department toll-free

12 Language you prefer to read Home address Home or work telephone number Occupation and employer Whether you are married or single Health history Care1st Health Plan may get this information from any of these sources: You A parent, guardian, or conservator Another health plan Your doctor Your application for the health care program Your health records Before Care1st Health Plan gives your health information to another person or group, we need your written approval. There are times when we may not get your written approval. This may happen when: A court, arbitrator, or similar agency needs your health information A subpoena or search warrant is requested A coroner needs your health information Your health information is needed by law Care1st Health Plan may give your health information to another health plan to: Make a diagnosis or treatment Make payment for your health care Review the quality of your health care Sometimes, we may also give your health information to: groups who license health care providers public agencies investigators probate courts organ donation groups federal or state agencies as required by law disease management programs If you have any questions or would like to know more about your health information, please call Care1st Health Plan. 10 Care1st Health Plan Member Services Department toll-free

13 HOW TO USE CARE1ST HEALTH PLAN Your Identification (ID) Card Show your Care1st Health Plan ID Card to your doctor or hospital when you go for health care services. Look on your card for the important phone numbers you need: Your Primary Care Doctor Care1st Health Plan toll free member service line Always carry your Care1st Health Plan ID card with you in case of an emergency. You are the only person who can get health care services under your Care1st Health Plan ID card number. If you let someone else use your Care1st Health Plan ID card, we may not be able to keep you on our plan. You can find your effective date of coverage on your Care1st Health Plan ID card. This is the date when you can begin getting your health care benefits through Care1st Health Plan. Making an Appointment With Your Doctor Whenever possible, you should call to schedule an appointment before a visit to your Primary Care Physician. For routine office visits, please call your Primary Care Physician at least 48 hours in advance to schedule an appointment. For health assessment appointments, such as your yearly physical, please call at least two or three weeks in advance. If you need more immediate attention, call your Primary Care Physician right away and request the next available appointment. 11 Care1st Health Plan Member Services Department toll-free

14 IF YOU NEED TO CANCEL YOUR APPOINTMENT, CALL YOUR PRIMARY CARE PHYSICIAN AS FAR IN ADVANCE AS POSSIBLE; PREFERABLY AT LEAST 24 HOURS BEFORE YOUR SCHEDULED APPOINTMENT. Initial Health Assessment Care1st offers preventive health services to you, which includes an annual health assessment to help you maintain good health. As part of the preventive services, it is important to schedule a visit to your Primary Care Physician for an initial health assessment so that the Primary Care Physician can assess your health status and health care needs. This is also an opportunity for you to get to know the Primary Care Physician. Call your PCP for an appointment and tell them you are a Care1st Health Plan member. Have your Care1st Health Plan card with you when you call; you may be asked for the numbers on the card. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED Care1st Health Plan 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 Care1st Health Plan s network by calling Care1st Health Plan and asking for a provider directory. Care1st s website and the Provider Directory show the level of Physical Accessibility/ Medical Equipment Accessibility for contracted providers. In most cases, you need to get care within Care1st Health Plan s network. That is not the case if you need emergency care or need urgent care outside of San Diego County. This is talked about more in the Emergency and Urgent Care Services section of this handbook. Choosing a Primary Care Physician (PCP) A Primary Care Physician (PCP) is a provider who will be your regular doctor. Inside the Provider Directory, you will find a list of primary care doctors near you who work with Care1st Health Plan. You should choose one of these doctors for your primary care within thirty days after the effective date. Failure to timely select a Provider will result in auto assignment by Care1st Health Plan. If you would like to change your Primary Care Physician call us at Also, if you are pregnant, please call us so that we can make sure you get the care you need and help you choose a primary care doctor for your baby. You can choose a nurse midwife (NMW), a physician's assistant (PA), or nurse practitioner (NP) as your primary care provider. These health care providers are called "mid-level practitioners". When you get your Care1st Health Plan card, you will only see the name of the doctor that your mid-level practitioner works for. However, you can still see the mid-level practitioner you picked. 12 Care1st Health Plan Member Services Department toll-free

15 Specialist Care You may need to see a specialist (or other qualified health care professional) for a long time if you have a condition or disease that is chronic (such as diabetes or asthma), life-threatening (such as HIV/AIDS), or disabling. This is called a standing referral. A standing referral is made to a specialist who is in Care1st Health Plan s network or who is with a contracted specialty care center. If Care1st Health Plan does not have a qualified specialist, Care1st Health Plan will send you to a specialist outside their network. A standing referral needs an approval by Care1st Health Plan. You can ask your PCP doctor for a standing referral. Or, your doctor can ask Care1st Health Plan for a standing referral. Care1st Health Plan must decide on your request for a standing referral within three (3) business days. Once you have a standing referral, you will not need permission for each visit with the specialist. Standing referrals are issued on a month-to-month basis. Your Medi-Cal eligibility status must be active at the time that you go to see the specialist. Otherwise, you will not be able to see him or her under your Care1st Medi-Cal coverage. Your specialist will develop a treatment plan for you. The treatment plan will show how often you need to go to the doctor. Once the treatment plan is approved, the specialist will coordinate the care you get. This specialist will be authorized to provide health care services the same way your PCP doctor would, based on his or her skill, training, and the treatment plan. Prior Authorizations and Referrals Your PCP must approve all health care services before you receive them. This is called prior authorization. A referral is when you request health care services that your PCP does not normally provide. Some services do not require a referral. Refer to the Summary of Benefits section. Routine referrals take up to five working days to process ( working days are Monday through Friday), but may take up to 14 calendar days (Sunday through Saturday) 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 Care1st Health Plan if you have not received a response within the above timeframes. All health care services are reviewed, approved, or denied according to medical necessity. If you would like a copy of the policies and procedures Care1st Health Plan uses to decide if a service is medically necessary, call Care1st Health Plan. 13 Care1st Health Plan Member Services Department toll-free

16 Referrals to Non-Physician Providers You may get services from non-physician providers who work in your PCP s network. Nonphysician providers may include, but not limited to Clinical Social Workers, Family Therapists, and Nurse Midwives. You may need a referral from your PCP to see these types of providers. For more information, ask your PCP, or call Care1st Health Plan. Getting a Second Medical Opinion You might have questions about a treatment or surgery that your doctor says you need. You may want a second opinion. You should speak to your doctor if you want a second opinion. You will get a second opinion from a qualified health care provider. If you need a second opinion for specialty care, it will be provided by a doctor of the same specialty in the Care1st Health Plan network. If there is no qualified provider that works with Care1st Health Plan, we will approve a second opinion by another qualified provider. Care1st Health Plan will consider your ability to travel. Care1st will ensure that the Utilization Management program allows for a second opinion from a qualified health professional at no cost to you. When you ask for a second opinion, Care1st Health Plan will decide quickly. If the medical condition is a chronic illness, or could cause loss of life, limb or bodily function, Care1st Health Plan will decide within 72 hours. For more information about second opinions, call Care1st Health Plan s Member Services at If you are denied a second opinion, you may call us at or write to Care1st Health Plan, Appeals and Grievances Department, 601 Potrero Grande Dr. Monterey Park, Ca to file an appeal, or to request a copy of our written policy on second opinions. Changing Your Primary Care Doctor Most of the time, it's best to keep the same doctor, so she or he can really get to know your medical needs and history. You may find out later that you need to change doctors. If you need to change doctors please call us at We want to do everything we can to be sure you are happy with your doctor. You can change your doctor for any reason. You must choose a doctor who will see new patients; we can help you find one. If you choose a doctor who is not available, we will help you choose another one. It is important to know that when you change doctors often, your health care may not be as good as it could be. We will let you know when you can begin seeing the new doctor. 14 Care1st Health Plan Member Services Department toll-free

17 Care1st Health Plan or your doctor may ask you to change doctors for reasons that include: Care1st Health Plan no longer works with your doctor You are unable to get along or agree with your doctor You keep making appointments and not showing up for them You are often very late for your appointments You behave in a rude or abusive way, or disrupt the doctor's office We will tell you in writing if we need to make this change. How To Keep Seeing Your Doctor If Your Doctor Has Left The Plan Sometimes Care1st Health Plan 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, if he/she agrees and has been treating you for any of the following conditions: Acute condition Serious chronic (long-term) condition Last six (6) months of pregnancy High-risk (difficult) pregnancies Delivery-related services If you have an acute or serious chronic condition, you will continue to receive services from your provider for at least 90 days (or a longer period of time if necessary for a safe transfer). After the delivery of your baby you can continue to receive delivery related services from your provider until a safe transfer can be made to another doctor in your network. Care1st Health Plan will help to make this a safe transfer. If you have a terminal illness you can continue to receive services from your provider for the duration of the terminal illness. Please call Care1st Health Plan if you have any questions. How To Keep Seeing Your Doctor If Your Doctor is not with the Plan Members transitioning from Medi-Cal fee-for-service (FFS) into a Medi-Cal managed care health plan have the right to request continuity of care. As a member, if you have a pre-existing provider relationship and request to continue to see that provider, Care1st will give you the option to continue treatment for up to 12 months with your out of network provider, when the following has been met: 15 Care1st Health Plan Member Services Department toll-free

18 Care1st is able to determine that you have an ongoing relationship with the provider. The provider is wiling to accept the higher of Care1st s contract rates or Medi-Cal FFS rates; and The provider meets Care1st s applicable professinal standards and has no disqualifying qualityof-care issues. An existing relationship means that you have seen the out-of-network primary care or specialist provider at least once during the 12 months prior to the date of your initial enrollment with Care1st Health Plan for a non-emergency visit. Care1st is not required to provide continuity of care for services not covered by Medi-Cal or carved-out services. As a member, you may make a direct request for continuity of care. Once the request is made, Care1st will begin to process the request within five (5) working days after the receipt of the request. The continuity of care process begins when Care1st determines there is a pre-existing relationship and has entered into an agreement with the provider. If your provider won t work with Care1st Health Plan, you will need to find a new provider. Federally Qualified Health Centers (FQHCs) As a member of Care1st Health Plan, you have the right to receive your primary care at a Federally Qualified Health Center that is contracted with Care1st Health Plan. Federally Qualified Health Centers are health centers that receive money from the federal government. Federally Qualified Health Centers are located in areas that do not have a lot of health care services. Call Care1st Health Plan for the names and addresses of the Federally Qualified Health Centers that contract with Care1st Health Plan. Preventive Care Care1st wants you and your children to stay healthy. Many health problems can be stopped if they are found early. The following preventive care services are covered and recommended by Care1st for all children or young adults as described by the American Academy of Pediatrics (AAP) which include all components required by the Child Health and Disability Program (CHDP). Preventive care for children Complete health history Physical exam including growth assessment Nutritional health assessment Vision screening 16 Care1st Health Plan Member Services Department toll-free

19 Dental screening Hearing screening Immunizations Laboratory tests, including tests for anemia, diabetes, and urinary tract infections Tuberculosis (TB) screening Sickle cell trait screening, when appropriate Lead blood level testing, when needed Health education Meeting with the parent, guardian or emancipated minor regarding the meaning of the exam Any service provided by the State of California s Child Health and Disability Prevention Program (CHDP). Please contact your child s primary care doctor for more information about these services. Preventive care for adults These preventive care services are covered and recommended for all adults: History and physical exam Blood pressure check Cholesterol check Breast exam for women as appropriate for age Mammogram for women as appropriate for age Pap smear for women as appropriate for age and health status Tuberculosis (TB) screening Immunizations as appropriate Laboratory tests for diagnosis and treatment Health education Family planning services Prenatal and postpartum care Programs To Keep You Well Sensitive and Private Care Adolescent Sensitive Services If you are between the ages of 12 and 18 you are eligible for "sensitive services," or "minor consent" services. That means you can see a doctor for the following reasons without the permission of your parent or guardian: Outpatient mental health services for sexual abuse, physical abuse, harmful behavior to yourself or others 17 Care1st Health Plan Member Services Department toll-free

20 Pregnancy Family planning Sexual assault Sexually transmitted diseases drug and alcohol abuse HIV/AIDS testing The care you receive for these services is kept between you and your doctor. The doctor or clinic does not have to be a part of Care1st Health Plan. These services are provided at no cost to you. For more information about sensitive services, call Care1st Health Plan Member Services at Abortion Services for Adults and Adolescents (12 years of age or older) Care1st Health Plan will pay for abortion services provided by any Care1st Health Plan network provider. These services are kept private between you and your doctor. For more information about sensitive services, call Care1st Health Plan Member Services at Adult Sensitive Services As an adult, you may not want to see your regular doctor for sensitive and private care. You may pick any doctor or clinic for the following sensitive and private services: family planning sexually transmitted disease testing and care HIV/AIDS testing The doctor or clinic does not have to be a part of Care1st Health Plan. These services are provided at no cost to you. For more information about sensitive services, call Care1st Health Plan Member Services at Emergency and Urgent Care Services 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 Care1st Health Plan 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 18 Care1st Health Plan Member Services Department toll-free

21 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. A doctor is available by phone 24 hours a day, seven (7) days a week, and also on weekends and holidays. 3. Tell them about your condition and follow their instructions. You may receive same-day urgent care services. It should not take longer than 48 hours from the time you call to request an appointment to get urgent care services from your PCP doctor. If you are outside of San Diego County, you do not need to call your PCP doctor or get prior authorization before getting urgent care services. Be sure to let your PCP doctor know about this care. You may need follow-up care from your PCP doctor. What is Emergency Care? Emergency services are covered 24 hours a day, seven (7) days a week, anywhere. Emergency care is a service a member reasonably believes is necessary to stop or relieve: Serious illnesses or symptoms Injuries or conditions requiring immediate diagnosis and treatment Emergency services and care include ambulance, medical screening, examination, and evaluation by a doctor or other medical personnel. Emergency services include both physical and psychiatric emergency conditions as well as active labor. Examples of emergencies include but are not limited to: Having trouble breathing Seizures (convulsions) Lots of bleeding Unconsciousness/blackouts (when you can t wake up) Lots of pain (including chest pain) Swallowing of poison or medicine overdose Active labor Broken bones Head injury Eye injury Examples of psychiatric emergency medical conditions include but are not limited to: Thoughts or actions about hurting yourself or someone else Unable to care for yourself, such as being unable to feed, shelter or dress yourself due to a mental disorder 19 Care1st Health Plan Member Services Department toll-free

22 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 (regular) 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. Outside of San Diego County? If you have an emergency when you are not in San Diego County, you can get emergency services at the nearest emergency facility. Emergency services do not require a referral or okay from your PCP doctor. If you are admitted to a hospital not in Care1st s network or to a hospital your PCP doctor or other provider does not work at, Care1st has the right to move you to a network hospital as soon as it is medically safe. You may need hospital care after an emergency to stabilize your condition. This is called poststabilization care. If you do, the hospital will call Care1st to ask for an okay. The hospital may ask you for your Plan name and phone number. Show the hospital your Care1st ID card. If you don t have your ID card, tell them to call Care1st. Your PCP doctor must provide follow-up care when you leave the hospital. What to do after an emergency 1. Call Care1st within 24 hours of receiving emergency care or as soon as you can. 2. Follow the instructions of the emergency room doctor. 3. Call you PCP doctor to make an appointment for follow-up care. Not sure you have an emergency? If you are not sure, call your PCP doctor. Do what your PCP doctor tells you to do. Nonemergency problems may include, but are not limited to, the following: earaches, colds, the flu, and sore throats. Do not call 911 for non-emergency problems. Call your PCP doctor. Not sure what kind of care you need? Sometimes it s difficult to know what kind of care you need, so we have licensed health care professionals available to assist you by phone 24 hours a day, seven days a week. Here are some of the ways they can help you: 20 Care1st Health Plan Member Services Department toll-free

23 They can answer questions about a health concern and instruct you on self-care at home if appropriate. They can advise you about whether you should get medical care and how and where to get care (for example, if you are not sure whether your condition is an emergency medical condition, they can help you decide whether you need emergency care or urgent care, and how and where to get that care). They can tell you what to do if you need care and your PCP doctor s office is closed. You can reach one of these licensed health care professionals by calling Care1st Health Plan at and press the option to speak with the Nurse Advice Line. When you call, a trained support person may ask you questions to help determine how to direct your call. Information In Other Languages, Hearing Impaired, Visually-Impaired and Disability Access Information in other languages 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 Americans with Disabilities Act (ADA) of 1990 protect you if you do not speak English or have a disability and need help communicating with your doctor. Your doctor s office, clinic, or hospital can t deny services to you because you do not speak English or have a disability. You have the right to free interpreting services including American Sign Language interpreters when getting health care service or other services that are paid for by your health plan, including after-hours interpreting 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 or who use sign language to talk with and understand each other. This is also more private because you are not telling your child, family member, or friend to interpret for you. If you need interpreting services Interpreting services in your language, including American Sign Language, are free 24 hours a day, seven (7) days a week. You should not use children or family members as interpreters. Call Care1st Health Plan or your doctor if you need interpreting services. We will work with you and your PCP doctor to make sure you can have services in a language you understand. 21 Care1st Health Plan Member Services Department toll-free

24 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. CRS can also help a non-tty user call a TTY user. Trained operators take phone calls and help hearing people and non-hearing people communicate. Statewide access for voice or TTY/TDD is 711. Members and providers can dial 711 on their phones to call the California Relay Service directly. 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 May not look like they have a disability or had a disability in the past The ADA law makes sure there are equal chances for people with disabilities in employment and in state and local government services, including health care. A doctor s office, clinic, or hospital can t deny you services 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 if services are hard to get. Below 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 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 your language You feel that you were denied services because of a disability 22 Care1st Health Plan Member Services Department toll-free

25 How To Get Prescription Drugs What Can My Doctor Prescribe? Care1st Health Plan uses a chosen list of drugs called a "formulary" to help your doctor decide which drug to prescribe. A group of doctors and pharmacists updates this list of drugs every three months. Updating this list helps to ensure that the drugs on it are safe and useful. If your doctor thinks you need to take a drug that is not on this list, your doctor will call us, or submit a written request for prior authorization review. Some drugs require Care1st Health Plan approval. If you would like to know if a drug is on this list or for a copy of the Care1st Health Plan Medi-Cal Formulary, please call Care1st Health Plan s Member Services at However, even though a drug is on the list, your doctor will decide which drug is best for you. Where To Get Your Prescriptions Filled? In our Provider Directory you will find a list of drug stores near you that work with Care1st Health Plan. You must go to one of these drug stores for your prescription drugs. Your medicine will not be covered if you go to a drug store that is not on the Care1st Health Plan pharmacy listing. If it's an emergency and you can't go to a drug store on the Care1st Health Plan pharmacy listing: go to the nearest drug store and have them call us at Your medicine will not be covered if you go to a drug store outside of California, unless it's an emergency. You can call us at if you need help finding a drug store near you or have any questions about your pharmacy benefits. Your prescription must be prescribed by a physician for the care and treatment of an injury or an illness. When you get your prescription filled, no more than a 30-day supply of medicine will be given. Your doctor may write the prescription so you can get refills. Usually the pharmacy will call your doctor to check if refills can be given. There are some exceptions to this supply limitation, please call us at Care1st Health Plan Member Services Department toll-free

26 Transportation Medical Transportation Services Emergency ambulance transportation to the first hospital which actually accepts the member for emergency care is covered in connection with emergency services. These services include ambulance and ambulance transportation services provided through the 911 emergency response system. If the responding paramedics determine that you do not have a lifethreatening health condition that requires emergency ambulance transportation, you will be denied the ambulance transportation service at that time. Non-emergency medical transportation is also covered for a member who cannot use public transportation services due to medical contraindications, and 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 a Plan provider, and Authorized in advance by Care1st Health Plan. Non-medical Transportation Care1st Health Plan offers non-medical transportation to and from your doctor s office. Transportation services are provided via taxicab. All members requesting transportation must be eligible for the services for the month the transportation is requested. Requests must be made at least 24 hours in advance and a limit of two (2) transportations per month will be arranged. Please call Care1st Health Plan Member Service s at to schedule a pick-up, or if you have any questions. 24 Care1st Health Plan Member Services Department toll-free

27 Other Things You May Need To Know You may be able to get help from your county's Women, Infants and Children (WIC) Program. The WIC Program gives out food vouchers and can tell you about other programs in your area. Call Care1st Health Plan Member Services at for WIC's telephone number. You can have access to your medical records. At least once a year, Care1st Health Plan will send a form to some of its members to find out if they are happy with their health care. So that we can pay for your health care, Care1st Health Plan has the right to get information from anyone giving you that care. We keep this information between you, the health care provider, and Care1st Health Plan. The services covered by Care1st Health Plan can be changed without your agreement. We will let you know of any changes by mail. Your benefits depend on what is covered on the date you get the service. If we need to tell you about any changes in the plan, we will contact you at the address we have in our records - so if you move, tell your eligibility worker at your county Department of Social Services right away. 25 Care1st Health Plan Member Services Department toll-free

28 SUMMARY OF BENEFITS Your PCP must arrange and authorize all your care before you receive services. All health care services are reviewed, approved, or denied according to medical necessity. It is important that you learn about your benefits before you need them. There are some services your PCP does not need to arrange or authorize. These services include: California Children Services (CCS) Child Health and Disability Prevention (CHDP) Confidential HIV testing Emergency services Family planning services Immunizations (Shots) Certain Obstetrical/Gynecological (OB/GYN) services, including pregnancy-related services. Call an OB/GYN doctor who is in the same network as your PCP to make an appointment. Native American Indians who receive health care from Indian Health Centers or a Native American Health Clinic. Sexually Transmitted Disease (STD) services Women, Infant and Children (WIC) services Services The services listed below are subject to all terms, conditions, limits, and exclusions described in this Member Handbook. This is not a complete list. Substance Use Disorder Preventive Services Cost: There is no cost to the member. Description: Alcohol misuse screening services are now a benefit covered by Care1st Health Plan for all members ages 18 and older. The services for alcohol misuse covered are: Covered Services: If indicated, one (1) expanded screening for risky alcohol use per year Up to three (3) 15-minute brief intervention sessions to address risky alcohol use per year 26 Care1st Health Plan Member Services Department toll-free

29 Not Covered: Treatment for major alcohol and drug problems. Services for these disorders are available through the County Screening, Brief Intervention, and Referral to Treatment (SBIRT) Cancer Screening All generally medically accepted cancer screening tests. Mammography for screening or diagnostic purposes. Cervical Cancer Screening Test: if you are referred by your PCP or treating provider, you may get any other Cervical Cancer Screening test that is approved by the Food & Drug Administration (FDA) in addition to the usual Pap Smear Test. Cancer Clinical Trials: if you have cancer, you may be able to be part of a cancer clinical trial. The cancer clinical trial must meet certain requirements, when referred by your Care1st Health Plan PCP 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), Food and Drug Administration (FDA), U.S. Department of Defense, or the U.S. Veteran s Administration. If you are part of an approved cancer clinical trial, Care1st Health Plan will provide coverage for all routine patient care cost related to the cancer clinical trial. If you have a life threatening or debilitating 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. Confidential HIV Testing You do not need prior authorization from your PCP for confidential HIV testing. You may receive confidential HIV testing from any health care provider licensed to provide these services. Examples of where you can get confidential HIV testing include: San Diego County Department of Health Services Family planning services providers PCP Prenatal clinics Please call Care1st Health Plan to request a list of testing sites. 27 Care1st Health Plan Member Services Department toll-free

30 Diabetic Services The following services are covered for diabetics when medically necessary: 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 to prevent or treat diabetes-related complications - Insulin syringes - Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin Training and education for self-management Family education for self-management Doctor Office Visits All visits, exams, treatments, shots, and CHDP visits are provided by your PCP. You may also get CHDP services from school-based programs or the San Diego County Department of Health Services. Drugs /Medications Prescription drugs and over-the-counter drugs on the Care1st Health Plan formulary are covered. Durable Medical Equipment (DME) DME is medical equipment that is used repeatedly by a person who is ill or injured. Examples include: Apnea monitors Blood glucose monitors, including monitors for the visually impaired for insulin dependent, non-insulin dependent and gestational diabetes Insulin pumps and all related supplies 28 Care1st Health Plan Member Services Department toll-free