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«Partnership HealthPlan of California Medi-Cal Member Handbook Together for your Health Our Service Area Del Norte, Humboldt, Lake, Lassen, Marin, ...»

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Partnership HealthPlan of California

Medi-Cal Member Handbook

Together for your Health

Our Service Area

Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano,

Sonoma, Trinity and Yolo Counties

Dear Member,


You are now a member of the Partnership HealthPlan of California (PHC). PHC is a health plan

for people who have Medi-Cal.

As a new PHC member there are some things you need to do.

 Choose a Primary Care Provider (PCP) from the list of providers you received from PHC.

This list of medical providers is called a Provider Directory.

 Tell the PHC Member Services Department which PCP that you chose.

 Please call your PCP as soon as possible to schedule an appointment for a checkup. You should have this checkup within 120 days from the date you became eligible for MediCal. Your provider will review your current medical and preventive health care needs.

Checkups are a great way for you to know that you are in good health. Checkups are also a good way for your provider to prevent health problems. The name and phone number of your assigned PCP is printed on your PHC ID card.

Please read this Handbook carefully. It will answer many questions about PHC. If you have any questions call PHC’s Member Services Department at (800) 863-4155. We are available to help you Monday – Friday, 8:00 a.m. – 5:00 p.m. Hearing and/or speech impaired members can call the California Relay Service by calling (800) 735-2929 or call 711. Don’t forget to visit our website at www.partnershiphp.org.

Let's work together for your health!

Sincerely, Partnership HealthPlan of California Table of Contents Section A - Important Phone Numbers

Section B - Member Rights and Responsibilities

Section 1 – Welcome to PHC!

 A quick look at what you need to know as a new PHC member.

Section 2 – How to Enroll in Medi-Cal

 What to know when you first become a member.

Section 3 – Who gives me health care?

 Learn about different kinds of providers and our network.

Section 4 – How do I get primary (routine) care?

 Learn about choosing a PCP and getting primary care.

Section 5 – How do I get specialty care?

 Learn about Prior Approval and types of specialty care.

Section 6 – Outpatient Mental Health Care

 Learn about getting mental health care from our network.

Section 7 – Urgent and Emergency Care

 Learn about how and where to get urgent and emergency care.

Section 8 – Transportation

 Learn about different types of transportation services.

Section 9 – Covered services

 A list of benefits covered by PHC, State Medi-Cal or Other Programs.

Section 10 – What does Medi-Cal not cover?

 Learn about what is not covered by PHC or Medi-Cal.

Section 11 – Prescription Drugs

 Learn about our prescription drug benefit and how to get covered drugs.

Section 12 – How to file a grievance

 Learn about your grievance rights.

Section 13 – Coordination of Benefits and Other Information

 Learn about estate recovery, coordination of benefits.

Section 14 – Your Privacy Rights

 Learn about your rights regarding your medical information.

Section 15 – How you can make a difference

 Learn about how to participate in the policy making process at PHC.

Section 16 – Notice of Privacy Practices

 Learn about what PHC does with your information and your rights.

Section 17 – Help PHC Stop Fraud, Waste and Abuse

 Learn about helping stop Fraud, Waste and Abuse.

Section 18 – Glossary

 Learn more about the names and words we use in this handbook.      Section A - Important Phone Numbers

–  –  –

 Respectful treatment and privacy. You have the right to be treated with respect, giving due consideration to your right to privacy and need to maintain confidentiality of your medical information. You also have the right to be free of any form of restraint or seclusion used as a means of coercion, discipline, or retaliation.

 Choice and involvement in your care. You have the right to participate in decision making regarding your own health care, including your right to refuse treatment. You have a right to receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand, regardless of cost or benefit coverage. You also have the right to make advance directives.

 Have access to health care. You have a right to be provided with information about PHC and its services, including covered services. You also have the right to choose a Primary Care Provider within PHC’s network.

 Have access to special services. You have the right to have access to a women’s health specialist and Minor Consent Services. You also have a right to receive care from a certified nurse mid-wife or certified nurse practitioner if you can’t get care from these providers in our network.

 File a complaint. You have the right to file grievances about PHC or the care you received. You also have the right to request a State Hearing and get information about how to get an Expedited State Hearing.

 Information in your language. You have the right to request an interpreter at no charge to you. You should not use children to interpret for you. You also have the right to get this Member Handbook and other information in another language or format (such as audio, large print, or Braille).

 Access your medical records. You have the right to have access to, and where legally appropriate, receive copies of, amend or correct your medical records.

 Know your rights. You have a right to exercise these rights without adversely affecting how you are treated by PHC providers or the State. You also have a right to receive information about your rights and responsibilities, and to make recommendations about these rights and responsibilities.

 Talk to an Advice Nurse about health questions or worries about your symptoms.

PHC provides free telephone advice nurse services, 24 hours a day, 7 days a week. The number for PHC’s Advice Nurse is (866) 778-8873.

Page 2 of 66As a member of PHC, you have a responsibility to:

 Treat your provider with respect and courtesy. You are responsible for treating your provider(s) and their staff in a respectful and courteous way. You are responsible for showing up to your appointments on time. If you’re unable to make an appointment, you must call your provider at least 24 hours before the appointment to cancel or reschedule.

 Treat PHC staff with respect and courtesy. You are responsible for treating PHC staff in a respectful and courteous way. You are responsible for making requests, such as for transportation, in advance, and calling PHC to cancel any transportation if you have to cancel or reschedule your medical appointment.

 Play an active part in your care. You are responsible to provide, to the extent possible, information that PHC and its medical providers need in order to care for you. You are responsible for talking to your medical provider about things you can do to improve your overall health.

 Understanding treatment options. You are responsible to understand problems and participate in developing mutually agreed upon treatment goals to the degree possible.

 Calling your provider. You are responsible for calling your provider for appointments when you need medical care, including routine checkups.

 Listen to your provider. You are responsible for telling your medical provider about your medical condition and any medications you are taking. You are also responsible for following instructions for the care you have received from your medical provider.

 Use the Emergency Room (ER) only in an emergency. You are responsible for using the emergency room in cases of an emergency or as directed by your provider or the PHC Advice Nurse.

 Report wrongdoing. You are responsible for reporting fraud or wrongdoing to PHC.

You can do this without giving your name by calling PHC’s hotline at (800) 601-2146, 24 hours a day, 7 days a week. You can also call the Department of Health Care Services Medi-Cal Fraud and Abuse Hotline toll-free at (800) 822-6222.

–  –  –

Partnership HealthPlan of California (PHC) is a local governmental agency that was created in 1993 in Solano County. PHC, also called a County Organized Health System, was created to help people like you receive quality health care.

Today, PHC serves people with Medi-Cal in 14 counties across Northern California. We are proud to call ourselves your local health plan with offices and staff in several areas.

Our mission is “To Help Our Members and Communities We Serve Be Healthy!” The Basics As a member of PHC, you may have some questions about your membership. We hope you find this information useful. You can also look at the Table of Contents to find the information you need.

When this Handbook says “we”, “us”, or “our” it means Partnership HealthPlan of California (PHC).

What is Partnership HealthPlan of California (PHC)?

PHC is a managed care plan for people who are eligible to receive Medi-Cal benefits in their county.

What is a managed care plan?

A managed care plan, sometimes called a Health Maintenance Organization, or HMO is responsible for making sure you get the care you need.

What is a Primary Care Provider (PCP)?

A PCP is your personal provider who will provide basic health care and arrange all of your medical health care needs.

This provider will refer you to specialty care when needed. Some referrals require Prior Approval by PHC.

All PHC members, except Special Case Managed members are assigned to a PCP.

You must receive all medical care from your PCP unless they refer you for specialty care, or unless the type of care you need does not require a referral or Prior Approval. See Section 9 of this Handbook for more information.

–  –  –

PHC’s Member Services Department can help you with questions, concerns and certain

problems you may have:

 Getting a new ID card  Changing your Primary Care Provider (PCP)  Questions about your medical benefits  Problems getting medical care  Getting information on prenatal care  Filing a complaint, appeal or State Hearing PHC’s Member Services Department is open Monday through Friday, 8:00am to 5:00pm.

Language Interpreter Services You have a right to receive interpretation services at no cost to you, any time you get health care.

If you have problems getting interpretation services or need face-to-face interpreting service at your provider’s office, call PHC’s Member Services Department.

To choose a provider or medical group who can speak your language, look in your PHC Provider Directory to see which languages are spoken at each office.

Translation of Written Material PHC has some member materials like this Handbook available in English, Spanish and Russian.

If you need this Handbook or another PHC document translated into one of these languages, call PHC’s Member Services Department.

Materials for Visually Impaired Members If you need this Handbook or another PHC document in large print, audio format, or on a CD, call PHC’s Member Services Department.

Braille versions are available for members with hearing and visual disabilities.

Services for the Hearing Impaired If you have trouble hearing, you can call PHC’s Member Services Department through the California Relay Service (CRS) at (800) 735-2929 or by dialing 711. This service is also available in Spanish by calling (800) 855-3000.

–  –  –

If you change your address or telephone number, you should contact the following people:

 If you receive SSI, call the Social Security Administration (SSA) office at (800) 772 All other members should call their local Medi-Cal eligibility office  Call PHC’s Member Services Department at (800) 863-4155 Triage Services Sometimes it’s difficult to know what kind of care you need. A health care professional will be available to assist you by phone, 24 hours a day, 7 days a week. This is known as “triage”. We offer triage services both through your provider’s office during their business hours, and through our Advice Nurse at (866) 778-8873.

Here are some of the ways that triage can help you:

 They can answer your questions about a health concern and tell you about self-care at home  They can tell you if you should get medical care and how and where to get that care (for example, if you need emergency or urgent care)  They can tell you what to do if you need care when your provider’s office is closed PHC will make sure that you speak with a health care provider over the phone in an amount of time that is appropriate for your medical condition. The waiting time to receive a return call from a doctor or nurse will not be longer than 30 minutes. In some cases, you might have to wait longer if the doctor or nurse does not think that the wait will have a bad effect on your health.

PHC makes sure that its network providers have an answering service or answering machine that tells you how to get urgent or emergency care after hours.

Your PCP’s phone number is on your PHC ID card, as well as the Advice Nurse number. If you have any questions about this information, call PHC’s Member Services Department at (800) 863-4155, 8am to 5pm, Monday through Friday. TTY users should call (800) 735-2929, or dial 711.

Page 6 of 66 Section 2 – How to Enroll in Medi-Cal  What to know when you first become a member.

To enroll in the Medi-Cal program, call or visit your county department that handles Medi-Cal enrollment. This may be called the Department of Social Services, the Department of Health and Social Services, or something similar. You can also enroll in Medi-Cal through Covered California at www.coveredca.com or toll free at (800) 300-1506, (888) 889-4500 TTY.

We serve Medi-Cal members in the following counties:

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