«Partnership HealthPlan of California Medi-Cal Member Handbook Together for your Health Our Service Area Del Norte, Humboldt, Lake, Lassen, Marin, ...»
Most people in these counties will be enrolled into PHC.
The State of California requires people who are eligible for Medi-Cal to receive health care through a Managed Care Health Plan like PHC. This means joining PHC is required for you to get your Medi-Cal benefits.
Your PHC Identification (ID) Card As a PHC member, you will get a PHC ID card. You might also have a card from another type of health coverage, like a Medicare card. Be sure to tell your provider about any and all insurance coverage you have, including Medi-Cal.
Showing your PHC ID card helps your provider know who to call for questions, Prior Approval,
and coordinating your care. Your ID card has the following information:
Your name, date of birth and PHC ID number The date you are assigned to your PHC Primary Care Provider (PCP) Your PCP’s name and phone number Information to help your providers bill us for your care If you change your PCP, or move to another county served by PHC, you may get a new ID card from PHC. You can also call PHC’s Member Services Department to ask for a new ID card at any time.
To learn more about your PCP, or how to pick one, please see Section 4 of this Handbook.
In order for you to get any health care service through PHC, the service must be both:
1) A covered benefit in Medi-Cal managed care; and
2) Medically necessary A “covered benefit” means you can get this service through your PHC Medi-Cal benefit. Some Medi-Cal services are provided by other providers, such as Specialty Mental Health Care. To learn more about Medi-Cal services covered by other providers, see Section 9 of this Handbook.
Can I be disenrolled from PHC?
You can ONLY be disenrolled from PHC for one of the following reasons:
You have moved to a county not covered by PHC You have lost your Medi-Cal eligibility Your Medi-Cal coverage changes to a category not covered by PHC Your enrollment in PHC is based on the type of Medi-Cal you receive and the county you live in.
Enrollment in PHC is required for you to get Medi-Cal benefits. Members cannot choose to leave PHC to go to State Medi-Cal.
If you lose your Medi-Cal coverage If you lose your Medi-Cal benefits, call Covered California at (800) 300-1506, TTY (888) 889Covered California can help you find out if you qualify for other health insurance options.
Learn about different kinds of providers and our network.
This section of the Handbook tells you who you can get care from. PHC works with a large group of providers, including Primary Care Providers (PCPs), specialists, pharmacies, hospitals and other health care providers. We may call these providers “contracted” or “network” providers.
Your PCP gives you most of your care Your PCP is responsible for making sure you get all of your regular health care. Your PCP will also help you get specialty care, prescription drugs and other medically necessary services.
See Section 4 of this Handbook for more information on primary (routine) health care in your Home County.
PHC works with Health Centers to make sure there is access to care in the service area. If you need to know which clinics are in our network, call PHC’s Member Services Department.
Health Centers include Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC) and Indian Health Centers. You can choose one of these Health Centers to receive your primary care. These Health Centers may also offer specialty care and other Medi-Cal services.
Medical groups are like Health Centers. Medical groups have many providers that work together to provide you care. Sometimes these medical groups have specialists, so you can be referred in the group for specialty care by your PCP.
Individual Practices In some counties, PHC may work with private practices for primary care services.
Specialists give you care for certain conditions Your PCP will refer you to a specialist when you have a medical condition that needs care by a provider who specializes in a certain area of medicine. You need a referral or Prior Approval from your PCP before you see a specialist.
See Section 5 of this Handbook for more information on specialty care.
Female members who need an OB/GYN in network don’t need Prior Approval from PHC or their PCP.
Family Planning Services are provided to members of childbearing age to let them decide how many children they wish to have, and when. These services include all methods of birth control approved by the federal Food and Drug Administration (FDA).
As a member, you have a right to get Family Planning Services from any certified Medi-Cal provider. This means you can choose a Family Planning provider that is not in PHC’s network, without Prior Approval from your PCP or PHC.
Here are some examples of covered Family Planning Services that you can get without Prior
Office visits for Family Planning Services Birth control, including emergency contraception Tubal ligation Vasectomy Abortion Pregnancy testing and counseling Sexually transmitted disease (STD) testing and treatment Providers with a Moral Objection Your provider has the right to decline to give you Family Planning Services. This is called a Moral Objection.
If your provider tells you they have a Moral Objection (sometimes called an ethical or religious objection), your provider is required to help you find a provider that can give you the services you need. If you need help getting services call PHC’s Member Services Department at (800) 863-4155. You can also call the Department of Health Care Services, Office of Family Planning toll-free at (800) 942-1054 for information about Family Planning Services. The Office of Family Planning provides information about services, consultation and referrals to Family Planning providers.
Certified Nurse Midwives and Certified Nurse Practitioners If a Certified Nurse Midwife or Certified Nurse Practitioner is not available through your PCP assignment, call PHC’s Member Services Department for information on providers that have Nurse Midwives and Nurse Practitioners on staff.
Certified Nurse Midwife services are available outside of PHC’s network with Prior Approval.
To find out more, ask your PCP or call PHC.
Health care providers can be paid in a few ways by PHC or the medical group they have a
contract with. Providers can be paid by:
A fee for each service Capitation (a set amount for each member per month) Provider incentives or bonuses Call PHC if you would like to know more about how your provider is paid or about financial incentives or bonuses.
Learn about choosing a PCP and getting primary care.
This section of your Handbook will talk about receiving primary care.
Who can be my PCP?
You can choose from a list of PCPs in your Home County by looking in your Home County’s PHC provider directory.
You may also choose a Health Center or medical group as your PCP. When you choose a Health Center or medical group, the Health Center or medical group may help you choose a PCP within their practice.
Choosing a PCP As a member of PHC, we will ask you to choose a Primary Care Provider soon after you are
enrolled. Sometimes we can’t give you the PCP you choose. Some of the reasons are:
The PCP is not taking new patients The PCP does not work with PHC The PCP only sees patients of a certain age (pediatric) If you did not get the PCP you wanted, you can call PHC’s Member Services Department to see if that PCP is available or to choose a new PCP.
We have PCPs in our network that speaks other languages in addition to English. You can see which languages a PCP office speaks by looking in your Home County’s PHC Provider Directory.
If you have other family members enrolled with PHC, you do not have to choose the same PCP for all of your family members.
To pick a PCP call PHC’s Member Services Department or fill out a PCP Selection Form for you and any family members that have PHC.
Changing your PCP If you want to change your PCP you can choose a PCP at any time from your Home County’s PHC Provider Directory and call PHC’s Member Services Department with your choice. Our staff will update your records and send you a new PHC identification card.
If you call PHC’s Member Services Department before the fifteenth (15th) of the month, you can start going to your new PCP the first day of the next month. If you call PHC’s Member Services
Special Case Managed Members Not all members will be assigned to a PCP through PHC. Below are examples of the type of members that are not assigned to a PCP. New members are Special Case Managed for their first month with PHC, unless they have picked a PCP before they joined PHC. Other members will be Special Case Managed after their first month with PHC, such as children in Foster Care, members with End Stage Renal Disease, and members who are enrolled in California Children’s Services (CCS).
Even though Special Case Managed members can see any Medi-Cal provider, Prior Approval is still needed for certain services. If you think you may qualify for Special Case Managed assignment, please contact PHC’s Member Services Department.
Getting care as a new member In your first month as a PHC member, you are usually a Special Case Managed member. See Section 4 of this Handbook to learn more about Special Case Managed members.
You will get a PHC ID card with your assigned Primary Care Provider (PCP), this Handbook, and your Home County’s Provider Directory. The Provider Directory helps you pick a new PCP if you don’t like the PCP we picked for you.
Your assigned PCP is the provider you will start seeing for primary care starting the month after you join PHC. The date you have to start seeing your PCP is on your ID card. Until that time, you can receive medical care from any Medi-Cal provider that is willing to bill PHC.
Prior authorization (also called Prior Approval) may be required for certain services, even when you’re not assigned to PCP. If you need help getting Prior Approval during your first month with PHC, call PHC’s Member Services Department.
Getting primary care outside of your Home County Unless you get Prior Approval from PHC, you must get primary care services from your assigned PCP.
If you live in one of the following counties call PHC’s Member Services Department to see if
you can be assigned to a PCP that is closer to your home:
PHC believes it is very important for new members to get a checkup with their PCP soon after enrollment, even if you’re not sick! This checkup is sometimes called a new member checkup, well visit, or initial health assessment. To get this checkup, call your PCP using the number on your PHC ID card.
Your first visit is very important. During your first visit, your PCP gets to know you and your medical history. Your PCP can see what treatments you have received and begin any new treatments you may need.
It’s also important to get a checkup at least once a year. This is sometimes called a “well visit” or a physical. Well visits help you stay healthy and helps keep medical conditions you have from getting worse.
Children also need regular checkups at least once a year. Your child’s PCP will tell you more about the regular care your child needs to grow up healthy and happy.
Timely access to primary care When you call your PCP’s office to schedule an appointment, you should get an appointment within 10 business days (about 2 weeks) from the date of your call. It should not take longer than 48 hours from the time of your call to get an appointment for urgent care from your PCP. Your PCP’s number is on your PHC ID card. It may take longer to get a physical.
If you have trouble getting an appointment, or you are told that it will take a long time to get an appointment, call PHC’s Member Services Department for help.
Disenrollment from your PCP A PCP can ask PHC to disenroll a member from their practice. Requests for disenrollment from a PCP are reviewed by PHC. If this happens you must choose a new PCP.
Some reasons for disenrollment include:
Abusive, violent or disruptive behavior Frequently missing scheduled appointments A breakdown in the patient-physician relationship PHC encourages all of its members to be respectful and courteous towards their providers and their staff. This is one of your responsibilities as a member of PHC. To learn more about your rights and responsibilities as a member of PHC, see Section B of this Handbook.
Looking for how to receive primary or routine care? See Section 4 of this Handbook.
This section talks about other kinds of care you can get with PHC:
Specialty Care Services that need Prior Approval Hospital Care (Inpatient Care) New Technology What is Specialty Care?
Specialty care is care that you get from a Specialist. A Specialist is a medical provider who has extra education in a special area of medicine. Specialist providers usually focus on only certain parts of the body, health problems or age groups.
Here are a few examples of specialists:
Oncologists care for patients with cancer Cardiologists care for patients with heart conditions Ophthalmologists care for patients with eye conditions When and if you need specialty care, your PCP will make a referral for you. This referral from your PCP is your approval to see a specialist.