«Partnership HealthPlan of California Medi-Cal Member Handbook Together for your Health Our Service Area Del Norte, Humboldt, Lake, Lassen, Marin, ...»
Most of your medications will be covered by Medicare Part D. PHC will still cover some drugs that are not covered by Medicare.
If you qualify for Medicare Part D, you cannot use your PHC Medi-Cal coverage to pay for a drug that is covered by Medicare.
To find out more about Medicare Part D, or to choose a Medicare Prescription Drug Plan call Medicare at (800) 633-4227 (800-MEDICARE) 24 hours a day, 7 days a week. You can also go to www.medicare.gov.
Section 12 – How to file a grievance Learn about your grievance rights.
What is a Grievance?
There are two kinds of grievances.
An appeal is when you don’t agree with a decision by PHC to not cover a service.
Each type of grievance has rules and a limit on how long you can wait to file the grievance.
When you send us a grievance, you will get a letter from PHC telling you that we are working on your complaint or appeal within five (5) calendar days. You will get another letter within 30 calendar days of the date your complaint or appeal was received by PHC.
If PHC needs more time to work on your complaint or appeal, we will send you a letter. PHC will have 14 more calendar days to work on your complaint or appeal.
Is there a time when I can’t file a grievance with PHC?
If you have another insurance, like Medicare or insurance through your work, and your grievance is about a service the other insurance covers or provides, you must file your grievance with that insurance.
If you have a grievance about your Medi-Cal eligibility.
Medi-Cal eligibility is handled by your Home County’s eligibility office. Call your eligibility office if you need help with your eligibility.
If you aren’t sure who you can file your grievance with, call PHC’s Member Services Department.
Grievances about Outpatient Mental Health Services Beacon is responsible for grievances about Outpatient Mental Health Services Beacon provides. Beacon will work with you on your grievance, including State Hearings.
Call Beacon at (855) 765-9703 if you have questions about Beacon and your grievance.
Grievances for Members with Kaiser Kaiser Permanente is responsible for grievances that are filed by its members. Kaiser will work with you on your grievance, including State Hearings.
Call Kaiser Member Services at (800) 464-4000, TTY (800) 777-1370 if you have questions about Kaiser Permanente and your grievance.
How do I make a complaint?
When you don’t like a service or the care you received, you have 180 days (about 6 months) from the day you got the care or service that made you unhappy.
You can make a complaint about the service or care you got from a PCP, specialist, medical group or Health Center, hospital, pharmacy or PHC.
To make a complaint, you can call PHC’s Member Services Department at (800) 863-4155. TTY users should call (800) 735-2929 or by dialing 711. You can make a complaint over the phone, in person or ask for a Grievance Packet to be sent to your home.
If you have Internet access, you can also file a complaint online. Go to our website at www.partnershiphp.org and go to the “For Members” section of our website. Pick the Medi-Cal program, and then “How to File a Complaint, Appeal and/or Hearing.” How do I file an appeal?
If PHC denies a request for Prior Approval, we will send you a letter called a “Notice of Action”, or “NOA.” The NOA will tell you if your provider’s request was denied, pended for more information or
was modified. The NOA will also include your appeal rights:
You can file an appeal within 90 calendar days of the date on your NOA letter You can request a State Hearing within 90 calendar days of the date on your NOA letter.
State Hearings are talked about in more detail later in this section.
To file an appeal, you can call PHC’s Member Services Department at (800) 863-4155. TTY users should call (800) 735-2929 or by dialing 711. You can file an appeal over the phone, in person or ask for a Grievance Packet to be sent to your home.
Aid Paid Pending (Continuing Services) When you are receiving a service that was authorized before by PHC or State Medi-Cal, and that service is stopped or changed by PHC, you can ask for Aid Paid Pending when you file your appeal or ask for a State Hearing.
Aid Paid Pending lets you get the service that PHC had approved before while your appeal or State Hearing is in process.
You have 10 calendar days from the date on your NOA letter to ask PHC or the Department of Social Services (DSS) for Aid Paid Pending.
You cannot ask for Aid Paid Pending if:
Your request is made more than 10 calendar days after the date on your NOA; or You asked for Aid Paid Pending for a service that PHC or State Medi-Cal didn’t pay for Aid Paid Pending is only given when you were getting a service, approved and paid for by PHC or State Medi-Cal that is stopped by PHC.
What is a State Hearing?
You have the option of filing your appeal through a State Hearing. You can ask for a State Hearing at any time by calling the State Hearing Division at the California Department of Social Services (CDSS) at (800) 952-5253.
A State Hearing is when your appeal is heard by an Administrative Law Judge (ALJ). The ALJ will look at information from you, your provider, and PHC to decide what needs to happen with your appeal.
The ALJ will tell you their decision within 90 calendar days of your hearing.
You can choose to file an appeal through a State Hearing, PHC, or both.
Contacting PHC about your appeal will usually get you a quicker response and issues can be resolved before a State Hearing is needed.
What is an Expedited State Hearing?
If you feel that you can’t wait to have a State Hearing, because a long wait would be a threat to your health, you can ask for an Expedited State Hearing by calling CDSS at (800) 952-5253, TDD (800) 952-8349.
You can also send a letter to CDSS at:
California Department of Social Services State Hearing Division PO Box 944243 Mail Station 9-17-37 Sacramento, CA 94244-2430
You can also fax CDSS at:
(916) 651-5210 or (916) 651-2789 PHC gives you a copy of a State Hearing request form in your Grievance Packet and with any NOA.
About Legal Assistance You may seek legal counsel to represent you at a State Hearing. For more information on obtaining free legal aid, contact your local legal aid office or welfare rights group.
About the Office of the Medi-Cal Managed Care Ombudsman The Medi-Cal Managed Care Ombudsman is responsible for looking into complaints about health plans. You can reach the Ombudsman at (888) 452-8609 from 8am to 5pm, Monday through Friday if you feel that the health plan has not resolved your issue.
Section 13 – Coordination of Benefits and Other Information Learn about estate recovery, coordination of benefits.
What if I have another insurance (“Coordination of Benefits”)?
If you have another insurance, like Medicare or commercial coverage through your work or your family (with a company like Blue Cross of California, Blue Shield of California, Health Net, or Kaiser Permanente) you must get your care covered by your “primary” insurance first. This is called Coordination of Benefits.
Medi-Cal is the “payer of last resort” by state and federal law. This means that Medi-Cal cannot pay for health care if another insurance plan you have could pay for that same health care first.
PHC will not pay for health care unless your primary insurance has paid their part, or has denied the health care as not covered.
If you have another insurance, call PHC’s Member Services Department to make sure PHC knows you have this kind of coverage. We can also answer any questions you have about how your Medi-Cal works with your other insurance.
Third Party Liability The next two topics in this section are about Third Party Liability, or TPL. TPL is a situation where you are getting care because of an injury you got at work, or because you were in an accident.
You must tell your provider and PHC if you need care because of an injury at work or an accident. California State law requires that PHC not pay for health care when one of these situations happens.
What if I have Worker’s Compensation?
Worker’s Compensation, also called “Worker’s Comp” is insurance for people who were hurt at work. If you have an injury or illness that happened at work, your Worker’s Comp will cover the care you need to get better for that injury or illness.
PHC will not pay for health care that is covered by Worker’s Comp.
What if I have coverage because of an accident?
If you were in an accident, like a car accident, the health care you get for any injury or health condition from the accident may be covered by someone’s car or liability insurance.
PHC will pay for the care you get if there is an emergency, including ambulance or air ambulance rides to get you to a hospital. Your emergency care will also be covered.
PHC and the State of California will then work with any insurance plans (auto or liability insurance plans) to pay for the health care you received.
Advance Directives An Advance Directive is a signed legal document that lets you make decisions about your beliefs and wishes about your health care if you are ever unable to make those decisions for yourself. It also lets you choose a person that will make sure your choices are followed by your providers.
If you have questions about Advance Directives, or want to know how to make one, talk to your PCP.
Estate Recovery The State of California is required to seek repayment of Medi-Cal benefits from the estate of a deceased Medi-Cal beneficiary for services received on or after the beneficiary’s 55th birthday.
For Medi-Cal beneficiaries in a managed care plan, like PHC, the State will recover “capitation payments” for the time the beneficiary was enrolled in the health plan. Capitation payments are payments made by the State to a health plan to pay for your care.
This means that if you are 55 years of age or older and enrolled in PHC, your estate will be financially impacted even if you didn’t receive services from PHC.
Additionally, any other payments for services given to you by providers not with PHC will also be recovered from the estate.
For further information regarding the Estate Recovery program only, call (916) 650-0490 or seek legal advice.
What do I pay for health care?
If you get a bill for medical services, don’t ignore it. Make sure you were eligible with us at the time of service. If you were, call the provider who is billing you; their phone number will be listed on the bill. Tell the office that you were covered by PHC for that date of service and give them your PHC ID number. Ask the office to bill PHC. If you have done this but keep getting a bill, call PHC’s Member Services Department. We can’t help you with bills that are more
than a year old. You may send a copy of the bill to us at:
Partnership HealthPlan of California Attn: Member Services Department Billing Issues 4665 Business Center Drive Fairfield, CA 94534
Do I have to pay a monthly charge called a “premium” (not share of cost) for my MediCal?
If you have been told you have to pay a premium, you may visit your Home County eligibility office or call (800) 880-5305.
Transitional Medi-Cal Transitional Medi-Cal (TMC) is for members who lose their cash aid or Medi-Cal eligibility because they make more money from their work, from a marriage or a spouse returning to work.
Medi-Cal members who qualify for TMC may keep their Medi-Cal for up to 12 months and keep their membership in PHC.
If you lose eligibility for Medi-Cal because you have more income, you should contact your Medi-Cal eligibility worker right away. For more information about the Medi-Cal TMC program, contact the Department of Health Care Office phone number toll free at (800) 880or contact your Home County eligibility office.
Organ Donation Donating organs and tissues provide many social benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability.
If you are interested in organ donations, please speak with your provider. Organ donation begins at the hospital when a patient is pronounced brain dead and identified as a potential organ donor.
An organ procurement organization will become involved to coordinate the process.
The Department of Health and Human Services’ Internet website (www.organdonor.gov) has additional information on donating your organs and tissues. You can also call (800) 355-7427 to get a donor card and to obtain more information about organ donation.
Section 14 – Your Privacy Rights Learn about your rights regarding your medical information.
You have the right to keep your medical records confidential. That means that only people who need to see your records so you can get good health care will see them.
You can request a copy of our Notice of Privacy Practices by calling PHC’s Member Services Department. A copy of the Notice is also included at the end of this Handbook and on our website at www.partnershiphp.org.
Privacy of your Health Information PHC understands how important it is to protect medical records and other confidential member information. We want to let you know what PHC does to keep your and your family’s health
information private. We:
Train our staff, when they are hired and annually on what information is protected and how it must be treated Monitor reports from staff, members and providers on any privacy issues so we can fix them Follow state and federal laws on privacy and confidentiality