A Guide to Medi-Cal Managed Care for People with Developmental Disabilities, their Families and Professionals
Table of Contents
I. Getting Started ……………………………………………… 1
A. You Must Be Eligible For Medi-Cal …………………………… 1
1. Eligibility ………………………………………… 1
2. Beneficiary Information Card (?BIC?) …………………….. 1
B. You Must Know Your Aid Code ……………………………… 2
1. Aid Code Means Why You Get Medi-Cal ………………….. 2
2. If You Do Not Know Your Aid Code ……………………… 2
C. You Must Know Your County ………………………………. 2
1. Where Your Home Is ……………………………….. 2
2. Where You Live …………………………………… 3
II. How You Get Medi-Cal Services in Your County ………………………. 4
A. Not All Counties Have Medi-Cal Managed Care ………………….. 4
B. Use the Chart …………………………………………. 4
1. Regular …………………………………………. 5
2. Two Plan ……………………………………….. 5
3. GMC …………………………………………… 5
4. COHS ………………………………………….. 5
C. Review What You Should Know …………………………….. 6
III. Will I Get Medi-Cal Services Through Managed Care? ………………….. 7
IV. Things That May Change Whether You Receive Medi-Cal Managed Care Services 9
A. You Get Medicare and Medi-Cal …………………………….. 9
1. Sacramento, San Diego, and Two Plan Counties ……………. 9
2. Napa, San Mateo, Santa Barbara, Santa Cruz, Orange and Solono Counties ………………………………………… 9
3. Orange County ……………………………………. 9
B. You are in a Waiver Program ……………………………… 10
1. Department of Developmental Services (DDS) Home and CommunityBased Waiver Program …………………………….. 10
2. Other Waiver Programs …………………………….. 10
C. You Have Private Insurance ………………………………. 11
1. Sacramento, San Diego, and Two Plan Counties …………… 11
2. Napa, San Mateo, Santa Barbara, Santa Cruz, Orange, or Solano Counties ……………………………………….. 11
D. You Live Far Away from Health Care Providers …………………. 11
1. Sacramento, San Diego and Two Plan Counties ……………. 12
2. All Other Counties ………………………………… 12
E. You Are in Foster Care or the Adoption Assistance Programs ……….. 12
1. Orange, San Mateo, Santa Barbara, Santa Cruz, and Solano Counties ……………………………………….. 12
2. Other Counties …………………………………… 12
F. You Need Nursing Home Care …………………………….. 13
1. Sacramento, San Diego, and Two Plan Counties …………… 13
2. County Organized Health Systems (COHS): Napa, San Mateo, Santa Barbara, Santa Cruz, Orange, or Solano Counties ………….. 14
G. You Need an Organ Transplant ……………………………. 14
1. Sacramento, San Diego, and Two Plan Counties …………… 14
2. Napa, San Mateo, Santa Barbara, Santa Cruz, Orange, and Solano Counties ……………………………………….. 15
V. What is Medi-Cal Managed Care? ………………………………. 16
A. Learning the Language ………………………………….. 16
1. ?Enrollment? Means Officially Joining the Group ……………. 16
2. A ?Health Plan? is the Group You Are Joining ……………… 16
3. ?Capitation? is the Way Your Health Plan Gets Paid for Your Care . . 17
4. Your Usual Doctor is Your ?Primary Care Provider? …………. 18
5. A ?Network? is the Group of Care Providers in a Health Plan …… 18
6. ?Prior Authorization? is Like Permission ………………….. 19
7. ?Co-Pay? Means the Small Amount You Pay for Some Care ……. 20
8. Reviewing What You Have Learned ……………………. 20
B. How Does Medi-Cal Managed Care Compare to Regular Medi-Cal? …… 20
VI. What You Do to Get Enrolled in Medi-Cal Managed Care …………………. 22
VII. Information to Help You Enroll ………………………………….. 23
VIII. Choosing or Knowing Your Health Plan …………………………… 24
A. What Kinds of Health Plans Are There? ………………………. 24
1. Prepaid Health Plans (PHPs) …………………………. 24
2. County Organized Health Systems (COHS) ……………….. 25
3. Primary Care Case Management (PCCM) ………………… 27
B. What are My County?s Health Plan Choices? …………………… 27
1. Two Plan Counties ………………………………… 27
2. GMC Health Plans ………………………………… 28
3. COHS Has Only One Choice …………………………. 28
IX. Choosing Your Primary Care Provider …………………………….. 29
A. Your Primary Care Provider is Important ……………………… 29
B. You Have a Choice and You Should Choose …………………… 29
C. Finding a PCP that Understands Your Needs …………………… 30
D. Using a Specialist as a Primary Care Provider ………………….. 30
1. Two Plan & GMC Counties …………………………… 30
2. COHS ………………………………………… 32
E. Primary Care Providers for Families, Group Home or Board and Care Facilities ……………………………………………. 32
X. Letting Medi-Cal Know Your Choices …………………………….. 33
A. Two Plan and GMC County Mandatory Group Enrollment ………….. 34
1. You Get Help from an Enrollment Broker or an HCO Contractor …. 34
2. You Will Get an Enrollment Form ………………………. 34
3. You Will Go Through the HCO Process ………………….. 34
B. Two Plan and GMC County Voluntary Group Enrollment ………….. 36
C. COHS County Enrollment ………………………………… 36
XI. Common Enrollment Questions …………………………………… 37
A. What Happens if I Do Not Choose a Health Plan? – ?Default Enrollment? . . 37
B. What Happens if I Do Not Choose a Primary Care Provider? – ?Default? . . 37
C. If I Am in a Mandatory Group, Can I Be Exempted from Enrollment in Medi-Cal Managed Care? ………………………………………. 37
D. How Do I Get Services until My Enrollment is Complete? ………….. 38
E. Can I Change Health Plans? ………………………………. 38
F. Can I Change Primary Care Providers? ………………………. 39
G. What Do I Do if I Am Assigned to a Health Plan by Mistake? ………… 39
H. What Happens if I Do Not Get the Provider I Chose? ……………… 39
I. Once I Am Enrolled, How Do I Get Out of Medi-Cal Managed Care? -?Disenrollment? ……………………………………….. 40
1. Two Plan Counties ………………………………… 40
2. GMC Counties …………………………………… 42
3. COHS Counties ………………………………….. 43
XII. How to Make Managed Care Work for You …………………………. 44
XIII. What To Do if You Have Problems with Medi-Cal Managed Care …………. 45
A. Know Your Options …………………………………….. 45
1. Kinds of Problems ………………………………… 45
2. Kinds of Help ……………………………………. 46
B. Fair Hearing Rights …………………………………….. 46
1. You Should Get A Notice ……………………………. 47
2. If You do not Get a Notice …………………………… 47
3. You Have a Right to a Hearing for Your Problem ……………. 48
4. You Must Ask for the Hearing ………………………… 49
5. Always Ask for a Fair Hearing ………………………… 49
6. Tips for the Hearing ……………………………….. 49
7. You Can Appeal the Hearing Decision ………………….. 51
C. ?Aid Paid Pending? Rights ………………………………… 52
D. Plan Grievance Procedures ………………………………. 52
1. Grievance Procedures Under COHS?s …………………… 53
2. Grievance Procedures in Two Plan and GMC Counties ………. 53
3. Nothing Within the Grievance Process Affects Your Right to a Fair Hearing ………………………………………… 53
E. Administrative Complaints ………………………………… 54
F. Ombudsman Programs ………………………………….. 54
G. Private Lawsuits ………………………………………. 54
XIV. Common Services Questions ……………………………………. 55
A. Can I Get Services from the Regional Center? ………………….. 55
1. What are Regional Center Services? ……………………. 55
2. Who is Eligible for Regional Center Services? …………….. 56
3. How Does Managed Care Work with Regional Center Services? … 56
4. How Can the Regional Center Help You with Your Health Plan? … 59
B. Can I Get Services in an Emergency? ……………………….. 59
1. What is an Emergency for Medi-Cal Managed Care Purposes? …. 60
2. Can I Get Emergency Services When I am out of Town? ……… 60
3. What Should I Expect at the Emergency Room? ……………. 60
C. Can I Receive Family Planning Services? …………………….. 61
1. What are Family Planning Services? ……………………. 61
2. Is An Abortion Considered a Family Planning Service under Medi-Cal? ………………………………………. 62
3. Can I See Any Family Planning Provider I Want? …………… 62
4. What if My Chosen Family Planning Provider does not Want to Provide the Particular Service I Choose? ………………………. 62
5. Where Can I Learn About Family Planning Services and Providers? 63
6. Do I Need Prior Authorization Before I Can See a Family Planning Provider? ………………………………………. 63
7. Can I Keep Confidential the Family Planning Services Care I Receive Out of Plan? …………………………………….. 63
8. Are There Special Rules for Care for Sexually Transmitted Diseases? ………………………………………. 63
9. What are Minor Consent Services? …………………….. 64
D. Can I Receive Dental Care Services? ………………………… 64
1. Are Dental Services Available through Regular Medi-Cal or through Managed Care? ………………………………….. 65
2. Can I Get General Anesthesia for Dental Services? …………. 65
E. Can I Get Mental Health Services? ………………………….. 66
1. How Do I Know if I Need Mental Health Care? …………….. 66
2. What Mental Health Care is Available from an MHP? ………… 66
3. What is a Coordinated Service Plan for MHP Care? …………. 66
4. How Do I Get the Medications and Tests Prescribed by My MHP Doctor? ………………………………………… 67
5. How Are My Physical Health Needs and My Mental Health Needs Coordinated if I am in Medi-Cal Managed Care and Receive MHP Services? ………………………………………. 68
F. What Supplemental Medi-Cal Services are Available to Children Under 21? 68
1. Health Assessments ……………………………….. 68
2. Supplemental Treatment Services ……………………… 69
3. When Supplemental Treatment Services must be Provided to Children ……………………………………….. 70
4. Vision, Hearing or Dental Services …………………….. 71
5. Case Management Services …………………………. 71
6. How to Get these Services …………………………… 71
G. Can I Get Translation Services or Language Assistance with My Care?………………………………………………….. 72
1. Care in Your Own Language …………………………. 73
2. Choosing a Provider who Speaks Your Language …………… 73
3. Getting a Translator for Your Appointments and the Hospital, Including a Sign Interpreter …………………………………… 73
4. Using Family Members as Interpreters …………………… 74
5. If You do not Get Translation Services or an Interpreter ………. 74
H. Can I Get California Children?s Services through Medi-Cal Managed Care? ………………………………………………….. 75
1. Services Available through CCS ………………………. 75
2. Qualifying for CCS Services ………………………….. 75
3. Why You Might Want CCS Services ……………………. 76
4. How CCS Services are Delivered in a Health Plan ………….. 77
5. Services Before CCS Determines Eligibility ……………….. 79
6. Treatment, Therapy or Equipment not Covered by CCS ………. 80
7. Your Health Plan and CCS Cannot Agree on Who Pays for Services 80
I. Can I Get Prescriptions with Managed Care? …………………… 80
1. How Do I Get Prescription Drugs? ……………………… 80
2. What is a Formulary? ………………………………. 80
3. Finding Prescription Drugs on the Formulary ………………. 81
4. Getting Drugs that are not on Your Health Plan?s Formulary ……. 81
5. If Your Health Plan Takes a Drug off its Formulary after You Begin Taking the Drug ………………………………….. 82
6. Limits on the Number of Prescriptions You can Get in a Month ….. 83
7. Time Frames for Approval of Off-Formulary Prescription Drugs …. 83
8. If Your Health Plan Denies Approval for a Drug Prescribed by Your Provider ……………………………………….. 84
9. If You Need Medication in an Emergency ………………… 84
10. If You Need Drugs Prescribed by a Mental Health Provider ……. 85
11. If Your Pharmacist Tells You that Your Health Plan will not Pay for Your Drugs …………………………………………. 85
12. If Your Pharmacist will not Request Prior Approval for Your Drug ……………………………………………… 85
13. If Your Health Plan will not Approve a Medicine You Previously Received ………………………………………. 85
J. Can I Get Transportation Services? …………………………. 86
1. Transportation Available ……………………………. 86
2. Reimbursement of Travel Expenses …………………….. 87
K. Can I Get Care in My Home from Medi-Cal Managed Care? ………… 88
1. Home Health Services ……………………………… 88
2. In-Home Medical Care Services ……………………….. 88
3. In-Home Supportive Services (IHSS) Program …………….. 89
4. Home Health Care for Children ……………………….. 89
L. Are Medical Supplies and Equipment Available? ………………… 89
Appendices
Appendix 1: Copy of Beneficiary Identification Card
Appendix 2: Managed Care Models by County
Appendix 3: My Medi-Cal Managed Care Worksheet
Appendix 4: Managed Care Group According to Aid Code
Appendix 5: Who To Call To See If You Aid Code is Mandatory, Voluntary or Excluded
Appendix 6: Health Plan Choices in Two Plan Counties
Appendix 7: A Checklist To Help You Choose Your Health Plan
Appendix 8: Health Plan Choices in MC Counties
Appendix 8: Health Plan Choices in MC Counties
Appendix 9: County Organized Health Systems Health Plans
Appendix 10: A Checklist to Help Choose Your Primary Care Provider
Appendix 11: Health Care Options (?HCO?)
Appendix 12: Sample Enrollment Forms Two Plan GMC Sacramento CalOPTIMA
Appendix 13: Sample Diary Pages
Appendix 14: Sample Letter Requesting a Fair Hearing and Aid Paid Pending
Appendix 15: Sample Letter of Doctor Support for Fair Hearing
Appendix 16: Sample Letter Requesting A Second Opinion
Appendix 17: Sample Letter Requesting to See the Evidence Against You
Appendix 18: Administrative Agencies for Complaints About Medi-Cal Managed Care
Appendix 19: Ombudsman Programs
Appendix 20: California Regional Centers
Appendix 21: County Mental Health Plans
Appendix 22: Sample Letter for Your Doctor to Ask Your Health Plan for Supplemental Services for A Child Under Age 21
Appendix 23: Office of Civil Rights Complaint Information
Appendix 24: Department of Justice Discrimination Complaint Information
Appendix 25: California Children Services Conditions
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