The People's Guide

35th Edition 2013-2014

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The People's Guide 2013-2014 46 Medi-Cal 4. How to Choose a Health Plan When you first enroll in Medi-Cal you will get a packet in the mail from the state. The packet will contain a "Medi-Cal Choice Form" that must be filled out with the doctor and your health plan choice for each person in the family who is required to choose a health plan. You should get a book with some of the doctors, doctor groups and health plan choices in your area. If you don't see your doctor you can call Health Care Options and ask for a book for the whole county or for another area, or just call your clinic and ask which plans they take. Fill out the "choice form" and send it back to Health Care Options within 30 days. Keep the pink copy of the form for your records. Send the form by certified mail. If you don't complete the form and return it within 30 days, the state will choose a health plan for you that may not be convenient for you. To get a packet or more information, call Health Care Options at (800) 430-4263 or (800) 430-9009. The TDD line for hearing impaired is (800) 430-7077. If you have questions or problems call the Health Consumer Center at (800) 896- 3203 for assistance. It is very important to consult with any health care provider you already have and want to keep seeing before choosing a plan. Also ask if you can keep going to the clinic, pharmacy and hospital you want. You and your other family members may choose to join the same health plan and chose the same doctor, called a "Primary Care Provider" (PCP), or you can choose different health plans s and PCPs. Once you select a health plan, you will be mailed a plastic health plan member- ship card to use when you need medical services. Enrollment usually takes 30-45 days. If you or your family need medical care before you receive the health plan card, you may use the regular Medi-Cal card, or if you are already in an health plan and are just switching plans, use your current health plan until you are told you are in the new one. People in the groups that may, but do not have to, enroll in a health plan will automatically get a packet in the mail even though they do not have to join a plan. You should not be asked to make a choice of an health plan when you apply or at your redetermination. People who are already in a health plan when they apply for Medi-Cal should not get a packet in the mail. • Recipients with a Share of Cost, re- stricted Medi-Cal or who also have one of the following; private insurance, or CHAMPUS PRIME HMO. 1. Fee-for-Service (Regular Medi-Cal) In regular Medi-Cal you can use any doctor, clinic, hospital, pharmacy or other provider willing to accept Medi-Cal. You must tell the doctor or clinic that you have Medi- Cal before you get care. If you don't, the provider can legally bill you for all services that you get. A provider cannot accept your Medi-Cal for some part of your care and then charge you money and refuse to bill Medi-Cal for other parts of your care, unless that provider does not provide that service under Medi-Cal. For example, a doctor cannot accept your Medi-Cal for your prenatal care but then refuse to bill Medi-Cal for your blood tests and try to charge you. 2. Managed Care ("Health Plan") When you join a health plan, you must see the doctors, pharmacists and hospitals that are part of your plan. You must select a health plan and a primary care provider that is in the health plan. Unless you have an emergency, you must get approval for most of your care from your primary care provider. The health plan will receive money each month for your health care even if you don't get services. The health plan is responsible for providing or making arrangements for you to get all Medi-Cal covered services. Every one is supposed to be seen by a doctor within four months of joining the health plan. After you are in a health plan, you may still use your Benefits Identification Card (BIC) to get family planning, dental, and mental health services outside of the health plan. If you have any questions contact Legal Aid (pg. 68) 3. Dental care Dental care is fee-for-service in Los Angeles unless you choose to join a dental plan. In fee-for-service, you must get all your dental services from a dental provider willing to accept Medi-Cal. In a dental plan, you must start all dental care with the primary dentist you selected. If you are In a dental plan and want to switch to fee for service dental care call Health Care Options at 1-800-430-4263. You may be asked to attend a "Health Care Options" talk. You do not have to go. If you go, you do not have to choose a plan that day unless you want to. You will get a second envelope in the mail about dental managed care. It is optional; you don't have to enroll. You can still use your Medi-Cal card with any dentist who accepts Denti-Cal. 5. Medical Exemptions and Continuity of Care Most participants must enroll in a health plan; unless you apply for and receive a "Medical Exemption" in order to keep regular fee for service Medi-Cal. You may be able to get an exemption if you have a "complex medical condition" such as pregnancy, kidney disease, diabetes, HIV/ AIDS, cancer, asthma, or multiple scle- rosis, or receive skilled nursing services at your home, AND if the doctor or clinic that treats you is not part of any available offered health plan and you would lose them if you joined a plan . The state is now making it very difficult to get medical exemptions and you may need an advocate to assist you and your doctor. See "Good Advice (pg. 68) for advocate listing. You and your doctor must fill out a form (which is in the packet that you get in the mail) and send it to the state. Do this before the date you would have to go into the health plan. If the state denies your exemption, file an appeal. You should be able to stay in regular Medi-Cal while your appeal is heard and decided. The exemption is good for up to one year, then you will get another packet in the mail to complete, or you must ask for another Medical Exemption. You may call Heath Care Options with questions, or iIf you have questions or problems call the Health Consumer Center at (800) 896-3203 for assistance. 6. Fees In both health planss and regular Medi-Cal, you may have to pay $1.00 for prescrip- tions and many services unless you are pregnant, over age 64, or under age 19. Also, there may be a charge of $5.00 for non-emergency care given in the emer- gency room. The state is currently not collecting these fees.

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