Healthy San Diego

Many Medi-Cal beneficiaries are mandated to enroll in a Medi-Cal Managed Care Plan. The benefit of being on a Medi-Cal Managed Care Plan is improved access to health care including specialists and care coordination. Although some services are covered by other programs, such as the County Behavioral Health Services, California Children’s Services and Denti-Cal, the Medi-Cal Managed Care Plan ensures treatment is well coordinated and have a responsibility to ensure their members receive necessary health care.

Beginning June, 2011, Medi-Cal members within the ‘Seniors & Persons with Disabilities’ (SPD) group who are solely Medi-Cal beneficiaries (not dual coverage), must enroll in a Medi-Cal Managed Care Plan during their birthday month. The State of California will send beneficiaries plan information for one of the options available including Care 1st, Community Health Group, Health Net, Molina and Kaiser Permanente. (If a beneficiary does not select a plan, the State has a process in place to select the member’s plan for them.) Once a selection has taken place, the beneficiary is enrolled and contacted by their new health plan with a welcome call and next steps.

Beneficiaries with both Medi-Cal and Medicare (dual eligible) are not required to enroll in a Medi-Cal Managed Care Plan. On a voluntary basis they can choose a Plan or remain on Fee for Service Medi-Cal and Medicare.

If a beneficiary has a problem getting necessary care, members and providers should always contact the health plan’s Customer Service Department first. In most cases the health plan can resolve any issues. Occasionally a member may feel their needs aren’t being met and may need a third party to help break down a barrier. The Consumer Center for Health Education & Advocacy can help. The Consumer Center for Health Education & Advocacy works closely with the health plans and can help figure out where the barrier is and how to resolve the problem. The Consumer Center can be reached by calling (877) 734-3258.

Implementation of 1115 Waiver/Transition of Seniors and Persons with Disabilities

Frequently Asked Questions Many Medi-Cal beneficiaries are mandated to enroll in a Medi-Cal Managed Care Plan. Some of the advantages of being on a Medi-Cal Managed Care Plan include easier access to health care, referrals to specialists and care coordination. The plans have a responsibility to make sure their members receive necessary health care. Some Medi-Cal benefits are covered by other programs, including services provided by the San Diego Regional Center, County Behavioral Health Services, California Children’s Services and Denti-Cal. Though the Medi-Cal Managed Care Plan do not cover these services, they are responsible to ensure treatment is well coordinated. Below please find Frequently Asked Questions regarding the enrollment of the Seniors and Persons with Disabilities (SPD) transition to Medi-Cal Managed Care Plans. When is the enrollment date for SPD enrollees? Enrollment will begin June 1, 2011 and will be based upon the enrollee’s birth month. What is the enrollment/notification process? The first notification is sent ninety days prior to the enrollee’s birth month. For example, letters were sent March 1, 2011 for enrollee’s with an effective date of June 1, 2011. The notification gives a brief explanation of the change in Medi-Cal coverage and encourages the enrollee to contact Health Care Options (HCO). The second notice is sent approximately sixty days prior to the effective date, and includes a Health Plan Choice Packet. The third and final letter is sent if no response is received notifying the enrollee that if they do not select a health plan, one will be chosen for them. Telephone calls are made to the enrollee after each notification to inform them of the Medi-Cal changes and answer any questions they may have. The members may choose a plan during any of these calls. What enrollees are affected by the change in Medi-Cal? This will affect SPD enrollees with only Medi-Cal coverage. This is not for dual-eligibles that also have Medicare. If an enrollee gets their health care through Fee for Service (FFS) Medi-Cal, they will be required to join a health plan. If they are currently in a health plan, they will no longer be able to choose FFS Medi-Cal coverage.

How can the enrollees choose a health plan? Enrollees can choose a health plan or change a health plan anytime in a number of ways. They can make a choice by going to the HCO website (http://www.healthcareoptions.dhcs.ca.gov/HCOCSP/Home/default.aspx) or by calling Health Care Options at 1-800-430-4263. They can also select a plan by filling out the health plan choice form that will be sent in the mail. They will also have the opportunity to choose over the phone when they are called regarding their health plan enrollment. Will health benefits change? All of the health care benefits and services that are currently covered will stay the same. Will the enrollees be able to keep their doctor? Whenever possible, the enrollees can keep their current physician. The health plan websites list participating Primary Care Physicians and Community Clinics. This information should be referenced when determining the best health plan to meet their medical needs. Will the enrollee continue to have access to prescription drugs? Yes, the enrollee will have access to prescription medication that is a covered Medi-Cal benefit. However, drug formularies vary by health plan. The formularies are listed on the health plans’ websites and should be referenced when determining the best health plan for an enrollee. What is the enrollment process if a health plan is not chosen? Every effort will be made to have the enrollees select a health plan prior to their effective date. If this does not occur, the State will choose a plan and Primary Care Physician based upon the enrollee’s prior Medi-Cal utilization. They will match physicians the enrollee has been seeing with the plans’ provider networks to determine the most appropriate health plan option to assist in continuity of care. If there are any other questions, please reference the Department of Health Services website: http://www.dhcs.ca.gov/individuals/Pages/MMCDSPDEnrollment.aspx Or call the Healthy San Diego Information Line at (619) 515-6584

Your Health Plan Choices

Care 1st Health Plan Community

Health Group Health Net Community

Solutions, Inc (Health Net) Kaiser Permanente Molina Healthcare

Standard Benefits

Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services

Plan Network Hospitals*

*Call your

provider about using other

locations in an emergency.

Fallbrook Hospital Paradise Valley Palomar Medical Center Pomerado Hospital Rady Children’s Hospital San Diego Scripps Mercy Hospital – Chula Vista Scripps Green Hospital Scripps Memorial Hospital Encinitas Scripps Memorial Hospital La Jolla Scripps Mercy Hospital Sharp Chula Vista Medical Center Sharp Coronado Hospital Sharp Grossmont Hospital Sharp Mary Birch Hospital for Women and Newborns Sharp Memorial Hospital Tri City Medical Center

Alvarado Hospital & Medical Center Fallbrook Hospital Palomar Medical Center Paradise Valley Hospital Pomerado Hospital Promise Hospital Rady’s Children’s Hospital San Diego Scripps-Chula Vista Hospital Scripps Clinic-Green Hospital Scripps-Encinitas Hospital Scripps-La Jolla Hospital Scripps- Mercy Hospital Sharp-Chula Vista Medical Center Sharp-Coronado Hospital Sharp-Grossmont Hospital Sharp-Mary Birch Hospital for Women Sharp Memorial Hospital Tri-City Medical Center

Alvarado Hospital & Medical Center Fallbrook Hospital Promise Hospital Rady’s Children’s Hospital San Diego Scripps-Chula Vista Hospital Scripps Clinic-Green Hospital Scripps-Encinitas Hospital Scripps-La Jolla Hospital Scripps- Mercy Hospital Tri-City Medical Center

Kaiser Hospital

Fallbrook Hospital Rady’s Children’s Hospital San Diego Scripps Chula Vista Hospital Scripps-Mercy Hospital Sharp-Chula Vista Medical Center Sharp-Coronado Hospital Sharp-Grossmont Hospital Sharp-Mary Birch Hospital for Women Sharp Memorial Hospital Tri-City Medical Center

Doctors you can choose

Call Member Services 1 (800) 605-2556

Call Member Services 1 (800) 224-7766

Call Member Services 1 (800) 675-6110

or go to www.healthnet.com

Call Member Services 1 (800) 464-4000

Call Member Services 1 (888) 665-4621

Urgent Care Centers

Call your provider during business hours. After hour locations, call 1 (800) 605-2556.

Call your provider during business hours. After hours, call 1 (800) 647-6966.

Call your provider during business hours. After hours call 1 (800) 675-6110.

Call your provider during business hours. After hours, call 1 (800) 290-5000.

Call your Primary Care Provider during business hours. After hours call 1 (800) 357-0163.

Pharmacies

Over 335 pharmacies countywide, including all major pharmacies, such as Vons, Wal-Mart, Rite Aid, Longs and independent neighborhood pharmacies. Many provide 24 hour home delivery. Call Member Services at 1 (800) 605-2556.

290 locations, including Longs, Sav-On, Vons, K-Mart, Wal-Mart, Rite Aid and independent pharmacies. Thirteen are open 24 hours and 105 make deliveries. Call Member Services at 1 (800) 224-7766.

Over 375 pharmacies including Albertson’s, Alpine Pharmacy, Children’s Hospital Pharmacy, Costco, CVS, K-Mart, Leo’s Pharmacy, Longs, Med-Rx, NCHS San Marcos Health Center, Ralph’s, Rite Aid, Sharp Reese-Steely Pharmacy, UCSD Medical Center Pharmacy, Vista Clinic Pharmacy, Vons, Walgreens, Wal-Mart, White Cross and more.

There is a pharmacy at every Kaiser Permanente location: San Diego, Bonita, Carlsbad, Clairemont, Eastlake, El Cajon, Escondido, La Mesa, Mission Bay, Otay Mesa, Point Loma, Rancho Bernardo, San Marcos, and Vista. Call Member Services at 1 (800) 464-4000.

Molina has over 300 locations, including Sav-On, Rite Aid, Walgreens, Wal-Mart and many independent neighborhood pharmacies which provide 24-hour home delivery. Call Member Services at 1 (888) 665-4621.

Vision Plan Yes, Vision Plan at 1 (800) 605-2556

Yes, Vision Service Plan at 1 (800) 877-7195

Yes, Health Net Member Services, 1(800) 675-6110.

Yes, Vision Plan at 1 (800) 464-4000

Call Member Services at 1 (888) 665-4621 for more information.

Assistance with public

transportation

Call 1 (800) 605-2556 for free door to door transportation to medical appointments

Call 1 (800) 224-7766 for bus and trolley tokens for medical appointments.

Please call Health Net’s Member Services Department at 1 (800) 675-6110 for assistance.

Yes, written directions to Kaiser sites by car and bus are available. Call 1 (800) 464-4000.

Call Member Services at 1 (888) 665-4621 for more information.

Health Education

Health Education offers classes on many subjects including “What to do if your child is sick.” Multilingual brochures on over 17 topics. Member newsletters and an information line 1 (800) 605-2556

Over 20 topics offered in English, Spanish and Vietnamese. Call Member Services for information at 1(800) 224-7766.

Health education classes, community events, weight management, member newsletter, and written materials. Please call 1(800) 804-6074

Yes, at Kaiser provider locations. Call Health Education at 1 (619) 641-4194.

Molina offers Health Education classes including Motherhood Matters, Weight Management, Diabetes and Asthma. To receive more information on Health Education services in your area, call Molina at 1 (888) 665-4621.

Interpreter Services

Spanish, Russian, Mandarin, Vietnamese, Armenian, Hmong, Cantonese. Other languages available through the language line services. Call Member Services 1 (800) 605-2556.

Spanish, Vietnamese, Cambodian & Tagalog. Other languages and help line for the hearing impaired available through Member Services at 1 (800) 224-7766.

Spanish, Arabic, Vietnamese, Tagalog, Farsi, Russian, Lao, Cantonese, Mandarin, Samoan, Cambodian, and other languages available through Member Services at 1(800) 675-6110. Help line for the hearing and speech impaired. 1(800) 431-0964.

Contact 1 (800) 464-4000 for Interpreter Services. TTY information for hearing impaired; call 1 (619) 528-5138.

Spanish, Russian, Ukrainian, Vietnamese, Hmong, Mien, Lao, Cantonese, Filipino, and other languages available through the Language Line Services. Call Member Services at 1 (888) 665-4621.

24 Hr. Nurse Advice Line

1 (800) 605-2556

1 (800) 647-6966

1(800) 675-6110

1 (800) 290-5000

1 (800) 357-0163

Please make sure that the Health Plan you select has providers in your area. See the Health Plan’s Provider Directory ***Please note that providers are subject to change***

Welcome to Medi-Cal Managed Care Your Medi-Cal benefits can now be provided by a Medi-Cal Health Plan. A Medi-Cal Health Plan gives you access to a network of doctors, clinics, specialists, pharmacies and hospitals. How Does Managed Care Work? Each Medi-Cal Health Plan has a list of primary care providers you can choose from. If you have a doctor now, you will need to find out if that doctor belongs to a Medi-Cal Health Plan. Your primary care provider will be responsible for managing your overall health care needs and referring you to other doctors if needed. Who Can Join a Medi-Cal Health Plan? Anyone who is on Medi-Cal, lives in San Diego County, and has a qualifying aid code gets Medi-Cal Health Plan coverage. This chart and an enrollment packet are provided to all persons who, like you, qualify based on their current aid code(s). Use the information in this comparison chart and the enrollment packet to examine your health plan choices. To order an enrollment packet or for assistance in filling out a choice form, please call 1-800-430-4263. Translators are available. The TDD Line for the hearing impaired is 1-800-430-7077. There is no charge to join a health plan.

Medi-Cal Health Care Options In San Diego County

This material is being provided to help you better understand your choices. It is not an endorsement of any specific Medi-Cal Health Plan.

Benefits Identification Card (BIC)

Choosing a Medi-Cal Health Plan If you already have a doctor, check the provider directory to see if he/she works with a Medi-Cal Health Plan. Then ask these questions when you compare the health plans:

• Can I keep the same doctor if I already have one? • Will it be easy to get to the doctor?

The answers to these questions can help you decide which Medi-Cal Health Plan is best for you. If you do not find the answers, you can call the health plan member services hotline to get the information you need.

County of San Diego Health and Human Services Agency

P.O. Box 85222 San Diego, CA 92186-5222

Medi-Cal benefits can now be provided under a Medi-Cal Health Plan. All Medi-Cal Health plans offer standard Medi-Cal benefits: Member Services

Every Medi-Cal Health Plan has a Member Services telephone number for the following services:

• To help you choose or change your Primary Care Physician • To change your address or phone number • For questions about your benefits or where services are available • For complaints or grievances • For assistance with public transportation

What are other benefits?

When you choose a Medi-Cal Health Plan, your Medi-Cal benefits stay the same. Other benefits include: • Family Planning Services

You can always get family planning services from ANY family planning provider accepting Medi-Cal.* • Indian Health Centers

American Indians and Alaskan natives can always get services through any Indian Health Center.* • Dental Services

Your BIC is good at any Medi-Cal dentist. Call DENTI-CAL at 1-800-322-6384 to find a Medi-Cal dentist. • Well Child Check-Ups (CHDP) Call 1 (800) 675-2229.

*Services do not require prior approval.

How to resolve issues? • Medi-Cal Ombudsman 1(888) 452-8609 • Consumer Center for Health Education and Advocacy 1(877) 734-3258 • State Department of Managed Health Care 1 (888) HMO-2219 • Healthy San Diego Program (619) 515-6584 (message line)

What If There Is an Emergency?

An emergency is defined as those services required for alleviation of severe pain, or immediate diagnosis and treatment of unforeseen medical conditions, which, if not immediately diagnosed and treated, would lead to disability or death. If you or someone in your family has an emergency, you should: • Call your doctor, OR • Go to the nearest emergency room, OR • Call 9-1-1

What About Behavioral Health Services?

You can get behavioral health services (including mental health, alcohol and drug treatment, counseling, etc) in two ways. Call your health plan doctor, or call the San Diego County Access and Crisis Line at 1-800-479-3339.

Other information For information about other health and social services in San Diego County, call 2-1-1.

HHSA: HSD 5 (04/2011)

1

Healthy San DiegoMedi-Cal Managed Healthcare

in San Diego County

Presented by

SPD Work Team

2

Objective:

Provide an Overview ofHealthy San Diego (HSD)

3

HSD is the Medi-Calmanaged care system inSan Diego County.

4

Healthy San Diego Vision

• Patient choice– selecting health plans

• “Value added” – local involvement in

assuring quality and access

• Local oversight– problem solving and

continuous quality improvement of the delivery system

5

This is a unique Partnership of:• Consumers• Providers• Health Plans• State Department of Health Care

Services/Medi-Cal Managed Care Division

• County of San Diego Health and Human Services Agency

6

Current Participating Health Plans:

Care1stCommunity Health GroupHealth NetKaiser PermanenteMolina

7

Focus of HSD

• Enrollment of new beneficiaries– Each month over 6,000 persons

are reached through Health Care Options presentations provided by county staff.

• Quality Improvement– Ensuring recipients receiving

quality service and care.

8

Enrollment• As of February 2011• More than 429,000 Medi-

Cal beneficiaries in San Diego County.

• Approximately 232,000 enrolled in a Healthy San Diego Health Plan.

9

HSD Advisory Committee Structure

Chief Administrative Officer

Director HHSA

Joint Consumer & Professional Advisory Committee

Quality Improvement Subcommittee

Board of Supervisors

Behavioral Health WG

Enrollment WG

FacilitySite

ReviewWG

HealthEducation

andCultural/

LinguisticsWG

HealthPlanWG

SanDiego

RegionalCenter

WG

SPD Work Team

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There is a State mandate tocoordinate Public Health and Managed Care. This isaccomplished throughMemorandums of Agreement (MOAs)

Community Collaborative

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Memorandums of Agreement

• California Children Services • Child Health and Disability

Program• Children’s Emergency Shelter

Care Facility (Polinsky Center)

• Community Epidemiology• Hansen’s Disease (Leprosy)• Immunization Program• Maternal and Child Health

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Memorandums of Agreement(Cont)

• Behavioral Health• Sexually Transmitted Disease

Control Program• Tuberculosis Control

Program• Office of Aids Coordination• Women, Infants and Children

(WIC) Providers in the County• San Diego Regional Center

Seniors and Persons with Disabilities

• In 2011 Healthy San Diego Behavioral Health and San Diego Regional Center workgroups merged together to become the SPD Work Team.

• This was done to ensure a smooth transition for Medi-Cal beneficiaries who will be mandatory enrollees in managed care health plans.

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Seniors and Persons with DisabilitiesSPD Work Team

• Beginning June 2011, all Medi-Cal only beneficiaries will be required to enroll in a Medi-Cal Managed Care Plan. The plans will be required to provide enhanced services to this new population.

• Care coordination will be more important than ever. The plans will be required to ensure care coordination even when the services are paid for by another program. Examples of programs covered separately are Specialty Mental Health, Alcohol & Drug, Dental, Developmental, and Home and Community Based Services.

• In 2011, Healthy San Diego developed the SPD Work Team which consists of representation from nearly every HHSA program in San Diego County. The purpose of this Work Team is to identify barriers and ensure care coordination.

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Grievance SystemEach plan is required to have a grievance system.

If member has a problem or issue, they can call their plan’s Customer Service # or the Consumer Center for Health Education & Advocacy (CCHEA).

The health plans and Consumer Center for Health Education and Advocacy work collaboratively to resolve beneficiary concerns.

Care 1st 1 (800) 605-2556Community Health Group 1 (800) 224-7766Health Net 1 (800) 675-6110Kaiser 1 (800) 777-5131Molina 1 (800) 665-4621

CCHEA 1 (877) 734-3258

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Questions