CONTRA COSTA HEALTH PLAN Contra Costa Health Services

Document Sample
CONTRA COSTA HEALTH PLAN Contra Costa Health Services Powered By Docstoc
					                          Medi-Cal Members
This Combined Evidence of Coverage and Disclosure Form is only a summary
of the Health Plan contract. The Health Plan Contract must be read to find
the exact terms and conditions of coverage. The Health Plan Contract is
available for you to read.

If you want to join the Contra Costa Health Plan, you may look at this Combined
Evidence of Coverage and Disclosure Form (EOC) before joining. You should
read this entire booklet. If you have any special health care needs, you should
carefully read those sections that talk about your special needs.

A “Health Plan Benefits Chart” is in Section 6 of this booklet. It will help you
understand the benefits, the things not covered and the limitations of coverage with
Contra Costa Health Plan.

                   1-877-661-6230 (press 2),
             CALIFORNIA RELAY 1-800-735-2929.

                        Contra Costa Health Plan
                       595 Center Avenue, Suite 100
                            Martinez, CA 94553
                      California Relay 1-800-735-2929
Medi-Cal Evidenced of Coverage & Disclosure Form

SECTION 1. WELCOME!                                                    Community Provider Network (CPN) -
                                                                        (doctors and other providers from private
Welcome to Contra Costa Health Plan (CCHP)!                             practice), or
Please read this Combined Evidence of Coverage                  •   Kaiser Permanente - (doctors, hospitals and
(EOC) and Disclosure Form booklet. This booklet,                    other providers who are part of Kaiser
along with the Member Services Guide and Provider                   Permanente
Directory, tell you:
• How to best use CCHP and its services;                        You may also change your choice of doctors at any
                                                                time by following the steps in this booklet.
• The services you can get as a member;
• How to get your health care benefits;
                                                                The PCP you pick should arrange for any referrals to
• What benefits are not covered or limited;                     specialists (when medically necessary), hospital stays
• Your rights and responsibilities as a member;                 or other services unless this booklet tells you
• What to do if you have a question or concern.                 differently.    Also, CCHP needs to okay these
                                                                services. If your primary care provider refers you to a
You can best use our services at CCHP when you                  specialist when medically necessary, the referring
know how to use our Health Plan.                                doctor will determine the time frame for the referral
                                                                based on your medical condition .You should expect
•   If you are a Kaiser Permanente member, please               to have the referral appointment to be within 6 weeks
    see your Kaiser Permanente Evidence of                      or more quickly depending on your medical
    Coverage. You may still keep this CCHP booklet              condition.
    handy in case you decide to switch your network
    back to CCHP’s Regional Medical Center                      For more information on how to get a specialist,
    Network or Community Provider Network.                      please call your PCP or for information about the
•   CCHP is a federally qualified “Health                       process for referrals to specialists, call your Member
    Maintenance Organization” (HMO). CCHP has                   Service Representative Monday through Friday, 8
    been caring for Contra Costa County residents               a.m. to 5 p.m. at 1-877-661-6230 (press 2).
    since 1973.
•   CCHP contracts with the California Department                  If you pick a PCP in the RMCN, your doctor
    of Health Care Services (DHCS) to give certain                  visits, and services done outside a hospital will
    health care services to Medi-Cal members who                    be done at one of our county Health Centers in
    choose CCHP.                                                    Antioch, Bay Point, Brentwood, Concord,
•   Getting health care from a health care service                  Martinez, Pittsburg, Richmond and North
    plan may be new to you, so please read this                     Richmond. Your Hospital care will be at Contra
    booklet carefully and get to know all the terms                 Costa Regional Medical Center (CCRMC) in
    and conditions of your health coverage.                         Martinez. CCRMC is open everyday and can
                                                                    give you full services including:
If you have other questions, feel free to call one of                    • Obstetrics,
our Member Service Representatives, Monday                               • Emergency room care,
through Friday, 8 a.m. to 5 p.m. at 1-877-661-6230                       • Intensive care,
(press 2); or if hearing impaired California Relay 1-                    • Specialty programs in geriatrics and
800-735-2929.                                                                 more.

All of us at CCHP WELCOME YOU and                                  If you pick a PCP in the CPN, your doctor visits,
wish you good health!                                               and services done outside a hospital will be done
                                                                    in their private offices. Your hospital care will be
                                                                    given either at the CCRMC or at a community
Facilities, Doctor Visits and Outpatient                            hospital that has an agreement with CCHP.
Services                                                            Other professional services may be done by
When you join CCHP’s Medi-Cal program, you can                      providers in the CPN. If you get services from a
choose your Primary Care Physician (PCP) from:                      community hospital with an agreement with
     Regional Medical Center Network (RMCN)                        CCHP, your PCP (or Specialty Care Physician to
        - (county’s Health Centers, doctors and                     whom you have been referred) must admit you to
        other providers who practice at those                       the community hospital and have privileges
        centers),                                                   there.

Medi-Cal 2011_EOC                                       EOC-2
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                   Medi-Cal Evidenced of Coverage & Disclosure Form

   If you pick a PCP from Kaiser Permanente, your                 Medi-Cal Program rules also say that beneficiaries in
    benefits including doctor visits, hospital services,           the    Public   Assistance    Aged/Blind/Disabled,
    and other services are given at Kaiser                         Medically Needy Aged/Blind/Disabled and Foster
    Permanente facilities located in Antioch,                      Care Medi-Cal programs may choose a managed care
    Martinez, Walnut Creek and Richmond or by                      plan or Medi-Cal Fee-For-Service.
    other providers who are selected by Kaiser and
    part of the Kaiser Permanente Network.                         Multilingual Services
                                                                   •   Interpreters are available for all Limited English
Please keep in mind that some providers may not be                     Proficient (LEP) members at no charge.
taking new patients at this time. If the provider you              • You can request a face-to-face or telephone
pick is not taking new patients, call Member Services                  interpreter. If you know that you will need an
for help in picking another PCP from the Provider
                                                                       interpreter for an upcoming medical service or
                                                                       discussion of medical information, please ask for
                                                                       the interpreter when you make the appointment.
Effective Date of Coverage                                         • Our Member Services can help you find a PCP
Your PCP assignment letter tells you the date your
                                                                       who speaks your language.           Call Member
coverage starts. Coverage starts on the first day of
                                                                       Services at 1-877-661-6230 (press 2) or for
the calendar month in which your name is added to
                                                                       hearing impaired calls California Relay 1-800-
the list of members provided by the California State
Department of Health Care Services (DHCS) to                           735-2929.
CCHP. Within seven (7) days after you start with                   • You do not have to use family members or
CCHP we will send you the following by mail:                           friends as interpreters.
                                                                   • CCHP providers can get our 24-hr interpreter
•   CCHP Identification (ID) card;                                     services whenever needed.
•   Letter listing your PCP’s name, address and                    • This EOC and other informational materials,
    phone number;                                                      have been translated into Spanish. If you need
•   A booklet that contains a Member Services                          these materials in other formats, call our Member
    Guide; a CCHP Provider Directory; and an                           Services at 1-877-661-6230 (press 2) or for
    Evidence of Coverage.                                              hearing impaired call California Relay 1-800-
                                                                       735-2929 and we will work with you get them in
If you do not get these materials, call your Member                    other formats like Braille, large size print, or
Services Representative at 1-877-661-6230 (press 2)                    audio formats.
or California Relay 1-800-735-2929.                                • To ask for translated materials, call the Cultural
                                                                       and Linguistic Department at 925-313-6063 or
Who is Eligible?                                                       for hearing impaired call California Relay 1-800-
You are eligible for CCHP’s Medi-Cal program if                        735-2929.
you live within Contra Costa County and if you have                If you feel that your language needs are not being
been found eligible by the county for one of the                   met, you can file a grievance. Please see Section 8
following Medi-Cal programs without a share of cost:               for more information on how to file a grievance.

•   Public Assistance Family, Aged, Blind,                         Your Membership Identification (ID)
    Disabled;                                                      Card
•   Medically Needy Family, Aged Blind, Disabled;                  Your member ID card tells doctors and other
•   Medically Indigent Children;                                   providers that you belong to CCHP. Everyone in
•   Refugee/Entrant;                                               your family who is a member of CCHP needs to have
•   Foster Care;                                                   an ID card. (If you picked the Kaiser Permanente
•   Medically Indigent Pregnant Adults.                            Network, you may have a CCHP card and a Kaiser
                                                                   Permanente card. CCHP will give Kaiser Permanente
Medi-Cal Program rules say that beneficiaries in the               your name and Kaiser Permanente will send you their
Public Assistance Family, Medically Needy Family,                  card.)
Medically Indigent Children, and refugee/entrant
Medi-Cal programs must choose between CCHP or                      •   Always carry your Plan ID card with you. Show
another health plan designated by the Department of                    it every time you see your doctor or health
Health Care Services.                                                  provider. If you don’t show your card, your

                                                           EOC-3                              Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

    doctor or other provider may not know you                     ACUTE CONDITION - A medical condition that
    belong to CCHP. They may bill you or refuse to                involves a sudden onset of symptoms due to an
    give you services. To get covered services and                illness, injury, or other medical problem that requires
    avoid receiving a bill in error, be sure to always            prompt medical attention and that has a limited
    carry your ID card.                                           duration.
    •   Always carry your Medi-Cal BIC
        (Beneficiary Identification Card) card with               ADVICE NURSE - Advice Nurse is an RN
        you. Your BIC card shows that you get                     (Registered Nurse) capable of assessing and advising
        Medi-Cal, and you will need it when you get               you about your health condition on the telephone.
        Medi-Cal Services not covered by CCHP,
        like certain optional benefits such as dental             AGREEMENT - This Evidence of Coverage (EOC),
        services:                                                 the appendices, all endorsements, all amendments
                                                                  and all applications for enrollment in the Plan are the
        •           For members under 21, or;                     Agreement (Contract) issued by CCHP.              This
        •           For pregnant women, if part of                Agreement sets forth the benefits, things not covered,
                    their pregnancy-related care or for           payment administration and other conditions under
                    services to treat a condition that            which CCHP will provide services to members of the
                    may cause problems in pregnancy;              Plan. If you are in the Kaiser Permanente Network,
        •           For members living in a skilled               the benefits, things not covered, and other conditions
                    nursing facility; or                          are in the Kaiser Health Plan Evidence of Coverage.
        •           For members receiving services                (See also Health Plan Contract).
                    directly from a physician; and
        •           Received in a hospital outpatient             AMENDMENT - A written description of additional
                    department.                                   provisions to the Health Plan Contract which CCHP
                                                                  will send to members when such changes occur. Any
•   Your Plan ID card is not sent every month. You                Amendment gotten from the Plan should be read and
    will only get a new card if you lose it or your               then attached to this Combined Evidence of Coverage
    card information changes. If you do not get your              & Disclosure Form booklet.
    card, or if it was lost, stolen or, if you have any
    other ID card problems please call a Member                   AUTHORIZATION (AUTHORIZED or OKAYED)
    Services Representative immediately at 1-877-                 - The approval (okay) given by CCHP, in advance of
    661-6230 (press 2), or California Relay 1-800-                a benefit or service being provided to a member.
    735-2929. We will send you a new card within                  Even if authorization by the CCHP is not required for
    one (1) week. If you need health care before                  a certain service under this Evidence of Coverage,
    getting your new card, call Member Services for               except for Emergency Services, Sensitive Services
    help.                                                         and other services for which you can self-refer (such
                                                                  as access to OB/GYN), those services which are
NOTE: DO NOT LOAN YOUR CARD TO                                    listed in this Evidence of Coverage as benefits will
ANYONE. DO NOT LET ANYONE ELSE GET                                not be covered by the CCHP unless you are referred
SERVICES WHILE USING YOUR ID CARD.                                for such services by your PCP. For members in
Your ID card is only for you to use when getting                  Kaiser Permanente Network, authorization is the pre-
covered health care services. If you lose your ID                 approval and referrals given by Kaiser Permanente
card, don’t borrow someone else’s card. Instead, call             according to rules established by Kaiser Permanente.
Member Services. CCHP may stop your membership
if you misuse your ID Card.                                       BENEFITS (COVERED SERVICES) - Those
                                                                  medically necessary services, supplies and drugs
                                                                  which a member is entitled to get pursuant to the
SECTION 2. DEFINITIONS                                            terms of this Evidence of Coverage, which is the
                                                                  Service Agreement and Disclosure Form. A service
ACTIVE LABOR - Means a labor at a time at which                   will not be covered as a benefit under this Plan, even
either of the following would occur: (1) There is                 if identified as a benefit in this Evidence of
inadequate time to effect safe transfer to another                Coverage, if it is not medically necessary. All
hospital prior to delivery. (2) A transfer may pose a             benefits must be provided by doctors within CCHP’s
threat to the health and safety of the patient or the             provider network, unless previously okayed by the
unborn child.                                                     Plan.

Medi-Cal 2011_EOC                                         EOC-4
                                                                                CONTRA COSTA HEALTH PLAN
                                                               Medi-Cal Evidenced of Coverage & Disclosure Form

BIC CARD - Beneficiary Identification Card that                DURABLE MEDICAL EQUIPMENT (HOME
shows eligibility for Medi-Cal.                                MEDICAL EQUIPMENT) - Equipment that can
                                                               withstand repeated use in the home, usually for a
CALENDAR YEAR - A period starting at 12:01 a.m.                medical purpose. Generally, a person does not use
on January 1 and stopping at 12:00 a.m. January 1 of           Durable Medical Equipment in the absence of illness
the following year.                                            or injury. To qualify as a benefit under this Plan,
CCHP - Contra Costa Health Plan                                Durable Medical Equipment must be medically
                                                               necessary, prescribed by a participating doctor and
CCS - Services covered by California Children’s                okayed by the Plan for use in your home. These
Service                                                        items may include oxygen equipment, wheelchairs,
                                                               hospital beds, and other items that CCHP determines
CENTERS FOR MEDICARE AND MEDICAID                              to be medically necessary.          Durable Medical
SERVICES (CMS) - The new name for the Health                   Equipment may be either purchased or rented by
Care Financing Administration, the Federal agency              CCHP as determined by CCHP
responsible for administering the Medicare and
Medicaid Programs.                                             EFFECTIVE DATE - The date, as shown in CCHP’s
                                                               records and on which CCHP coverage starts for you
CHDP SERVICES - State of California Child Health               under this contract. You will get written notification
Disability Prevention Program.                                 of your effective date once CCHP has confirmed
                                                               your enrollment.
provider from the Community Provider Network                   ELIGIBLE PERSON - A Medi-Cal beneficiary who
(CPN). CPN providers are not employed by Contra                meets the enrollment requirements of the Plan and
Costa Health Services Department, and do not                   the Department of Health Care Services, whose
otherwise provide services at any of the Health                county of residence for the purpose of Medi-Cal
Centers located in Antioch, Bay Point, Brentwood,              eligibility determination is Contra Costa County, and
Concord, Martinez, Pittsburg, Richmond and North               who resides in CCHP’s service area.
Richmond (referred to as the RMCN).
                                                               EMERGENCY            (EMERGENCY             MEDICAL
COMMUNITY PROVIDER - A participating doctor,                   CONDITION) - A medical condition manifesting
professional, or ancillary provider from the CPN.              itself by acute symptoms of sufficient severity,
                                                               including severe pain, such that a prudent layperson
COMMUNITY PROVIDER NETWORK (CPN) - A                           with average intelligence and knowledge of medicine
network of providers contracted to provide covered             would believe that the absence of immediate medical
services by CCHP that are not employed by Contra               attention could result in: (1) placing the health of the
Costa Health Services Department, and do not                   individual (or in the case of a pregnant woman, the
otherwise provide services at any of the Health                health of the woman and her unborn child) in serious
Centers in the RMCN.                                           medical jeopardy; or (2) serious impairment to bodily
                                                               functions; or (3) serious dysfunction of any bodily
CONTRACT - See Health Plan Contract                            organ or part.

CONTRACTING PROVIDER - See participating                       EMERGENCY SERVICES OR CARE - Medical
provider                                                       screening, exam, and evaluation by a doctor or
                                                               psychiatrist to determine whether an emergency
COSMETIC PROCEDURES - Any surgery, service,                    medical or psychiatric emergency medical condition
drug or supply designed to alter or reshape normal             or active labor exists. To the extent permitted by
structures of the body in order to improve                     applicable law and under the supervision of a doctor
appearance.                                                    or psychiatrist, other appropriate personnel may
                                                               conduct the examination or screening to determine if
COUNTY - Contra Costa County                                   an emergency medical condition, psychiatric
                                                               condition or active labor exists. Emergency services
COVERED SERVICES - See Benefits                                or care do not require prior authorization or referral
                                                               by the Plan.
CUSTODIAL CARE - See Long Term Care

                                                       EOC-5                               Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

EPSDT SERVICES - State of California Early                             (6) There is a reasonable expectation that the
Periodic Screening, Diagnosis and Treatment                            investigational service will significantly
Program.                                                               prolong the intended patient's life or will
                                                                       maintain or restore a range of physical and
EVIDENCE OF COVERAGE - The document that                               social function suited to activities of daily
explains the services and benefits covered by CCHP                     living.
and defines the rights and responsibilities of the               All     investigational    services      require    prior
member and CCHP.                                                 authorization. Payment will not be authorized for
                                                                 investigational services that do not meet the above
EXCLUSION - Services, equipment, supplies or                     criteria, or for associated inpatient care when a
drugs which are not benefits under this Plan.                    beneficiary needs to be in the hospital primarily
                                                                 because she/he is receiving such non-approved
EXPERIMENTAL PROCEDURES AND ITEMS                                investigational services. If you are denied an
(INVESTIGATIONAL SERVICES) - Services,                           experimental or investigational service, you may
drugs, equipment, and procedures (a Service) are                 access the Department of Managed Health Care’s
considered to be experimental or investigational if:             Independent Medical Review (IMR) process. See
                                                                 Section 8 below for more about IMR.
(a) The service is not recognized in accordance with
generally accepted medical standards, as being safe              FEE FOR SERVICE - A payment system by which
and effective for treating the condition in question,            doctors, hospitals and other providers are paid a
whether or not the service is okayed by law for use in           specific amount for each service performed as it is
testing or other studies on human patients; or                   rendered and identified by a claim for payment.
(b) The service approval of any governmental                     GENERIC - A chemically equivalent copy designed
authority prior to use and such approval has not been            from a brand-name drug whose patent has expired.
granted when the service is to be rendered; or                   Typically less expensive and sold under the common
                                                                 name for the drug, not the brand name.
(c) The service can only be legally provided as part
of a research or investigational program okayed by a             HEALTH CARE OPTIONS (HCO) - The California
governmental authority.                                          Department of Health Care Services’ Contractor who
                                                                 makes presentations and provides information on
Off-label use of drugs are not considered
                                                                 managed care and enrolls Medi-Cal eligible
experimental or investigational just because they are
                                                                 beneficiaries in a managed care plan in Contra Costa
prescribed for a different purpose from what they are
approved by the FDA, as long as certain conditions
are met in California law. Experimental services are
                                                                 HEALTH PLAN - The Contra Costa Health Plan
not a benefit under this Plan, even if such service is
recommended or referred by your doctor.
Investigational services are not covered except when
                                                                 HEALTH PLAN CONTRACT - (See also
it is clearly documented that all of the following
                                                                 Agreement) The Combined Evidence of Coverage,
                                                                 Disclosure form and Service Agreement which sets
                                                                 forth the benefits, exclusion, payment administration
     (1) Conventional therapy will not adequately
                                                                 and other conditions under which CCHP will provide
     treat the intended patient's condition;
                                                                 services to members of the Plan under this contract,
     (2) Conventional therapy will not prevent
                                                                 including all amendments, appendices, and
     progressive disability or premature death;
                                                                 applications for coverage.
     (3) The provider of the proposed service has
     a record of safety and success with it
                                                                 HOSPICE - Care and services provided in a home or
     equivalent or superior to that of other
                                                                 facility by a licensed or certified provider that are: a)
     providers of the investigational service;
                                                                 designed to provide palliative and supportive care to
     (4) The investigational service is the lowest
                                                                 individuals who have gotten a diagnosis of terminal
     cost item or service that meets the patient's
                                                                 illness with one (1) year or less life expectancy; b)
     medical needs and is less costly than all
                                                                 directed and coordinated by medical professionals;
     conventional alternatives;
                                                                 and c) okayed by CCHP. Hospice is not long term
     (5) The service is not being performed as a
     part of a research study protocol;

Medi-Cal 2011_EOC                                        EOC-6
                                                                                   CONTRA COSTA HEALTH PLAN
                                                                  Medi-Cal Evidenced of Coverage & Disclosure Form

                                                                  MIDWIFE – A person licensed as a Registered
HOSPITAL - A health care facility licensed by the                 Nurse, who is currently certified as a nurse by the
State of California, and accredited by the Joint                  California Board of Registered Nursing, under the
Commission on Accreditation of Health Care                        supervision of a licensed physician, attends cases of
Organizations, as either an acute care hospital or a              normal childbirth and provides before, during and
psychiatric hospital. A facility which is principally a           after pregnancy care, including family planning care,
rest home, nursing home or home for the aged, or a                for mothers and immediate care for the newborn.
distinct part Skilled Nursing Facility portion of a
hospital is not included as a hospital.                           NETWORK – See Provider Networks

IDENTIFICATION CARD – The “ID” card issued                        OCCUPATIONAL THERAPY – Treatment under
by the CCHP to each member. This card must be                     the direction of a participating doctor and provided
presented to all providers when health care services              by a certified occupational therapist, utilizing arts,
are gotten. You may also be issued a card from                    crafts, or specific training in daily living skills, to
Kaiser Permanente if you choose them to be your                   improve and maintain a patient’s ability to function.
provider network.
                                                                  OFF-LABEL USE OF PRESCRIPTION DRUGS -
INPATIENT – An individual who has been admitted                   Use of Food and Drug Administration (FDA) okayed
to a hospital as a registered bed patient and is                  drug for purposes other than those okayed by the
receiving services under the direction of a doctor.               agency.       Examples of off-label uses include
                                                                  prescribing for a disease, dose, route, or formulation
INVESTIGATIONAL SERVICES –                                        not okayed by the FDA. Off-label use of medications
See Experimental Procedures and Items.                            is a benefit (for plans which cover prescription drugs)
                                                                  when used for a life-threatening or chronic and
KAISER PERMANENTE NETWORK – A network                             seriously debilitating condition. The use of the drug
of doctors, health care professionals, hospitals, and             must be safe, effective, and medically necessary.
other health care facilities that are employed by,
owned, or contracted by Kaiser Permanente to                      ORTHOSIS (ORTHOTIC) – An orthopedic
provide covered services to Medi-Cal members who                  appliance or apparatus used to support, align, prevent
select the Kaiser Permanente Network.                             or correct deformities or to improve the function of
                                                                  movable body parts.
LIFE THREATENING – Either (1) diseases or
conditions where the likelihood of death is high                  OUT OF AREA COVERAGE – Emergency services
unless the course of the disease or condition is                  gotten while a member is outside of the service area.
interrupted; and/or (2) diseases or conditions with               No services are covered outside the United States,
potentially fatal outcomes, where the end point of                except     for    emergency      services    requiring
clinical intervention is survival.                                hospitalization in Canada or Mexico only. Urgent
                                                                  services and out-of-state treatment plans may be
LONG TERM CARE – The provision of health,                         covered out of area only under limited conditions.
personal and social services to individuals who lack
some function capacity (for example, the chronically              OUTPATIENT – A person receiving services under
ill, the elderly, and the disabled). This care is                 the direction of a participating doctor, but not as an
provided on a long-term basis usually in institutions             inpatient.
(i.e., nursing homes or at-home basis). Hospice is not
long term care.                                                   PARTICIPATING PHYSICIAN OR DOCTOR – A
                                                                  physician who is a participating provider.
MEDICALLY NECESSARY – Includes all covered
services that are reasonable and necessary to protect             PARTICIPATING PROVIDER – A doctor, clinic,
life, prevent significant illness or significant                  hospital, or other health care professional or facility
disability, or to alleviate severe pain through the               under contract with CCHP to arrange or provide
diagnosis or treatment of disease, illness or injury              benefits to members.
including services necessary to correct or ameliorate
defects and physical and mental illnesses and                     PHARMACY BENEFIT MANAGER – Firms that
conditions discovered by the screening services.                  contract with plans to manage pharmacy services.

                                                          EOC-7                               Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

PHYSICIAN OR DOCTOR – An individual licensed                     condition or conditions associated with a request for
and okayed to engage in the practice of medicine or              a second opinion.
osteopathic medicine.
                                                                 RECONSTRUCTIVE SURGERY – Surgery
PLAN PHYSICIAN OR DOCTOR – A physician                           performed to correct or repair abnormal structures of
having an agreement with CCHP to provide medical                 the body caused by congenital defects, developmental
services to CCHP members.                                        abnormalities, trauma, infection, tumors or disease to
                                                                 do either of the following:
PREFERRED DRUG LIST (PDL) – A list of drugs
that do not require Prior Authorization.                         (a) To improve function;
                                                                 (b) To create a normal appearance, to the extent
PRESCRIPTION MEDICATION – A drug which                               possible.
has been okayed for use by the Food and Drug
Administration, and which can, under federal or state            REFERRAL PROVIDERS – Any health care
law, be dispensed only by a prescription order from a            provider who is under contract with CCHP to whom
licensed doctor, nurse practitioner or dentist. In               a member is specifically referred for health services
addition, insulin is included as a prescription                  by a PCP. A member may be referred to a provider
medication under this Evidence of Coverage.                      not under contract to CCHP only when medically
                                                                 necessary, when an appropriate referral provider is
PRESCRIPTION ORDER OR PRESCRIPTION                               not available, and with the prior authorization of
REFILL – The authorization for a prescription                    CCHP’s Medical Director.
medication issued by a provider who is licensed to
make such an authorization in the ordinary course of             REGIONAL MEDICAL CENTER NETWORK
his or her professional practice.                                (RMCN) – Health Centers located in Antioch, Bay
                                                                 Point, Brentwood, Concord, Martinez, Pittsburg,
PRIMARY CARE PHYSICIAN (OR PROVIDER)                             Richmond and North Richmond, the doctors who
(PCP) – The doctor (or nurse practitioner working                practice at those centers, and the hospitals and other
with your doctor) selected from CCHP’s list of PCPs              health providers under contract to CCHP. (Referred
for the member’s primary care.         The PCP is                to as the RMCN).
responsible for supervising, coordinating and
providing the member’s initial and primary care; for             SENSITIVE SERVICES – Diagnosis and treatment
making referrals to Specialty Care Physicians and                of sexually transmitted diseases (STD), Family
other specialist care; and for all of the member’s               Planning Services provided to individuals of
health     care      needs     as     okayed     by              childbearing age to temporarily or permanently
CCHP.                                                            prevent or delay pregnancy, HIV testing and
                                                                 counseling, abortion, treatment for rape and sexual
PRIOR AUTHORIZATION – See Authorization.                         assault. These services are those which a member
                                                                 may self-refer (without referral by the PCP or
PROSTHESIS – An artificial part, appliance or                    authorization from CCHP), including to a Medi-Cal
device used to replace a missing part of the body.               provider who is not under contract with the Plan.

PROVIDER NETWORKS – One of the three (3)                         SERIOUS CHRONIC CONDITION - A medical
health care provider networks described in this                  condition due to a disease, illness, or other medical
Evidence of Coverage. These networks are the                     problem or medical disorder that is serious in nature
Community Provider Network, Regional Medical                     and that persists without full cure or worsens over an
Center Network and the Kaiser Permanente Network.                extended period of time or requires ongoing
                                                                 treatment to maintain remission or prevent
QUALIFIED HEALTH CARE PROFESSIONAL                               deterioration.
appropriately qualified health care professional is a            SERIOUSLY DEBILITATING – Diseases or
Primary Care Physician or a specialist who is acting             conditions that cause major irreversible morbidity.
within his or her scope of practice and who possesses
a clinical background, including training and                    SERVICE AREA – The geographic area served by
expertise, related to the particular illness, disease,           CCHP which is Contra Costa County.

Medi-Cal 2011_EOC                                        EOC-8
                                                                                  CONTRA COSTA HEALTH PLAN
                                                                 Medi-Cal Evidenced of Coverage & Disclosure Form

SKILLED NURSING CARE – Services that can only                    and prior authorization, please note that within the
be performed by licensed nursing personnel. For                  service area, Urgent Care Services are benefits only if
home care, these services are intermittent.                      obtained from a participating provider.

SKILLED NURSING FACILITY – A skilled nursing                     UTILIZATION REVIEW – Evaluation of the
facility has two (2) levels of care: (1) Skilled Care-           necessity, appropriateness, and efficiency of the use
Services necessitating the daily intervention and                of medical services and facilities. Helps insure
supervision by a licensed individual (i.e., registered           proper use of health care resources by providing for
nursing personnel or a doctor) for long-term or acute            the regular review of such areas as admission of
illness; and (2) Custodial Care – Services to assist             patients, length of stay, services performed and
patients with activities of daily living (ADL’s) not             referrals.
requiring licensed personnel. For example, custodial
care may include help in walking, getting in and out             SECTION 3. WHO WILL BE MY
of bed, bathing, dressing, eating and taking
medications.                                                     DOCTOR?
SKILLED REHABILITATIVE SERVICES –                                 You also may request a list of CCHP's contracting
Intermittent skilled care performed by a registered                providers with specific information about these
physical / occupational / speech therapist. For home              providers. To request a list, you may call Member
care, these services are intermittent.                                  Services at 1-877-661-6230 (press 2).

SPECIALTY CARE PHYSICIAN OR DOCTOR –                             Choice of Doctors and Providers -
A physician who provides certain specialty medical               Choosing your PCP
care upon referral by the member’s PCP and                       Your CCHP Provider Directory comes with this
authorization by CCHP.                                           booklet and tells you which PCP's, doctors, clinics,
                                                                 hospitals, other professionals and facilities are
SPEECH THERAPY – Treatment under the direction                   available to you. The directory will help you pick
of a participating doctor and provided by a licensed             your own PCP and one for each family member who
speech pathologist or speech therapist, to improve or            is also a member of CCHP. If you join the Kaiser
retrain a patient’s vocal skills which have been                 Permanente Network, then their providers will be in
impaired by illness or injury.                                   their directories and information they give to you.
                                                                 You may also pick an OB/GYN as a PCP if the
SUBACUTE CARE – Medical and skilled nursing                      OB/GYN is qualified to be a PCP. See your Provider
services provided to patients who are not in an acute            Directory.
phase of an illness but who require a level of care
higher than that provided in a long-term care setting.           Your PCP will provide your health care. Your PCP
                                                                 will also okay and manage your health care. Services
SUBSCRIBER – An individual who satisfies the                     from your PCP do not need CCHP's okay. Your PCP
eligibility requirements of CCHP as set forth in this            will provide preventive services and referral to a
Evidence of Coverage and who is enrolled and                     Specialty Care Provider (when medically necessary).
accepted by CCHP as a subscriber, and has                        Your PCP will also refer and manage covered
maintained Plan membership in accordance with this               hospital care when necessary.
Agreement. (May also be referred to as a member)
                                                                 Your Choice of PCP will Decide Your
URGENT CARE SERVICES – Medically necessary
services provided in response to the member’s need               Hospital and Provider Network
for a diagnostic work-up and/or treatment of a                   Once you pick a PCP, you will get your health care
medical or mental disorder that could become an                  from either Kaiser Permanente, RMCN or CPN
emergency if not diagnosed and/or treated in a timely            networks connected with that doctor. Your PCP will
manner and delay is likely to result in prolonged                also decide which hospital you will go to if you need
temporary impairment or prolonged treatment,                     a hospital.
increased likelihood of more complex or hazardous
treatment, development of chronic illness, or severe             You have 30 days to pick a PCP. CCHP will give
physical or psychological suffering of the member.               you a PCP when you join so you can get an
While Urgent Care Services do not require referral               appointment for services right away. You can change
                                                                 this and pick another doctor at any time within the

                                                         EOC-9                               Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

first 30 days and your choice will be effective                     SECTION 4. HOW TO GET
immediately. If you don’t like the PCP we pick,
please call a Member Services Representative at 1-                  HEALTH CARE SERVICES
877-661-6230 (press 2), California Relay 1-800-735-
2929 and we’ll help you change your doctor.                         Health Services by Participating
Sometimes you might not get the PCP you pick. This                  As a CCHP member using a CCHP provider, you can
may be because:                                                     get covered benefits that are in Section 7 and the
(1) The PCP is no longer contracted with the Plan;                  Benefits Chart in Section 6. These services must be:
(2) The PCP has too many patients and is not taking
    any new patients;                                               •   Medically necessary,
(3) The PCP's relationship with you did not work.                   •   Referred by your PCP (except when such referral
                                                                        is not required, such as for Sensitive Services or
Changing Your PCP or Provider                                           access to an OB/GYN), and
Network                                                             •   Okayed in advance by CCHP when that is
CCHP wants you to be close to your PCP. If you are                      required by CCHP rules.
not happy with your PCP, you may pick another PCP.
If you are not satisfied with your Provider Network,                Authorization (Okay) for Health Care
you may pick another Network that you might like                    Services for RMCN and CPN Members
better. Remember, though, you should not change                     Except for the cases below, if you use other doctors
doctors without good reasons or when you are being                  or providers – who are not CCHP participating
treated because this could hurt your treatment and                  providers – without okay from CCHP, CCHP will not
affect your health care.                                            pay for the services you get.
                                                                    Services from your PCP do not require an okay. This
If you are in the CPN or RMCN, and want to change                   includes:
your PCP or Provider Network, please call a Health
                                                                    • Direct referrals for evaluation,
Plan Member Services Representative to change your
                                                                    • Direct referrals for consultation, or
PCP or network. Member Services Representative
may be reached at 1-877-661-6230 (press 2), or                      • Direct referrals for care by a contracting
California Relay 1-800-735-2929.                                         specialty care provider in your same network.

Sometimes a PCP may ask that you change doctors.                    For all other services except emergency and out-of
This may be because of:                                             area urgent care, family planning services, basic
                                                                    prenatal care, sexually transmitted disease services
(1)   Fraud;                                                        and HIV testing services, your PCP or CCHP must
(2)   Repeated verbal abuse;                                        provide, prescribe or okay all of your health care.
(3)   Threats to the provider;                                      If you are a female member, you may get exams,
(4)   Your failure to follow a treatment plan that could            consultations, and other in-office visits from an
      cause great risk to you, the plan or provider.                Obstetrician/Gynecologist who is part of your
                                                                    provider network without referral by your PCP or
If you are in the Kaiser Permanente Network, please                 prior okay from the Plan.
call Kaiser to change your provider. Remember that
changes within or between the CPN and the RMCN                      Note: if the OB/GYN refers you to other Specialist
can happen as soon as you call Member Services, but                 Physicians or hospitals, or wants you to get services
changes to or from Kaiser Permanente generally will                 outside the OB/GYN’s office (such as certain
not happen until the first day of the next month.                   diagnostic services, ambulatory surgery, or similar
                                                                    procedures) referral from the PCP, and in some cases,
                                                                    okay from CCHP is still required as described in this

                                                                    You may also get sensitive services without prior
                                                                    okay from your PCP or from CCHP. These are:
                                                                    • Pregnancy testing,
                                                                    • Pregnancy-related services,
                                                                    • Family Planning Services and,

Medi-Cal 2011_EOC                                          EOC-10
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                   Medi-Cal Evidenced of Coverage & Disclosure Form

•   Treatments in the event of rape                                Referral for Health Services given by
•   Treatments for sexual assault.                                 Non-CCHP Provider
                                                                   If you can’t get covered services from a CCHP
When you need a prior okay from CCHP, your PCP                     provider you may get those services from a non-
or Specialty Care Physician will ask CCHP for the                  CCHP provider. Without a referral and okay, a non-
appropriate health care services. If the request meets             CCHP provider may give you:
medical criteria CCHP will give your provider an
okay to go ahead then CCHP will tell you so. If the                •   Emergency care or urgent care outside of Contra
request does not meet criteria and is denied, CCHP’s                   Costa County,
Medical Director will review the request. Only your                •   Sensitive Services,
PCP or CCHP’s Medical Director may make
                                                                   •   HIV testing and counseling, and the treatment of
treatment and service authorization denials. If the
                                                                       a sexually transmitted disease (STD).
service your provider asked for is denied, we will tell
you and your doctor about your appeal rights.
                                                                   All other services from a non-CCHP provider must
                                                                   be asked for by your PCP and okayed in advance by
Sometimes, CCHP may need to secure and
                                                                   CCHP before you get any health services.
coordinate medically necessary covered service(s) for
you, which a provider will not do because of a moral
objection (such as religious or ethical objections). In            Second Opinion Policy
these cases, services that are given through referrals             You may ask for a second medical opinion from a
will be done at no additional expense to Department                participating qualified health care professional of
of Health Care Services (DHCS).                                    your choice within the same physician organization
                                                                   for free.
Authorization (Okay) for Kaiser
                                                                   •   You and/or the provider may ask for a second
Permanente Members                                                     opinion evaluation to see if recommended
If Kaiser Permanente is your provider network, you                     services are the best method of treating your
will get an Evidence of Coverage booklet from                          condition or if there is another treatment that can
Kaiser Permanente that will tell you their benefits,                   be started;
things not covered, conditions and authorization                   •   CCHP may also require a second opinion before
procedure. Generally, authorization is the pre-                        the okay of services.
approval and the referrals given by Kaiser
Permanente according to rules established by Kaiser                Other reasons for a second opinion may include the
Permanente.                                                        following:

Initial Health Assessment                                          (1) You question the reasonableness or necessity of
If you are new to CCHP you should schedule an                          recommended surgical procedures;
initial health assessment appointment with your PCP                (2) You question a diagnosis or treatment plan for a
or clinic.                                                             serious chronic condition or condition that could
                                                                       cause loss of life, loss of limb, loss of bodily
•   The initial assessment starts the patient-doctor                   function, or substantial impairment;
    relationship and helps your PCP get to know                    (3) Your provider’s advice is not clear, or it is
    your health care needs;                                            complex and confusing;
•   For children 18 months and under, the                          (4) Your provider is unable to diagnose the
    assessment should be scheduled within 60 days                      condition or the diagnosis is in doubt due to
    of when the child became a member;                                 conflicting test results;
•   For adults and children over 18 months of age,                 (5) The treatment plan in progress has not improved
    assessments should be scheduled within one                         your medical condition within an appropriate
    hundred twenty (120) days of when you become                       period of time;
    a Plan member;                                                 (6) You have attempted to follow the plan of care or
•   CCHP pays for the first assessment and all age                     consulted with the initial provider regarding
    specific assessments and services required by the                  serious concerns about your diagnosis or plan of
    CHDP program. It is part of your benefits.                         care.

                                                                   An appropriately qualified health care professional is:

                                                          EOC-11                               Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

•   A PCP or specialist acting within his or her                    •   Treatment for sexual assault;
    scope of practice                                               •   Treatment for sexually transmitted diseases if
•   Who has a clinical background, including                            you are twelve (12) or older;
    training and expertise, for a particular illness,               •   Abortion.
    disease, or condition related to the request for a
    second opinion.                                                 Children twelve (12) years or older also do not need
•   For a specialist, the second opinion shall be                   parental consent to access drug and alcohol abuse and
    given by any provider of your choice from any                   outpatient mental health services within the provider
    independent practice association or medical                     network. Outpatient mental health care for children
    group as applicable within CCHP’s provider                      twelve (12) years of age or older is available without
    network of the same or equivalent specialty.                    parental consent for those who are mature enough to
                                                                    participate Intelligently and where either (1) there is
In case there is no participating plan provider who                 danger of serious physical or mental harm to the
meets the definition of a qualified health care                     minor or others, or (2) the children are the alleged
professional, then CCHP shall okay a second opinion                 victims of incest or child abuse. Minors may call the
by an appropriately qualified health professional                   Advice Nurse Program at 1-877-661-6230 (press 1)
outside of CCHP’s provider network. In approving a                  to get more information or they can go to their PCP,
second opinion either inside or outside of CCHP’s                   local Health Department or any other qualified
provider network, CCHP shall take into account your                 provider.
ability to travel to the provider.
                                                                    Standing Referrals
•   For a second opinion, you or your provider may                  A Standing Referral (subject to time and visit
    call CCHP’s Authorization Unit at: toll-free                    limitations) allows you to see a Specialty Care
•   1-877-661-6230 (press 4 – for Medical / Mental                  Physician/Provider on a repeated basis to continue
    Health authorizations);                                         treatment of an ongoing problem. You may get a
•   If we okay your request, we will give you an                    Standing Referral to one or more Specialty Care
    authorization approval number;                                  Physicians/Providers, following a treatment plan that
•   If we deny or modify your request, we will tell                 your PCP and Specialty Care Physician/Provider
    you and your provider and send you information                  develop together.
    about how you can appeal our decision;
•   We will tell you and your provider in writing and               •   CCHP will decide if there is medical necessity
    by telephone within two (2) working days of our                     for a standing referral within three (3) business
    decision.                                                           days of your request.
                                                                    •   You or your PCP may make the request.
After the second opinion is done, the second opinion                •   All medical records and information needed for
health professional will give you and the initial health                CCHP to decide must be given to CCHP.
professional a consultation report. This report will                •   Once CCHP decides, CCHP will make the
have any recommended procedures or tests that the                       referral within four (4) business days of the date
second opinion health professional believes are                         the proposed treatment plan, if any, is submitted
appropriate. CCHP may, based on its own decision,                       to CCHP’s Medical Director or designee.
okay additional medical opinions about your medical                 •   CCHP’s Medical Director must okay the
condition.                                                              Standing Referral.
                                                                    •   Written communication of the determination to
Minor Consent Services                                                  the member and involved practitioners will be
If you are under eighteen (18) years old you may get                    provided within two (2) business days from the
certain services, considered sensitive services,                        date of the determination.
without approval from your parents and without their                •   The Standing Referral may limit the number of
okay. These services include:                                           visits to the Specialty Care Physician /Provider,
                                                                        limit the period of time that the visits are okayed,
•   HIV testing;                                                        or     require    that    the    Specialty      Care
•   Pregnancy testing and other pregnancy-related                       Physician/Provider give the PCP regular reports
    services;                                                           on the health care given to you.
•   Family Planning Services;                                       •   To get an okay for the Standing Referral, you
•   Treatment for rape;                                                 must need continuing specialty care over a long
                                                                        period of time, and have a life-threatening,

Medi-Cal 2011_EOC                                          EOC-12
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                   Medi-Cal Evidenced of Coverage & Disclosure Form

     degenerative or disabling condition that needs                    to exceed twelve (12) months from the contract’s
     coordination of care by a Specialty Care                          end date;
     Physician/Provider instead of your PCP.                       •   Performance of surgery or other procedure that
These requirements do not require a referral to a                      has been okayed by the plan as part of a
specialist provider that’s not employed by or under                    documented course of treatment and has been
contract with CCHP, unless there are no specialists                    recommended and documented by the provider
within CCHP’s network that are appropriate to give                     to occur within one hundred eighty (180) days of
treatment to you. This language does not imply that                    the contract’s end date.
you do not need a referral to seek ongoing care from
a non-contracting provider (or a provider who is not               You may ask CCHP to allow medically necessary
an employee of the Plan).                                          treatment by that provider until the services are done,
                                                                   but no longer than twelve (12) months from the end
To ask for a standing Referral, call the Authorization             of the contract (unless otherwise stated above).
Unit at 1-877-661-6230 (press 4).                                  CCHP will pay the provider for benefits, but the
                                                                   terminated provider must accept in writing the same
You may get a list of the Plan’s providers who have                terms and conditions of the terminated provider’s
expertise in treating a specific life-threatening or               previous agreement. This includes payment that’s
disabling condition or disease by calling a CCHP                   similar to currently contracting providers giving
Member Services Representative at 1-877-661-6230                   similar services and who are practicing in a similar
(press 2).                                                         location area as the terminated provider. If the
                                                                   terminated provider does not accept these same
Continuity of Care - Terminated Provider                           terms, conditions and rates, then CCHP does not have
When CCHP and a provider end their contract, you                   to continue providing such services.
may be able to get continuity of care. See below on
how to ask CCHP for continuity of care. If CCHP                    Asking for Continuity of Care
ends a contract with a provider group or hospital, we              •   You can write CCHP or come to our offices;
will tell you in writing sixty (60) days before it                 •   Your request will be given to Utilization
happens. We will also tell you which provider group                    Management (UM);
or hospital you will be re-assigned to. If CCHP ends               Whenever possible, your request should be made to
an agreement with a provider group or hospital                     the attention of UM at: Contra Costa Health Plan,
without notice to avoid a danger to our members,                   595 Center Ave. Suite 100, Martinez, CA 94553 or at
CCHP will tell all members assigned to that provider               1-877-661-6230 (press 4).
group or hospital within thirty (30) days of that date.
                                                                   If you ask for continuity of care services, UM will
If you are being treated for a specific condition when             document the request and get back to you at the time
we end a contract with a participating provider (for               the request is made. Each verbal or written request
reasons other than medical disciplinary cause,                     should include:
criminal activity, or the provider’s voluntary
termination), you may be able to continue getting                  •   The name and contact information of your
covered care from the provider for your condition.                     existing provider,
These specific conditions are:                                     •   How long you have seen this existing provider,
                                                                   •   The services being given by the existing
•   An acute condition (See Section 2 for definition)                  provider, and
    for the duration of the acute condition;                       •   Why you think you should continue with this
•   A serious chronic condition (See Section 2 for                     existing provider.
    definition), for a duration enough to complete a
    course of treatment and arrange for a safe                     As soon as UM gets reasonably necessary
    transfer, not to exceed twelve (12) months from                information it will decide whether to grant or deny
    the contract’s end date;                                       your request for continuity of care. This decision
•   A pregnancy, for the duration of the pregnancy                 will be made in a timely manner appropriate for the
    and the immediate post-partum period;                          nature of the member’s clinical condition. If a request
•   A terminal illness (See Section 2 for definition),             is granted or denied, CCHP will tell you in writing
    for the duration of the terminal illness;                      within 5 business days or up to 30 days if we need
•   Care for a newborn child whose age is between                  and ask for more information to make a decision.
    birth and thirty six (36) months, for a period not

                                                          EOC-13                               Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

If you would like to ask for a copy of our continuity               doctor. This also makes it easier for doctors and
of care policy, please call Authorizations at 1-877-                nurses to give the right shots at the right time and to
661-6230 (press 4).                                                 remind their patients when they need a shot.

Continuity of Care - Exemptions to                                  Who can my doctor or nurse share the shot
Continue Medi-Cal Fee-For-Service                                   information with and why?
If you are an American Indian or a member of an                     Your doctor or nurse may share the information
American Indian household or you choose to get                      about your or your child’s shots with other doctors
health care services through an Indian Health Service               and nurses who give you or your child medical care.
facility and you have written acceptance from an                    Information also can be shared with agencies who
Indian Health Service facility for care on a fee-for-               need to know about the shots you or your child
service basis, you may request an exemption to                      received, including local and state health
continue Medi-Cal fee-for-service for up to twelve                  departments, WIC, schools, childcare facilities,
(12) months.                                                        family childcare homes, healthcare plans, welfare
                                                                    agencies (including Cal-WORKS), foster care
If you are getting fee-for-service Medi-Cal treatment               agencies and other agencies allowed by the California
from a Medi-Cal provider who’s not under contract                   Health and Safety Code. The information can be
with CCHP, you may ask for a medical exemption to                   used to see if you or your child have all the shots that
continue fee-for-service Medi-Cal. You must have a                  are needed, to give the right shots at the right time, to
“complex medical condition” as defined in California                let you know when you or your child need a shot, and
Law.                                                                to bill your insurance company. The information
                                                                    may not be used for any other reason.
•   If the Health Care Options Program gives you a
    medical exemption, you may continue treatment
    with a fee-for-service provider until your                      What information can my doctor or nurse share
    medical condition stabilizes enough to allow you                with other users of CCAIR?
                                                                    This is a list of the information that your doctor or
    to safely move to a CCHP provider.
                                                                    nurse can share:
•   You will have up to twelve (12) months from the
                                                                    • Name and gender
    date the medical exemption is first allowed by
    the Health Care Options Program (subject to                     • Date and place of birth
    extension).                                                     • Current address and telephone number
•   Your fee-for-service treating doctor and DHCS                   • Parent or guardian’s name
    will decide whether the medical condition has                   • Immunizations (shots) gotten
    stabilized.                                                     • Health problems you or your child may have had
•   If you are given an exemption because of                            after getting a shot
    pregnancy, you may stay with the fee-for-service                • Other non-medical information needed to
    Medi-Cal provider through delivery and the end                      correctly identify your or your child's shot
    of the month in which ninety (90) days after                        record.
    birth occurs.
                                                                    What are my rights?
Childhood Immunizations –Contra Costa                               You have the right to:
                                                                    • Look at your or your child's shot record and
Automated Immunization Registry                                        report any mistakes.
(CCAIR) Information and Disclosure for                              • Find out who has looked at your or your child’s
Parents                                                                shot information through this computer system.
                                                                    • Refuse to allow shot information to be shared
What is an immunization registry?                                      through the computer system.
In Contra Costa County, there is a computer system                  • Refuse to get reminder postcards from CCAIR to
that doctors and nurses can use to help keep track of                  let you know that you or your child needs shots.
their patients’ immunizations (shots) called the
Contra Costa Automated Immunization Registry                        What do I do if I want to exclude myself or my child
(CCAIR). Doctors can use this computer system to                    from CCAIR?
share information about their patients’ shots with                  Contact CCHP’s Member Services or contact:
other doctors. This makes it simple to keep track of a
patient’s shots even if the patient visits more than one            Erika Jenssen, Immunization Registry Coordinator

Medi-Cal 2011_EOC                                          EOC-14
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                  Medi-Cal Evidenced of Coverage & Disclosure Form

597 Center Avenue, Suite 200A                                     •     If you think you need substance abuse services,
Martinez, CA 94553                                                      call the Contra Costa Health Services Access
(925) 313-6734                                                          Unit at 1-800-846-1652.
                                                                  How to Use the Medi-Cal Fee-For-Service
California Children’s Services (CCS) For                          Program
Eligible Medi-Cal Members Under the                               •     When you use the Medi-Cal Fee-For-Service
Age of 21                                                               program for Medi-Cal benefits that are not
                                                                        covered by CCHP, you must find a provider who
You have the right to services for your children                        is contracted by the State for these services and
(eligible Medi-Cal members under the age of 21)                         who will accept Medi-Cal payment.
who qualify for the California Children’s Services                •     You should then take your Medi-Cal Beneficiary
(CCS) program. A child may be eligible to get CCS                       Identification Card (BIC) to the provider who
                                                                        has agreed to give you the service.
services if he or she has a qualifying condition.
• A qualifying condition is a serious illness or                  •     For additional information, please call a Member
                                                                        Services Representative at 1-877-661-6230
     chronic medical condition.
                                                                        (press 2), California Relay 1-800-735-2929.
• When a child is determined by the County CCS
     program to be eligible for CCS services, CCHP
     will give primary care and services unrelated to             SECTION 5. EMERGENCY
     the CCS eligible condition and will coordinate               CARE BY PARTICIPATING AND
     services with the CCS program.                               NON-PARTICIPATING
• CCHP will provide medically necessary covered
     services until CCS eligibility has been                      PROVIDERS
For more information about CCS and how to access                  What Should Be Done in an Emergency?
CCS services from providers outside of CCHP’s                     •     If there is an emergency, including active labor,
network, call CCHP’s Authorization Unit at 925-957-                     you should go to the nearest hospital emergency
7260 or call CCS at 925-313-6100. The CCS                               department.
Coordinator and CCS staff can tell you which                      •     IF LIFE IS IN DANGER, you should CALL
providers you may use for services related to your                      911 IMMEDIATELY or go to the nearest
child’s CCS-eligible condition.                                         hospital emergency department. You are asked
                                                                        to use the 911 emergency response system
How to Obtain Mental Health Services                                    appropriately.
                                                                  •     If you are not sure about an emergency or urgent
•   Outpatient mental health services (except those
                                                                        care need, call CCHP’s Advice Nurse. Advice
    that are within the scope of practice of your PCP)
                                                                        Nurses can help you twenty-four (24) hours per
    or acute psychiatric inpatient services are not a
                                                                        day, three hundred sixty five (365) days a year.
    covered benefit of CCHP.
•   These services are covered by the county’s
                                                                  Emergencies and Urgently Needed Care are benefits
    Mental Health Managed Care Program.
                                                                  twenty-four (24) hours a day, three hundred and
•   If you think you need mental health services, call
                                                                  sixty-five (365) days a year, both inside and outside
    the Mental Health Central Assessment and
                                                                  of CCHP’s service area.
    Referral Line toll free at 1-888-678-7277.
                                                                      CCHP Advice Nurse: 1-877-661-6230 (press 1) /
How to Obtain Alcohol and Drug                                          Authorizations: 1-877-661-6230 (press 4)
Treatment Services
•   Except for our tobacco, alcohol and drug health               If possible, you or someone acting on your behalf
    education programs (See Section 7), Alcohol and               should call your PCP or CCHP’s Advice Nurse
    Drug Treatment services are not a covered health              during the emergency service or as soon as possible
    benefit of CCHP.                                              after the emergency service. If you are outside
•   These services are covered by the county’s                    CCHP’s Service Area, you should go to the nearest
    Alcohol and Other Drug Administration                         appropriate hospital emergency room for services
    (AODA) Program.                                               (limited to United States, Canada and Mexico).

                                                         EOC-15                                Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

Kaiser Permanente Emergency Number
If you are a Kaiser Permanente member, please call                 Duty to Notify
Kaiser Permanente’s twenty-four (24) hour                          You must notify CCHP whenever you get Emergency
emergency number at 1-800-464-4000.                                or Urgent Care Services. You must tell us as soon as
                                                                   reasonably possible.
Emergencies and Urgently Needed Care
 “Emergency Services” and “Emergency Care” mean                    Right to Move Member to Participating
medical screening, exam, and evaluation by a doctor                or Network Facility
or psychiatrist to see if you have an emergency                    If you, as a result of an emergency, are admitted to a
medical, psychiatric emergency medical or active                   non-participating or non-network facility, CCHP may
labor condition. Other appropriate personnel may do                move you to a participating or network facility as
the exam or screening to see if you have an                        soon as you are medically stable and, as determined
emergency medical, psychiatric or active labor                     by CCHP and treating doctor, when such move is
condition if it’s allowed under the law and a doctor or            medically appropriate. If you refuse to consent to a
psychiatrist watches over the personnel.                           medically appropriate move, CCHP may refuse to
                                                                   cover any services from the non-participating or non-
If you meet these conditions, your emergency care or               network facility the day following such refusal.
services will include the care, treatment and surgery
by a doctor needed to relieve or eliminate your                    Emergency and Urgent Care
emergency medical condition, or to relieve or
eliminate your emergency psychiatric condition,                    Transportation
within the capability of the facility.                             CCHP will pay for medically necessary emergency
                                                                   transportation   including    licensed   ambulance
“Emergency Medical Condition” means a medical                      companies for air or ground services when okayed by
condition showing itself by acute symptoms of                      a participating doctor or okayed by CCHP. Air
enough severity (including severe pain) such that a                transportation must be pre-okayed by CCHP. CCHP
prudent layperson with average intelligence and                    shall not require prior okay for ambulance and
knowledge of medicine would believe that the                       ambulance support services given as a result of the
absence of immediate medical attention could                       911 emergency response system, if you asked for the
reasonably be expected to result in any of the                     services and reasonably thought the condition
following:                                                         required emergency ambulance services.

•   Placing the health of the person (or if a pregnant             CCHP’s Advice Nurses may give an okay for
    woman, the health of the woman or her unborn                   medically necessary urgent care transportation either
    child) in serious jeopardy;                                    at the time of the need for urgent care transportation
•   Serious impairment to body functions; or                       or as soon as possible afterwards. If urgent care
•   Serious dysfunction of any body organ or part.                 transportation is used and CCHP’s Advice Nurse was
                                                                   not told (or was told but the Advice Nurse did not
                                                                   okay the services) and CCHP finds that the urgent
Urgent Care Services                                               care transportation was not medically necessary as
If you are in need of Urgent Care Services, CCHP                   explained in this booklet, you may have to pay for the
will see you within 48 hours of your request.                      costs of those services.
“Urgent Care Services” is talking about those
services given in response to the patient’s need for a
fast diagnostic work-up and/or treatment of a medical
or mental disorder that:
1. Could become an Emergency if not diagnosed or
     treated; or
2. If not treated in a timely manner would result in
     a delay that:
     a) Is likely to result in a prolonged temporary
          impairment or prolonged treatment
     b) Increases likelihood of more complex or
          hazardous treatment, development of
          chronic illness, or severe physical or
          psychological suffering of the member.

Medi-Cal 2011_EOC                                         EOC-16
                                                                         CONTRA COSTA HEALTH PLAN
                                                         Medi-Cal Evidenced of Coverage & Disclosure Form

                            SECTION 6. BENEFIT CHART
  Note: The services and benefits for a Contra Costa Health Plan Medi-Cal member are based on benefits
          approved by the State Department of Health Care Services and are subject to change.

      BENEFIT DESCRIPTION                                             COVERAGE
ABORTION                                          Covered by any Medi-Cal provider
ACUPUNCTURE                                       Not Covered*
ALCOHOL ABUSE, EMERGENCY CARE                     Covered for life threatening situations or in a true
BIOFEEDBACK                                       Not Covered
BLOOD                                             Covered
CANCER SCREENING                                  Routine tests including mammograms, annual cervical
                                                  cancer screening (Including the conventional Pap test,
                                                  human papillomavirus (HPV) screening test that is
                                                  approved by the federal Food and Drug Administration
                                                  (FDA), and the option of any cervical cancer-screening
                                                  test approved by the FDA), prostate specific antigen
                                                  testing and digital rectal exams for screening and diagnosis
                                                  of prostate cancer, and screening for colorectal cancer are
CHIROPRACTOR                                      Not Covered* (Only covered at FQHC and RHC pending
                                                  approval of California State Plan Amendment)
CIRCUMCISION                                      If medically necessary
CONTACT LENSES                                    Not Covered 
CORNEAL TRANSPLANTS                               Covered
COSMETIC SURGERY                                  Not Covered (Except Reconstructive Surgery after
CUSTODIAL CARE AT A SKILLED NURSING               Covered for month of admission and following month
FACILITY                                          after which patient can be disenrolled from CCHP and
                                                  converted to Fee-For-Service Medi-Cal for continued
                                                  coverage (Except for Hospice which is not long term care)
DENTAL CARE                                       Not Covered (except for initial assessment, coordination
                                                  and referral by physician to a dental provider. Medical
                                                  services not provided by dentists or dental anesthetist are
                                                  also covered with a referral and authorization as well as
                                                  fluoride varnish from a child’s PCP for members under six
                                                  (6) years of age. Please see Section 7 for more information
                                                  on dental care)* (Only covered at FQHC and RHC
                                                  pending approval of California State Plan Amendment)
DRUG ABUSE, EMERGENCY CARE                        Covered for life-threatening situations or in a true
DIABETES MANAGEMENT                               Equipment and supplies for management and treatment of
                                                  insulin-using diabetes, non-insulin diabetes, and
                                                  gestational diabetes are covered as medically necessary
DURABLE MEDICAL EQUIPMENT (HOME                   Covered for In-Home Use (up to Medi-Cal guidelines and
MEDICAL EQUIPMENT)                                coverage is subject to change)
EYEGLASSES                                        Not Covered *
EXPERIMENTAL      TREATMENT       OR              Not Covered
FAMILY PLANNING (A TYPE OF SENSITIVE              Covered by any Medi-Cal provider

                                                EOC-17                              Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

 HEARING AID (STANDARD)                                     Covered (Replacement batteries are not covered)
 HEARING TESTS (AUDIOLOGY)                                  Covered 
 A. ACUTE                                                   Covered
 B. CHRONIC                                                 Covered
 HIV TESTING (A TYPE OF SENSITIVE                           Covered by any provider
 HOME HEALTH SERVICES – MEDICALLY                           Covered for medically necessary skilled services only
 HOSPITALIZATION                                            Covered for covered services and procedures
 HYPNOTHERAPY                                               Not Covered
 INFERTILITY SERVICES                                       Not Covered
 INTRAOCULAR LENSES                                         Implant following cataract surgery only
 LONG TERM CARE – AT A SKILLED                              Month of admission and following month after which
 NURSING FACILITY OR INTERMEDIATE                           patient can be disenrolled from CCHP and converted to
 CARE FACILITY OR SUBACUTE FACILITY                         Fee-For-Service Medi-Cal for continued coverage
 MATERNITY CARE                                             Covered
 A. OUTPATIENT PSYCHOLOGY                                   Not Covered* (Unless within scope of practice of PCP)
 B. OUTPATIENT PSYCHIATRY                                   Not Covered*

 C. ACUTE PSYCHIATRIC INPATIENT CARE                        Not Covered
 NEWBORN COVERAGE                                           Month of birth and following month (includes testing for
                                                            detection and treatment of phenylketonuria (PKU)). To
                                                            continue newborn coverage beyond this period, the baby
                                                            must be enrolled in CCHP as a Medi-Cal subscriber before
                                                            the end of this period.
 NON-REUSABLE MEDICAL SUPPLIES                              Covered except for tapes, gloves. (Limited coverage for
                                                            incontinence supplies and washes)
 A. RENAL OR CORNEAL                                        Covered
 B. ALL OTHER ORGANS                                        Not Covered*
 Organ donation is a gift. It's a gift that saves lives.
 Many very ill people have been given new, healthier
 lives from transplants. But many more are waiting
 for organs because there are too few donors. They
 need organs and tissue such as heart, lungs, eyes,
 kidneys, skin and bone. And often just one donor
 can help many people in need. You can help. It
 doesn't cost any money to be a donor. And you'll
 still get the best medical care. Let your family know
 of your wish to be a donor. Ask your health care
 provider about an organ donor card.
 ORGAN TRANSPLANTS                                          Not Covered except for renal or corneal.* If you need an
                                                            organ transplant (except renal or corneal) you may be
                                                            disenrolled by the state Health Care Options contractor
                                                            and go back to Fee-For-Service Medi-Cal if you are
                                                            accepted as a transplant candidate. You are covered for all
                                                            medically necessary services until you have been

Medi-Cal 2011_EOC                                          EOC-18
                                                                                CONTRA COSTA HEALTH PLAN
                                                                Medi-Cal Evidenced of Coverage & Disclosure Form

                                                        disenrolled from CCHP.          Call a Member Services
                                                        Representative to assist you. In respect to renal or corneal,
                                                        donor services are not covered unless the recipient is a
ORTHOPTIC (EYE TRAINING)                                Not Covered
ORTHOTIC APPLIANCES                                     Covered (except shoe inserts, arch supports and heal lifts
                                                        unless necessary for diabetics)
OUTPATIENT OFFICE VISITS                                Covered for covered services and procedures
OVER-THE-COUNTER DRUGS (OTC)                            Covered only for drugs which are a Medi-Cal benefit
ORTHODONTIA                                             Not Covered*
PERSONAL & COMFORT ITEMS                     (NON-      Not Covered
PHYSICAL EXAMS                                          Covered
PODIATRY                                                Not Covered (Only covered at FQHC and RHC pending
                                                        approval of California State Plan Amendment)
PREMARITAL EXAMS                                        Covered
PRESCRIPTION MEDICINES AND DRUGS                        All inpatient medications are covered by CCHP.
NOTE FOR DUAL ELIGIBLES AND SSI                         Outpatient prescription medicines and drugs are covered
RECIPIENTS: If you are eligible for both                when prescribed by a physician and obtained from a
Medicare and Medi-Cal or you are an SSI                 participating pharmacy. Except for emergency services or
Recipient, your prescription drugs will be covered      urgent care services out of area, drugs obtained from a
by Medicare. Please look at your "Medicare &            non-participating pharmacy are not covered. CCHP
You" handbook, which is mailed to all people with       requires that unless the prescribing physician specifically
Medicare each fall. This handbook contains              requests a brand name drug and it is okayed by CCHP, that
information about Medicare coverage including           all prescriptions be filled with generic drugs when
Medicare's new coverage for prescription drugs.         available.    Outpatient prescriptions are filled at a
                                                        frequency that is considered medically necessary.
                                                        Certain classifications of medication require prior okay
                                                        from CCHP.
                                                        Not Covered:
                                                        A. Weight Control (unless found medically necessary by
                                                            CCHP’s Medical Director)
                                                        B. Cosmetic Products
                                                        C. Certain Psychotherapeutic, HIV/Antiviral and Anti-
                                                            Parkinson Drugs*
PROSTHETIC           DEVICES         (CORRECTIVE        Covered
APPLIANCES           &      ARTIFICIAL         AIDS,
RADIAL KERATOTOMY (Including Lasik and                  Not Covered
other forms of laser eye vision correction)
REFRACTIONS (MEASURING PART OF THE                      Covered
REVERSAL OF STERILIZATION                               Not Covered
SEXUALLY           TRANSMITTED              DISEASE     Covered
SKILLED          NURSING           FACILITY        /    Covered only for the month of admission and the
INTERMEDIATE CARE FACILITY                              following month, after which patient can be disenrolled
                                                        from CCHP and converted to Fee-for-Service Medi-Cal
                                                        for continued coverage. Hospice patients do not need to
                                                        disenroll in order to have continued coverage.

                                                       EOC-19                              Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

    STERILIZATION                                             Covered
    SKILLED REHABILITATIVE SERVICES                           Provided for conditions which are expected to result in
    A. PHYSICAL THERAPY,                                      significant improvement in a reasonable and generally
    B. SPEECH THERAPY                                        predictable period of time or to establish an effective
    C. OCCUPATIONAL              THERAPY                      maintenance program in connection with a specific disease
       (OUTPATIENT)                                           state or condition.
    TRANSPORTATION                                            Covered (emergency or medically necessary as okayed by
                                                              CCHP/ physician)
*Available through the Medi-Cal Fee-For-Service Programs
 Effective July 1, 2009 this service is not longer covered for most adults. Your benefits under Medi-Cal will remain the same
only if:
               -    You are under age 21,or
               -    You are pregnant and the service is part of their pregnancy-related care or for services to treat
                    a condition that may cause problems in pregnancy or
               -    You are living in a skilled nursing facility or
               -    You are receiving benefits through the California Children’s Services Program or
               -    You are receiving benefits through a Program of All-Inclusive Care for the Elderly or
               -    You are receiving services directly from a physician or
               -    You are receiving some services in a hospital outpatient department, Federally Qualified
                    Health Centers, Rural Health Clinics, Indian Health Services, adult day health care centers, or
                    through home health agencies.

SECTION 7. MEDI-CAL                                                  •    Use of operating room, special treatment rooms,
                                                                          delivery room, newborn nursery and related
PROGRAM BENEFITS WHEN                                                     facilities;
MEDICALLY NECESSARY                                                  •    Intensive care unit and services;
                                                                     •    Drugs, medications, biologicals and oxygen
BENEFITS WHILE IN THE HOSPITAL                                            administered in the hospital;
Hospital services will be given to you for injury or                 •    Surgical and anesthetic supplies, dressings and
illnesses that need hospitalization including its                         cast materials, surgically implanted devices and
recurrences and complications.                                            prostheses, other medical supplies and medical
                                                                          appliances and equipment administered in the
•     Hospital services are given at CCRMC unless                         hospital;
      the participating provider (Attending Doctor) is a             •    Hospital ancillary services including diagnostic
      CPN doctor and chooses to admit patients to                         laboratory, X-ray and therapy services including,
      another participating hospital;                                     but not limited to electrocardiography and
•     A Kaiser Permanente doctor will give services at                    electroencephalography;
      a Kaiser Permanente hospital;                                  •    Radiation therapy, chemotherapy and renal
•     Sometimes a participating doctor may refer you                      dialysis;
      to a hospital that is not a participating hospital             •    Skilled Rehabilitative Services including
      because of a special medical need; except in an                     physical therapy, speech therapy, occupational
      emergency, these services must be okayed in                         therapy and other rehabilitation services which
      advance by CCHP.                                                    are expected to result in the significant
                                                                          improvement of your condition within a period
CCHP shall provide or arrange for the following                           of two (2) months, unless the Medical Director
services if medically necessary:                                          finds additional services are medically necessary;
                                                                     •    Other diagnostic and therapeutic services as
Inpatient Hospital Services                                               medically appropriate, including respiratory
•     Semi-private room and board, unless a private                       therapy;
      room is medically necessary, including                         •    Coordinated discharge planning including the
      customary furnishings, equipment, and meals                         planning of such continuing care as may be
      (including special diets as medically necessary);                   needed;
•     General nursing care and special duty nursing                  •    Blood and blood products, as well as the
      when medically necessary;                                           administration of blood and blood products,

Medi-Cal 2011_EOC                                           EOC-20
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                    Medi-Cal Evidenced of Coverage & Disclosure Form

    including the      cost   of   in-hospital   blood                  meeting with you, the doctor will decide if the
    processing.                                                         visit is at your home or at one of our facilities.

Inpatient Doctor Services                                           For mastectomies and lymph node dissections, the
•   All doctor and paramedical personnel services                   length of stay is to be decided by your doctor after
    asked for or directed by the attending doctor and               meeting with you. The doctor’s decision will be in
    rendered, including general medical, specialists,               line with sound clinical principles and procedures.
    surgical and obstetrical care, referral and
    consultation;                                                   Emergency Medical Treatment for
•   Surgical procedures both major and minor, as                    Alcohol and Substance Abuse Overdose
    found to be medically necessary.                                •   Treatment may include the removal of toxic
                                                                        substances from the body;
Inpatient Maternity Care                                            •   Treatment may also be for overdose or adverse
•   CCHP covers hospital and doctor services                            reactions to alcohol, narcotic substances,
    relating to pregnancy and interrupted pregnancy                     tranquilizers, sedatives and/or psychotropic
    as any other medical condition;                                     substances;
•   Inpatient hospital maternity care covers normal                 •   Treatment will continue only until you are
    delivery, Cesarean section, complications or                        medically stable;
    medical conditions arising from pregnancy or                    •   Except for this coverage, CCHP does not cover
    resulting childbirth.                                               inpatient alcohol and substance abuse treatment.

Newborn Care                                                        Skilled Nursing Facility Care
Coverage for subscriber’s baby starts at birth, and                 Subject to all inpatient hospital service provisions,
continues for the month of birth and the following                  medically necessary Skilled Nursing Facility care
month, for no less than thirty (30) days. Charges or                services for the treatment of an illness or injury,
expenses related to the testing and treatment of                    including subacute and/or custodial care, will be
phenylketonuria (PKU) are covered.                                  covered:

To continue newborn coverage beyond this period:                    •   When given in a participating Skilled Nursing
• The baby must be enrolled in CCHP as a Medi-                          Facility and;
    Cal subscriber before the end of this period;                   •   When prescribed by your PCP, and;
• It is a good idea to notify your Eligibility Worker               •   Okayed by CCHP.
    when you become pregnant;
• You must get a Social Security Number for the                     This benefit is covered for month of admission and
    baby and call your Eligibility Worker after the                 following month after which patient can be
    baby is born to add your baby to Medi-Cal;                      disenrolled from CCHP and converted to Fee-For-
• Once your newborn is added to Medi-Cal, call                      Service Medi-Cal for continued coverage. Hospice is
    the Health Care Options Contractor (HCO) at 1-                  not long term care.
    800-430-4263 to enroll the baby in CCHP.
                                                                    To the extent required by law, CCHP does not
Length of Hospital Stay for Deliveries and                          require you to be placed only in a Skilled Nursing
Mastectomies                                                        Facility which is a participating provider if you are
                                                                    returning to a Skilled Nursing Facility following a
•   CCHP does not restrict benefits for any
                                                                    hospital admission.
    maternity hospital stay to less than forty-eight
    (48) hours in the case of a normal vaginal birth,
    or to less than ninety-six (96) hours in the case of            Subacute Care
    a cesarean section;                                             New payment methods, cost controls and advances in
•   If you and your doctor agree after meeting, you                 technology have led to shorter hospital stays and
    and your baby may be allowed to go home                         increased use of alternative or subacute settings for
    before the forty-eight (48) hour/ ninety-six (96)               care. One of these alternatives for patients who need
    hour time periods;                                              nursing care is a Skilled Nursing Facility. Other
                                                                    types of subacute care are covered to the same extent
•   If the doctor orders a follow up, CCHP will give
                                                                    as described above in Skilled Nursing Facility Care.
    a follow-up visit within forty-eight (48) hours of
                                                                    If you have any questions about CCHP’s subacute
    the time you were allowed to go home. After

                                                           EOC-21                                  Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

care policy, please call the Authorizations Unit at 1-                CCHP or health care organizations affiliated
877-661-6230 (press 4).                                               with CCHP.
                                                                  Health Information and Education
BENEFITS AVAILABLE ON AN                                          You can get education and information about health
OUTPATIENT BASIS                                                  problems and health hazards at the County Health
                                                                  Centers and through county-sponsored health
Ambulatory Care/Surgery Center                                    education programs. No extra cost is needed for
                                                                  county-sponsored health education services including
(Outpatient Hospital Services)                                    prenatal education, Family Planning, alcohol, drug
•   Services and supplies for diagnosis and treatment             and smoking cessation classes.
    including radiation and chemotherapy;
•   Surgery in an outpatient hospital setting or
                                                                  Professional and Diagnostic Services
    ambulatory surgery center;
                                                                  These services are covered when given by
•   Skilled Rehabilitative Services including                     participating providers subject to things not covered
    physical therapy, speech therapy, occupational                and limitations (See section below).
    therapy and other rehabilitation services which
    are expected to result in the significant
                                                                  •   PCP and Specialist Care Physician office visits
    improvement of your condition within a period
                                                                      for exam, diagnosis and treatment of a medical
    of two (2) months (commencing on the first day
                                                                      condition, illness or injury;
    of such treatment), unless the Medical Director
                                                                  •   Prenatal and postnatal office visits;
    finds additional visits are medically necessary
    and will result in significant improvement of                 •   Second opinions or other consultations;
    your condition in a reasonable and generally                  •   Doctor office surgery and other medically
    predictable period of time or to establish an                     necessary procedures;
    effective maintenance program in connection                   •   Outpatient diagnostic radiology and laboratory
    with a specific disease state or condition.                       services;
                                                                  •   Allergy testing and treatment.
Preventive Health Care Services
CCHP shall give preventive health care services                   Sensitive Services
(including services for the detection of asymptomatic             An adult or adolescent member may get sensitive
diseases) from the PCP, or as medically necessary,                services without barriers. These services include:
from another participating doctor, as follows:                    • Family Planning Services,
                                                                  • HIV testing and counseling,
(1) Reasonable health appraisal exams on a periodic               • Diagnosis and treatment of STD’s,
    basis;                                                        • Abortion
(2) Family Planning Services (See Family Planning                 • Treatment for rape
    Services which is a type of sensitive service                 • Treatment for sexual assault.
    described in separate section below);
(3) Prenatal care;                                                Members may self-refer (without referral by the PCP
(4) Vision testing;                                               or okay from CCHP), including to a provider who is
(5) Hearing testing (only if you are under 21) († For             not under contract with CCHP.
    excepted members, see Page 20 for more
    information);                                                 Family Planning
(6) Immunizations for children in accordance with                 Family Planning Services are a type of sensitive
    the recommendations of the American Academy                   services that are given to you at any age when you
    of Pediatrics and immunizations for adults as                 can get pregnant.
    recommended by the U.S. Preventive Services                   • These services may include giving you different
    Task Force;                                                        methods of birth control.
(7) Sexually Transmitted Disease (STD) tests;
                                                                  • You may pick any qualified Family Planning
(8) Cytology exams on a reasonable periodic basis;
                                                                       provider you want for these services. Your
(9) Health education services, including information
                                                                       CCHP Primary Care Physician or Obstetrician is
    regarding personal health behavior and health
                                                                       there to give Family Planning Services; you may
    care, and recommendations regarding the
                                                                       also pick a doctor or clinic not connected with
    optimal use of health care services provided by
                                                                       CCHP for Family Planning Services.

Medi-Cal 2011_EOC                                        EOC-22
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                    Medi-Cal Evidenced of Coverage & Disclosure Form

•    You do not need to get an okay (“authorization”)                   of this booklet which is limited in time, amount
     from CCHP for Family Planning Services.                            or scope, where such limited benefit has been
• CCHP will pay the doctor or clinic for the                            used up by you, the member;
     Family Planning Services you get.                              •   Services that can be done for you by a family
• Also covered are emergency contraceptive drugs                        member or a non-medical person without direct
     given to you by a contracting pharmacist or                        supervision of a licensed health care professional
     given to you by a non-contracting pharmacist                       (even if a person to perform such services for
     when there is a medical emergency and a                            you is unavailable or unwilling to perform such
     contracting pharmacist is unavailable.                             services).
• Abortion is also a sensitive service.
If you want, call the California Department of Health               NOTE: When the overall continuing care (long-
Care Services Office of Family Planning toll free at                term) of Home Health Care is more than the
1-800-942-1054 for more information or for a                        monthly cost of maintaining this patient in a
qualified doctor or clinic.                                         board and care, intermediate care, or nursing
                                                                    home, CCHP will consider requiring institutional
Treatment of Sexually Transmitted                                   placement unless there are very important social
                                                                    reasons why the person should not be
Diseases (STD’s) and HIV                                            institutionalized or the patient is consistently
You may get your treatment for STD or be tested for
                                                                    rejected by long-term care facilities.
STD or HIV without prior okay from CCHP. These
are considered sensitive services and you may get
these services from your PCP, the Local Health                      Hospice Services
Department, a clinic, or any other qualified provider               Services of a licensed/certified hospice are covered
whether connected to CCHP or not.                                   for persons with a terminal illness as found by a
                                                                    participating doctor and okayed by CCHP. Hospice
                                                                    is not long term care.
Home Health Care Services
CCHP shall provide or arrange for medically
necessary Home Health Services. These services                      Diabetes Management
may include:                                                        The following equipment and supplies for the
                                                                    management and treatment of insulin-using diabetes,
• Diagnostic and treatment services provided in
                                                                    non-insulin-using diabetes, and gestational diabetes
    the home.
                                                                    are covered as medically necessary and as okayed by
• Skilled rehabilitation services performed by a
    Registered Nurse, Public Health Nurse, Licensed
    Vocational      Nurse,    physical     therapist,
                                                                    •   Blood glucose monitors and blood glucose
    occupational therapist, speech therapist († For
                                                                        testing strips;
    excepted members, see Page 20 for more
    information) or medical social worker.                          •   Blood glucose monitors designed to assist the
                                                                        visually impaired;
Home Health Care Services are medically necessary                   •   Insulin pumps and all related necessary supplies;
and provided to you as a homebound member                           •   Ketone urine testing strips;
following an okayed Home Health Care Treatment                      •   Lancets and lancet puncture devices;
Plan designed to move you from institutionalization                 •   Pen delivery systems for the administration of
or to prevent institutionalization.                                     insulin;
                                                                    •   Podiatric devices to prevent or treat diabetes-
Home Health Care Services do not include any of the                     related complications;
following:                                                          •   Insulin syringes;
• Services that are non-skilled, custodial,                         •   Visual aids, excluding eyewear, to help the
     convalescent or domiciliary care, as defined by                    visually impaired with proper dosing of insulin.
     CCHP. If services are part custodial care and
     part skilled medical services, CCHP will cover                 Members with prescription benefits are also covered,
     only the costs of the Home Health Care which                   if medically necessary, for:
     are directly connected to the giving of the skilled
     medical services;                                              •   Insulin;
• Services that are given as a substitute for Skilled               •   Prescriptive medications for the treatment of
     Nursing Facility benefits or for any other benefit                 diabetes;

                                                           EOC-23                                  Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

•   Glucagon.                                                      •   Outpatient prescriptions are filled at a frequency
                                                                       that is considered medically necessary.
Coverage is given for diabetes outpatient self-
management training, education, and medical                        Off-label use of drugs are covered provided all of the
nutritional therapy needed to help you properly use                following conditions are met:
the equipment, supplies, and medications listed above
and additional diabetes outpatient self-management                 (1) The drug is approved by the FDA.
training, education and medical nutrition therapy                  (2) (A) The drug is prescribed by a participating
upon the direction or prescription of those services by                    licensed health care professional for the
your participating doctor.                                                 treatment of a life-threatening condition; or
                                                                       (B) The drug is prescribed by a participating
Enteral Nutrition Products                                                 licensed health care professional for the
Certain nutrition supplement products are covered                          treatment of a chronic and seriously
when used for therapy to prevent serious disability or                     debilitating condition, the drug is medically
death if you are diagnosed with a condition that                           necessary to treat that condition, and the drug
prevents you from using regular food. The nutrition                        is on CCHP’s formulary. If the drug is not on
product must be used on an outpatient basis, for a                         CCHP’s       formulary,     the    participating
specified quantity and for a period of time not to                         subscriber's request shall be considered
exceed six months. Extensions of time are available                        pursuant to the Prior Authorization process
with prior okay that meets the clinical guidelines                         required for non-formulary drugs.
used by CCHP.                                                      (3)     The drug has been recognized for treatment
                                                                           of that condition by one of the following: (A)
Outpatient Prescriptions                                                   The American Medical Association Drug
Medically necessary outpatient prescription drugs are                      Evaluations. (B) The American Hospital
covered as described in this booklet. Prescription                         Formulary Service Drug Information. (C) The
drugs are provided through CCHP’s arrangement                              United States Pharmacopoeia Dispensing
with PerformRx. PerformRx offers an extensive                              Information, Volume 1, "Drug Information
network of participating pharmacies. Call CCHP’s                           for the Health Care Professional." (D) Two
Pharmacy Services Department at 1-877-661-6230                             articles from major peer reviewed medical
(at the main menu, press 3) for a participating                            journals that present data supporting the
pharmacy in your area.                                                     proposed off-label use or uses as generally
                                                                           safe and effective unless there is clear and
                                                                           convincing contradictory evidence presented
•   Outpatient prescription drugs are covered when
                                                                           in a major peer reviewed medical journal.
    prescribed by a doctor and obtained from a
    participating pharmacy.                                                 •    It shall be the responsibility of the
•   Except for Emergency or out-of-area Urgent                                   participating provider to submit to
    Care Services and emergency contraceptive                                    CCHP       documentation      supporting
    drugs given by a non-contracting pharmacist                                  compliance       with     the     above
    when there is a medical emergency and a                                      requirements, if requested by CCHP.
    contracting pharmacist is unavailable, drugs
    obtained from a non-participating pharmacy are                          •    Any coverage required by this section
    not covered.                                                                 shall also include medically necessary
•   CCHP requires that unless a brand name drug is                               services     associated     with     the
    specifically requested by the prescribing                                    administration of a drug, subject to the
    Physician or the prescription states, “prescribe as                          conditions of the contract.
    written, “ or “do not substitute,” and CCHP                             •    For purposes of this section, "life-
    approves this through its prior authorization                                threatening" means either or both of the
    process, that all prescriptions be filled with                               following: (1) Diseases or conditions
    generic drugs when available.                                                where the likelihood of death is high
•   One exception is for Narrow Therapeutic Index                                unless the course of the disease is
    (NTI) drugs. NTI drugs are those with potential                              interrupted. (2) Diseases or conditions
    equivalency issues. In these cases, you will be                              with potentially fatal outcomes, where
    provided the brand name drug as written by the                               the end point of clinical intervention is
    provider and you will be responsible only for the                            survival.
    brand name copayment.

Medi-Cal 2011_EOC                                         EOC-24
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                   Medi-Cal Evidenced of Coverage & Disclosure Form

         •   For purposes of this section, "chronic                •   If you are already a member, and for those drugs
             and seriously debilitating" means                         after the three-month period, drugs will only be
             diseases or conditions that require                       changed if the prescribing provider prescribes
             ongoing      treatment    to   maintain                   another drug covered by CCHP that is
             remission or prevent deterioration and                    appropriate for you.
             cause significant long-term morbidity.
                                                                   If you would like information about whether a
A Note about our Preferred Drug List                               particular drug will require an okay, or would like to
Our Preferred Drug List (PDL) has a list of drugs that             request a list of these drugs, please call the CCHP’s
were okayed by our Pharmacy and Therapeutics                       Pharmacy Services Department at 1-877-661-6230
(P&T) Committee.                                                   (At the main menu, press 3). You may also call this
• Our P & T Committee has doctors and                              number if you would like to obtain a list of applicable
    pharmacists who pick drugs for the PDL.                        NTI drugs.
• They consider many factors, including safety and
    effectiveness.                                                 Pediatric Asthma Coverage
• The P&T Committee meets at least four (4)                        Outpatient prescription drug coverage includes
    times per year to update the PDL.                              coverage for medically necessary education, supplies,
• They can meet more often if there are urgent                     and durable medical equipment relating to pediatric
    matters.                                                       asthma, including inhaler spacers, nebulizers, face
• They ensure our PDL provides you quality- drug                   masks and tubing, and peak flow meters.
                                                                   * NOTE FOR MEMBERS WITH MEDICARE
Our PDL also allows you to get drugs that are not on               AND MEDI-CAL
the PDL if a participating doctor decides that they are
medically necessary. Please read the part below to                 •   Medicare is going to provide your prescription
learn more about our drug Prior Authorization (PA)                     drugs
process. This PA process is for drugs not on the                   •   You will get to pick between Medicare
PDL. Please remember that a drug on the PDL does                       prescription drug plans or Medicare Advantage
not guarantee that you will be prescribed that drug by                 plans with drug coverage.
your PCP for a particular medical condition.                       •   You will get information in the mail.
                                                                   •   If you do not pick a plan, you will be
Prior Authorization Process for Medically                              automatically placed in one.
Necessary Non-PDL Drugs                                            •   It is best that you pick a plan so you can compare
If a provider feels that you need a drug that is not on                and choose the plan that meets your drug needs.
our PDL, the provider can always use our PA                        •   If you are not sure how to pick a plan, or if the
process.                                                               plan you choose does not meet all of your drug
• CCHP staff and pharmacists at PerformRx will                         needs, call Health Insurance Counseling and
     look over PA requests for drugs not on our PDL.                   Advocacy Program (HICAP) at 1-800-510-2020
• They will compare these PA requests against PA                       for assistance.
     guidelines developed by CCHP and okayed by                    •   You may need to go to a different pharmacy on
     the P & T Committee.                                              the new plan.
• If the request does not meet the guidelines, a                   •   You may have to make co-payments for some
     CCHP Medical Director or someone okayed by                        medications on the new plan.
     the Medical Director will review the PA request.              •   Be prepared; know the name and dosage of the
• Before any drug is denied, we will try to                            drugs you take.
     communicate with the prescribing doctor. A                    •   At your next appointment, ask your doctor or
     doctor, or pharmacist under doctor supervision,                   pharmacist to tell you the generic AND brand
     will approve all denials.                                         name of the drugs you take. It will be easier for
                                                                       you to select the best plan if you have this
Pre-existing Prescriptions                                             information.
•   If you are a new member and are currently using                •   If you pick a plan and it does not work well for
    a prescription drug that is not on our PDL, you                    your needs, you can choose another.
    can still use that drug for three months to help               •   If for any reason your new drug plan has not
    with a smooth transition.                                          taken effect when you join CCHP, CCHP will

                                                          EOC-25                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

    cover your prescription drugs until your new                  •   Pulmonaides and related supplies;
    drug plan starts.                                             •   Nebulizer machines, tubing and related supplies;
                                                                  •   Spacer devices for metered dose inhalers.

***NOTE FOR SSI RECIPIENTS                                        Things not covered include (but not limited to) the
If you are eligible for SSI, your prescription drugs              following:
will be covered by either a Medicare prescription
drug plan or a Medicare Advantage plans with drug                 •   Comfort and convenience items;
coverage. Please look at your "Medicare & You"                    •   Exercise and hygiene equipment;
handbook which is mailed to all people with                       •   Experimental or research equipment;
Medicare each fall. This handbook contains
                                                                  •   Devices that are not medical in nature such as
information about Medicare coverage including
                                                                      sauna baths and elevators;
Medicare's new coverage for prescription drugs. For
                                                                  •   Modifications to the home or automobile;
more information call HICAP 1-800-510-2020.
                                                                  •   Deluxe equipment like motorized wheelchairs;
                                                                  •   More than one piece of equipment that serves the
Durable Medical Equipment (Home                                       same function.
Medical Equipment)
Medical equipment appropriate for use in the home                 Hearing Aids
which:                                                            We select the provider or vendor that will furnish the
1. Is intended for repeated use;                                  covered device. Coverage is limited to the standard
2. Used to serve a medical purpose; and                           hearing aid that adequately meets your needs.
3. Generally used only when a person is injured or
    ill.                                                          •   One hearing aid is covered when prescribed by a
                                                                      participating doctor. A hearing aid for each ear
Coverage is limited to the standard item equipment as                 is covered only when your doctor determines that
prescribed by your doctor that adequately meets your                  both are required to provide significant
medical needs for use in your home (or an institution                 improvement that is not obtainable with only one
used as your home). Durable Medical Equipment is                      hearing aid;
covered up to Medi-Cal guidelines and coverage is
subject to change. CCHP will also cover equipment,                •   A replacement hearing aid when prescribed by
including oxygen-dispensing equipment and oxygen                      your doctor is covered if your hearing
used during a covered stay in a participating hospital                impairment requires amplification or correction
or Skilled Nursing Facility, if the Skilled Nursing                   not within the capability of your current hearing
Facility ordinarily furnishes the equipment.                          aid. If, due to circumstances beyond your
                                                                      control, your hearing aid is lost, stolen or broken,
CCHP decides whether to rent or buy equipment, and                    we cover a replacement. You must provide a
CCHP picks the vendor. CCHP will fox or replace                       written statement detailing the circumstances of
the equipment without charge, unless the repair or                    the loss, theft or breakage.
replacement is because of misuse, abuse, negligence               •   Visits to verify that the hearing aid conforms to
or loss. You must give the equipment back to us                       the prescription, and visits for fitting, counseling
when it is no longer prescribed.                                      adjustment, cleaning, and inspection after the
                                                                      warranty is exhausted are covered.
Coverage for Durable Medical Equipment may
include, (but not limited to) the following:
                                                                  Orthotics and Prosthetics
                                                                  Orthotics and Prosthetics are covered up to Medi-Cal
•   Rental or purchase as okayed by CCHP for
                                                                  guidelines and are subject to change. Coverage
    standard equipment like wheelchairs and
                                                                  • Medically necessary replacement prosthetic
•   Repair or replacement unless caused by misuse,
                                                                       devices as prescribed by a licensed practitioner
    abuse, negligence or loss;
                                                                       acting within the scope of his or her license;
•   Oxygen and oxygen equipment;
                                                                  • Medically necessary prosthetic devices for
•   Blood glucose monitors;
                                                                       reconstructive surgery after a mastectomy;
•   Apnea monitors;
                                                                  • Medically necessary orthotic devices (except
•   Insulin pumps and related necessary supplies;                      shoe inserts, arch supports and heal lifts unless
•   Ostomy bags, urinary catheters and supplies;

Medi-Cal 2011_EOC                                        EOC-26
                                                                                     CONTRA COSTA HEALTH PLAN
                                                                    Medi-Cal Evidenced of Coverage & Disclosure Form

    necessary for diabetics) when prescribed by a                   child health worker at 925-313-6150. The program
    doctor or ordered by a licensed health care                     will help find transportation to appointments for
    provider acting within the scope of his or her                  CHDP/EPSDT members if needed.
•   The first and subsequent prosthetic devices and                 The Benefits Chart in Section 6 shows the full
    installation accessories to restore a method of                 coverage you will have.
    speaking incident to a laryngectomy, and
    therapeutic footwear for diabetics.                             Limitations and Things Not Covered
                                                                    In General: No service is a benefit to which you are
Things not covered include but may not be limited                   entitled from CCHP unless it is medically necessary,
to the following:                                                   even though it is not specifically listed as an
                                                                    exclusion or limitation. The fact that a doctor or
•   Dental appliances;                                              other provider may prescribe order, recommend or
•   Electronic voice producing machines;                            approve a service or supply does not in itself make it
•   More than one (1) device for the same part of the               medically necessary. CCHP excludes from coverage
    body.                                                           all services, whether or not described in this booklet
                                                                    as a benefit, that are not medically necessary. When a
Benefits from Non-Participating                                     service is not covered, all services related to the non-
Providers                                                           covered services are excluded, except that this
                                                                    exclusion does not apply to services we would
•   If CCHP’s Medical Director decides that you
                                                                    otherwise cover to treat complications of the non-
    need covered benefits at a skill level not
                                                                    covered service.
    available from CCHP’s participating providers
    then CCHP will arrange that benefits to be given
                                                                    CCHP Changes: No Vesting. The benefits, things
    to you by a non-participating provider.
                                                                    not covered and limitations are subject to change,
•   CCHP may transfer you back to a network                         cancellation or discontinuance at any time either by
    provider when it decides that it is medically                   the State Department of Health Care Services or by
    appropriate.                                                    CCHP following at least thirty (30) day’s written
•   CCHP also may deny coverage for non-                            notice by CCHP to the subscriber. There is no vested
    emergency services ordered by a non-plan                        right to obtain benefits. Benefits for services,
    provider without referral and okay by CCHP.                     supplies, equipment or drugs furnished after the
                                                                    effective date of any benefit modification, limitation,
Transportation                                                      exclusion or cancellation shall be provided based on
Emergency medical transportation is covered,                        that    modification, limitation, exclusion or
without prior okay, to the nearest health care site that            cancellation.
can meet your emergency medical needs. Please see
Section 5 for a detailed description of the emergency               All health services are limited to CCHP’s provider
transportation benefit.                                             networks, (including the county’s RMCN and
                                                                    CCRMC, CPN and Kaiser Permanente Network) who
All non-emergency medical transportation needed to                  have been contracted by CCHP as participating
obtain benefits is paid only when prescribed by your                providers, except for emergency and urgently needed
PCP and okayed by CCHP.                                             care, sensitive services and other okayed benefits.

Most of our facilities and doctors are located near bus             In the event there are circumstances beyond CCHP’s
stops. For information on bus routes, call Central                  control such as war, riot, epidemic or natural disaster
Contra Costa Transit Authority at 925-676-7500; Tri                 affecting the county’s personnel or facilities, CCHP
Delta Transit at 925-754-040; BART Express 925-                     will take appropriate action (to the extent possible) to
676-2278 (for Central County) or 510-236-2278 (for                  refer you to other participating providers. If other
West County); or Wheels at 925-455-7500.                            participating providers are not available, you will be
                                                                    referred to other medically appropriate providers. In
Members who are getting Child Health & Disability                   such circumstances, other medically appropriate
Prevention Program (CHDP) / Early and Periodic                      providers will do their best to provide needed
Screening Diagnosis & Treatment (EPSDT) services                    services; if necessary, you should go to the nearest
can get help with scheduling appointments and                       doctor or hospital for emergency services. CCHP
transportation by calling a CHDP/EPSDT Program

                                                           EOC-27                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

will later provide appropriate reimbursement for such                    services. CCHP will cover treatment of tumors
emergency services.                                                      of the gum and anesthesia and associated facility
                                                                         charges for dental services when performed in an
Only those services that are specifically described as                   inpatient setting for a dental procedure which the
benefits within this Evidence of Coverage and                            clinical status or underlying medical condition of
Disclosure Form are benefits of CCHP. Such                               the patient requires the dental procedure to be
services are benefits only if obtained in accordance                     performed in a hospital setting, or the enrollee is
with the procedures described in this document,                          under seven (7) years of age, or developmentally
including all authorization requirements and                             disabled, regardless of age. Surgical alignment of
referral/coordination by your PCP.                                       the jaw or T.M.J. retrogenathatic surgery, and
                                                                         services to treat a malocclusion are covered only
Unless exceptions to the following things not covered                    if medically necessary for the treatment of a
are specifically made somewhere else in this                             medical and not a dental disorder. For more
document or in any rider, addendum, attachments or                       information on dental care please call Denti-Cal
amendments to this document, no benefits are                             Beneficiary Telephone Service Center at 1-800-
provided which are for:                                                  322-6384;
                                                                   10.   DME – Those items listed as exclusions in
1.   Alcoholism – Alcoholism, alcoholism treatment                       Section 7 of this EOC;
     and rehabilitation, substance abuse or substance              11.   DNA testing - Genetic testing is not covered
     abuse treatment or rehabilitation on an inpatient                   except when determined by CCHP to be
     or outpatient basis, whether or not court-ordered,                  medically necessary to treat you for an
     except as provided in this Evidence of Coverage;                    inheritable disease. Genetic testing will not be
2.   Art, Dance or Music Therapy;                                        covered for non-medical reasons or when you
3.   Autologous Blood Donations;                                         have no medical indication or family history of a
4.   Biofeedback;                                                        genetic abnormality. The AFP (Alpha
5.   Care for conditions that state or local law                         Fetoprotein) Program, is available to you under
     requires to be treated in a public facility;                        fee-for-service for all pregnant members under
6.   Chemical Dependency – Chemical dependency                           20 gestational weeks;
     admissions (whether or not court-ordered),                    12.   Educational and Vocational - Academic
     unless medically necessary for acute medical                        coaching or tutoring for skills such as grammar,
     detoxification;                                                     math; educational skills related to gaining
7.   Convenience Items – Convenience items such                          academic knowledge or increase employment
     as telephones, televisions, guest trays and                         skills for employment counseling or training;
     personal hygiene items;                                       13.   Eligibility – any services and benefits rendered
8.   Cosmetic – Cosmetic surgery, prescription for                       prior to your effective date of coverage or after
     cosmetic use and “reconstructive surgery” unless                    the date you cease to be a member (except as
     deemed medically necessary by a CCHP                                provided with respect to an extension of benefits
     participating provider and except further when,                     under this Plan);
     to the extent required by California Health and               14.   Experimental – Any health care service, drug
     Safety Code Section 1367.63-1367.635, it is to                      (except off-label drugs), device or treatment that
     “improve function” or restore “normal                               is experimental or investigational. You have the
     appearance.” Reconstructive surgery following a                     right to ask for an IMR (Independent Medical
     mastectomy is also not excluded;                                    Review) if we deny a request to use an
9.   Dental Care – Any services customarily                              experimental service, drug, device or treatment;
     provided by dentists or oral surgeons will be                 15.   Home/Vehicle         Improvements        –     Any
     covered by fee-for-service Medi-Cal if you are in                   modifications or attachments made to dwellings,
     an excepted category          († For excepted                       property or motor vehicles including non-
     members, see Page 20 for more information),                         portable ramps, elevators, stair lifts, swimming
     including dental x-rays, dental hygiene,                            pools, air filtering systems, environmental
     hospitalization incident thereto; orthodontia                       control equipment, spas, hot tubs or automobile
     (dental services to correct irregularities or                       hand controls;
     malocclusions of the teeth for any use of                     16.   Hearing Aid Batteries – Hearing aid batteries
     dentures,     dental     implants      (endosteal,                  are not covered unless it is an initial hearing aid
     subperiosteal or transosteal) treatment of the                      battery supplied with the hearing aid that has
     gums, jaw joints, jawbones or any other dental                      been prior authorized;

Medi-Cal 2011_EOC                                         EOC-28
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                 Medi-Cal Evidenced of Coverage & Disclosure Form

17. Incontinence Creams and Washes († For                              psychiatric condition or for treatment of a
    excepted members, see Page 20 for more                             physically related sexual dysfunction that is not
    information);                                                      related to infertility services.        Emergency
18. Infertility Treatment – in vitro fertilization,                    services arising from, or incident to penile
    Gamete Introfallopian Transfer (G.I.F.T.)                          implant devices will be covered if it is clinically
    procedure or any form of induced fertilization;                    appropriate     and     consistent     with    good
19. Lost or Stolen Drugs – Subject to case by case                     professional practice;
    review by CCHP/PBM staff with appropriate                    29.   Physical Exams – Physical exams and
    documentation requested by CCHP;                                   immunizations,       required      for    licensure,
20. Non-Benefits – Any service, drug, equipment,                       employment, insurance, participation in school
    treatment or other benefit that is not medically                   or participation in recreational sports, ordered by
    necessary or which is listed as an exclusion in                    a court, or for travel, unless the exam
    this Evidence of Coverage or does not meet the                     corresponds to the schedule of routine physical
    clinical guidelines used to determine coverage of                  exams;
    the service;                                                 30.   Podiatry – Not covered unless the member is in
21. Non-Skilled Care – Care that can be rendered                       an excepted category († For excepted members,
    safely and effectively by family members or                        see Page 20 for more information) as set forth
    persons without licensure certification or                         in this Evidence of Coverage;
    supervision from a licensed nurse, except in the             31.   Private Duty Nursing – Private or special duty,
    case of hospice services;                                          unless medically necessary and okayed as part of
22. Obesity – Surgery for morbid obesity or weight                     an okayed hospital or Skilled Nursing Facility
    control programs unless found to be medically                      admission;
    necessary by CCHP’s Medical Director;                        32.   Psychiatric/Psychological Care – inpatient or
23. Organ Donors – Any services (other than                            outpatient psychiatric services except as
    emergency services or any medically necessary                      provided in this Evidence of Coverage. Benefits
    services arising from or caused by complications                   do not include testing for intelligence or learning
    from the donor harvesting) to you in connection                    disabilities or services in respect to mental
    with donor transplant services;                                    retardation, treatment of autism (except initial
24. Organ (Major) transplant (except renal and                         diagnosis), psychiatric therapy as a condition of
    corneal covered by fee-for-service Medi-Cal);                      parole, probation or court orders, ability,
25. Orthotics and Prosthetics – Those items listed                     aptitude, intelligence or interest psychological
    as exclusions in Section 7 of this EOC;                            testing or treatment for chronic conditions;
26. Over-the-counter Drugs, Supplies and Devices                 33.   Quantity Limits- For certain drugs, we limit the
    – such as over-the-counter medications not                         amount of the drug that we will cover per
    requiring a prescription, vitamins, mineral, food                  prescription or for a defined period of time. For
    supplements, or food items for special diets or                    example, most oral medications, such as pills or
    nutritional supplements (even if written on a                      other drugs that you swallow, the maximum is
    prescription form by a doctor) that are not a                      up to a 90-day supply or 100 pills, whichever is
    Medi-Cal benefit. This exclusion does not apply                    greater (or less than a 90-day supply or 100 pills
    to formulas or special food products to treat                      if your doctor orders less). For medications other
    phenylketonuria or PKU; this exclusion also                        than ones you swallow, the maximum depends
    does not apply to enteral nutrition products as                    on the type of medication.
    covered by Medi-Cal guidelines;                              34.   Self Referred – Not provided by, prescribed or
27. Pain Management – Confinement in a pain                            referred by your PCP and not okayed in
    management center to treat or cure chronic pain,                   accordance with CCHP requirements except for
    except for medically necessary pain management                     those services for which PCP referral and for
    in a pain management center which may be                           which okay is not required by specific provisions
    covered, subject to prior authorization                            of this Evidence of Coverage;
    requirements and concurrent review guidelines.               35.   Sexual Dysfunction – Incident to non-physically
    CCHP covers pain management services through                       related sexual dysfunction;
    its     participating     providers,    including            36.   Skin Aging – Relating to the diagnosis and
    participating hospitals for intractable pain or                    treatment to retard or reverse the effects of aging
    traction;                                                          of the skin;
28. Penile Devices – Penile implant devices and                  37.   Smoking Cessation – Drugs or aids for smoking
    surgery, except if medically necessary for a non-                  cessation unless prescribed in conjunction with a

                                                        EOC-29                                     Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

    smoking cessation program provided by CCHP                      •   Dental and Orthodontics (Denti-Cal Beneficiary
    to you (See Section 7 for more on Health                            Telephone Service Center 1-800-322-6384
    Information and Education);
                                                                    •   California Children’s Services
38. Special Packaging – Unless provided by
    manufacturer, “unit of use packaging” is not                    •   Acupuncture
    covered without prior authorization;                            •   Chiropractic
                                                                    •   Methadone/Outpatient Heroin Drugs
39. Step Therapy - In some cases, we require you to                 •   Alcohol and Drug Treatment Services available
    first try one drug to treat your medical condition                  under Short-Doyle Medi-Cal (SDMC) Program
    before we will cover another drug for that
    condition. For example, if Drug A and Drug B                    •   Local Education Agency (LEA) Service
    both treat your medical condition, we may                       •   Mental Health Services
    require your doctor to prescribe Drug A first. If               •   Psychotherapeutic, HIV/Antiviral, and Anti-
    Drug A does not work for you, then we will                          Parkinson’s Drugs
    cover Drug B. All step therapy cases are subject
    to CCHP’s expeditious process for authorizing                   If you need Long-Term Care, or an organ transplant
    exceptions to step therapy when medically                       and are accepted as a transplant candidate (except
    necessary;                                                      renal or corneal) or enroll in a Medi-Cal home and
40. Teaching Art, Dance or Music;                                   community based waiver program you may be
41. Teaching Manners and Etiquette - Services for                   disenrolled by the state Health Care Options
    social skills such as manners or etiquette                      contractor and go back to Fee-For-Service Medi-Cal.
    appropriate to social activities or behavioral                  Call a Member Services Representative to assist you.
    skills on how to interact appropriately when                    However, you may stay in CCHP if you enroll in the
    engaged in the usual activities of daily living                 Multi-Purpose Senior Services Program (MSSP). ). If
    such as eating, work and play;                                  you are placed in a Medi-Cal Home and Community
42. Transportation – Transportation services other                  Based Services (HCBS) waiver program, you will
    than emergency ambulance services or other                      continue to be enrolled in CCHP but you will receive
    transportation services as specifically provided in             your HCBS services from the waiver program.
    this Evidence of Coverage;                                      Long-term care includes care in a nursing facility
43. Vasectomy and Tubal Ligation Reversal - Or                      such as a Skilled Nursing Facility, sub-acute nursing
    incident to the reversal of a vasectomy or tubal                facility, pediatric sub-acute facility or intermediate
    ligation, repeat vasectomy or tubal ligation or the             care facility.
    infertility resulting therefrom, except in the event
    these services are medically necessary;
44. Vision Care - Surgery to correct refractive error
                                                                    SECTION 8. COMPLAINTS AND
    (such as but not limited to radial keratonomy;                  GRIEVANCES
    refractive keratoplasty, lasik and other forms of
    laser or non-laser vision correction), lenses and               Resolution of Complaints and Grievances
    frames for eye glasses and medically necessary                  If you have a concern or complaint about any CCHP
    contact lenses, other than the once every two (2)               services, you can file a grievance and CCHP will
    year benefit for a member in an excepted                        make a decision about your grievance within thirty
    category († For excepted members, see Page                      (30) days. You can informally try and talk about the
    20 for more information) as set forth in this                   problem where it occurred, but you are not required
    Evidence of Coverage;                                           to do so. If you have a concern or complaint about
45. Weight Control or Exercise Programs - Does                      your doctor or any provider, you can also try to talk
    not include medically necessary surgery as                      about the problem with your doctor or provider, but
    authorized by the plan or programs offered by                   you are not required to do so. You may use CCHP’s
    CCHP health education.                                          formal grievance process at any time. Call Member
                                                                    Services to help you at 1-877-661-6230 (press 2),
In addition, the following services are not covered                 California Relay 1-800-735-2929. You can write a
benefits by CCHP. They may be covered under some                    complaint to CCHP, phone us or come and talk about
other specially funded program or under Medi-Cal                    the problem. Our CCHP providers also have
Fee-For-Service.                                                    grievance forms in their offices. Our address is:
• Prayer Healing
• Adult Day Care                                                                 Contra Costa Health Plan

Medi-Cal 2011_EOC                                          EOC-30
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                   Medi-Cal Evidenced of Coverage & Disclosure Form

           595 Center Avenue, Suite 100                            request for reconsideration within thirty (30) days of
                Martinez, CA 94553                                 receipt. Please read below for more information on
               877-661-6230 (press 2)                              Medi-Cal Fair Hearings.
          California Relay 1-800-735-2929
                                                                   Medi-Cal Fair Hearing Right
If you file a complaint, your Member Services                      You have the right to use the Medi-Cal Fair Hearing
Representative will try to solve the problem. They                 process. You don't need to file a complaint or
will always try to answer your questions and solve                 grievance with CCHP or wait for a complaint or
your complaints at the time when first contact is                  grievance to be decided by CCHP.
made.                                                              You have only ninety (90) days after the order or
                                                                   action you are complaining of to file your Fair
If this does not work, you may file a “grievance”                  Hearing. You may go yourself or have someone else
which is a written or verbal expression of                         talk for you. This can be a lawyer, relative, friend or
dissatisfaction. All complaints and grievances will                anyone you decide to bring.
be resolved within thirty (30) days. You may write
us at the above address or call Member Services at 1-              To file a Fair Hearing, call 1-800-952-5253 (TDD
877-661-6230 (press 2), California Relay 1-800-735-                call 1-800-952-8349) or write to:
2929. You may also find a grievance form on our
website          at:                          California Department of Social Services                                                          P.O. Box 944243, MS 19-37
The following steps will help solve your complaint.                         Sacramento, CA 94244-2430

•   All grievances will be given to a Member                       Faster (Expedited) Medi-Cal Fair
    Services Representative;
                                                                   Hearing Process
•   All    grievances      are    considered     secret
                                                                   You or your doctor can ask the state to decide your
    (confidential) and information is used only to
                                                                   Medi-Cal Fair Hearing request faster if it involves
    investigate and resolve your grievance. We will
                                                                   imminent and serious threat to your health (such as
    keep information in a safe and protected place
                                                                   severe pain or potential loss of life, limb, or major
    and we will follow our rules of keeping medical
                                                                   body function). To ask for a faster decision, call 1-
    information secret (confidential);
                                                                   800-952-5253 (TDD call 1-800-952-8349) or write
•   If you file a grievance, CCHP will tell you in                 to:
    writing that we got it within five (5) days;
•   CCHP will give you a specific Member Service                            California Department of Social Services
    Representative’s name and phone number to                               Expedited Hearings Unit
    contact;                                                                State Hearings Division
•   Within thirty (30) days after we get your                               744 P Street, Mail Station 19-65
    grievance, CCHP will review and make a                                  Sacramento, CA 95814
    decision. CCHP provides only one level of
    grievance resolution or appeals;
                                                                   Expedited Review of Grievances
•   You have one hundred eighty (180) days after                   The Expedited Review Process applies to requests for
    something happens to file a grievance;                         services or supplies that:
•   Any services previously authorized by CCHP
    will continue while your grievance is being                    •   You believe are medically urgent but you have
    reviewed and resolved.                                             not gotten an okay or a referral for services; or
                                                                   •   You are getting and you think are medically
Appeals Process for Claims and Services                                urgent, and CCHP should keep providing.
Denials for reimbursement or benefits may be the
subject of a grievance. If you feel:                               You may ask CCHP to use this process when you file
• That you have not been given a needed benefit of                 a grievance or a request for consideration. We will
    CCHP, or                                                       use the Expedited Review Process if waiting thirty
• You need pay back for something you paid for;                    (30) days for a decision might seriously harm your
                                                                   health. For reviews that require expedited handling,
You may send Member Services a written request for                 we will give an answer no later than three (3) days
reconsideration within ninety (90) days of the date of             after we get your request.
CCHP’s denial. CCHP will answer your written

                                                          EOC-31                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

If we deny your request for an expedited review, we
will tell you in writing within three (3) days and use            Right to Conference
the regular thirty (30) days’ grievance process to                If you are terminally ill and CCHP says you cannot
review your request.                                              have an experimental or investigational service, you
                                                                  have one hundred eighty (180) days to write to
Whenever there is a case needing an expedited                     Member Services to ask for a conference. If you
review, you also have the right to tell the Department            cannot meet this deadline, please call Member
of Managed Healthcare of the grievance.                           Services at 1-877-661-6230 (press 2), California
                                                                  Relay 1-800-735-2929 for how to proceed.
Filing a Complaint with the Department
of Managed Health Care (DMHC)                                     •   Within five (5) business days from the denial,
                                                                      CCHP will give you information about grievance
The California Department of Managed                                  procedures and how to ask for a conference.
                                                                              o You will be told exactly why your
Health Care is responsible for regulating                                          coverage was denied.
health care service plans. If you have a                                      o You will be told about other types
grievance against your health plan, you                                            of treatments, services, or supplies
should first telephone your health plan at                                         covered by CCHP, if any.
1-877-661-6230 and use your health
                                                                  •   Within thirty (30) days of receiving a request for
plan’s     grievance     process    before
                                                                      a conference, CCHP will set up a conference
contacting the department. Utilizing this                             with you and the people you pick to talk about
grievance procedure does not prohibit                                 why CCHP denied coverage and if there are
any potential legal rights or remedies that                           other possible choices. Someone from CCHP
may be available to you. If you need help                             with power to decide on the complaint will run
                                                                      the conference.
with a grievance involving an emergency,
a grievance that has not been                                     •   If your doctor and the CCHP’s Medical Director
satisfactorily resolved by your health                                think that a delay in treatment will make it
plan, or a grievance that has remained                                substantially less effective, CCHP will set up a
unresolved for more than 30 days, you                                 conference within five (5) business days after
may call the department for assistance.                               your request.
You may also be eligible for an                                   In addition to requesting a conference, you can also
Independent Medical Review (IMR). If                              immediately request an Independent Medical Review
you are eligible for IMR, the IMR process                         (IMR) with the Department of Managed Health Care.
will provide an impartial review of                               See the section below for more information on IMR.
medical decisions made by a health plan                           You may also call the department at toll-free
                                                                  telephone number (1-888-HMO-2219) and TDD line
related to the medical necessity of a                             (1-877-688-9891) for the hearing and speech
proposed service or treatment, coverage                           impaired.
decisions for treatments that are
experimental or investigational in nature                         Independent Medical Review (IMR) -
and payment disputes for emergency or                             Independent Medical Review of
urgent medical services. The department                           Experimental or Investigational Services
also has a toll-free telephone number (1-                         If CCHP has decided not to give you a service, drug,
888-HMO-2219) and a TDD line (1-877-                              device, procedure, or other therapy (referred to as
                                                                  “Requested Service”) because it is an experimental or
688-9891) for the hearing and speech                              investigational service, you may ask for an
impaired. The department’s Internet                               independent medical review offered by the
Web site has                            Department of Managed Health Care’s (DMHC)
complaint forms, IMR application forms                            Independent Medical Review (IMR) process. You
and instructions online.                                          may qualify for this review if:

Medi-Cal 2011_EOC                                        EOC-32
                                                                                   CONTRA COSTA HEALTH PLAN
                                                                 Medi-Cal Evidenced of Coverage & Disclosure Form

•   Your doctor certifies that you have a life                   come with any grievance decision letter you get from
    threatening or seriously debilitating condition;             CCHP that denies, modifies or delays health care
    and                                                          services because they are not medically necessary. If
•   Your doctor certifies that standard treatments               you decide not to use the Independent Medical
    have not been effective in improving the                     Review process, this may cause you to give up any
    condition; and                                               statutory right to pursue legal action against CCHP
•   Your doctor has recommended the requested                    regarding the disputed health care services.
    service that may be more helpful than any
    available standard treatment; and                            How Eligibility for Independent Medical Review
•   CCHP has denied you coverage of this requested               Will Be Decided
    service; and
•   This requested service would be of benefit to you            The DMHC shall have the final authority to
    if it were not considered an experimental or                 determine whether a case qualifies for IMR. Your
    investigational service.                                     application for Independent Medical Review will be
                                                                 reviewed by the DMHC to make sure that:
Note:                                                            1.   (a) Your provider has recommended a health
• If you are eligible, CCHP will notify you in                        care service as medically necessary; or
    writing of the opportunity to request an IMR                      (b) You have gotten Urgent Care Services or
    within five business days of the decision to deny                 Emergency Services that a provider determined
    coverage;                                                         were medically necessary; or
• The Department of Managed Health Care does                          (c) You have been seen by an in-plan
    not require that you participate in CCHP’s                        (contracted) provider for the diagnosis or
    grievance system prior to seeking an IMR of a                     treatment of the medical condition for which you
    denial for an experimental or investigational                     seek independent medical review;
• If your doctor determines that the proposed                    2.   The disputed health care service has been denied,
    therapy would be significantly less effective if                  modified, or delayed by CCHP or one of the
    not promptly initiated, the analyses and                          contracted providers, based wholly or partly
    recommendation of the experts on the IMR panel                    because the health care service is not medically
    shall be rendered within seven days of the                        necessary; and
    request for expedited review.                                3.   You have filed a grievance or a request for
                                                                      reconsideration with CCHP or its contracting
Independent Medical Review (IMR) of                                   provider and the disputed decision is upheld or
Denials based on Medical Necessity                                    remains unresolved after thirty (30) days. If your
You may also ask for an Independent Medical                           grievance or request for reconsideration requires
Review of disputed health care service from the                       expedited review, you may bring it immediately
Department of Managed Health Care if you think that                   to the attention of the Department of Managed
health care service has been wrongly denied,                          Health Care. In unusual cases, the Department
modified or delayed by CCHP or by one of our                          of Managed Health Care may not require that
contracted providers.                                                 you follow CCHP’s grievance process.

A “disputed health care service” is any health care              If your case is found to be eligible for Independent
service eligible for coverage and payment under your             Medical Review, the dispute will be given to a
subscriber contract which has been denied, modified              medical specialist who will make an independent
or delayed wholly or partly by CCHP or one of our                finding of whether or not the care is medically
contracting providers because the service is not                 necessary. You will get a copy of the findings made
medically necessary.                                             in your case. If the Independent Medical Review
                                                                 finds the service is medically necessary for you,
The Independent Medical Review process is in                     CCHP will give the health care services.
addition to any other procedures or remedies that
may be available to you. There are no application or             •    For non-urgent cases, the Independent Medical
processing fees for an Independent Medical Review.                    Review organization designated by the
You have the right to give information in support of                  Department of Managed Health Care must give
the request for an Independent Medical Review. An                     its finding within thirty (30) days after receiving
Independent Medical Review application form must

                                                        EOC-33                                    Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

     your Independent Medical Review application                   Mandatory Disenrollment
     and supporting documents.                                     You must disenroll when:
• For urgent cases involving immediate and                         (a) You ask for disenrollment;
     serious threat to your health, including but not              (b) Your eligibility for enrollment with CCHP is
     limited to: potential loss of life, limb or major                 stopped or eligibility for Medi-Cal is stopped,
     bodily function, severe pain, or the immediate                    including your death;
     and serious worsening of your health, the                     (c) There is an enrollment mistake and you are
     Independent Medical Review organization must                      placed into the wrong plan by the California
     give its finding within three (3) business days.                  Department of Health Care Services’ enrollment
For more information about the Independent                             contractors;
Medical Review Process, or to ask for an                           (d) You are enrolled in the plan due to prohibited
application form, please call the Department of                        marketing practices by the plan;
Managed Health Care. The department also has a                     (e) You are asking for Medi-Cal benefits which are
toll-free telephone number (1-888-HMO-2219)                            excluded under the terms of CCHP’s contract
and a TDD line (1-877-688-9891) for the hearing                        and which require disenrollment from CCHP
and speech impaired. The department’s Internet                         (major organ transplant, home and community
Web       site        has                based waiver program);
complaint forms, IMR application forms and                         (f) You change your place of residence to outside
instructions online.                                                   CCHP’s service area;
                                                                   (g) You are a resident of a long-term care facility for
Kaiser Permanente Grievance Processes                                  longer than the month of admission plus thirty
Kaiser Permanente Member Services Representatives                      (30) days;
will handle your grievances if you are assigned to the             (h) You are put in jail in a youth or adult
Kaiser Permanente Network. Please call 1-800-464-                      correctional facility;
4000 to file a grievance at Kaiser. If you’re not                  (i) Your plan is reorganized or merged with another
satisfied with the way your grievance is answered,                     organization for any cause within sixty (60) days
you may call the Contra Costa Member Services Unit                     after the effective date of the reorganization or
at 1-877-661-6230 (press 2), California Relay 1-800-                   merger occurrence;
735-2929 for more help.                                            (j) After a Plan Initiated Disenrollment Request is
                                                                       reviewed and approved by DHCS.
California DHCS Ombudsman Program
The California Department of Health Care Services                  A mandatory disenrollment usually takes from fifteen
has a Medi-Cal Ombudsman Program that can help                     (15) to forty-five (45) days to complete.
you with complaints about a Medi-Cal Managed Care
health plan or enrollment into a Medi-Cal health plan.             Disenrollment for Cause
If you need assistance, call 1-888-452-8609. You                   CCHP may ask the California Department of Health
also have the right to change your health plan at any              Care Services (DHCS) to stop your membership if
time.                                                              there is good cause for stopping your membership.
                                                                   Stopping your membership for cause may include the
SECTION 9. DISENROLLING                                            following situations:

FROM CCHP                                                          (1) You use fraud or deception to use or obtain
                                                                       drugs. You use fraud or deception when using
We hope you like the services you get as a member                      CCHP facilities or obtain other CCHP services.
of CCHP’s Medi-Cal managed care program.                               CCHP may also ask to stop your membership if
However, if you are not satisfied, you can ask to                      you intentionally allow another to fraudulently
disenroll at any time and for any reason. You can                      use CCHP facilities or obtain CCHP services.
call Health Care Options (HCO), the company that                       Examples of this may include, but are not limited
helped you to enroll at 1-800-430-4263 to ask for a                    to the following:
disenrollment form. You can also ask them where                        • You intentionally misuse or let someone else
you can go in Contra Costa County to get one.                               misuse a CCHP Identification Card;
Health Care Options will mail a disenrollment form                     • You intentionally give CCHP wrong or
to you.                                                                     incomplete material information in any
                                                                            document or fail to tell CCHP of material
                                                                            changes in the your status or coverage that

Medi-Cal 2011_EOC                                         EOC-34
                                                                                  CONTRA COSTA HEALTH PLAN
                                                                  Medi-Cal Evidenced of Coverage & Disclosure Form

        may affect eligibility for membership or                  It will take about three (3) days for an expedited
        benefits;                                                 disenrollment to go through.
    •   You intentionally misrepresent membership
        status or coverage;
    •   You intentionally present an invalid
                                                                  SECTION 10. YOUR RIGHTS
(2) You continually refuse to follow recommended                  AND RESPONSIBILITIES
    treatment or established procedure of the Health
    Plan or the PCP. (Before any such request to
    end your membership, CCHP will offer you the                  Your rights include, but are not limited to
    opportunity to develop an acceptable relationship             the following:
    with another PCP);
                                                                  1.  As a member of CCHP, you are entitled to get
(3) You disrupt the operation of CCHP or any                          considerate and courteous care regardless of your
    related health facilities so that they cannot                     race, religion, education, sex, cultural
    effectively provide health care to you or to other                background, physical or mental handicaps, or
    patients;                                                         financial status.
                                                                  2. You have the right to pick a PCP who has the
(4) There is a break down in patient-physician
                                                                      responsibility to give, coordinate and supervise
    relationship involving you and your provider,
                                                                      your medical care.
    which is irreconcilable.
                                                                  3. You have the right to be seen for appointments
                                                                      within a reasonable period of time.
If the Department of Health Care Services or Health
                                                                  4. You have the right to participate in your health
Care Options approves CCHP’s request to stop your
                                                                      care decisions. To the extent allowed by law,
membership, it will stop at midnight on the last day
                                                                      this includes the right to refuse treatment.
of the calendar month in which the request was
                                                                  5. You have the right to get a courteous response to
                                                                      all questions.
                                                                  6. You have the right to file a verbal or written
Expedited Disenrollment                                               complaint and to stop your membership. You
In some special cases, Member Services must help                      have the right to request a fair hearing.
you end your membership quickly. This is called an                7. You have the right to Health Plan information
emergency disenrollment or expedited disenrollment.                   including, but not limited to benefits and things
                                                                      not covered, after hours and emergency care,
The reasons for an expedited disenrollment are:                       referrals to specialty providers, and services,
                                                                      procedures regarding choosing and changing
(a) Children placed in Foster Care or Adoption                        providers, and types of changes in services.
    Assistance Programs;                                          8. You have the right to seek Family Planning
(b) You have special health care needs not covered                    Services outside your provider network without
    by CCHP (such as major organ transplants or                       referral if you choose to do so.
    long term care);                                              9. You have the right to formulate Advance
(c) You are incarcerated;                                             Directives. Please see Section 14 of this EOC
(d) You have a complex medical condition and were                     booklet for more information on Advance
    defaulted into a plan and within the first ninety                 Directives.
    (90) days of membership you want to return to                 10. You have the right to confidentiality concerning
    care from your previous health care provider                      your medical care. This includes the right to be
    who is not contracted with CCHP. You will also                    told why there is another person present while
    need a medical exemption form. Call a Health                      care is being given.
    Care Options office to request one;                           11. You have the right to access your medical
(e) You are already enrolled in another Medi-Cal or                   record.
    Commercial managed care plan;                                 12. You have the right to have access to emergency
(f) You are a Native American who wants to stop                       services outside of CCHP’s provider network.
    membership to seek services from an Indian
    Health Center or on a Fee-For-Service basis.

                                                         EOC-35                                  Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

Your responsibilities include, but are not                           have been given at CCHP’s expense, CCHP and our
limited to the following:                                            participating providers reserve the right to get
                                                                     reimbursement from any OHC for the cost of services
1.   It is your responsibility to read all CCHP                      given, but not more than the amount payable under
     materials so that you know how to use your                      such OHC. In this case, you would be asked to sign
     CCHP benefits.        Call a Member Services                    any documents needed for such payment to be made
     Representative to ask questions when needed. It                 to CCHP or your participating provider. The Plan
     is your responsibility to follow the rules of your              will coordinate benefits so that coverage given is
     CCHP membership as explained in this Evidence                   secondary to all other coverage.
     of Coverage and Disclosure Form.
2.   It is your responsibility to give complete and                  SECTION 12. PUBLIC POLICY
     accurate information about your past and present
     medical illnesses and conditions including                      CCHP is advised by the Managed Care Commission
     medications and other related matters.                          (MCC). Anyone wanting to be heard regarding
3.   It is your responsibility to follow the treatment               public policy may speak at the Managed Care
     plan recommended by your health care                            Commission meetings. Sometimes, there are
     providers.                                                      openings on the Managed Care Commission. If you
4.   It is your responsibility to ask questions about                would like to serve on the Managed Care
     your condition and treatment plan until you                     Commission, you can call the CCHP Administration
     clearly understand.                                             at 925-313-6004 for more information about getting
5.   It is your responsibility to keep scheduled                     involved in establishing public policy.
     appointments or to call at least 24 hours in
     advance to cancel.                                              SECTION 13. OTHER SERVICES
6.   It is your responsibility to call in advance for
     prescription refills.
7.   It is your responsibility to be courteous and                   Transitional Medi-Cal
     cooperative to people who provide you or your                   If you lose your Medi-Cal eligibility, call your
     family with health care services.                               Eligibility Worker at the Contra Costa County Social
8.   It is your responsibility to actively participate in            Services Office for help with Transitional Medi-Cal
     your health and the health of your family. This                 (TMC). Transitional Medi-Cal can give you no cost
     means taking care of problems before they                       Medi-Cal for up to twelve (12) months and let you
     become serious, following your provider’s                       stay in your health plan.
     instructions, taking all your medications as
     prescribed, and participating in health programs                Federally Qualified Health Centers
     that keep you healthy.                                          You can get medical care from a Federally Qualified
9.   It is your responsibility to give to CCHP any                   Health Center (FQHC) if it is part of the RMCN. A
     address changes, family status changes and                      list of Federally Qualified Health Centers is shown in
     information about other insurance or health care                your Provider Directory.
     service plan coverage that is important to your
     health plan coverage.                                           If you want to get services from a Federally Qualified
                                                                     Health Center, you will need to pick a PCP who is
                                                                     connected with the facility that you want to use. You
SECTION 11. COORDINATION                                             can call a Member Services Representative at 1-877-
OF BENEFITS                                                          661-6230 (press 2), California Relay 1-800-735-2929
                                                                     to help you in picking a Federally Qualified Health
The following Coordination of Benefits (COB)                         Center physician. If you wish to stop using a
provisions apply to bill payment by CCHP when you                    Federally Qualified Health Center, you may call a
have additional health care coverage:                                Member Services Representative to change to
                                                                     another PCP in another location.
Benefit Coordination with Other Health
Coverage                                                             Indian Health Centers
The benefits given under CCHP will be coordinated                    The American Indian Health Services Program says
with any other health care coverage under which you                  that Native Americans who can get Medi-Cal are not
are covered. If you are eligible to get benefits under               required to be members in a Medi-Cal managed care
Other Health Coverage (OHC) for services which                       plan. Those who are members of CCHP may get

Medi-Cal 2011_EOC                                           EOC-36
                                                                                   CONTRA COSTA HEALTH PLAN
                                                                  Medi-Cal Evidenced of Coverage & Disclosure Form

their medical care from any Indian Health Center                  that decisions are what you want them to be, it is
even if it is not part of the CCHP provider network.              helpful if you say in advance what you want to
A Native American may also stop membership at any                 happen if you cannot speak for yourself.
time and seek services from an Indian Health Center
on a Fee-For-Service basis. There are no Indian                   There are several kinds of “Advance Directives” that
Health Centers located in Contra Costa County.                    you can use to say what you want and to designate
                                                                  someone to speak for you.
Nurse Midwife and Nurse Practitioner
Services                                                          California law now provides that an Advance
Nurse Midwives and Nurse Practitioners are a                      Directive means either an “individual health care
covered benefit under Medi-Cal managed care. Call                 instruction or a power of attorney for health care.” In
your Member Services Representative for a list of                 July 2000, California enacted the Health Care
contracting or out-of-plan Nurse Midwives.                        Decisions Law that consolidated previous California
                                                                  advance directive laws to allow you to express in
                                                                  advance what you want to happen. A new advance
SECTION 14. YOUR RIGHT TO                                         directive called the Advance Health Care Directive
MAKE DECISIONS ABOUT                                              (AHCD) replaces previous documents such as the
                                                                  “Living Will” and the Durable Power of Attorney for
MEDICAL TREATMENT                                                 Health Care. The Advanced Health Care Directive
                                                                  allows you to:
This section explains your rights to make health care
decisions and how you can plan what should be done
                                                                  •   Create a Power of Attorney for Health Care,
when you cannot speak for yourself.
                                                                      thereby designating an agent to make health care
                                                                      decisions for you, the principal.
You have the right to be informed by CCHP of State
                                                                  •   Provide instructions for future health care
law regarding advance directives, and to get
                                                                      decisions including whether or not to prolong
information from CCHP regarding any changes to
                                                                      life or alleviate pain in certain circumstances.
that law. The information will tell you about changes
in State law for advance directives as soon as
possible, but no later than ninety (90) calendar days             Who can fill out this form?
after the effective date of change.                               You can if you are eighteen (18) years or older and of
                                                                  sound mind. You do not need a lawyer to fill it out.
A federal law requires us to give you this                        You must, however, comply with statutory
information. We hope this information will help                   requirements such as having the document dated,
increase your control over your medical treatment.                signed and acknowledged by a notary or witnessed
                                                                  by two (2) witnesses (one of which must not be either
                                                                  related by blood, marriage, adoption or entitled to
How do I know what I want?
                                                                  any portion of your estate upon your death). Other
Your physician must tell you about your medical
                                                                  requirements may apply if you are currently in a
condition and about what different treatments can do
                                                                  Skilled Nursing Facility. A detailed description of
for you. Many treatments have “side effects.” Your
                                                                  these requirements can be found in California Probate
physician must offer you information about serious
                                                                  Code Sections 4670 et seq.
problems that the medical treatment is likely to cause
                                                                  Who can I name to make medical
Often more than one treatment might help. People                  treatment decisions when I am unable to
also have different ideas about which treatment is                do so?
best. Your physician can tell you which treatments                You can choose an adult relative or friend you trust
are available to you, but your doctor cannot choose               as your “agent” to speak for you when you are too
for you. The choice depends on what is important to               sick to make your own decisions. You would use the
you.                                                              Advance Health Care Directive to appoint this
What if I am too sick to decide?
If you cannot make treatment decisions your                       Another way to name an adult relative or friend to
physician may ask your closest available relative or              make medical decision on your behalf is to designate
friends to help decide what is best for you. To ensure            a “surrogate” by personally informing the supervising
                                                                  health care provider. This oral designation must be

                                                         EOC-37                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

promptly recorded in your health care record. It is                   for your wishes as well as a properly executed
only effective during the course of treatment or                      Advance Health Care Directive.
illness, or during the stay in the health care institution
when the designation is made.                                         Once you communicate such a directive to your
                                                                      physician or other supervising health care provider,
How does this person know what I would                                the provider who knows of the existence of an
want?                                                                 Advance Health Care Directive is required to record
After you choose someone, talk to that person about                   its existence in the patient’s health care record. If
what you want. You can also write down in the                         your directive is in writing, the provider is further
Advance Health Care Directive when you would or                       required to request a copy to be kept with your
would not want medical treatment. Talk to your                        medical records.
physician about what you want and give your
physician a copy of the form. Give another copy to                    Are Living Wills and Durable Powers of
the person named as your agent. Also, take a copy                     Attorneys created prior to the new law
with you when you go into a hospital or other                         still valid?
treatment facility.                                                   Yes. If you completed an advance directive prior to
                                                                      July 2000, it will remain valid and it is unnecessary
Sometimes treatment decisions are hard to make and                    to use the new Advance Health Care Directive so
it helps your family and physicians if they know what                 long as the prior advance directive was valid under
you want. The Advance Health Care Directive also                      the law in existence prior to July 2000.
gives them legal protection when they follow your
wishes.                                                               What if I change my mind?
                                                                      You can change or revoke any of these documents at
What if I do not have anybody to make                                 any time as long as you can communicate your
decisions for me?                                                     wishes.
You can still use the Advance Health Care Directive
to indicate your instructions for health care treatment.              Do I have to fill out this form?
Prior to the Health Care Decisions Law, the now                       No, you do not have to fill out the Advance Health
repealed California Natural Death Act provided for a                  Care Directive if you do not want to. You can just
“Living Will” called a declaration. This declaration                  talk with your physicians and ask them to write down
is now a part of the Advance Health Care Directive.                   what you have said in your medical chart. You can
Under either the “Living Will” declaration or the                     also talk with your family…but your treatment
provisions of the Advance Health Care Directive, you                  wishes will be clearer to your family if you write
are telling your doctor that you do or do not want any                them down. Your wishes are also more likely to be
treatment that would only prolong your dying. If you                  followed if you write them down.
instruct it, all life-sustaining treatment would be
stopped if you were terminally ill and your death was                 Will I still be treated if I do not fill out
expected soon, or if you were permanently
unconscious. However, you would still get treatment                   this form?
to keep you comfortable.                                              Absolutely, you will still get medical treatment. We
                                                                      just want you to know that if you become too sick to
                                                                      make decisions, someone else will have to make
How do I issue an “individual health care                             them for you.
An individual instruction means that you, as a patient                Remember that:
can issue either a written or an oral direction                        The Advance Health Care Directive lets you
concerning health care decisions for yourself. As                        name someone to make treatment decisions for
indicated above, one way to issue a direction is to use                  you. That person can make most medical
the Advance Health Care Directive. You can also                          decisions (not just those about life-sustaining
just write down your wishes on a piece of paper.                         treatment) when you cannot speak for yourself.
Your physicians and family can use what you write in                     Besides naming an agent, the form allows you to
deciding about your treatment. Keep in mind,                             state when you would and would not want
however, that oral instructions and written                              particular kinds of treatment;
instructions other than those in the Advance Health                    If you do not have someone you want to name to
Care Directive may not give as much legal protection                     make decisions when you cannot, you can still

Medi-Cal 2011_EOC                                            EOC-38
                                                                                      CONTRA COSTA HEALTH PLAN
                                                                     Medi-Cal Evidenced of Coverage & Disclosure Form

    use the Advance Health Care Directive to state                   not provide bonuses, however providers are given
    that you do not want life-prolonging treatment if                incentives related to quality performance and
    you are terminally ill or permanently                            processes. If you would like more information about
    unconscious;                                                     payment for participating providers, you may call
   If you already have a valid advance directive                    Member Services at 1-877-661-6230 (press 2) or
    (such as a Durable Power of Attorney for Health                  your own Community Provider. The statements here
    Care or Living Will) executed prior to July 2000,                apply to the RMCN and the CPN. For information
    this document is still valid under the new law.                  about Kaiser Permanente’s payment for providers,
                                                                     please see Kaiser Permanente’s booklet or call Kaiser
How can I get more information about                                 Permanente’s Member Services.
Advance Directives?
Ask your physician, nurse, social worker or legal                    Arbitration
professional to get information for you. You may                     Kaiser Permanente uses arbitration to settle disputes.
also read the Health Care Decisions Law found in                     Members who choose Kaiser Permanente are subject
California Probate Code Sections 4600 et seq.                        to their arbitration policies and procedures stated the
                                                                     Kaiser Permanente booklet. For rules covering this
Important information for CCHP                                       arbitration process, please see the Kaiser Permanente
                                                                     booklet or call Kaiser Permanente’s Member
Members about Advance Directives                                     Services.
CCHP shares your interest in preventive care and in
maintaining good health. However, eventually every
family must face the possibility of serious illness in               Individual and Family Benefit Plans – If
which important decisions must be made. We                           Your Medi-Cal Eligibility Stops
believe it is never too early to think about decisions               If your eligibility for coverage under this Medi-Cal
that may be very important in the future, and to                     Managed Care Plan stops, you may apply for private
discuss these topics with your family and friends.                   coverage through one of CCHP’s Individual and
CCHP complies with California laws on Advance                        Family benefit plans. Benefits provided under the
Directives. We do not condition the provision of care                Individual and Family plans are different from those
or discriminate against anyone based on whether or                   under the Medi-Cal Managed Care Health Plan
not you have an Advance Directive. We have                           Contract. Individual and Family applications go
policies to ensure that your wishes about treatment                  through review by our Medical Department. You are
will be followed.                                                    responsible for applying for the Individual and
                                                                     Family plan, and if accepted, for paying all premiums
Copies of the forms mentioned in this section are                    due for such coverage.
available when you are admitted to a hospital. If you
have completed a Durable Power of Attorney, Living                   Individual and Family Plans –
Will, Natural Death Act Declaration Form or                          Termination for Nonpayment
Advance Health Care Directive, please give your                      Following due notice of at least fifteen (15) days and
physician a copy and take a copy with you when you                   billing for an unpaid premium charge, your coverage
check into a hospital or other health facility so that it            and membership may cease if you fail to pay a
can be put in your medical record.                                   premium payment for the private coverage, which is
                                                                     owed to CCHP.
                                                                     Notice of Information Practices
Payment for Providers                                                The Confidentiality of Medical Information Act
CCHP does not use financial penalties meant to limit                 states that CCHP will keep medical information
health care.      Some participating providers are                   about a patient, enrollee or subscriber confidential
salaried. Others are paid a fee for each of the services             and will not disclose such information unless
they give. CCHP does pay a case management fee to                    disclosure is okayed by the patient, enrollee or
some PCP's who are Community Physicians based in                     subscriber or okayed by statute pursuant to California
part on the total cost of health care provided to all of             Law.
the members who have selected PCP's who are
Community Physicians. No payment, however, is                        The Insurance Information and Privacy Protection
made to a participating provider based directly on                   Act states that CCHP may gather personal
that provider’s use of referral services. CCHP does                  information from persons other than the individual or

                                                            EOC-39                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

individuals applying for insurance coverage. CCHP              • The Contra Costa Health Plan
will not disclose any personal or privileged                   • All employees, physicians, health care professional
information about an individual, which CCHP may                staff, and others authorized to enter information into
have gathered or gotten in connection with an                  your medical or health record.
insurance transaction unless the disclosure is                 • Volunteers or persons working with us to help you.
following the written okay of the individual or                • Selected county employees responsible for payment
individuals.                                                   and operational support.
Individuals who have applied for insurance coverage            • Self insured group dental plans and flexible
through CCHP may ask to get and correct personal               spending health accounts for County employees.
information that may have been gathered in                     • All providers that the above named entities contract
connection with the application for insurance                  with to provide medical services.
                                                               All of the above named entities will follow the terms
A statement describing CCHP’s policies and                     of this Notice. In addition, all of the above may share
procedures for preserving the confidentiality of               medical information with each other for treatment,
medical records is available and will be furnished             payment, or health care operations purposes as
to you upon request.                                           described in this Notice.

For more information about this policy and your                Our promise regarding your medical information
rights, you may contact:                                       Contra Costa County documents the care and services
                                                               you receive in written and electronic records. In this
                Member Services                                Notice, we will refer to those records as “medical
            Contra Costa Health Plan                           information”. We need this information to provide
          595 Center Avenue, Suite 100                         you with quality health care and customer services,
               Martinez, CA 94553                              evaluate benefits and claims, administer health care
           1-877-661-6230 (press 2), or                        coverage, measure performance, and to fulfill legal
         California Relay 1-800-735-2929                       and regulatory requirements. We understand that
                                                               medical information about you and your health is
HIPAA NOTICE OF PRIVACY                                        personal.
 CCHP IS COMMITTED TO PROTECTING YOUR                          We are committed to protecting your medical
                PRIVACY                                        information and following all state and federal laws
                                                               related to the protection of your medical information.
HIPAA Notice of Privacy Practices                              This Notice tells you about the ways in which we
THIS NOTICE DESCRIBES HOW MEDICAL                              may use and disclose medical information about you.
INFORMATION ABOUT YOU MAY BE USED                              It also describes your rights and certain obligations
AND DISCLOSED AND HOW YOU CAN GET                              we have regarding the use and disclosure of medical
ACCESS TO THIS INFORMATION PLEASE                              information.
REVIEW IT CAREFULLY                                            We are required by law to:
                                                               • make sure that medical information that identifies
Who will follow this notice                                    you is kept private (with certain exceptions);
This Notice describes Contra Costa County’s privacy            • give you this Notice describing our legal duties and
practices for:                                                 privacy practices with respect to medical information
• Contra Costa Regional Medical Center                         about you; and
• The Ambulatory Care Health Centers and affiliated            • follow the terms of the Notice that is currently in
satellite clinics located in Antioch, Bay Point,               effect.
Brentwood, Concord, Martinez, North Richmond,
Pittsburg, and Richmond
                                                               How we may use and disclose medical information
• The Mental Health Centers of Contra Costa
                                                               about you
County, and the Contra Costa Mental Health Plan                Sometimes we are allowed by law to use and disclose
• The Public Health Centers and programs of Contra             your medical information without your permission.
Costa County                                                   We briefly describe these uses and disclosures and
• The Alcohol and Other Drug Services programs of              give you some examples. Some medical information,
Contra Costa County                                            such as certain mental health and drug and alcohol
• Emergency Medical Services

Medi-Cal 2011_EOC                                     EOC-40
                                                                                    CONTRA COSTA HEALTH PLAN
                                                                   Medi-Cal Evidenced of Coverage & Disclosure Form

abuse patient information, and HIV and genetic tests               plan about a proposed treatment to determine whether
have stricter requirements for use and disclosure, and             your plan will cover the treatment or medication. We
your permission will be obtained prior to some uses                may also share your information, when appropriate,
and disclosures. However, there are still                          with other government programs such as Medicare or
circumstances in which these types of information                  Medi-Cal in order to coordinate your benefits and
may be used or disclosed without your permission. If               payments, or with practitioners outside the hospital or
you become a client of our Alcohol and Other Drug                  health centers who are involved in your care, to assist
Services programs, we will give you a separate                     them in obtaining payment for services they provide
written Notice, as required by law, about your                     to you.
privacy rights for your chemical dependency medical
information.                                                       The County Health Plans (including the Contra Costa
                                                                   Health Plan and the self insured group dental plans
How much medical information is used or disclosed                  and flexible spending health accounts for County
without your permission will vary depending on the                 employees) may use or disclose medical information
intended purpose of the use or disclosure. When we                 about you to determine eligibility for plan benefits,
send you an appointment reminder, for example, a                   obtain premiums, facilitate payment for the treatment
very limited amount of medical information will be                 and services you receive from health care providers,
used or disclosed. At other times, we may need to use              determine plan responsibility for benefits, and to
or disclose more medical information such as when                  coordinate benefits.
we are providing medical treatment.
                                                                   For Health Care Operations
For Treatment                                                      We may use and disclose medical information about
We may use medical information about you to                        you for certain health care operations. For example,
provide you with treatment or services. We may                     we may use your medical information to review the
disclose medical information about you to doctors,                 quality of the treatment and services we provided, to
nurses, therapists, technicians, interns, medical                  educate our health care professionals, and to evaluate
students, residents or other health care personnel who             the performance of our staff in caring for you. We
are involved in taking care of you, including offering             may also combine medical information about many
you medical advice, or to interpreters needed in order             patients to decide what additional services we should
to make your treatment accessible to you. For                      offer, or whether certain new treatments are effective.
example, a doctor may use the information in your                  Your medical information may also be used or
medical record to determine what type of                           disclosed for licensing or accreditation purposes.
medications, therapy, or procedures are appropriate
for you. The treatment plan selected by your doctor                The County Health Plans may use and disclose health
will be documented in your record so that other                    information about you to carry out necessary
health care professionals can coordinate the different             insurance- related activities. Examples include
things you need, such as prescriptions, lab tests,                 underwriting, premium rating, conducting or
referrals, etc.                                                    arranging medical review, legal and audit services,
                                                                   fraud and abuse detection, business planning,
We also may disclose medical information about you                 management, and general administration. However,
to people outside our facilities who may be involved               the County Health Plans are prohibited from using or
in your continuing medical care, such as skilled                   disclosing genetic information about you for
nursing facilities, other health care providers, case              underwriting purposes.
managers, transport companies, community agencies,
family     members,       and     contracted/affiliated            For Reminders
pharmacies.                                                        We may contact you to remind you that you have an
                                                                   appointment, or that you should make an
For Payment                                                        appointment at one of our facilities.
We may use and disclose medical information about
you so that the treatment and services you receive                 For Health-Related Benefits & Services
may be billed to and payment may be collected from                 We may contact you about benefits or services that
you, an insurance company, or a third party. For                   we provide. We will not sell or give your information
example, we may need to give your health plan                      to an outside agency for the purposes of marketing
information about a surgery you received so your                   their products to you.
health plan will pay us. We may also tell your health

                                                          EOC-41                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

For Treatment Alternatives                                           information can generally be used or disclosed for
We may tell you about or recommend possible                          research without your permission if an Institutional
treatment options or alternatives that may be of                     Review Board (IRB) approves such use or disclosure.
interest to you.                                                     An IRB is a committee that is responsible, under
                                                                     federal law, for reviewing and approving human
                                                                     subjects research to protect the safety and welfare of
For Fund-Raising                                                     the participants and the confidentiality of medical
We may contact you to provide information about                      information. Your medical information may be
raising money for the hospital and its operations                    important to further research efforts and the
through a foundation related to the hospital. We                     development of new knowledge. For example, a
would only use contact information, such as your                     research study may involve a chart review to
name, address, phone number, and the dates you                       compare the outcomes of patients who received
received treatment or services at Contra Costa                       different types of treatment.
Regional Medical Center. If you do not want the
hospital to contact you for fund-raising efforts, write              We may disclose medical information about you to
the Privacy Office of Contra Costa County at 50                      researchers preparing to conduct a research project.
Douglas Drive #310-E, Martinez, CA 94553.                            On occasion, researchers contact patients regarding
                                                                     their interest in participating in certain research
                                                                     studies. Enrollment in those studies can only occur
For the Hospital Directory                                           after you have been informed about the study, had an
When you are a patient in Contra Costa Regional                      opportunity to ask questions, and indicated your
Medical Center, we create a hospital directory that                  willingness to participate by signing a consent form.
only contains your name and location in the hospital.
Unless you object in writing at the time of admission,
this directory information will be released to people                As Required By Law
who ask for you by name. (Note: If you are admitted                  We will disclose medical information about you
to a psychiatric care unit, no information about you                 when required to do so by federal, state, or local law.
will be listed in the hospital directory.)
                                                                     To Avert A Serious Threat To Health Or
To Family and Others When You Are                                    Safety
Present                                                              We may use and disclose your medical information
Sometimes a family member or other person involved                   when necessary to prevent or lessen a serious and
in your care will be present when we are discussing                  imminent threat to your health or safety or someone
your medical information. If you object, please tell us              else’s. Any disclosure would be to someone able to
and we won’t discuss your medical information, or                    help stop or reduce the threat.
we will ask the person to leave.
                                                                     For Disaster Relief
To Family And Others When You Are                                    We may disclose your name, city where you live,
                                                                     age, sex, and general condition to a public or private
Not Present                                                          disaster relief organization to assist disaster relief
There may be times when it is necessary to disclose                  efforts, and to notify your family about your location
your medical information to a family member or                       and status, unless you object at the time.
other person involved in your care because there is an
emergency, you are not present, or you lack the
decision-making capacity to agree or object. In those                For Organ And Tissue Donation
instances, we will use our professional judgment to                  If you are an organ or tissue donor, we may release
determine if it is in your best interest to disclose your            your medical information to organizations that handle
medical information. If so, we will limit the                        organ procurement or organ, eye, or tissue
disclosure to the medical information that is directly               transplantation or to an organ-donor bank, as
relevant to the person’s involvement with your health                necessary to facilitate organ or tissue donation and
care. For example, we may allow someone to pick up                   transplantation.
a prescription for you.
                                                                     For Military         Activity      And     National
For Research                                                         Security
Research of all kinds may involve the use or                         We may sometimes use or disclose the medical
disclosure of your medical information. Your medical                 information of armed forces personnel to the

Medi-Cal 2011_EOC                                           EOC-42
                                                                                      CONTRA COSTA HEALTH PLAN
                                                                     Medi-Cal Evidenced of Coverage & Disclosure Form

applicable military authorities when they believe it is              attorneys, and court employees in the course of
necessary to properly carry out military missions. We                conservatorship and certain other judicial or
may also disclose your medical information to                        administrative proceedings.
authorized federal officials as necessary for national
security and intelligence activities or for protection of            We may also use and disclose your medical
the president and other government officials and                     information, to the extent permitted by law, without
dignitaries.                                                         your consent to defend a lawsuit.

For Worker’s Compensation                                            For Law Enforcement
We may release medical information about you to                      If asked to do so by law enforcement, and as
workers’ compensation or similar programs, as                        authorized or required by law, we may release
required by law. For example, we may communicate                     medical information:
your medical information regarding a work-related                    • to identify or locate a suspect, fugitive, material
injury or illness to claims administrators, insurance                  witness, or missing person;
carriers, and others responsible for evaluating your                 • about a suspected victim of a crime if, under
claim for workers’ compensation benefits.                              certain limited circumstances, we are unable to
                                                                       obtain the person’s agreement;
For Public Health Disclosures                                        • about a death suspected to be the result of criminal
We may use or disclose medical information about                       conduct;
you for public health purposes. These purposes                       • about criminal conduct at one of our facilities; and
generally include the following:                                     • in case of a medical emergency, to report a crime;
• to prevent or control disease (such as cancer or                     the location of the crime or victims; or the identity,
  tuberculosis), injury, or disability;                                description, or location of the person who
• to report births and deaths;                                         committed the crime.
• to report suspected child abuse or neglect, or to
  identify suspected victims of abuse, neglect, or                   To Coroners And Funeral Directors
  domestic violence;                                                  We may release medical information to a coroner or
• to report reactions to medications or problems with                medical examiner to identify a deceased person or
  products or medical devices;                                       determine the cause of death. We may also release
• to notify people of recalls of products they may be                medical information about patients to funeral
  using;                                                             directors as necessary to carry out their duties.
• to notify a person who may have been exposed to a
  disease or may be at risk for contracting or                       Inmates
  spreading a disease or condition;                                  If you are an inmate of a correctional institution or
• to comply with federal and state laws that govern                  under the custody of a law enforcement official, we
  workplace safety; and                                              may release medical information about you to the
• to notify emergency response employees regarding                   correctional institution for certain purposes, for
  possible exposure to HIV/AIDS, to the extent                       example, to protect your health or safety or someone
  necessary to comply with state and federal laws.                   else’s. Note: Under the federal law that requires us to
                                                                     give you this Notice, inmates do not have the same
For Health Oversight Activities                                      rights to control their medical information as other
As health care providers and health plans, we are                    individuals.
subject to oversight by accrediting, licensing, federal,
and state agencies. These agencies may conduct                       Multi-Disciplinary Personnel Teams
audits on our operations and activities, and in that                 We may disclose medical information to a multi-
process they may review your medical information.                    disciplinary personnel team relevant to the
                                                                     prevention, identification, management or treatment
For Lawsuits And Other Legal Actions                                 of an abused child and the child’s parents, or elder
In connection with lawsuits, or other legal                          abuse and neglect.
proceedings, we may disclose medical information
about you in response to a court or administrative                   Special Categories of Information
order, or in response to a subpoena, discovery                       In some instances, your medical information may be
request, warrant, summons, or other lawful process.                  subject to restrictions that limit or preclude some uses
We may disclose your medical information to courts,                  or disclosures described in this Notice. For example,

                                                            EOC-43                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

there are special restrictions on the use or disclosure
of certain categories of information, such as tests for            We may charge a fee for the costs of copying,
HIV or treatment for mental health conditions or                   mailing, or other supplies associated with your
alcohol and drug abuse. Government health benefit                  request. If the copy is in an electronic form, the fee
programs, such as Medi-Cal, may also limit the                     shall not be greater than the labor costs incurred in
disclosure of beneficiary information for purposes                 responding to your request. If we don’t have the
unrelated to the program.                                          record you asked for but we know who does, we will
                                                                   tell you who to contact to request it.
All other uses and disclosures of your
medical information require your prior                             We may deny your request to inspect and copy in
                                                                   certain very limited circumstances. If you are denied
written authorization                                              access to medical information, in most cases, you
Other uses and disclosures of medical information                  may have the denial reviewed. Another licensed
not covered by this Notice or the laws that apply to us            health care professional chosen by Contra Costa
will be made only with your written permission. If                 County will review your request and the denial. The
you provide us permission to use or disclose medical               person conducting the review will not be the person
information about you, you may revoke that                         who denied your request. We will comply with the
permission, in writing, at any time. Please note that              outcome of the review.
the revocation will not apply to any authorized use or
disclosure of your medical information that took
place before we received your revocation. Also, if                 Right To Correct Or Update Your
you gave your authorization to secure a policy of                  Medical Information
insurance, including health care coverage from us,                 If you feel that your medical information is incorrect
you may not be permitted to revoke it until the                    or important information is missing, you may request
insurer can no longer contest the policy issued to you             that we correct or add to (amend) your record. Please
or a claim under the policy.                                       write to us and tell us what you are asking for and
                                                                   why we should make the correction or addition.
Your rights regarding your medical                                 Submit your request to the Privacy Office of Contra
                                                                   Costa County, 50 Douglas Drive #310-E, Martinez,
information                                                        CA 94553. We may deny your request if it is not in
Your medical information is the property of Contra                 writing or does not include a reason to support the
Costa County. You have the following rights,                       request. In addition, we may deny your request if you
however, regarding your medical information, such                  ask us to amend information that:
as your medical and billing records. This section
                                                                   • was not created by us;
describes how you can exercise these rights.
                                                                   • is not a part of the medical information kept by or
                                                                      for us;
Right To Inspect And Copy                                          • is not part of the information which you would be
With certain exceptions, you have the right to see and                permitted to inspect and copy; or
receive copies of your medical information that was
                                                                   • is accurate and complete in the record.
used to make decisions about your care, or decisions
                                                                   We will let you know our decision within 60 days of
about your health plan benefits. If your medical
                                                                   your request. If we agree with you, we will make the
information is maintained in an electronic health
                                                                   correction or addition to your record. If we deny your
record, you may obtain a copy of that information,
                                                                   request, you have the right to submit an addendum, or
with certain exceptions, in electronic format, and if
                                                                   piece of paper written by you, not to exceed 250
you choose, you may direct us to transmit an
                                                                   words, with respect to any item or statement you
electronic copy directly to another entity or person.
                                                                   believe is incomplete or incorrect in your record. If
Any such designation must be clear, conspicuous,
                                                                   you clearly indicate in writing that you want the
and specific.
                                                                   addendum to be made part of your medical record,
                                                                   we will attach it to your records and include it
If you would like to see or receive a copy of your
                                                                   whenever we make a disclosure of the item or
record on paper or electronically, please write us at
                                                                   statement you believe to be incomplete or incorrect.
the address where you received care. If you don’t
know where the record that you want is located,
please write us at the Privacy Office of Contra Costa              Right To An Accounting Of Disclosures
County, 50 Douglas Drive #310-E, Martinez, CA                      You have the right to receive a list of the disclosures
94553.                                                             we have made of your medical information. An
                                                                   accounting or list does not include certain

Medi-Cal 2011_EOC                                         EOC-44
                                                                                   CONTRA COSTA HEALTH PLAN
                                                                  Medi-Cal Evidenced of Coverage & Disclosure Form

disclosures, for example, disclosures to carry out
treatment, payment, and health care operations;                   To request confidential communications, you must
disclosures that occurred prior to April 14, 2003;                make your request in writing, specify how or where
disclosures which you authorized us in writing to                 you wish to be contacted, and submit it to the Privacy
make; disclosures of your medical information made                Office of Contra Costa County at 50 Douglas Drive
to you; disclosures to persons acting on your behalf.             #310-E, Martinez, CA 94553. When we can
To request this list or accounting of disclosures, you            reasonably and lawfully agree to your request, we
must submit your request in writing to the Privacy                will.
Office of Contra Costa County, 50 Douglas Drive
#310-E, Martinez, CA 94553. Your request must                     Right To A Paper Copy of This Notice
state the time period to be covered, which may not be             You have the right to a paper copy of this Notice
longer than six years and may not include dates                   upon request. One way to obtain a paper copy of this
before April 14, 2003. You are entitled to one                    Notice is to ask at the registration area of any Contra
disclosure accounting in any 12-month period at no                Costa Health Services’ facility. Or, call the Contra
charge. If you request any additional accountings less            Costa Health Plan Member Services at 1-877-661-
than 12 months later, we may charge a fee.                        6230, option 2, or the Privacy Office of Contra Costa
                                                                  County at 925-957-5430. You may also obtain a copy
We will notify you as required by law if your medical             of this Notice of Privacy Practices on our website at:
information is unlawfully accessed or disclosed.        
Right To Request Limits On Uses And
Disclosures Of Your Medical Information                           Changes to this Notice
You have the right to request a restriction or                    We may change this Notice and our privacy practices
limitation on the medical information we use or                   at any time, as long as the change is consistent with
disclose about you for treatment, payment, or health              state and federal law. Any revised Notice will apply
care operations. However, by law, we do not have to               both to the medical information we already have
agree to your request. Because we strongly believe                about you at the time of the change, and any medical
that this information is needed to appropriately                  information
manage the care of our members/patients, we rarely                created or received after the change takes effect. We
grant such a request. If we do agree, we will comply              will post a copy of our current Notice in all of the
with your request unless the information is needed to             Contra Costa Health Services’ facilities and on our
provide you emergency treatment.                                  website at:
We will honor a request to restrict disclosures to a              The effective date of the Notice will be on the first
health plan for services that have been paid out-of               page, in the top right-hand corner.
pocket, in full, unless the disclosure is required by
law or is determined to be necessary for treatment                Questions
purposes.                                                         If you have any questions about this Notice, please
                                                                  contact the Privacy Office for Contra Costa County at
To request restrictions, you must make your request               925-957-5430.
in writing to the Privacy Office of Contra Costa
County, 50 Douglas Drive #310-E, Martinez, CA                     If you have questions related to health information
94553. In your request, you must tell us (1) what                 privacy, access the Office for Civil Rights’ database
information you want to limit; (2) whether you want               under “HIPAA” at:
to limit our use, disclosure, or both; and (3) to whom
you want the limits to apply, for example, disclosures            Complaints
to your spouse.                                                   If you believe your privacy rights have been violated,
                                                                  you may file a complaint with any of the following:
Right To Choose How We Send Medical
Information To You                                                Contra Costa Health Plan members, please call
You have the right to request that we communicate                 Member Services at 1-877-661-6230, option 2.
with you about medical matters in a certain way or at
a certain location. For example, you can ask that we              Clients of the Contra Costa Mental Health Plan may
only phone you at work or use a P.O. Box when we                  call the Office of Quality Assurance at 925-957-
send mail to you.                                                 5131.

                                                         EOC-45                                   Medi-Cal 2011_EOC
Medi-Cal Evidenced of Coverage & Disclosure Form

                                                                     Please attach all additional changes or amendments to
You can write the Privacy Office of Contra Costa                     your original Evidence of Coverage booklet as soon
County, 50 Douglas Drive, #310-E, Martinez, CA                       as they are received.
94553, or call our 24-hour Privacy Hotline at 1-800-
659-4611.                                                            Policy Against Discrimination
                                                                     CCHP does not discriminate on the basis of race,
Medi-Cal beneficiaries may file a privacy complaint                  color, national origin, ancestry, religion, sex, marital
with the California Department of Health Care                        status, sexual orientation, age or disability. Bilingual
Services: Privacy Officer, c/o Office of Legal                       staff is available to assist you.
Services; P.O. Box 997413, MS0011, Sacramento,
CA     95899-7413.     (916)    440-7750     email:

You may file a written complaint with the secretary
of the Department of Health & Human Services.
Instructions on how to file a compliant are found by
clicking on “How to File a Complaint” under the
section on “HIPAA” at:

Or, you can call the San Francisco Office for Civil
Rights at (415) 437-8310 to request the Health
Information Privacy Complaint Form package.

We will not take retaliatory action against you if
you file a complaint about our privacy practices.

Other Uses of Medical Information
Other uses and disclosures of medical information
not covered by this notice or the laws that apply to us
will be made only with your written permission. If
you provide us permission to use or disclose medical
information about you, you may revoke that
permission, in writing, at any time. If you revoke
your per-mission, this will stop any further use or
disclosure of your medical information for the
purposes covered by your written okay, except if we
have already acted in reliance on your permission.
You understand that we are unable to take back any
disclosures we have already made with your
permission and that we are required to retain our
records of the care that we provided to you.

Changes to this Evidence of Coverage
If there are any changes in the information included
in this Evidence of Coverage or any changes in
benefits or the availability or location of benefits, you
will be notified in writing at least thirty (30) days
prior to the effective date of the changes. In
unforeseen circumstances, you may be notified
within fourteen (14) days of the change. Any
notification sent to you will have been okayed by the
California Department of Health Care Services.

Medi-Cal 2011_EOC                                           EOC-46

Shared By: