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1 Getting started as a memberIf you would like to be a part of this group, call [member services telephone number](TTY [member services TTY number or 711]).[MCP should insert other ways for members to get involved.][MCP may edit or delete the above section as appropriate.]Call member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].12

[MCP may add logo here]2. About yourhealth planHealth plan overview[MCP] is a health plan for people who have Medi-Cal in [the following service areas:].[MCP] works with the State of California to help you get the health care you need.You may talk with one of the [MCP] member services representatives to learn moreabout the health plan and how to make it work for you. Call [member services telephonenumber] (TTY [member services TTY number or 711]).When your coverage starts and ends[MCP may edit this paragraph.] When you enroll in [MCP], you should receive a[n][MCP] member ID card within two weeks of enrollment. Please show this card everytime you go for any service under the [MCP].[MCP must insert other details for starting coverage.]You may ask to end your [MCP] coverage and choose another health plan at any time.For help choosing a new plan, call Health Care Options at 1-800-430-4263 (TTY 1-800430-7077). Or visit www.healthcareoptions.dhcs.ca.gov. You can also ask to end yourMedi-Cal.Sometimes [MCP] can no longer serve you. [MCP] must end your coverage if: You move out of the county or are in prisonYou no longer have Medi-CalYou qualify for certain waiver programsYou need a major organ transplant (excluding kidneys)You are in a long-term care facility in excess of two months [MCP to remove thisbullet point if in a CCI county][MCP must insert other mandatory reasons for ending coverage.]If you are an AmericanIndian, you have the right to get health care services at Indian health service facilities.Call member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].13

2 About your health planYou may also stay with or disenroll from [MCP] while getting health care services fromthese locations. American Indians have a right to not enroll in a Medi-Cal managed careplan or may leave their health plans and return to regular (fee-for-service) Medi-Cal atany time and for any reason. To find out more, please call Indian Health Services at1-916-930-3927 or visit the Indian Health Services website at www.ihs.gov. [MCP mayadjust this language to fit model type.]How your plan works[MCP] is a health plan contracted with DHCS. [MCP] is a managed care health plan.Managed care plans are a cost-effective use of health care resources that improvehealth care access and assure quality of care. [MCP] works with doctors, hospitals,pharmacies and other health care providers in the [MCP] service area to give healthcare to you, the member.[Member services] will tell you how [MCP] works, how to get the care you need, how toschedule provider appointments, and how to find out if you qualify for transportationservices. [MCP should edit this list as appropriate.]To learn more, call [member services telephone number] (TTY [member services TTYnumber or 711]). You can also find member service information online at [MCP URL].Changing health plansYou may leave [MCP] and join another health plan at any time. Call Health CareOptions at 1-800-430-4263 (TTY 1-800-430-7077) to choose a new plan. You can callbetween 8:00 a.m. and 5:00 p.m. Monday through Friday, or visit [MCP URL].It takes [time for processing request] to process your request to leave [MCP]. To find outwhen Health Care Options has approved your request, call 1-800-430-4263(TTY 1-800-430-7077).If you want to leave [MCP] sooner, you may ask Health Care Options for an expedited(fast) disenrollment. If the reason for your request meets the rules for expediteddisenrollment, you will get a letter to tell you that you are disenrolled.Beneficiaries that can request expedited disenrollment include, but are not limited to,children receiving services under the Foster Care or Adoption Assistance Programs;Members with special health care needs, including, but not limited to major organCall member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].14

2 About your health plantransplants; and Members already enrolled in another Medi Cal, Medicare orcommercial managed care plan.You may ask to leave [MCP] in person at your local county health and human servicesoffice. Find your local office at es.aspx. Or call Health Care Options at 1-800-430-4263 (TTY 1-800-4307077). [MCP should insert other details for changing health plans.]College students who move to a new countyIf you move to a new county in California to attend college, [MCP] will cover emergencyservices in your new county. Emergency services are available to all Medi-Cal enrolleesstatewide regardless of county of residence.If you are enrolled in Medi-Cal and will attend college in a different county, you do notneed to apply for Medi-Cal in that county. There is no need for a new Medi-Calapplication as long as you are still under 21 years of age, are only temporarily out of thehome and are still claimed as a tax dependent in the household.When you temporarily move away from home to attend college there are two optionsavailable to you. You may: Notify your local county social services office that you are temporarily moving toattend college and provide your address in the new county. The county willupdate the case records with your new address and county code in the State’sdatabase. If [MCP] does not operate in the new county, you will have to changeyour health plan to the available options in the new county. For additionalquestions and in order to prevent a delay in the new health plan enrollment, youshould contact Health Care Options at 1-800-430-4263 (TTY 1-800-430-7077) forassistance with enrollment.OR Choose not to change your health plan when you temporarily move to attendcollege in a different county. You will only be able to access emergency roomservices in the new county. For routine or preventive health care, you would needto use the [MCP] regular network of providers located in the county of residencefor the family. An exception to this is if [MCP] operates in your new county ofresidence, as described above.Call member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].15

2 About your health planContinuity of careIf you now see providers who are not in the [MCP] network, in certain cases you may beable to keep seeing them for up to 12 months. If your providers do not join the [MCP]network by the end of 12 months, you will need to switch to providers in the [MCP]network. [MCP should insert continuity of care limitations.]Providers who leave [MCP]If your provider stops working with [MCP], you may be able to keep getting servicesfrom that provider. This is another form of continuity of care. [MCP] provides continuityof care services for: [MCP should list continuity of care services offered.][MCP] provides continuity of care services if [MCP should insert continuity of careconditions].[MCP] does not provide continuity of care services if [MCP should insert continuity ofcare conditions].To learn more about continuity of care and eligibility qualifications, call [memberservices].CostsMember costs[MCP may adjust this language to fit model type.][MCP] serves people who qualify for Medi-Cal. [MCP] members do not have to pay forcovered services. You will not have premiums or deductibles. For a list of coveredservices, see "Benefits and services."You may have to pay a share of cost each month. The amount of your share of costdepends on your income and resources. Each month you will pay your own medical billsuntil the amount that you have paid equals your share of cost. After that, your care willbe covered by [MCP] for that month. You will not be covered by [MCP] until you havepaid your entire share of cost for the month. After you meet your share of cost for themonth, you can go to any [MCP] doctor. You do not need to pick a PCP.Call member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].16

2 About your health planHow a provider gets paid[MCP] pays providers in these ways: Capitation payments Fee-for-service payments [MCP] pays some providers a set amount of money every month for each[MCP] member. This is called a capitation payment. [MCP] and providerswork together to decide on the payment amount.Some providers give care to [MCP] members and then send [MCP] a billfor the services they provided. This is called a fee-for-service payment.[MCP] and providers work together to decide how much each servicecosts.[MCP should insert other ways they pay providers.]To learn more about how [MCP] pays providers, call [member services telephonenumber] (TTY [member services TTY number or 711]).[MCP should insert any provider incentive programs here.]Asking [MCP] to pay a billIf you get a bill for a covered service, call member services right away at [memberservices telephone number] (TTY [member services TTY number or 711]).If you pay for a service that you think [MCP] should cover, you can file a claim. Use aclaim form and tell [MCP] in writing why you had to pay. Call [member servicestelephone number] (TTY [member services TTY number or 711]) to ask for a claim form.[MCP] will review your claim to see if you can get money back.Call member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].17

[MCP may add logo here]3. How to get careGetting health care services[MCP may adjust the “How to get care” section as appropriate.]PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROMWHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.You can begin to get health care services on your effective date of coverage. Alwayscarry your [MCP] ID card and Medi-Cal BIC card with you. Never let anyone else useyour [MCP] ID card or BIC card.New members must choose a primary care provider (PCP) in the [MCP] network. The[MCP] network is a group of doctors, hospitals and other providers who work with[MCP]. You must choose a PCP within 30 days from the time you become a member in[MCP]. If you do not choose a PCP, [MCP] will choose one for you.You may choose the same PCP or different PCPs for all family members in [MCP].If you have a doctor you want to keep, or you want to find a new PCP, you can look inthe Provider Directory. It has a list of all PCPs in the [MCP] network. The ProviderDirectory has other information to help you choose. If you need a Provider Directory,call [member services telephone number] (TTY [member services TTY number or 711]).You can also find the Provider Directory on the [MCP] website at [MCP URL].If you cannot get the care you need from a participating provider in the [MCP] network,your PCP must ask [MCP] for approval to send you to an out-of-network provider.Read the rest of this chapter to learn more about PCPs, the Provider Directory and theprovider network.Initial health assessment (IHA)[MCP] recommends that, as a new member, you see your new PCP in the next 90 daysfor an initial health assessment (IHA). The purpose of the IHA is to help your PCP learnyour health care history and needs. Your PCP may ask you some questions about yourhealth history or may ask you to complete a questionnaire. Your PCP will also tell youCall member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].18

3 How to get careabout health education counseling and classes that may help you.When you call to schedule your IHA, tell the person who answers the phone that youare a member of [MCP]. Give your [MCP] ID number.Take your BIC and your [MCP] ID card to your appointment. It is a good idea to take alist of your medications and questions with you to your visit. Be ready to talk with yourPCP about your health care needs and concerns.Be sure to call your PCP’s office if you are going to be late or cannot go to yourappointment.Routine careRoutine care is regular health care. It includes preventive care, also called wellness orwell care. It helps you stay healthy and helps keep you from getting sick. Preventivecare includes regular checkups and health education and counseling. In addition topreventive care, routine care also includes care when you are sick. [MCP] coversroutine care from your PCP.Your PCP will: Give you all your routine care, including regular checkups, shots, treatment,prescriptions and medical adviceKeep your health recordsRefer (send) you to specialists if neededOrder X-rays, mammograms or lab work if you need themWhen you need routine care, you will call your PCP for an appointment. Be sure to callyour PCP before you get medical care, unless it is an emergency. For an emergency,call 911 or go to the nearest emergency room.To learn more about health care and services your plan covers, and what it does notcover, read Chapter 4 in this handbook.Urgent careUrgent care is care you need within 24 hours, but it is not an emergency or lifethreatening. Urgent care needs could be a cold or sore throat, fever, ear pain or asprained muscle.For urgent care, call your PCP. If you cannot reach your PCP, call [member servicestelephone number] (TTY [member services TTY number or 711]). Alternatively, you cancall [nurse line/triage services telephone number]. [MCP may add additional informationCall member services at [XXX-XXX-XXXX] (TTY [XXX-XXX-XXX]).[MCP] is here [days and hours of operation]. The call is toll free.Or call the California Relay Line at 711. Visit online at [MCP URL].19

3 How to get careabout the 24/7 nurse line/triage services here.]If you need urgent care out of the area, go to the nearest urgent care facility. You do notneed pre-approval (prior authorization).If your care is a mental health urgent care concern, contact the county Menta

Offer interpreter services if you do not speak English Offer information in other languages and formats [MCP may list other services offered.] If you need help, call [member services telephone number] (TTY [member services TTY number or 711]). [MCP] is here [days