Member Handbooks for Medi-Cal HMOS: How Useful Are They?

Table I.A. How to Choose a PCP

	Definition*	How to Choose	If You Don't Choose	Changing Your PCP**	Initial Appt.***	Referral
Alameda Alliance
Blue Cross
Contra Costa Health Plan
Foundation Health
Health Plan of San Joaquin
Inland Empire Health Plan
Kern Family Health Care
L.A. Care
Omni Healthcare
San Francisco Health Plan
Santa Clara Family Health Plan

*Plans received half credit if they define PCP only in a glossary/definitions section
**Plans received half credit if they list how but not when to change a PCP
***Plans received half credit if they do not mention the 120 day timeline for scheduling an initial appointment

Findings

Overall, the health plans do very well in describing how to choose a PCP. All eleven handbooks examined describe the process for choosing a PCP, explain that consumers can access specialists by getting a referral from their PCP, and mention the process for changing a PCP. Further, most of the plan describe what happens when consumers don't choose and urge consumers to schedule an initial health assessment appointment. However, only two of the eleven health plans define PCP in the "choosing a PCP" section in the main text of the handbook.

Definition

Only two health plans, L.A. Care and San Francisco Health Plan, define a PCP in the main text of their handbooks. L.A. Care's definition is short and clear:

A primary care physician (PCP) is your personal doctor. He/she will make sure that you get all the medical care you need. He/she will send you to a specialist, if needed.

Six of the health plans provide a definition of a PCP only in the glossary or "definitions" section. Alameda Alliance offers a good definition in its glossary:

Primary Care Provider: The doctor or clinic that you choose for your basic health needs when you become a member of a managed care health plan like the Alliance. Usually, you must go to your primary care provider before getting treatment from other providers.

Because cross-referencing within the member handbook may be difficult for Medi-Cal consumers, MedCAP recommends that the definition of a PCP be included in the main text of the handbook in the "choosing a PCP" section. These plans, therefore, only received half credit in this category.

Three health plans, Contra Costa Health Plan, Foundation Health, and the Health Plan of San Joaquin, do not directly define a PCP anywhere in their handbooks. MedCAP recommends that these health plans revise their member handbooks to explicitly define this term.

How to Choose

All eleven of the handbooks examined describe the process for choosing a PCP. Most of them refer consumers to the provider directories and/or instruct consumers to call Member Services for further assistance in choosing a doctor. Some health plans go a step further, and suggest things for consumers to think about when choosing a PCP. San Francisco Health Plan's handbook, for example, suggests that consumers consider:

=> Is the PCP close to my home, work, or school?
=> Is the PCP easy to get to by MUNI, bus, or BART?
=> Do the PCP or nurses speak my language?
=> Does the PCP work with a hospital that I like?
=> Does the PCP take care of children?

All of the health plans would benefit from incorporating information like this into their member handbooks to facilitate an informed choice of provider for consumers.

If You Don't Choose

Eight of the eleven member handbooks inform consumers that if they don't choose a PCP, one will be chosen for them. This is important information for consumers, who may not realize that they need to choose their PCP within a specified period of time if they do not want to be automatically assigned. Blue Cross, Inland Empire Health Plan and L.A. Care should add this information to their handbooks.

Changing Your PCP

Six health plans received full credit in this category for explaining to consumers when and how they can change their PCP. The other five plans received half credit because, although they tell consumers how to change their PCP, they don't explain the circumstances under which they can change. It is important that consumers know that they can change their PCP for any reason and at any time. Inland Empire Health Plan, for example, explains that consumers have the right "to change your Primary Care Doctor once a month if you are unhappy with the one you have." Similarly, L.A. Care tells consumers that they may "select a new doctor / PCP at any time, for any reason?."

Initial Appointment

Five of the health plans received full credit in this category for urging consumers to schedule an initial health assessment with their PCP within 120 days (or 4 months) of enrollment. Contra Costa Health Plan's handbook explains the importance of this appointment:

All new members should have a complete physical examination within 120 days of becoming a member of Health Partners. This exam will help you meet your Primary Care Provider or clinic, and give your Provider a chance to get to know you. Please call your Primary Care Provider to make an appointment as soon as you can.

Five of the health plans received half credit for referring to the initial health assessment without mentioning the 120 day recommended timeline. One health plan, Kern Family Health Care Plan, does not mention the initial health assessment at all. This appointment is an important opportunity to introduce consumers to their health plans, and should be discussed in detail by all of the member handbooks.

Referral

All eleven of the member handbooks examined discuss the process of referral to see a specialist. Kern Family Health Care explains, for example:

If you need the services of a specialist, you and your Primary Care Physician will discuss the necessary arrangements. Remember that all visits to a specialist for any reason must be pre-approved by your Primary Care Physician. This ensures that you are getting the most appropriate care available for your particular problem, and that KFHC will pay for the services.

B. Organization of Provider Directories

Consumers often choose a health plan based on the inclusion of a particular primary care provider or specialist in the plan's provider panel. Other consumers may not have a specific provider in mind, and will need information about office location, language spoken, and board certification in order to make an informed choice. It is important that the organization of the provider directories enables consumers to easily locate a specific physician or to choose a new one.

MedCAP recommends that, in order to fully facilitate choice, provider directories list physicians in three ways: by city, in alphabetical order, and by language spoken. Listing physicians by city will allow consumers to locate providers who are easily accessible. With an alphabetical index, a consumer can quickly determine whether or not her current physician is part of the plan's panel. Lastly, organizing physicians by language spoken will allow a consumer to easily find a provider who offers services in a rare dialect.

Further, provider directories should include a complete listing of specialists. Without this information, consumers cannot make a truly informed choice of health plan. Finally, the provider directories should list the board certification status of each physician in order to provide consumers with information about providers' qualifications.

MedCAP examined provider directories for all of the health plans to determine if they contain the following organization/information pertaining to choosing a physician:

group by city: directory groups physicians by city;
list by alphabet: directory lists physicians alphabetically;
group by language: directory groups physicians by language spoken;
specialists: directory lists specialty doctors in the plan's provider panel;
board certification: directory lists board certification status for each physician.

Table I.B. Provider Directories

	Group by City	List by Alphabet	Group by Language	Specialists	Board Cert.
Alameda Alliance
Blue Cross
Contra Costa Health Plan
Foundation Health
Health Plan of San Joaquin
Inland Empire Health Plan
Kern Family Health Care
L.A. Care
Omni Healthcare
San Francisco Health Plan
Santa Clara Family Health Plan

Findings

Overall, the provider directories do very well in organizing the list of physicians geographically, and many of them offer an alphabetical index. However, none of them list board certification status, and very few offer listings of specialists.

The Health Plan of San Joaquin and San Francisco Health Plan provider directories are very well organized, meeting four of the five MedCAP criteria. They include a full listing of specialists, and contain both alphabetical and language spoken indices. Neither directory, however, lists board certification status.

The Alameda Alliance for Health, Inland Empire Health Plan, and Kern Family Health Care each cover only one of the five MedCAP checklist points in their provider directories. They organize physician listings by city, but don't offer other indices or specialist listings. These directories should be reorganized in order to facilitate physician choice for Medi-Cal consumers.

Group by City

All of the provider directories group physicians by city and, within each city heading, list physicians alphabetically. The San Francisco Health Plan goes one step further, organizing physicians by neighborhood.

List by Alphabet

Seven of the health plans include an alphabetical index in their provider directories. Because an alphabetical index provides consumers with an easy way to locate a current physician, it should be incorporated by all of the health plans.

Group by Language

Although, as required by DHS, all of the health plans indicate language(s) spoken by each physician in their provider directory entries, only three of the plans provide an index or grouping by language. Health Plan of San Joaquin, San Francisco Health Plan, and Santa Clara Family Health Plan all include a section organized by language spoken so that a consumer can get an overview, for example, of all of the panel providers that offer services in Farsi. Grouping providers by language is an important tool for Medi-Cal consumers who speak a rare language. The provider directories of all of the health plans must consider and cater to this population.

Specialists

The Health Plan of San Joaquin, Omni Healthcare, and San Francisco Health Plan are the only health plans of those examined that include specialist listings in their provider directories. All of the health plans, when contacted by phone, stated that information on whether or not a specific specialist is included in the provider panel can be obtained by calling Member Services. However, MedCAP does not believe that this system is sufficient. A consumer with heart problems should have available a listing of all of the cardiologists included in the plan's panel. Medi-Cal consumers deserve to know the specialists in their health plan.

Board certification

None of the eleven health plans list board certification status of their physicians in the provider directories. Some private health plan directories, including Blue Cross CaliforniaCare Private, do contain information about board certification. We feel that Medi-Cal consumers, too, have a right to be informed about the qualifications of the physicians providing them with health care.

Section II
Grievance Procedures

The explanation of the grievance process is among the most important pieces of information in the Two-Plan Model member handbooks. With the expansion of private sector managed care in California have come concerns about quality of care, denial of services, and access to specialists. The Medi-Cal population, as it too is moved into managed care, may be even more vulnerable than its privately insured counterpart. Due to their high-risk socio-economic status and their reliance on a historically underfunded health insurance program, Medi-Cal consumers may be at even at a greater risk of encountering problems in managed care.

It is therefore crucial that Medi-Cal consumers be well informed about their right to file complaints and appeal health plan decisions. Protections are set forth in federal and state law and in the health plan contracts to insure that the due process rights of Medi-Cal consumers are not violated. In the Two-Plan Model, health plans must describe in their member handbooks the process for filing a formal internal grievance, as well as the avenues for filing complaints outside of the plan. External avenues include filing for a state fair hearing and logging a complaint with the Department of Corporations.

A. The Internal Grievance Process

Each health plan in the Two-Plan Model has a formal internal grievance process. As required by the Two-Plan Model health plan contracts, each plan must implement "a procedure to ensure timely resolution and feedback to complainant."4 The member handbooks should present the address and/or phone number needed to initiate the internal grievance process. The handbooks should also communicate the timeline set forth by contract: the health plan must acknowledge receipt of a complaint within 5 days, and must resolve or document reasonable efforts to resolve the complaint within 30 days. Finally, handbooks should lay out Medi-Cal consumers' rights in the grievance process: (1) the right to be represented by a friend, family member or legal counsel; (2) the right to have linguistically appropriate assistance; and (3) the right to see materials related to the grievance.

We examined member handbooks for all of the health plans to determine if they contain the following information pertaining to the formal internal grievance process:
how to file: the address and phone number needed to file a formal grievance;
timeline: explanation that the plan will acknowledge a grievance within 5 days and will resolve or document reasonable efforts to resolve the grievance within 30 days;
representation: notice that consumers have the right to be represented by a friend, family member, or legal counsel throughout the grievance process;
language: notice that consumers have the right to have assistance in the language they speak when filing a grievance;
materials: notice that consumers have the right to see materials related to their grievance.

Table II.A: Internal Grievance Process

	How to File	Time-Line*	Representation	Language	Materials	Referral
Alameda Alliance
Blue Cross
Contra Costa Health Plan
Foundation Health
Health Plan of San Joaquin
Inland Empire Health Plan
Kern Family Health Care
L.A. Care
Omni Healthcare
San Francisco Health Plan
Santa Clara Family Health Plan

*Plans received half credit if they list only one of the timeline deadlines

Findings

Overall, the member handbooks do very well in telling consumers how to file a grievance and in informing them of the 5 and 30 day deadlines. However, the handbooks do not do a good job of communicating consumer rights within the internal grievance process.

The Alameda Alliance for Health does the best job explaining consumer rights: its handbook clearly lays out each of the three rights on the MedCAP checklist. The Alliance, however, does not adequately discuss how to file a formal grievance or the grievance timeline.

The Contra Costa Health Plan and L.A. Care handbooks cover only one and a half of the five MedCAP checklist points in their internal grievance process sections (a phone number and the 30 day deadline). These handbooks must incorporate more information about the process in order to fully educate Medi-Cal consumers about their right to file an internal grievance.

How to file

Ten of the eleven member handbooks examined provide the address and/or phone number needed to initiate the internal grievance process. Alameda Alliance does not include a phone number or address in its section entitled "Filing a formal grievance." Although a phone number is included in the previous section on filing a complaint, MedCAP recommends that the information be repeated in the formal grievance section to avoid confusion.

Timeline

Ten of the eleven handbooks also provide information on at least one of the timeline deadlines (the 5 day acknowledgment of a grievance and the 30 day effort to resolve the grievance). Eight handbooks provide information on both the 5 day and the 30 day deadlines. Contra Costa Health Plan and L.A. Care, however, mention only the 30 day deadline and received half credit in this category. Alameda Alliance does not discuss either deadline.

Representation

The Alameda Alliance's handbook is the only one that informs consumers of their right to representation throughout the internal grievance process. The handbook clearly states that consumers have "the right to be represented by an advocate like a friend, family member, or lawyer." This is a vital piece of information for consumers, and should be incorporated into all of the handbooks.

Language

Three health plans discuss a consumer's right to have assistance in the language she speaks when filing a grievance: Alameda Alliance, Blue Cross, and Omni Healthcare. Omni's handbooks explains that "Our multi-lingual staff and interpreters will help make sure we understand your complaint exactly." Again, this is information that should be supplied by all the health plans.

Materials

As with the right to representation, Alameda Alliance is the only health plan to mention the consumer's right to access all documents relevant to the grievance. The Alliance tells consumers that they have "The right to see materials related to your grievance. This may include items like your medical record, policy and procedures, and any evidence presented." Information about this right should be incorporated into all of the handbooks.

B. The External Grievance Process

In addition to the formal internal grievance process, there are protections provided by federal and state law for Medi-Cal consumers who wish to file an external complaint regarding a Two-Plan Model health plan.

The federal Medicaid Act sets forth the right to a state fair hearing.5 California law and Two-Plan Model health plan contracts state that Medi-Cal consumers have the right to request a fair hearing "regardless of whether or not a complaint/grievance has been submitted or if the complaint/grievance has been resolved."6 At this hearing, an administrative law judge will review the disputed action. To request a hearing, the consumer may write to the State Department of Social Services (DSS), call the DSS toll-free number (800-952-5253), or contact local legal aid offices. Consumers must contact DSS within 90 days of the date the problem occurred, but late filings may be permitted for good cause. Consumers may represent themselves or may ask a relative, friend, advocate or legal counsel to be present.

Federal Medicaid regulations provide for a continuation of benefits, commonly called "aid paid pending," under some circumstances while a consumers is waiting for the outcome of a state fair hearing. In cases involving reduction or termination of ongoing care, a beneficiary may request that services be continued pending the final hearing decision. However, in order to qualify for aid paid pending, the consumer must request continued benefits before the disputed action takes effect or within ten days of receiving notice about the disputed action.

Consumers may also contact the Department of Corporations (DOC) to file a complaint against a Two-Plan Model health plan. The DOC is responsible for regulating health care services plans, and has a toll-free number to receive complaints regarding the plans. If Medi-Cal consumers need the DOC's help with a complaint involving an emergency grievance or with a grievance that has not been satisfactorily resolved by the plan, they should call the toll-free line: (800) 400-0815.

We examined member handbooks for all of the health plans to determine if they contain the following information pertaining to filing an external grievance:
right to file: explanation that consumers have the right to request a state fair hearing regardless of whether or not an internal grievance has been submitted or if the internal grievance has been resolved;
how to file: the address, phone number and TDD number needed to file for a fair hearing;
timeline: notice that consumers must file for a fair hearing within 90 days of the disputed action, but there may be exceptions for good cause;
representation: notice that consumers have the right to be represented by a friend, family member, or legal counsel at the fair hearing;
aid paid pending (APP):7 explanation that consumers may qualify for continued benefits if they request it before the disputed action takes place or within ten days of receiving notice about the disputed action;
DOC: information about when and how to file a complaint with the DOC.

Table II.B: External Grievance Process

	Right to File	How to File	Time-Line	Representation	APP	DOC
Alameda Alliance
Blue Cross
Contra Costa Health Plan
Foundation Health
Health Plan of San Joaquin
Inland Empire Health Plan
Kern Family Health Care
L.A. Care
Omni Healthcare
San Francisco Health Plan
Santa Clara Family Health Plan

*Plans received half credit if they list one or two but not all three of the ways to file for a hearing (address, phone, TDD)
**Plans received half credit if they discuss the 90 deadline for filing, but do not mention good cause late filings

Findings

Overall, the member handbooks do very well in explaining the right to a fair hearing (nine plans), and most provide at least some information on how to file for a fair hearing (ten plans). Additionally, nine plans provide information on when and how to file a complaint with the DOC. However, only one plan discusses the fair hearing timeline, only two plans mention the right to be represented, and none of the plans inform consumers about the possibility of continued benefits.
The Alameda Alliance for Health handbook does an excellent job of describing the right to a state fair hearing, meeting four of the MedCAP fair hearing criteria. It is the only handbook to explain that the consumer must file within 90 days from the disputed action, and it is one of only two handbooks that states that consumers have the right to be represented by a relative, friend or legal counsel. It does not, however, discuss aid paid pending.

The Contra Costa Health Plan handbook's description of the external grievance process for Medi-Cal consumers is severely lacking. We found no description or mention of the right to a state fair hearing. This handbook meets only one of the MedCAP criteria: it provides information about when and how to contact the DOC. This handbook must be revised to include basic information about the state fair hearing process, and it and many of the other handbooks should seek to include more detailed information about filing deadlines and the right to representation in the hearing process.

Right to File

Nine of the eleven member handbooks explain the right to file for a fair hearing regardless of whether or not an internal grievance has been submitted or if the grievance has been resolved. L.A. Care's handbook states that consumers may request a fair hearing "At any time, during or after the? L.A. Care grievance process?", but it does not specify that they may request a hearing before or instead of the internal grievance process. Contra Costa Health Plan does not mention the right to file for a fair hearing at all.

How to File

The Alameda Alliance and Blue Cross handbooks provide three routes for filing for a fair hearing: a phone number, a TDD number, and an address. Two plans list only the phone and TDD numbers, and six plans list only the phone number. These plans received half credit. One plan, the Contra Costa Health Plan, does not provide any information on how to file for a State Fair Hearing. The Santa Clara Family Health Plan handbook contains an error in this section. Although it lists the correct number for requesting a fair hearing (a State Department of Social Services number), it incorrectly identifies it as a Department of Health Services number.

Timeline

The Alameda Alliance handbook is the only one to mention the 90 day deadline, stating that consumers "must ask for a State Fair Hearing within 90 days from the date the problem occurred." However, it does not discuss the possibility of late filing for good cause, and thus received only half credit in this category. A discussion of the deadline and deadline extension for good cause when filing a state fair hearing is crucial for Medi-Cal consumers' due process rights, and should be included in all of the handbooks.

Representation

Only two plans, Alameda Alliance and Foundation, inform consumers in the member handbooks of their right to representation in a fair hearing. Foundation's handbook, for example, tells consumers they have "the right to be represented by legal counsel, a friend or other spokesperson." Again, this is important information about Medi-Cal consumers' due process rights, and should be included in all of the handbooks.

Aid Paid Pending

Not one of the eleven handbooks informs consumers of the possibility of continued benefits when filing for a state fair hearing. Member handbooks should not overlook the responsibility of informing consumers about their rights in the fair hearing process.

DOC

Ten of the eleven handbooks describe when and how to file a complaint with the DOC. The member handbooks for Kern Family Health Care does not mention the office of the DOC at all.

Section III
Emergency Services

Under fee-for-service Medi-Cal, Medi-Cal consumers routinely used emergency rooms for after-hour and urgent care. One of the goals of Medi-Cal managed care is to provide continuity of care for consumers and to reduce inappropriate use of emergency room services. Medi-Cal managed care encourages consumers to visit their primary care physicians for non-emergency problems like sore throats and earaches, rather than going straight to the expensive emergency room to receive services. To this end, Two-Plan Model member handbooks aim to educate consumers about the definition of a "true emergency." However, it is important that the handbooks do not go too far, discouraging Medi-Cal consumers from visiting the emergency room in the event of a real emergency. To this end, health plans should follow the definition of an emergency set out by federal and state law.

The federal Balanced Budget Act of 1997 sets forth the following definition of an emergency:

The term 'emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part.8

California state law sets forth a similar definition, though it does not explicitly mention the prudent layperson standard:

"Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(1) Placing the patient's health in serious jeopardy.
(2) Serious impairment to bodily functions.
(3) Serious dysfunction of any bodily organ or part.9

The DHS contract dictating the Two-Plan Model member handbooks does not mention the prudent layperson standard at all. Further, it does not explicitly allow for emergency care for medical conditions that might place health in serious jeopardy. The contract language reads:

Emergency Services means those health services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions, which if not immediately diagnosed and treated, could lead to disability or death.10

There are several aspects of the emergency definition that MedCAP recommends be emphasized by the Two-Plan Model member handbooks. First, health plans should state that severe pain can be a sufficient determining factor of an emergency. Second, there should be some mention of the prudent layperson standard. The health plans are asking consumers to determine the emergency status of their condition, and should therefore tell them that if it is the reasonable expectation of a prudent person that a situation constitutes an emergency, then it is one. Third, handbooks should state that a condition that places health in serious jeopardy is an emergency. This could be significantly different than requiring that a condition be such that it could lead to death or disability.

Member handbooks should also present a reasonable range of examples to illustrate emergencies. Most consumers will recognize unconsciousness or convulsions as an emergency, so it is important that health plans list less obvious examples of emergencies like unusual bleeding, possible ingestion of poison or medicine overdose, and suspected broken bones.

It is vital that handbooks instruct consumers to go straight to the emergency room or call 911 in life-threatening emergencies. However, they should also offer information for consumers with less severe conditions, those who do not know whether or not their condition qualifies as an emergency. This is important because health plans have given consumers responsibility for determining an emergency. Thus, under the emergency services section of the handbook, health plans should tell consumers how to contact a health care provider 24 hours a day (their PCP and/or a nurse advice hotline) if they are uncertain about their emergency status.

We examined member handbooks for all of the health plans to determine if they contain the following information pertaining to emergency services:

severe pain: mention of alleviation of severe pain in the definition of an emergency;
prudent layperson:11 mention of the prudent layperson standard in the definition of an emergency;
serious jeopardy: mention of conditions placing health in serious jeopardy in the definition of an emergency;
range of examples: a list of examples of emergencies including less extreme examples (i.e. severe pain, unusual bleeding);
24 hour phone line: information about 24 hour phone access to a health care provider for consumers who are uncertain about the emergency status of their condition.

Table III: Emergency Services

	Severe Pain	Prudent Layperson*	Serious Jeopardy	Range of Examples**	24 Hour Phone***
Alameda Alliance
Blue Cross
Contra Costa Health Plan
Foundation Health
Health Plan of San Joaquin
Inland Empire Health Plan
Kern Family Health Care
L.A. Care
Omni Healthcare
San Francisco Health Plan
Santa Clara Family Health Plan

*Plans received half credit if they mention severe pain or prudent layperson only in a glossary/definitions section
**Plans received half credit for an average range of examples
***Plans received half credit if they discuss who to call to determine if a condition is an emergency, but do not provide sufficient detail

Findings

Most of the member handbooks (nine) mention alleviation of severe pain, but very few discuss the prudent layperson standard (two) or the serious jeopardy standard (three). Four plans offer a good range of examples, and ten plans provide some information on who a consumer can call if she is uncertain about the emergency status of her condition.

L.A. Care does the best job in describing emergency coverage, meeting all four of the MedCAP checklist points. Santa Clara Family Health Plan, on the other hand, does not meet any of the stated criteria and should look to L.A. Care's handbook for guidance in improving its emergency services section.

Many of the handbooks inform consumers that they are covered for "true emergencies" only, and
that the health plan will pay the costs of emergency health services only if the condition meets the plan's emergency definition. This is extremely problematic for plans that offer an inadequate definition of an emergency. The Health Plan of San Joaquin handbook, for example, which does not mention the prudent layperson or serious jeopardy health standards and which does not list any examples, says:

If you have an emergency and you receive health care services, the Health Plan will cover the costs of your medical care if:

(1) You are in severe pain or your life or physical functioning would be jeopardized if you were not given immediate care by whatever appropriate provider or facility is available.
(2) You are unconscious, or otherwise unable to seek treatment through your doctor.

Severe Pain

Nine of the eleven health plans name alleviation of severe pain as a sufficient condition of an emergency in their definitions. Only the Alameda Alliance for Health and Santa Clara Family Health Plan handbooks do not mention severe pain. Alameda Alliance's definition reads simply "A medical emergency is a medical problem where there is a threat of death or disability if you go without treatment." We believe that this understates the federal definition of an emergency, and will discourage a consumer with severe pain (but without the threat of death or disability) from seeking emergency services.

Inland Empire Health Plan and Kern Family Health Care received half credit in this category because they mention alleviation of severe pain in their glossaries but not in the main text of the handbook regarding emergency coverage. In its glossary/definitions section for example, Kern Family Health Care defines an emergency thus: "A sudden, unexpected medical condition in which a person is in a lot of pain, or the person can die or become disabled." However, in the "Emergency Care" section of the same handbook, an emergency is defined only through examples. Cross-referencing may be difficult for a Medi-Cal consumer, and MedCAP recommends that the definition of an emergency, including mention of severe pain, must be included in the main text of the handbook.

Prudent Layperson

Only two health plans, L.A. Care and Inland Empire Health Plan, describe the prudent layperson standard in their handbooks. L.A. Care does a good job in breaking the prudent layperson standard down into understandable language:

Emergency care means those services required for the alleviation of severe pain, or immediate diagnosis and treatment of an unforeseen medical condition, which if not immediately diagnosed and treated could reasonably be believed to lead to disability or death.

The Inland Empire Health Plan handbook offers mention of the prudent layperson in its glossary/definitions section, but the language is more technical and harder to understand:

Emergency Services means those services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions, that, if not immediately diagnosed and treated, in the subjective belief of a reasonable person, could jeopardize their health if not treated in a timely basis.

Because prudent layperson is not mentioned in Inland Empire's "Emergency Health Care" section in the main text, this handbook only received half credit for this category.

Serious Jeopardy

Only three of the handbooks examined mention the "serious jeopardy to health" standard. The Contra Costa Health Plan states it in plain language, saying that an emergency is a medical condition that could "place the patient's life or health in danger." Similarly, Inland Empire Health Plan's handbook states that an emergency is a condition under which medical services "cannot be delayed without serious effects to your health." The Santa Clara Family Health Plan also mentions serious jeopardy. The distinction between jeopardy to health and jeopardy to life is a significant one, and should be communicated by all of the health plans.

Range of Examples

Four of the handbooks, according to the previously stated criteria, offer a good range of emergency examples: Alameda Alliance, Blue Cross, Foundation Health, and L.A. Care. These health plans list less obvious examples of emergencies including:

difficulty in breathing (Foundation, L.A. Care)
unusual or excessive bleeding (Foundation, L.A. Care)
suspected broken bones (Foundation, L.A. Care)
shock (Alameda Alliance)
head injury with confusion (Alameda Alliance)
fainting (Blue Cross)
severe burns (Blue Cross)
possible ingestion of poison, or medicine overdose (Foundation, L.A. Care)

The above good examples provide guidance for consumers who have an emergency less evident than unconsciousness, convulsions, gunshot wounds, or not breathing.

Three of the health plans, Santa Clara Family Health Plan, San Francisco Health Plan, and Kern Family Health Care list only extreme examples of emergencies. Contra Costa Health Plan's handbook lies somewhere in between, and thus received half credit. Health Plan of San Joaquin, Inland Empire Health Plan, and Omni Healthcare do not offer any examples at all.

While MedCAP recommends that the health plans expand their list of emergency examples to make them more inclusive, they should still clearly state that conditions not on the list may still qualify as an emergency.

24 Hour Phone Line

Handbooks should instruct consumers to go straight to the emergency room or to call 911 in case of an emergency. They should also provide instruction for consumers who are uncertain whether or not their condition qualifies as an emergency. Plans received full credit in this category if, under an "emergency services" heading, their handbooks directly instruct consumers to call their primary care physician (PCP) or another on-call health care provider 24 hours a day if they are uncertain about the emergency status of their condition.

Only two of the eleven plans, Alameda Alliance and Blue Cross, meet this qualification fully. The Blue Cross handbook provides a very good example for other health plans. In its emergency section, Blue Cross includes a subsection entitled "Not sure if it's an emergency?" This subsection reads:

If you are not sure if your health problem is an emergency, call your doctor or the Blue Cross 24-hour nurse advice line. Your doctor's number is on your Blue Cross card. Our nurse advice number is 1-800-224-0336. You can call our nurse advice line anytime, day or night, for free.

Similarly, Alameda Alliance's handbook includes a subsection entitled "What if you don't know what to do?" in its emergency section.

Eight of the handbooks received half credit in this category. These health plans may discuss who to call for advice, but leave out one or more of the stated criteria. San Francisco Health Plan's handbook, for example, tells consumers to call their PCP if they are not sure if their condition is an emergency, but does not indicate 24 hour availability. The Health Plan of San Joaquin's handbook provides consumers with a 24 hour advice nurse phone number to assistance in determining an emergency, but lists it under a section entitled "Getting Care After Hours" rather than under an "Emergency Services" heading. The information may therefore be more difficult to find when needed. Foundation Health Plan, in its emergency services section, instructs consumers on how to contact their PCP in an emergency, but does not direct them about who to call if they are unsure about the status of an emergency.

Contra Costa Health Plan's handbook does not discuss this issue at all in its "Emergency Care" section, and did not receive credit in this category.

Section IV
Carved-Out Services:
California Children's Services

As the Two-Plan Model unfolds, a great deal of confusion has emerged concerning carved-out services. Among Medi-Cal consumers, confusion is rampant concerning which services do and do not fall under the jurisdiction of the Two-Plan Model health plans, and how to access those that do not. It is important that health plans clearly communicate information about carved-out services and how to receive them in their member handbooks.


California Children's Services (CCS)12 is a carved-out service under the Two-Plan Model. Effectively, this means that a CCS-eligible child will receive services related to the CCS condition through regular fee-for-service (FFS) Medi-Cal, but will receive all other health services through a health plan in the Two-Plan Model. Children can be referred to CCS by anyone, including parents, other relatives, physicians, nurses, and social workers. The parent or guardian must complete and sign the application, but the referral can come from anywhere. It is not necessary to refer children through the Two-Plan Model health plan.

Handbooks should define CCS in plain language and explain what it means for CCS to be carved-out. Further, they should provide information on how to access CCS services, and tell consumers when their children might be eligible.

We examined member handbooks for all of the health plans to determine if they contain the following information pertaining to CCS carved-out services:

CCS definition: a definition of California Children's Services;
carve-out description: an explanation that the consumer will receive CCS services through regular FFS Medi-Cal, but will remain a member of the health plan for services unrelated to the CCS-eligible condition;
how to access: direction on how to receive CCS services (call your PCP/Member Services or call your county CCS program directly);
eligibility: a statement that a child may be eligible to receive CCS services if he/she has a serious illness or a chronic medical condition.

Table IV: Carved-Out Services - CCS

	CCS Definition*	Carve-Out Description	How to Access**	Eligibility
Alameda Alliance
Blue Cross
Contra Costa Health Plan
Foundation Health
Health Plan of San Joaquin
Inland Empire Health Plan
Kern Family Health Care
L.A. Care
Omni Healthcare
San Francisco Health Plan
Santa Clara Family Health Plan

* Plans received half credit if they list the definition only in a glossary/definitions section
**Plans received half credit if they direct consumers to call their PCP or Member Services, but do not inform them of their right to call their county CCS program directly.

Findings

The majority of the health plans (six) explain what it means for CCS services to be carved-out, but very few of them define CCS or explain who is eligible for it. Further, none of the plans inform consumers of their right to access CCS directly by contacting their county CCS program. Two health plans, Contra Costa Health Plan and Health Plan of San Joaquin, do not meet any of the four MedCAP checklist points. In fact, the Health Plan of San Joaquin handbook does not even mention CCS. These plans should incorporate more information about CCS carved-out services to fairly and fully inform Medi-Cal consumers.

CCS Definition

Only three of the eleven health plans define CCS in their member handbooks: Blue Cross, Inland Empire Health Plan, and Omni Healthcare. Blue Cross's definition is short and clear, but doesn't provide a lot of information:

California Children's Services is a program that provides access to special health care for children with special needs.

Blue Cross only gives this definition in its handbook glossary and not in the main text where carved-out services are discussed. Because cross-referencing may be difficult for the Medi-Cal population, Blue Cross received only half credit for its placement of the CCS definition. Omni Healthcare's definition is more comprehensive but probably too technical:

California Children's Services (CCS) Eligible Conditions, which are physically handicapping conditions defined in Title 22, CCR, Section 41800, are referred to the local CCS Program, the public health program which assures the delivery of specialized diagnostic, treatment, and therapy services to financially and medically eligible children under the ages of 21 years who have CCS-eligible conditions.

A definition of CCS that combines good information with easy-to-understand language might read:

California Children's Services is a program that pays for medical services to children with specific medical conditions such as cleft lip or palate, physical disabilities like paralysis, serious eye problems, cerebral palsy, sickle cell disease, and cancer. A child covered by Medi-Cal automatically meets CCS financial eligibility.

All of the member handbooks should incorporate some form of this definition, which provides examples of CCS-eligible conditions and information about financial eligibility, so that Medi-Cal
consumers will understand what CCS is.

Carve-Out Definition

Six of the eleven health plan member handbooks communicate what it means for CCS to be carved-out. Kern Family Health Care's handbook describes the CCS carve-out very precisely:

You maintain your membership with KFHC and obtain [CCS] services from a provider that will bill Medi-Cal, Fee-for-Service.

Omni Healthcare also offers a clear explanation:

When a Member's health condition meets the criteria for carve-out services listed below, the Member will continue to be enrolled in Omni, but Omni is required to refer Members eligible for the services to those organizations responsible for providing care for these health conditions. For those eligible, these carve-out services will be covered by the regular Medi-Cal fee-for-service program.

Contra Costa Health Plan's handbook does not define carve-outs at all. It simply tells Medi-Cal consumers that CCS is "Among other services that Contra Costa Health Plan does not cover." The handbook does not indicate that CCS is covered through another source. This handbook should be revised to include an explanation of carved-out services, indicating that they are available to Medi-Cal consumers even though the plan does not provide them.

How to Access

In order to receive full credit in this category, handbooks must tell consumers that they can access CCS services by calling their county CCS program directly, or by contacting their PCP or health plan member services department. None of the health plans meet this checklist point fully.

Five of the member handbooks inform consumers that they can access CCS carved-out services by calling Member Services or by talking to their PCP, and received half credit for this category. The Alameda Alliance for Health suggests that consumers "Talk to your child's primary care provider about special need care for your child." L.A. Care and Inland Empire Health Plan also indicate that consumers should talk to their child's PCP, and San Francisco Health Plan and Blue Cross direct consumers to call Member Services All of the health plans should tell consumers how to access carved-out services, including consumers' right to call their county CCS program directly.

Eligibility

Only two of the health plans, Alameda Alliance and L.A. Care, alert consumers that their children may be eligible for CCS. Parents should be made aware that they have the ability to refer a child to CCS under certain conditions. L.A. Care makes this clear, in a section nicely titled "Special Services for Children": "If your child has a chronic medical illness, he or she may be eligible for services under California Children's Services (CCS)." Similarly, the Alameda Alliance member handbook tells consumers that "If your child has a chronic or catastrophic medical problem, she or he may be able to get CCS." This information is instrumental to encouraging informed and involved parents.

Section V
Readability

To be effective, it is crucial that written materials targeted at the Medi-Cal population be easily readable. To this end, some states have insisted that written enrollment materials for Medicaid managed care meet certain grade level reading requirements. Enrollment materials in Pennsylvania and New York, for example, must be written on a fourth-grade reading level. California has taken steps to address this issue by requiring field testing of enrollment materials. However, at this time, California does not specify any standards for the reading level of member handbooks in its Two-Plan Model contracts. Mary Fermazin, Department of Health Services Chief of Policy and Quality Improvement of Medi-Cal Managed Care reports to MedCAP that the Departmetn requires that handbook be written at a fourth grade reading level.

We tested two sections in each of the member handbooks to determine readability. To augment the findings of other sections of this report, this section looks at the handbook descriptions of "how to choose a PCP" and "the internal grievance process." We tested the sections using the Microsoft Word 7.0a readability program. This program provides, among others, the following two readability scales:

Flesch Reading Ease: This index computes readability based on the average number of syllables per word and the average number of words per sentence. Scores range from 0 (zero) to 100. The average writing score is approximately 60 to 70. The higher the score, the greater the number of people who can readily understand the document.

Flesch-Kincaid Grade Level: This index computes readability based on the average number of syllables per word and the average number of words per sentence. The score in this case indicates a grade-school level. For example, a score of 8.0 means that an eighth grader would understand the document. Standard writing approximately equates to the seventh-to-eight-grade level.

There are many different available scales to determine reading level. For the purposes of this report the above scales are used only as a tool for comparison between plans.

Because readability is useless if sufficient information is not presented, the reading level outcomes of this section are cross-referenced with the content checklists outlined in sections I.A and II.A.

A. How to Choose a PCP

The Two-Plan Model health plan contracts require member handbooks to include information on the procedures for selecting a Primary Care Physician.13 This explanation is important because it educates the consumer about how to navigate in a managed care system. Thus, it is critical that choosing a PCP is communicated at a reading level that Medi-Cal consumers can easily understand. We ran the "how to choose a PCP" description from every health plan member handbook through the Microsoft Word readability program with the following results:

Table V.A: PCP Readability

Findings

According to the Microsoft Word program, the average reading ease of the member handbook descriptions is 60.3 and the average grade level is 9.51. The Alameda Alliance for Health scored the best on both scales (80.6, 5.1). Four other health plans scored above average on both scales: Blue Cross (74.9, 7), Health Plan of San Joaquin (66.3, 9.3), San Francisco Health Plan (68.3, 7.1), and Santa Clara Family Health Plan (61.7, 9.1). Foundation had the worst scores, with a reading ease level of 38.3 and a grade level of 14.1. We recommend that health plans not meeting a reasonable reading level revise their member handbook descriptions of "how to choose a PCP" to increase readability and facilitate understanding for Medi-Cal consumers.

Readability vs. Content

Alameda Alliance, which had the best scores for readability in this section, also scored very well on the "how to choose a PCP" checklist, meeting five of the six MedCAP checklist points in Section I.A. San Francisco Health Plan also scored above average for readability and met five of the six checklist points for choosing a PCP. Blue Cross, however, while scoring above average for readability, had one of the lowest scores in Section I.A. Although readability is very important, it is not relevant if important information is excluded. Handbooks should strive to present sufficient information at an appropriate reading level.

B. The Internal Grievance Process

The Two-Plan Model health plan contracts also require member handbooks to include information on the health plan's internal grievance process.14 To ensure Medi-Cal consumers' due process rights in the Two-Plan Model, this information must be clearly communicated. We ran the "internal grievance process" description from every health plan member handbook through the Microsoft Word readability program with the following results:

Table V.B: Internal Grievance Readability

Findings

According to the Microsoft Word program, the average reading ease of the member handbook descriptions is 62.86 and the average grade level is 8.94. Blue Cross scored the best on both scales (84.9, 5.5). Three other health plans scored above average on both scales: Alameda Alliance (63.4, 8.1), L.A. Care (69, 7.7), and San Francisco Health Plan (70.9, 6.7). Contra Costa Health Plan scored just above average on the reading ease scale (63.9) and Omni Healthcare scored just above average on the grade level scale (8.8). Kern Family Health Care had the worst scores, with a reading ease level of 50.5 and a grade level of 11.1. We recommend that health plans not meeting a reasonable reading level revise their member handbook descriptions of "the internal grievance process" to increase readability and facilitate understanding for Medi-Cal consumers.

Readability vs. Content

Alameda Alliance, which scored above average for readability in this section, also had one of the best performances on the internal grievance process checklist in Section II.A, meeting three of the five MedCAP checklist points. Other plans that scored above average for readability, however, did not provide adequate information: Blue Cross and San Francisco Health Plan handbooks met only two criterion, and L.A. Care met only one and a half of the checklist points. Again, although readability is very important, it is not relevant if important information is excluded. Health plans should provide consumers with all the necessary information at an appropriate reading level.

C. Overall Findings

Three health plan member handbooks consistently scored above average on both scales for both the "how to choose a PCP" and "the internal grievance process" sections: Alameda Alliance for Health, Blue Cross, and the San Francisco Health Plan. Three plans scored below average on both scales for both sections. Those plans, Foundation Health, Inland Empire Health Plan, and Kern Family Health Care, must revise their handbooks to make them more easily readable and thus more accessible to the population they are designed for.

Section VI
Summary

A. Content Summary

To summarize the accuracy and comprehensiveness of the member handbooks and provider directories, each health plan was assigned points for Sections I - IV. The health plans were assigned a point for each bullet and half a point for each half bullet received in the checklists concerning selecting a provider, grievance procedures, emergency services, and CCS carved-out services. Plans could receive up to a possible total of 31 points.

Table VI.A: Content Summary (Sections I - IV)

The Alameda Alliance for Health ranked first for the content of its member handbook, receiving 18 points. At the other end of the spectrum, Kern Family Health Care's handbook scored the worst, receiving only 10.5 points. With a total of 31 points possible, all of the handbooks, including those that scored the best, have room for improvement. All of the Two-Plan Model health plans should consider incorporating more of the information included in the MedCAP checklists into their handbooks in an effort to improve communication with consumers. Specific findings are summarized below.

Selecting a Provider

MedCAP Recommends:

Member handbooks should: (1) define the term "primary care provider" (PCP); (2) describe the process for choosing a PCP; (3) explain that if the consumer doesn't choose, a choice will be made for her; (4) inform the consumer of her right to change her PCP if she wishes; (5) outline the importance of scheduling an initial appointment with the PCP within 120 days of enrollment; and (6) explain how consumers can access specialty providers through the referral process.
Provider directories should list physicians in three ways: (1) by city; (2) in alphabetical order; and (3) by language spoken. Further, provider directories should include: (4) a complete listing of specialists; and (5) the board certification status of each physician.

Findings:

Only two of the eleven health plans define PCP in the "choosing a PCP" section in the main text of the handbook. Other plans' handbooks define PCP in their glossaries, but, because cross-referencing may be difficult for Medi-Cal consumers, MedCAP believes this is not adequate. With this notable exception, the handbooks do a good job in describing how to choose a PCP. All eleven handbooks examined describe the process for choosing a PCP and explain that consumers can access specialists by getting a referral from their PCP. Further, all plans mention the process for changing a PCP, and most of them describe what happens when consumers don't choose and urge consumers to schedule an initial health assessment appointment.
None of the provider directories list the board certification status of physicians, and only three offer listings of specialists. This information is important for informed consumer choice, and should be included in every directory. All of the provider directories, however, do list physicians by city, and many of them include an alphabetical index.

Grievance Procedures

MedCAP Recommends:

Member handbooks should include the following information about the internal grievance process: (1) the address and/or phone number needed to initiate the process; (2) (3) the grievance timelines set forth by contract; (4) the right to representation; (5) the right to linguistically appropriate assistance; and (6) the right to see grievance related materials.
Member handbooks should include the following information about the state fair hearing process: (1) the right to file; (2) how to file; (3) the deadline to file; (4) the right to representation; and (5) aid paid pending. Further, handbooks should explain (6) how and when to call the Department of Corporations.

Findings:

The handbooks do not do a good job of communicating consumers rights within the internal grievance process. Only one plan mentions the right to representation and the right to see grievance related materials. Health plans must inform consumers of these rights to ensure due process protection. The handbooks do well in telling consumers how to file a grievance and in informing them of the internal grievance timelines.
Only one handbook mentions the 90 day filing deadline for the state fair hearing, and none of them discuss the possibility of aid paid pending (continued benefits) or the right to representation. One handbook does not even mention the right to a state fair hearing. This information is critical, and should be included in all of the handbooks.
Ten handbooks provide at least some information on how to file for a fair hearing, nine explain the consumer's right to a fair hearing, and nine provide information on when and how to file a complaint with the DOC.

Emergency Services

MedCAP Recommends:

Member handbooks should include the following in their definition of an emergency: (1) severe pain can be a sufficient determining factor of an emergency; (2) the prudent layperson standard; (3) a condition that places health in serious jeopardy is an emergency. Further, member handbooks should: (4) present a reasonable range of examples to illustrate emergencies; and (5) offer direction for consumers who do not know whether or not their condition qualifies as an emergency.

Findings:

Only two of the handbooks mention the prudent layperson standard, and only three discuss serious jeopardy. This information should be included in all of the handbook definitions of an emergency in order to comply with federal and state standards. Further, only half of the handbooks provide a reasonable range of emergency examples. Ten of the handbooks, however, provide at least some information on who a consumer can call if she is uncertain about the emergency status of her condition, and nine handbooks mention alleviation of severe pain.

Carve-Outs: California Children's Services (CCS)

MedCAP Recommends:

Member Handbooks should: (1) define CCS, a program providing health care for children with special medical needs; (2) explain that the carve-out means children will stay enrolled in the health plan but will receive care for CCS-related conditions through FFS Medi-Cal; (3) provide information on how to access CCS services directly; and (4) tell consumers when their children might be eligible.

Findings:

Only two health plans define CCS in the main text of their handbooks, and only two handbooks discuss potential eligibility. Further, none of the handbooks provide adequate information about how to access CCS directly, and only half of them explain the carve-out. Two of the handbooks do not meet any of the MedCAP criteria. CCS carve-out information is crucial to Medi-Cal consumers' understanding of their benefits, and should be incorporated into all of the handbooks.

B. Readability Summary

To summarize the readability and accessibility of the member handbooks, the Flesch-Kincaid Grade Level scores for "choosing a PCP" and "the internal grievance process" in Section V were averaged. The results ranged from a 6.25 grade reading level to a 12.1 grade reading level.

Table VI.B: Readability Summary (Section V)

For readability, Blue Cross ranked number one (6.25) and Foundation Health ranked last (12.1). The average grade reading level for all of the plans was 9.2. As previously stated, while California's contracts with the Two-Plan Model health plans do not specify a reading level for member handbooks, Department of Health Services states that they require a fourth grade reading level for member handbooks. Clearly, many of the health plans' handbooks need to be revised to increase readability and understanding among the Medi-Cal population. Specific findings are summarized below.

Readability

MedCAP Recommends:

Member handbooks should be written at a reading level that Medi-Cal consumers can easily understand. This report uses the Microsoft Word 7.0a readability program to determine the readability of the handbook descriptions of (1) the procedures for selecting a PCP and (2) the internal grievance process. The Flesch Reading Ease index gives a score ranging from 0 to 100 (the higher the score, the greater the number of people who can understand the document). The Flesch-Kincaid Grade Level index gives a score reflecting a grade-level.

Findings:

The handbooks have an average Flesch Reading Ease for the "how to choose a PCP" descriptions of 60.3, with a range from 38.3 to 80.6. The Flesch-Kincaid Grade Level average was 9.51, with a range from 14.1 to 5.1.
The handbooks have an average Flesch Reading Ease for the "internal grievance process" descriptions of 62.86, with a range from 50.5 to 84.9. The Flesch-Kincaid Grade Level average was 8.94, with a range from 11.1 to 5.5.
Health plans with low reading ease score and high grade level scores must revise their handbooks to make them more easily readable and thus more accessible to the Medi-Cal population. Although California's Two-Plan Model health plan contracts do not specify a reading level for member handbooks, other states have reading level requirements ranging from a fourth- to a seventh-grade reading level.

Sources

Member Handbooks

Alameda Alliance for Health: Your Guide to Services: Customer Handbook. (Obtained 6/97).

Blue Cross of California Medi-Cal Managed Care Program: Member Services Guide/Evidence of Coverage. (Effective 8/97).

Contra Costa Health Plan's Health Partners: Member Services Guide for Medi-Cal. (Obtained 6/97).

Foundation Health: Evidence of Coverage for Foundation Health's Medi-Cal Commercial Plan. (Effective 6/97).

Health Plan of San Joaquin: Member Handbook. (Obtained 6/97).

Inland Empire Health Plan: Evidence of Coverage and Disclosure Form (Effective 5/97).

Kern Family Health Care: Medi-Cal Plan Combined Evidence of Coverage and Disclosure Form and Member Handbook.
(Effective 8/96).

L.A. Care Health Plan: Blue Cross of California: Member Handbook.15 (Effective 5/97).

Omni Healthcare: Member Handbook (Combined Evidence of Coverage and Disclosure Form); Medi-Cal Managed Care
Plan, Stanislaus County.16 (Effective 2/97).

San Francisco Health Plan: Member Handbook. (Effective 1/97).

Santa Clara Family Health Plan: Member Handbook and Combined Evidence of Coverage and Disclosure Form.
(Effective 1997).

Provider Directories

Alameda Alliance for Health: Where to Get Care: Provider List. (Effective 11/29/96).

Blue Cross of California Medi-Cal Managed Care Program: Medi-Cal Managed Care Program Provider Directory:
Alameda County.17 (Effective 5/97).

Contra Costa Health Plan's Health Partners: Provider Directory for Medi-Cal. (Effective 4/97).

Foundation Health: Medi-Cal Provider Directory Los Angeles County: PCP, Pharmacy & Vision Listings.18 (Effective 8/97).

Health Plan of San Joaquin: Provider Directory. (Effective 6/97).

Inland Empire Health Plan: Provider Directory. (Effective 5/15/97).

Kern Family Health Care: Provider Directory. (Effective 5/97).

L.A. Care Health Plan: Provider Directory. (Obtained 10/97).

Omni Healthcare: Medi-Cal Provider Directory: San Joaquin County.19 (Effective 4/97).

San Francisco Health Plan: Provider Directory: A Guide to Doctors, Clinics, Hospitals and Pharmacies.
(Effective Summer 1997).

Santa Clara Family Health Plan: Directory of Doctors and Health Care Services: Your Guide for Choosing a Doctor.
(Effective 7/97).

Health Plan Contracts

Local Initiatives:
L.A. Care / Department of Health Services Contract: March 1, 1997.

County of Contra Costa / Department of Health Services Contract: October 1, 1996.

San Francisco Health Authority / Department of Health Services Contract: January 1, 1997.

Commercial Plans:
Blue Cross CaliforniaCare / Department of Health Services Contract: February 1, 1996.

Endnotes

1. Often referred to as "evidence of coverage."

2. DHS/Health Plan contracts, Article VI, Section 6.10.2, Part B.3.

3. DHS/Health Plan contracts, Article VI, Section 6.9.9.

4. Article VI, Section 6.5.6.4 of the Two-Plan Model health plan contracts.

5. Medi-Cal Eligibility Manual, Article 18, Section 50951.

6. Article VI, Section 6.9.5.N of the Two-Plan Model health plan contracts.

7. In a letter to MedCAP dated January 7, 1998, the San Francisco Health Plan stated that "The Department of Health Services directed us to delete all references to APP." MedCAP believes that DHS should be encouraging, not prohibiting, health plans to include this important piece of information in their member handbooks.

8. Balanced Budget Act of 1997, Title IV-H, Section 4704.2(C).

9. California Health and Safety Code, Section 1317.1(b).

10.DHS/Health Plan contracts, Article II, Part Z.

11.MedCAP conducted its analysis using member handbooks collected in November 1997, and recognizes that health plans had not had sufficient time to adjust their handbooks to meet the requirements of the Balanced Budget Act. However, this report is an opportunity to encourage plans to revise their handbooks to comply with the new standards.

12.CCS covers children who have certain special medical needs because of physical disabilities, chronic medical conditions, or serious illnesses and who have adjusted family incomes below $40,000/year.

13.DHS/Health Plan contracts, Article VI, Section 6.9.5, Part D.

14.DHS/Health Plan contracts, Article VI, Section 6.9.5, Part L.

15.L.A. Care's member handbooks for all of its participating plans are identical to the L.A. Care Blue Cross handbook in the sections used for this report.

16.Omni Healthcare's member handbook for San Joaquin County is identical to the Stanislaus County handbook in the sections used for this report.

17.Blue Cross's provider directory organization for all of its commercial plan counties is identical to the Alameda County directory in the sections used for this report.

18.Foundation Health's provider directory organization for all of its commercial plan counties is identical to the Los Angeles County directory in the sections used for this report.

19.Omni Healthcare's provider directory organization for Stanislaus County is identical to the San Joaquin County directory in the sections used for this report.

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