Frequently Asked Questions - Medi-Cal
Many questions regarding the CalOptima Medi-Cal program in Orange County can be found on CalOptima's website using the following link: http://www.caloptima.org/index.asp?content=membersfaqs
For your convenience, those questions and their respective responses are reproduced below.
Click on one of these or scroll down for the complete list.
1. Can I change my primary care physician (PCP) if I'm unhappy with him/her?
2. Can I change health networks?
3. What do I do if I need to see a specialist or need special medical services?
4. Who do I follow up with regarding an authorization request my PCP/specialist submitted awhile ago?
5. What do I do if I get a bill for health care services?
6. What if I have other health insurance?
7. What should I do if I need care after hours?
8. How do I get care if I am outside of Orange County?
9. What is the benefits identification card (BIC)? What is the CalOptima ID card?
10. What do I do if I lose my benefits identification card?
11. How do I get mental health services?
12. What medications are covered?
13. How do I get prescription coverage when I'm out of town?
14. How do I access dental care?
15. Who do I report to regarding a change of name or address?
16. What if I have Medicare and Medi-Cal? How does that work with CalOptima?
17. Can I talk to my doctor in my own language?
Answers
1. Can I change my primary care physician (PCP) if I'm unhappy with him/her?
Yes. You can change your PCP for any reason. To do this, you need to call your health network's Customer Service Representative and they can assist you in changing PCPs. Arta Western's Customer Service Representative's phone number is on the front of your CalOptima membership identification card.
2. Can I change health networks?
If you are a new member with CalOptima, you can change health networks during the first three (3) months of becoming eligible with CalOptima. You can also change health networks during our annual open enrollment period. Our Annual Open Enrollment period is from September 15 to December 15. If you want to change your health network at any other time, you must call CalOptima’s Customer Service Department and give a reason for the change. CalOptima will decide if you may change your health network. You can reach CalOptima’s Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088, Monday through Friday from 8:00 AM to 5:30 PM.
3. What do I do if I need to see a specialist or need special medical services?
When you need to see a specialist or need special medical services, ask your PCP for a referral. If your PCP agrees, he or she can refer you to a specialist. When you ask your PCP for a referral, it is important to be very clear about why you think you need the referral.
4. Who do I follow up with regarding an authorization request my PCP or specialist submitted awhile ago?
Your PCP, specialist, or your health network can give you the status on your authorization request.
5. What do I do if I get a bill for health care services?
You should first call the provider who provided the service for which you have been billed. You should inform this provider that you have coverage through CalOptima, and give this provider your CalOptima Medi-Cal or Healthy Families coverage and/or other insurance information. You should then call Arta Western Medical Group's Customer Service Representative at 1-800-780-8879 on Monday through Friday from 8:00 am to 4:30 PM, or CalOptima's Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088, Monday through Friday from 8:00 am to 5:30 pm, for further assistance.
6. What if I have other health insurance?
Your other insurance will be the primary payor responsible for covering the services you received. CalOptima (Medi-Cal/Healthy Families) will be the last payor. You will need to seek payment for services through your primary insurance carrier before seeking reimbursement from CalOptima.
7. What should I do if I need care after hours?
Urgent care is medical care needed for a sudden illness or injury that cannot wait for a regular office visit. If you have an urgent situation, call your PCP first. If you cannot reach your PCP, call your health network.
8. How do I get care if I am outside of Orange County?
If you are outside of Orange County and have an emergency or urgent situation, go to the nearest hospital emergency room. Ask the hospital staff to call Arta Western Medical Group within 24 hours. If you are not sure if it is an emergency or urgent situation, call your PCP.
Do not use the hospital emergency room for routine care.
9. What is the benefits identification card (BIC)? What is the CalOptima ID card?
The BIC is a card issued by the Orange County Social Services Agency . This card is used to obtain CalOptima Medi-Cal covered services. The CalOptima ID card identifies you as a CalOptima member. It also tells you which health network you are enrolled in.
It is important to carry these cards at all times. You must present them to the provider when you need to access health care services.
10. What do I do if I lose my benefits identification card?
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If you lose your BIC, you need to call or visit your local Orange County Social Services Agency.
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If you lose your CalOptima identification card, you need to call or visit CalOptima.
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If you lose your health network identification card, you need to call your health network's Customer Service Representative. Your health network's Customer Service Representative's telephone number is on the front of your CalOptima Healthy Families identification card.
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11. How do I get mental health services?
Contact CalOptima’s Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088, Monday through Friday, 8:00 AM to 5:30 PM.
12. What medications are covered?
All medications that are on the CalOptima approved drug list are covered. If your doctor says you need a medication not on this list, your pharmacy must get prior authorization. All pharmacies that are contracted with CalOptima are responsible for obtaining all authorizations for medications. If you want to know if a particular medication is covered by CalOptima, call CalOptima’s Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088, Monday through Friday, 8:00 AM to 5:30 PM.
13. How do I get prescription coverage when I'm out of town?
In California, you may go to any CalOptima-participating pharmacy. Prescriptions filled outside of California need prior authorization from CalOptima. If you need help, call CalOptima’s Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088, Monday through Friday, 8:00 am to 5:30 pm.
14. How do I access dental care?
Contact CalOptima’s Customer Service Department at 1-714-246-8500 or toll free at 1-888-587-8088, Monday through Friday, 8:00 am to 5:30 pm.
15. Who do I report to regarding a change of name or address?
Contact the Orange County Social Services Agency and/or the U.S. Social Security Administration to report any changes such as name and/or address.
16. What if I have Medicare and Medi-Cal? How does that work with CalOptima?
Medicare will be your primary payor and CalOptima/Medi-Cal will be your secondary payor. CalOptima will cover most benefits that Medicare does not cover, such as prescription drugs.
17. Can I talk to my doctor in my own language?
Yes. As a CalOptima member, you can get free interpreter services when you have a doctor's appointment. You can also ask to have an interpreter assist you when you call your health network. This also includes sign-language interpreters. Call your Arta Western Medical Group Customer Service Representative at 1-800-780-8879, Monday through Friday from 8:30 AM to 4:30 PM for details.
Frequently Asked Questions – Healthy Families
Many questions regarding the CalOptima Healthy Families program in Orange County can be found on CalOptima’s website using the following link: http://www.CalOptima.org/CalOptimakids/index.asp?content=familiesfaqs
For your convenience, those questions and their respective responses are reproduced below.
Click on one of these or scroll down for the complete list.
1. Where can I apply for the Healthy Families program?
2. Do I have to pay a monthly premium?
3. How often must I re-qualify for the program?
4. How long will it take to know if my child(ren) qualify for the program?
5. Can I change my primary care physician (PCP) if I'm unhappy with him/her?
6. Can I change health networks?
7. What do I do if I need to see a specialist or need special medical services?
8. Who do I talk to or call regarding an authorization request my PCP/specialist submitted?
9. What do I do if I get a bill for health care services?
10. What should I do if I need care after hours?
11. How do I get care if I am outside of Orange County?
12. How do I get mental health services?
13. What medications/prescriptions are covered?
14. How do I get medication when I'm out of town?
15. How do I access dental care?
16. Can I talk to my doctor in my own language?
Answers
1. Where can I apply for the Healthy Families program?
There are many organizations in Orange County that can assist you in applying for the Healthy Families program. You can receive a referral to a local organization by calling Healthy Families at 1-800-880-5305. The Healthy Families program can also send you an application in the mail. CalOptima has certified application assistants who can help you with the application process. You can reach a CalOptima certified application assistant by calling 1-800-530-2899.
2. Do I have to pay a monthly premium?
Yes. Your monthly premium will be based on your income, the number of children covered, and the health plan you choose for coverage.
3. How often must I re-qualify for the program?
Each year you will be asked to confirm that your child still qualifies for the Healthy Families program. You will be notified by mail regarding the annual eligibility review process. Please call CalOptima at 1-800-530-2899 if you need assistance with the process.
4. How long will it take to know if my child (ren) qualify for the program?
You will receive an official notification within 10 days after submitting a completed Healthy Families program application.
5. Can I change my primary care physician (PCP" if I'm unhappy with him/her?
Yes. You can change your PCP for any reason. To do this, you need to call your health network's Customer Service Representative who will assist you in changing PCPs. Your health network's Customer Service Representative's telephone number is on the front of your CalOptima Healthy Families identification card.
6. Can I change health networks?
Yes. If you are not happy with your current health network, you can come into the CalOptima office or you can call CalOptima's Customer Service Department at 1-800-530-2899 to request a health network change. Our Arta Western Medical Group Customer Service Representative can also help you with your request; please call 1-800-780-8879, Monday through Friday, 8:00 AM to 4:30 PM. The change will be effective the following month.
7. What do I do if I need to see a specialist or need special medical services?
When you need to see a specialist or need special medical services, ask your PCP for a referral. If your PCP agrees, he or she can refer you to a specialist. When you ask your PCP for a referral, it is important to be very clear about why you think you need the referral.
8. Who do I talk to or call regarding an authorization request my PCP or specialist submitted?
Please contact your PCP, specialist or your health network.
9. What do I do if I get a bill for health care services?
You should first call the provider who provided the service for which you have been billed. You should give this provider your CalOptima Healthy Families program coverage and/or other insurance information. You should then call your health network or CalOptima at 1-800-530-2899 for further assistance.
10. What should I do if I need care after hours?
Urgent care is medical care needed for a sudden illness or injury that cannot wait for a regular office visit. If you have an urgent situation, call your PCP first. If you cannot reach your PCP, call your health network. Your PCP and health network phone numbers are listed on the front of your CalOptima identification card.
11. How do I get care if I am outside of Orange County?
If you are outside of Orange County and have an emergency or urgent situation, go to the nearest hospital emergency room. Please make sure to show your CalOptima identification card at the time of service. Ask the hospital staff to call your health network within 24 hours. If you are not sure if it is an emergency or urgent situation, call your PCP.
Do not use the hospital emergency room for routine care.
12. How do I get mental health services?
Most mental health services are provided by your health network. For a list of mental health providers that participate with your health network, call the health network Customer Service phone number listed on your CalOptima identification card.
13. What medications/prescriptions are covered?
All medications that are on the CalOptima Healthy Families approved drug list are covered. If your doctor says you need a medication not on this list, your pharmacy must obtain a prior authorization. All pharmacies that are contracted with CalOptima are responsible for obtaining all authorizations for medications. If you want to know if a particular medication is covered by CalOptima, call CalOptima's Customer Service Department at 1-800-530-2899, Monday through Friday, 8:00 AM to 5:30 PM.
14. How do I get medication when I'm out of town?
In California, you can go to any participating chain pharmacy. Prescriptions filled outside of California need prior authorization from CalOptima Healthy Families. If you need help, call CalOptima's Healthy Families Customer Service Department at 1-800-530-2899, Monday through Friday, 8:00 AM to 5:30 PM.
15. How do I access dental care?
Dental care is provided through the Healthy Families program. Refer to your dental identification card for the name of your dentist. For dental questions, please call 1-866-848-9166.
16. Can I talk to my doctor in my own language?
Yes. As a CalOptima Healthy Families member, you can get free interpreter services when you have a doctor's appointment. This also includes sign-language interpreters. Call the health network phone number listed on your CalOptima identification card to request free interpreter services.