Health Plan 101

How to Get the Most Out of Your Health Plan

A Cal MediConnect health plan is a type of managed care health plan. It’s a plan that coordinates provider services, medicines, hospital care, and special equipment to help you manage your health. Learn what that means and how to get the most out of this type of plan.

How is managed care (or a health plan) different than original Medicare and Medi-Cal?

In traditional Medi-Cal, also called Fee-For-Service, you can go to any Medicare or Medi-Cal provider for services, but they often do not work together or communicate with your other health care providers. Having a health plan means your doctors all work together, but you will need to stay within the network of doctors, hospitals, and pharmacies. Below is more information about how those networks work.

What is a provider network?

The provider network is a specific group of health care providers, including: primary care providers, specialists, pharmacies, nursing facilities, and suppliers of medical equipment. The health plan creates their own provider networks. These providers work together to make sure you get the services you need.

What is a provider group?

A provider group (also known as a clinic or medical group) is a set of health care providers who work together. They may be in the same office or they may have multiple offices. The Cal MediConnect health plan you choose may require you to get all your care from the same provider group. The health plan can tell you if this is the case.

What do I need to know about networks?

  • You must use the providers in your health plan’s network.
  • Providers who are not in your health plan’s network are called out-of-network providers.
  • You may also need to use providers in the same group, depending on your health plan.
  • You can choose another provider group within the health plan’s network.

How can I make an appointment with a provider in my health plan?

  • If you have seen the provider in the past, call the office directly to make an appointment.
  • If you are new to your health plan, call to get a list of providers in the network.
  • You can ask your health plan to help you choose a provider and make an appointment. If you are in a Cal MediConnect plan, your Care Coordinator can help you do this.
  • If you are in a Cal MediConnect plan, you can also ask for help arranging transportation to and from your appointment.

What can I do if my health plan will not cover a service that I need?

  • If your health plan or provider group denies, reduces, or stops your care, you can ask to have that decision reviewed and maybe changed. This is called filing an appeal. For example, you can file an appeal if you can’t get a medicine that you need.
  • You can also file an appeal if your health plan won’t pay for a service, medical supply, or prescription drug that you already have received.
  • Call your health plan to ask how to file an appeal.

What is prior authorization?

When you or your provider request a service (including treatments and prescriptions), your health plan may review the request. The plan then decides whether you need the service before it agrees to pay. The plan either approves or denies the request in writing. This is known as prior authorization or pre-approval.

How can I make the most of my appointment?

  • Make sure you have your benefit identification card or cards with you when you go to your appointment. This includes your Medi-Cal and Medicare cards. If you are in a Cal MediConnect plan, you will have only one card.
  • Bring a list of questions to discuss with your provider.
  • If you want, have a family member or caregiver go with you to the appointment.
  • If you are taking any medicines, bring a list of them with you. If you are in a Cal MediConnect plan, you can also call and tell them about your medicines, and they can help tell your providers.
  • If needed, make a follow-up appointment before leaving.
  • If you are in a Cal MediConnect plan, you can contact the plan with your questions or concerns between visits.