Medi-Cal managed Care - Out of Network Services

Publications
#5559.01

Medi-Cal managed care health plans have networks of providers. Providers are doctors, pharmacies, clinics, labs, and hospitals. Most of the time, you must use the plan providers. There are times when you can get health care from providers who are not plan providers. They are “out-of-network” providers. This pub tells you when you can use such a provider. If Medi-Cal tells you that you cannot go “out-of- network, the pub tells you what to do.

1.  What are out-of-network services?

Medi-Cal managed care organizations (MCO)1 have networks of providers, including doctors, pharmacies, clinics, labs, and hospitals (“plan providers”). Most of the time, members must use the plan providers when getting medical care in order for services to be covered by the MCO. There are instances when you can get medical services from providers who are not plan providers. These are called “out-of-network” providers. The services they provide are considered “out-of-network” services.

2.  Under what circumstances will my MCO pay for out-of-network providers/services?

Emergency Care

If you require emergency care you can go to an out-of-network provider. You also can call the MCO nurse hotline who may be able to help you get emergency or alternate care. Once in an emergency room and your condition has stabilized you may be moved to an in-network-provider for continuing care. Ambulance service may also be covered.2

What is considered an “emergency” is something that you reasonably believe to be an emergency. It does not matter that later it is determined that it was not an emergency.

You are receiving out-of-network services at the time you enroll into Medi-Cal managed care.

If you are seeing an out-of-network provider and you are now being told that you must enroll in a MCO, you may be able to continue to see this provider under what is called “continuity of care.” For more about continuity of care, see:

No in-network providers

If you need services that your MCO is required to provide, but it does not have providers within its network of plan providers “experienced in dealing with enrollee’s health care needs,”3 you may be able to get out-of-network services. For example, if you need to see a specialist like a pediatric neurologist, but there are no pediatric neurologists available in your MCO’s network, then you may be able to see a pediatric neurologist who is not in the network. Your MCO has to approve this.

You may be receiving services through a medical group or through a group of doctors and other providers in an individual practice association (IPA). The IPA or medical group may have contracted with the MCO to provide you services. The group may have also assumed some of the financial risk in providing you care. You should not be limited to the providers in the group. You should be able to go to an MCO provider outside the medical group or IPA and not have that considered to be out-of-network.

3.  What if my MCO and I disagree on whether I need to see a particular kind of specialist?

If there is a disagreement about whether or not you need to see a particular kind of specialist or a specialist experienced in dealing with your care needs, you can ask for a second opinion from a “qualified health professional:” a primary care physician or specialist who possesses a relevant clinical background, including relevant training and expertise.4

4.  I have heard that some services are “carved out” from the MCO plan. What does this mean?

There are services that an MCO does not provide because another agency is responsible for providing them. These services are considered “carved out” or not covered by the MCO. Although the MCO is not required to provide these services, the Medi-Cal program is still responsible for providing them. The MCO is also responsible for helping you get the carved-out services you need. A provider who is not in the MCO and who accepts Medi-Cal will provide the carved-out service. Depending on what your MCO covers, the carved-out services can include services through California Children’s Services (CCS), specialty mental health services,5 dental, vision and other services to address a substance use disorder: namely, alcohol or drug use problems. To access these services, you can ask your MCO help or contact us.

5.  What can I do if my MCO denies my request for an out-of-network service/provider?

You have several options if your MCO denies your request for an out-of-network provider.

File a Grievance

You can file a grievance with your MCO at any time. Ask your MCO how to do this. If your problem is urgent (a serious threat to your health), your MCO must give you a decision within 72 hours. If your problem is not urgent, your MCO has 30 days to give you a decision. For more information read Disability Rights California’s publication: Medi-Cal Managed Care Health Plans: What are they? What do I need to know about them?

File an Appeal

You can file an appeal with your MCO. For more information read Disability Rights California’s publication: Medi-Cal Managed Care Health Plans: What are they? What do I need to know about them?

Ask the Department of Managed Health Care for help

Before you file a complaint with the Department of Managed Health Care, you must first file a grievance or an appeal with your MCO. Under most MCO plans, you can file a complaint with the Department of Managed Health Care at (888) 466-2219 or TDD: (877) 688-9891 if you are unhappy with your MCO’s decision or if you have not received a decision within 3 days for an urgent problem or 30 days for a non-urgent problem. Also see: https://www.dmhc.ca.gov/FileaComplaint.aspx#.WBJ8JY3FA3E

You can also call DMHC’s Help Center at 1 (888) 466-2219. For more information read Disability Rights California’s publication: Medi-Cal Managed Care Health Plans: What are they? What do I need to know about them?

Ask for an Independent medical review

You can ask DMHC for an Independent Medical Review. An Independent Medical Review (IMR) is a way for you to get an external, independent medical review if your health plan denies, modifies, or delays services because of medical necessity. For more information read Disability Rights California’s publication: Medi-Cal Managed Care: An Independent Medical Review (IMR) Can Change a Plan’s No to Yes

It is very important that you review DRC’s publication on IMRs about the timing of filing an IMR and fair hearing request.

File for a Medi-Cal fair hearing

Starting July 1, 2017, new federal rules require MCO enrollees to exhaust their plan's grievance procedures before asking for a fair hearing. This means you must file an appeal with your MCO first if you are unhappy with your MCO’s decision. You must request a Medi-Cal fair hearing within 120 calendar days of receiving the Notice of Appeal Resolution. To ask for a Medi-Cal fair hearing call the State Hearings Division, Department of Social Services toll free at (800) 952-5253 or TDD at (800) 952-8349. You can also appeal by fax at (916) 651-2789. For more information read Disability Rights California’s publication: Medi-Cal Managed Care Health Plans: What are they? What do I need to know about them?

Change plan

Changing your plan may be a way to get to a health care professional able to address your medical needs. Before you do this, you will want to make sure that the MCO you are thinking of moving to has the provider(s) you need.

 

 

1 Members of a MCO choose a primary care physician (PCP) who they must go to first. The PCP can treat or refer members to a specialist within the network and sometimes outside of the network. – (Return to main document)

2 See California Health & Safety Code Section 1371.5. – (Return to main document)

3 42 C.F.R. Section 438.56(d)(2)(iv). Federal Medicaid managed care regulation grounds for disenrollment for cause also provides the basis for asserting a right to out-of-network care to receive services from a specialist experienced in dealing with enrollee’s type of health care needs. – (Return to main document)

4 California Health & Safety Code Section 1383.15(b) – (Return to main document)

5 See http://www.disabilityrightsca.org/pubs/508401.pdf for information on specialty mental health services. For mental health services provided by your MCO see: http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2013/APL13-018.pdf(Return to main document)