Care1st Health Plan wants to make sure you get good care and services. To help make this happen, we have created a complete Quality Improvement Program. The goal of the program is to make sure that our promise of giving good care to our members is being met. The program measures many different parts of the care and services we offer. You can find results for the program on our web site at www.care1st.com. You can also call and request the results by calling our Quality Improvement Department at 1-877-472-4332.
These measurements include:
Care1st Health Plan encourages appropriate use of benefits and services and discourages underuse of them. Care1st does not reward staff or doctors for keeping members from getting care.
Care1st Health Plan has established a Disease Management Program to provide education, care coordination and support to our members with certain chronic conditions.
Care1st refers to these programs as Care1stCARES. Participation in these programs is free and voluntary for all program eligible Care1st Health Plan members.
These programs provide the member with the education necessary to better manage their condition. Our Disease Management nurse will work closely with the member and their doctor to help keep them as healthy as possible and avoid unnecessary hospitalizations. The nurse will assist the member in coordinating their care and obtaining all required preventive health screenings.
All Programs are administered by Care1st Health Plan. Care1st automatically identifies members with these medical conditions who meet specific criteria and offers them participation in these programs. The more you learn about these conditions and the medicines used to treat it, the better you will be able to work with your doctor to control it. In order to help you meet these goals, Care1stCARES provides these programs to you.
If you want additional information or would like to discuss Care1stCARES Programs with our Disease Manager, you can call 1-866-991-8222.
The following Care1stCARES Programs are available:
Medi-Cal: Asthma &CHF
Medicare: COPD & CHF
Care1st uses the following guidelines to make sure that you have proper access to care:
When you call the doctor's office with an emergency medical condition they must arrange for you to be seen right away. They may refer you to the Emergency Room or call 911.
When you contact your doctor’s office with an urgent medical condition we require they see you within 24 hours. We strongly urge the doctor to work you in on a walk-in basis the same day. If a situation comes up where the doctor is not available he or she should refer you to a covering doctor or give you directions on where to be seen within 24 hours.
Sensitive Services / Sensitive services must be made available to you preferably within 24 hours but not to go beyond 48 hours of an appointment request. Sensitive services are services related to:
When you request an appointment for a routine, non-urgent condition, you must be given an appointment within 10 business days. A routine visit could be a follow-up for blood pressure, diabetes or asthma.
You do not need a prior authorization to see an OB/GYN doctor.
Care1st suggests you make this appointment within the first 60 days from when you became eligible. Your doctor should ask you to fill out "Staying Health Assessment" form at this appointment.
These same standards are required by doctors "on-call".
Doctors or office staff must return any non-emergency phone calls from you within 24 hours of your call. Urgent and emergency calls must be handled by the doctor or his or her "on-call" coverage immediately. Clinical advice can only be given by qualified staff (e.g.: physician, physician assistant, nurse practitioner or registered nurse).
30 minutes at the most after time of appointment
Care1st audits doctor's offices every three years to make sure they are following the rules of the Americans with Disabilities Act of 1990.
Care1st will arrange for seldom used specialty services from specialists outside the network when determined medically necessary.
If a patient does not show up for a scheduled appointment, it must be written in the medical record on the day of the missed appointment. The doctor's office must contact the patient by mail or phone within 48 hours to re-schedule the appointment. If a patient keeps missing appointments, the doctor can refer this issue to the Health Plan for counselling.
If you contact the specialist’s office with an emergency need they must contact your doctor right away or direct you to the Emergency Room or call 911.
When a doctor refers you for an urgent care need to a specialist (e.g., fracture) they are required to see you within 48 hours or sooner as appropriate from the time the referral was first authorized.
Within 30 Calendar Days.
Doctors are required by contract to give 24 hour, 7 days week coverage to members. Doctors "on-call" require the same standards of access and availability.
Doctor's, or office staff, must return any non-emergency phone calls from you within 24 hours of your call. The doctor or his or her "on-call" coverage must handle urgent and emergent calls immediately. Only qualified staff can give clinical advice (e.g.: physician, physician assistant, nurse practitioner or registered nurse).
30 minutes at the most after time of appointment.
Failed appointments must be written in the medical record the day of the missed appointment and the doctor's office is required to contact you by mail or phone to reschedule you within 48 hours. Repeated failed appointments could result in referring these issues to the health plan for counselling.
You will find a guide on how to choose a doctor in the Care1st Provider Directory. In this directory there is a list of doctors near you. If you do not choose a doctor within 30 days of enrollment one will be chosen for you. You have the right to change your doctor if you wish at any time. If you have any questions or need help contact our Member Services Department at 1-800-544-0088. If you are hard of hearing call the TTY line at 711.
You may have questions that are not answered by our provider directory. You can call our Member Services Department at 1-800-544-0088 (TTY 711) and get information such as:
If you lose your ID card call our Member Services Department at 1-800-544-0088 (TTY 711) to request a new card. If you are having trouble getting care because you lost your card, call the same number and someone will be able to help you.
It is important you always carry your Care1st ID card with you. If you think you have an emergency, call 911 or go to the nearest hospital emergency room. Call your doctor if you need medical care and he or she can help you to arrange care. If your doctor is not available contact our 1-800-544-0088 (TTY 711) and we will help you.
Care1st Health Plan wants to give you the best care and services. Sometimes you may not be satisfied with the services that have been given to you. Care1st wants to help you when you are unhappy or are having problems.
You can contact our Member Services Department at 1-800-544-0088 (TTY 711) with questions or to file a verbal complaint. Care1st also has complaint forms for you to complete if you wish to file a formal complaint in writing. Care1st will send you a written acknowledgement within five (5) days of your filing a complaint. Care1st will also send you a written decision within 30 days. You can also get a formal complaint form at your doctor's office or Click Here to file on-line.
Care1st Health Plan offers free transportation to your doctor's appointments.
This benefit is only for members in the following plans:
For transportation, please call the Care1st Member Services Department at 1-87-RIDEC1ST (1-877-433-2178) (TTY 1-800-735-2929), 8 a.m. to 6 p.m. Monday through Friday.
Our Care1st Member Services Department has staff that speaks several different languages. They will be able to help you in your language when you call. If you need interpreter services for appointments you can call 1-800-544-0088 and arrange for these services. We also offer face to face interpreter services and sign language services upon your request. Hard of hearing members should call the TTY line at 711.
It is very rare that Care1st denies care or services that have been requested. You or your doctor can appeal the denial in writing and Care1st will review the appeal. If Care1st does not change the initial decision, your case will be forwarded to the Independent Review Entity (IRE) to review your case.
For Medical Coverage:
We are required to send your appeal to the "Independent Review Organization". When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.
For Drug Coverage:
If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.
If you have a complaint about quality of care and think that your coverage for your hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation stay is ending too soon, you can file a complaint with the Quality Improvement Organization.
Members in Texas can file a complaint with KEPRO:KEPRO
Care1st Health Plan understands that health care is changing every day. There are new treatments being developed all the time. Care1st Health Plan looks at these new treatments all the time to decide how safe they are. We also look to see if they could help our members.
Care1st has a committee to look at new medicines. We have another committee to look at new treatments. These committees include doctors from all different specialties. It also includes medical directors.
Please click on the following links to get more information on Advance Directives: