Get To Know Your Health Plan

Get To Know Your Health Plan

Care1st Health Plan Takes Quality a Step Further

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:

  • Studies to ensure that appointments are available
  • Studies to ensure that after-hour services are available
  • Studies to measure how long patients wait in the office for an appointment
  • Facility site reviews - This includes looking at easy access to the facility for disabled people
  • Making sure that the network of doctors in your area fits your needs
  • Patient satisfaction surveys
  • Doctor satisfaction surveys
  • Quality of care studies to assure appropriate:
    • Colon and rectal cancer screening
    • Bone density screening
    • Breast cancer screening
    • Diabetes care
    • Glaucoma screening
    • High blood pressure care
    • Cholesterol management
    • Management of Chronic Lung Disease
    • Transitions of Care

Affirmative Statement:

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 Programs to Help You Manage Your Health Care

Care1st Programs

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.

Benefits to the Member

  • Regular Nurse Calls - telephone contact from our disease managers to review the member's health status and provide support and education.
  • Telephone Support - toll-free number available for our members to speak with our Disease Manager about their condition and answer any questions they may have.
  • Reminders - to obtain preventive health screenings, exams and tests as needed.
  • Educational Mailings - to help understand the member’s chronic condition.
  • Peak Flow Meter - (for Asthma only) ages >5 to help better manage and monitor the member's condition.

Benefits to the Physician

  • Member Compliance - with physician treatment plan
  • Detailed Reports - informing physician of member's status changes, or concerns that may require physician intervention
  • Comprehensive Member Medication Profile
  • Care Coordination - with PCP and Specialists.

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 Health Plan Assures Your Rights

You have the right to know:

  • Know your rights and responsibilities
  • Know about our services, doctors, and specialists
  • Be informed when your doctor is no longer contracted with Care1st Health Plan
  • Know about all our other caregivers
  • Be able to see your medical records and follow the State and Federal laws that apply
  • Have an honest talk with your doctor about all treatment choices for your condition, regardless of cost or benefit coverage

You have the right to be treated well:

  • Always be treated with respect and recognition of your dignity
  • Have your privacy kept safe by everyone in our health plan
  • Know that we keep all your information private

You have the right to be in charge of your health care:

  • Choose your primary care doctor
  • Say no to care from your primary care doctor or other caregivers
  • Be able to make choices about your health care
  • Make a living will. This is also called an advance directive
  • Voice complaints or appeals about Care1st or the care it offers
  • File a grievance if you do not receive services in the language you request

You have the right to receive the following range of services:

  • Family planning services
  • Preventive health care services
  • Minor consent services
  • Treatment for sexually transmitted diseases (STDs)
  • Emergency care outside of our network
  • Health care from a Federally Qualified Health Center (FQHC)
  • Health care at an Indian Health Center
  • A second opinion
  • Interpreter services at no cost. This includes services for the hearing-impaired
  • Informing information materials in other formats. For example, you can request large size print upon request

You have the right to suggest changes to our health plan

  • Tell us what you do not like about our health plan
  • Tell us what you do not like about the health care you get
  • Ask questions about our decisions about your health care
  • Tell us what you do not like about our rights and responsibilities policy
  • Ask the Department of Social Services for a Fair Hearing
  • Ask the Department of Managed Health Care for an Independent Medical Review
  • Choose to leave our health plan

You Have Important Responsibilities for Your Healthcare

We hope you will work with your doctors as partners in your health care. Please see the following:

  • Make an appointment with your doctor for an exam within 120 days of becoming a new member. This exam is called an initial health assessment
  • Tell your doctor what he or she needs to know to treat you
  • Learn as much as you can about your health
  • Follow the treatment plans you and your doctors agree to
  • Follow what the doctor tells you to do to take good care of yourself
  • Do the things that keep you from getting sick
  • Bring your ID card with you when you visit your doctor
  • Treat your doctors and other caregivers with respect
  • Use the emergency room for emergencies only. Your doctor will give you most of the medical care that you need
  • Report health care fraud

We want you to understand your health plan

  • Know and follow the rules of your health plan
  • Know that laws guide our health plan and the services you get
  • Know that we can not treat you different because of, age, sex, race, national origin, culture, language needs, sexual orientation and/or health

Having Access to Care is a Priority

Care1st uses the following guidelines to make sure that you have proper access to care:

Criteria / Standard

Emergency Exam / Immediately

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.

Urgent Doctor's Exam / Within 24 hours

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:

  • Sexual Assault
  • Drug or alcohol abuse
  • Pregnancy
  • Family Planning
  • Sexually Transmitted Diseases
  • Outpatient mental health treatment and counseling

Routine Doctor's, Non-urgent Exam / Within 10 business Days

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.

Initial Prenatal Visit to OB/GYN Doctor / Within 7 Calendar Days

You do not need a prior authorization to see an OB/GYN doctor.

Preventive Care and Physical Exam / Within 30 Calendar Days

Initial Health Assessments / Within 30 calendar days upon request

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.

After-hours Care / Doctors are required by contract to give 24 hour, 7 days week coverage to their patients.

These same standards are required by doctors "on-call".

Telephone Access

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).

Waiting Time in Office

30 minutes at the most after time of appointment

Access for Disabled Members

Care1st audits doctor's offices every three years to make sure they are following the rules of the Americans with Disabilities Act of 1990.

Seldom Used Specialty Services

Care1st will arrange for seldom used specialty services from specialists outside the network when determined medically necessary.

Failed Appointments (Patient does not show for a scheduled appointment)

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.

Care1st Evaluates Specialist Access to Care Standards

Emergency Care / Immediately

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.

Urgent Specialist Exam / Within 48 hours

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.

Routine Specialist Visit, Non-urgent Exam

Within 30 Calendar Days.

After-hours Care

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.

Telephone Access

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).

Waiting Time in Office

30 minutes at the most after time of appointment.

Failed Appointments (Patient fails to show for a scheduled 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.

Care1st Answers Frequently Asked Questions

How do I choose a doctor?

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.

How do I get more information about my doctor?

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:

  • Doctors office hours
  • Languages the doctor or staff speak
  • Is the doctor a man or a woman
  • How long have they been practicing
  • Medical training history

What do I do if I lose my ID Card?

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.

How do I get care after hours?

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.

How do I file a Complaint?

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.

How can I get transportation* to my appointments?

Care1st Health Plan offers free transportation to your doctor's appointments.
This benefit is only for members in the following plans:

  • Care1st AdvantageOptimum Plan (HMO)
  • Coordinated Choice Plan (HMO)
  • Care1st TotalDual Plan (HMO SNP)

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.

*The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply.

How can I get interpreter services?

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.

What if I have Medical Services Denied?

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.

What if I have a complaint about the quality of care I receive or think I my coverage for a hospital, home health agency, skilled nursing or comprehensive outpatient rehabilitation facility is ending too soon?

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:

(Quality Improvement Organization for Medicare)
Contact Information:
Call: 1-844-430-9504
TTY: 1-844-834-7129

5700 Lombardo Center Dr., Suite 100
Seven Hills, OH 44131

Website: www.keproqio.com

Please visit the Appeals section of the website for more information.
Details are also included in Chapter 9 of your Evidence of Coverage.

Care1st Assess New Medical Technology

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.

The committee:

  • looks at new medicines and treatments
  • keeps patient safety as the number one goal
  • looks to see if the government has approved the new treatment
  • looks to see if there are good studies that show a real benefit
  • looks to see if the treatment helps as much or more than treatments already approved
  • looks to see if the new treatment helps the overall health of the patient

Advance Directives Right Notification

  1. At enrollment, you have the right to accept or refuse treatment and to complete an advance directive and we will assist you on how to complete the advance directive
  2. You have the right to file a complaint with the state survey and certification agency

Please click on the following links to get more information on Advance Directives: