CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan) 2021
Emergency Medical Care
If you have a medical emergency, call 911 or go to the nearest emergency room.
- Emergency services are covered anywhere in the United States and its territories.
- You do not need to get approval from HPSM for emergency care.
- You do not need to get a referral from your PCP for emergency care.
- You can see network or non-network providers for emergency care.
- As soon as possible (within 48 hours, if possible), call or have someone call your PCP about your emergency. Your PCP’s phone number is on the front of your CareAdvantage CMC ID card.
What is a medical emergency?
A medical emergency is a medical condition that could result, without immediate medical attention, in any of the following:
- Severe pain or injury posing a danger to health
- Critical dysfunction of any bodily functions, organs or parts
- For a pregnant woman in labor, when transfer to another hospital could endanger the health or safety of the mother or child
The doctors who give you emergency care will decide when your condition is stable and the medical emergency is over. Then they may want you to stay in the hospital a while longer for "post-stabilization services" until you are healthy enough to go home. A CareAdvantage Navigator will talk with the doctors who gave you emergency care to help manage and follow up on your care. If you get emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible.
- It is important that you carry your CareAdvantage ID card at all times so a non-contracted hospital can get approval for your post-stabilization care
- CareAdvantage may not pay for unauthorized post-stabilization care or related transport provided by a non-contracted hospital or provider
- If your doctor says you can be safely moved to a network hospital, we will arrange and pay for your transfer to a CareAdvantage network hospital or nursing facility
What if it wasn't a medical emergency after all?
Sometimes you might go in for emergency care and the doctor will say it wasn’t a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor says it was not an emergency, we will cover your follow-up care only if you go to a network provider or it is considered urgently needed care.
Urgently needed care
Urgently needed care is care you get for a sudden illness, injury or condition that isn't an emergency but needs care right away. For example, you might have a flare-up of an existing condition and need immediate treatment. The preferred way to access urgent care is to contact your PCP, who will tell you where to go. If you cannot contact your PCP in a timely manner, you may go straight to an urgent care center.
Outside of the CareAdvantage Service Area
In most situations, we will cover urgently needed care only if you get this care from a network provider and you follow the other rules described in this section. However, if you can't get to a network provider in a timely manner, we will cover urgently needed care from an out-of-network provider.
If you are outside of the CareAdvantage service area, we will cover urgently needed care you get from any provider.
Getting Care During a Disaster
If the state or federal government declares a state of disaster or emergency in your geographic area, CareAdvantage will cover care from out-of-network providers and prescriptions filled at non-network pharmacies.
Search for a provider
Use the online provider search form to find the latest information for in-network primary care providers (PCP), specialists, pharmacies, clinics or hospitals. This directory is updated weekly. You may need a referral from your PCP before making an appointment with a specialist for non-emergency care. Call your PCP to find out if a referral is required.
CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call the CareAdvantage Unit or read the CareAdvantage Member Handbook.
Benefits and co-pays may change on January 1 of each year.
If you speak other languages other than English, language assistance services, free of charge, are available to you. Call 1-866-880-0606 (TTY: 1-800-735-2929). (Download this statement in multiple languages.)
Page updated December 28, 2020