Definitions

 

Administrative Member
Alliance Care In-Home Supportive Services (IHSS)
Alliance Identification Card
Auto Assignment
Benefits Identification Card (BIC)
Benefits or Covered Service(s)
California Children Services (CCS)
Central California Alliance for Health (the Alliance)
Clinic
Complaint or Grievance
Durable Medical Equipment
Emergency Care
Formulary
Healthy Kids Health Plan
Medically Necessary
Medicare
Medi-Cal

Medi-Cal Access Program (MCAP)
Medi-Cal Eligibility Worker
Member
Member Services Representative
Mental Health Benefits
Participating Provider
Primary Care Provider (PCP)
Prior Authorization
Provider Directory
Referral
Referral Authorization Form (RAF)
Referral Provider
Sensitive Services
Service Area
Share of Cost (SOC)
Treatment Authorization Request (TAR)
Urgent Care




Administrative Member

There are some Alliance Medi-Cal members who will not be assigned to a specific doctor or clinic. These members are called administrative members and they can be seen by any willing Medi-Cal provider.

 


Alliance Care In-Home Supportive Services (IHSS)

Alliance Care In-Home Supportive Services (IHSS) is a health plan for eligible Monterey County IHSS providers.

 


Alliance Identification Card

This is the card sent to you by the health plan. Always carry and show this card any time you get medical care or get medication. You should also show any other insurance cards you have for example, Medicare, Medi-Cal or insurance you have through a job. Your Alliance ID card will have the name, address and phone number of your doctor on it

 

Auto Assignment

When we assign you to a doctor or clinic because you did not choose one.

 

Benefits Identification Card (BIC)

This is the blue and white plastic Medi-Cal card that you get from the State. Providers use this card to check if you are eligible for Medi-Cal. You should keep this card even if you temporarily lose your Medi-Cal.


 

Benefits or Covered Service(s)

These are the medical services you are covered for under the Alliance.


 

California Children Services (CCS)

If your child has a chronic or life threatening illness, he or she may be eligible for the California Children’s Services (CCS) program. CCS is a state program for children. CCS only pays for the chronic illness. The Alliance will still pay for the medical care that is not related to your child’s CCS condition.


 

Central California Alliance for Health (the Alliance)

Central California Alliance for Health is your health plan.


 

Clinic

A place where doctors, nurses and other health providers work as a team to provide health care.


 

Complaint or Grievance

A complaint is when you are unhappy with services you get from a provider or from your health plan. The grievance system is how the Alliance will handle your complaint.


 

Durable Medical Equipment

Medical equipment for use in the home because of an illness or injury, such as a
wheelchair or walker.


 

Emergency Care

When you think you will die or have serious damage to your body if you don’t get immediate medical care. You are covered for emergency services both in and outside of the Alliance’s service area.


 

Formulary

The list of drugs that have been approved by the Alliance to be covered.


 

Healthy Kids Health Plan

A low-cost, health, dental and vision plan for Santa Cruz County children that ended operations on June 30, 2016.


 

Medically Necessary

Services that are safe and effective. They must also be used in a way that other providers in this area would use them to treat an illness, injury or medical condition. You are not covered for services that are only for the convenience of a member or a provider.


 

Medicare

Insurance provided by the Social Security Administration for people who are 65 years or older. You may also get Medicare if you have been disabled for over two years and were employed.


 

Medi-Cal

A federal and state program that pays for medical services if you have a low income or are disabled. The Alliance is the health plan for people in Monterey, Santa Cruz and Merced counties who have Medi-Cal.

 

Medi-Cal Access Program - MCAP

The Medi-Cal Access Program (MCAP) Program is a state-wide program that provides low-cost health coverage to pregnant women with incomes at or below 300% of the federal poverty level. Once enrolled, women receive care through the Medi-Cal program. The Alliance stopped receiving new MCAP enrollees after September 30, 2016. Claims, provider disputes and member complaints will continue to be processed under regulatory timeframes.


 

Medi-Cal Eligibility Worker

The person at the County Social Services office who decides if you qualify for Medi-Cal or not. He or she will look at your family size and income.


 

Member

A person eligible for coverage through the Alliance.


 

Member Services Representative

A person who works at the Alliance to help members who have questions about the health plan. They help members solve problems with their health plan coverage.

 

Mental Health Benefits

Services provided for the diagnosis and treatment of mental illness or an emotional disorder. Services can include counseling, therapy and medication.

 

Participating Provider

A doctor, clinic, pharmacy or other medical provider who has a contract with the Alliance. In most cases, the Alliance will only pay for services from a participating provider. Check your Provider Directory or call Member Services to see if your provider is a participating provider.


 

Primary Care Provider (PCP)

The doctor or clinic that manages all your health care. Most Alliance members are assigned to a PCP. This is the doctor you should call or see first when you need medical care. See your Provider Directory for a list of Primary Care Providers.


 

Prior Authorization

There are some services, medicines and medical equipment that have to be approved by the Alliance before you get them. This is called prior authorization. It means getting an ok from the health plan in advance. Your provider and the Alliance have to agree that the services you are going to get are medically necessary. Many benefits are paid for only with prior authorization. If you don’t get this authorization, we will not pay for that service.


 

Provider Directory

A list of health care providers who you can see as a member of the Central California Alliance for Health.


 

Referral

When your PCP sends you to another provider for services, or sends you for certain tests. Administrative members do not need referrals.


 

Referral Authorization Form (RAF)

The form that your PCP fills out if he or she is sending you to another doctor or to get certain tests.


 

Referral Provider

A doctor or a specialist to whom your PCP refers you.


 

Sensitive Services

Confidential services that include: pregnancy testing, AIDS/HIV testing, abortion, sexually transmitted disease testing and treatment, and sexual assault services.


 

Service Area

The geographic area served by the health plan. The Alliance’s service area is Santa Cruz, Monterey and Merced counties.


 

Share of Cost (SOC)

This is the amount some members may be required to pay each month to providers for their medical care. The amount depends on a member’s income. Your Medi-Cal eligibility worker at the Department of Social Services will make this decision. When a member meets his or her Share of Cost, they become eligible for the health plan and are considered administrative members.


 

Treatment Authorization Request (TAR)

This is the form used if the service, medicine or equipment needs to be approved by the Alliance. The provider that will be giving you the service, medicine or equipment will fill out a form and send it to the Alliance. The form is called a Treatment Authorization Request, or TAR for short. Your provider should know when a TAR is required. Some services that require a TAR are hospital stays that are not for an emergency, nursing home care, physical, occupational and speech therapy, certain tests like MRIs, some medicines (brand name drugs and medicines that are not on the list of drugs approved by the Alliance)


 

Urgent Care

Services that you get that are not an emergency, but when you think you need care quickly to prevent serious illness or injury.


 

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