CalViva Health Benefits Explained

Navigating healthcare benefits can often feel like deciphering a complex puzzle. With so many terms, coverages, and programs, it's easy to feel overwhelmed when trying to understand what your health plan truly offers. If you're a CalViva Health member, or considering becoming one, you've come to the right place. This comprehensive guide will break down the CalViva Health benefits explained in clear, easy-to-understand language, empowering you to make the most of your healthcare coverage.

What is CalViva Health?

CalViva Health is a locally managed public healthcare plan that operates under California's Medi-Cal Managed Care Program. Essentially, it's a health plan designed to provide comprehensive medical services to eligible individuals and families in specific Central Valley counties. CalViva Health is dedicated to improving access to quality healthcare for residents of Fresno, Kings, and Madera counties. As a managed care plan, it works with a network of doctors, specialists, hospitals, and pharmacies to coordinate your care.

Who Qualifies for CalViva Health Benefits?

CalViva Health primarily serves individuals and families who qualify for Medi-Cal. Medi-Cal is California's Medicaid program, providing healthcare coverage for low-income adults and children. You and your child may qualify if you reside in Fresno, Kings, or Madera County and meet the income requirements.

A significant development as of January 1, 2024, is that Medi-Cal now offers full coverage to all eligible Californians, regardless of immigration status. If you're unsure about your eligibility, you can contact CalViva Health directly or reach out to Health Care Options for assistance.

Comprehensive CalViva Health Benefits Explained

CalViva Health aims to provide a wide array of services to ensure its members receive the care they need, often at no cost if you qualify. Here’s a detailed look at the core CalViva Health benefits:

Primary and Specialty Medical Care

Your access to quality medical care is a cornerstone of CalViva Health benefits. This includes:

• Doctor Visits: You can see your primary care physician (PCP) for routine check-ups and general health concerns.
• Specialist Visits: If your PCP determines you need to see a specialist, such as a cardiologist or dermatologist, CalViva Health covers these visits.
• Hospital Care: Coverage for inpatient hospital stays when necessary.
• Urgent and Emergency Care: Both urgent care and emergency services are covered, including out-of-network emergency care.
• Nurse Advice Line: Have a health question in the middle of the night? CalViva Health offers a free, 24/7 Nurse Advice Line where you can speak to a nurse for medical advice and guidance.

Prescription Medications

Understanding your prescription drug coverage is vital. While CalViva Health helps manage your overall care, it's important to note a change regarding prescription drugs:

• Medi-Cal Rx: As of January 1, 2022, most Medi-Cal covered prescriptions are now managed through Medi-Cal Rx, a statewide program, rather than directly by CalViva Health. This means you'll fill your prescriptions at pharmacies that work with Medi-Cal Rx.
• Preferred Drug List (PDL): CalViva Health still maintains a Preferred Drug List (PDL) for drugs it covers, which is updated monthly. This list includes a range of brand and generic prescription drugs, vitamins, supplements, and vaccinations.
• Understanding Drug Restrictions: Some medications may require "prior authorization" (PA) from CalViva Health before they are covered, or "step therapy" (ST), where you might need to try a different medication first. Generally, there are no copays for prescription and over-the-counter (OTC) drugs if you follow the plan's rules.

Mental Health and Behavioral Wellness

Your mental well-being is just as important as your physical health. CalViva Health provides resources to support your behavioral health:

• Access to Providers: CalViva Health works with contracted third-party providers to offer mental health services, including access to therapists, counselors, and psychiatrists.
• Digital Resources: Programs like MyStrength offer personalized digital resources to help improve your mood and manage challenges like anxiety, depression, or substance abuse.
• County Mental Health Services: Depending on your Medi-Cal benefits, you may also be able to access behavioral health services through your county's mental health department.

Vision Care

Keeping your eyes healthy is part of your overall wellness. CalViva Health offers vision care benefits, which typically include:

• Routine Eye Exams: Coverage for regular check-ups to monitor your eye health.
• Eyeglasses: Benefits often include coverage for new eyeglasses. For children and young adults under 21, this typically means one eye exam and one pair of glasses every two years.

Dental Care

A healthy smile contributes to your overall health. CalViva Health plans may include dental coverage, providing access to dentists and dental specialists. Covered dental services can include:

• Oral Exams and Cleanings: Routine check-ups and professional cleanings.
• X-rays: To help diagnose any dental issues.
• Restorations: Services like fillings and crowns may be covered, though crowns might require prior authorization and have limits.
• Emergency Dental Services: Coverage for urgent dental needs.
• Dentures: Some plans may also cover dentures.

It's worth noting that dental procedures not covered by your CalViva Health plan might still be covered under the broader Medi-Cal Dental program.

Specialized Programs for Your Well-being

Beyond the core medical, pharmacy, vision, and dental services, CalViva Health offers additional programs designed to support specific health needs:

• CalViva Health Pregnancy Program: This program provides comprehensive prenatal and postpartum care, along with free educational packets on nutrition, exercise, and newborn care.
• Disease Management Programs: If you live with chronic conditions like asthma or diabetes, CalViva Health offers programs to help you manage your health effectively, including educational materials and nurse consultations.
• Care Connections: This free program provides comfort and support for members facing serious progressive illnesses such as cancer, liver disease, AIDS, or COPD, focusing on pain and symptom management.

Additional Resources and Support

CalViva Health provides several resources to help you understand and navigate your benefits:

• Krames Online: An extensive online patient education resource with over 4,000 topics related to health and medication, available 24/7.
• Member Services: Friendly and helpful customer service is available 24 hours a day, 7 days a week, to answer your questions and provide information in your preferred language.
• Transportation Benefit: Some plans, particularly dual-eligible plans that combine Medicare and Medi-Cal (like Wellcare CalViva Health Dual Align), may offer a medical transportation benefit to help you get to appointments.

Maximizing Your CalViva Health Benefits

To ensure you get the most out of your CalViva Health coverage, consider these actionable tips:

1. Understand Your Eligibility: Regularly confirm your Medi-Cal eligibility with your local county office, especially if your address or income changes.
2. Carry Your ID Cards: Always have your CalViva Health ID card and your Medi-Cal Benefits Identification Card (BIC) with you when seeking services or prescriptions.
3. Choose a Primary Care Provider (PCP): Your PCP is your main point of contact for most healthcare needs and can refer you to specialists when necessary. You can change your PCP monthly if needed.
4. Utilize the Nurse Advice Line: For non-emergency health questions, the 24/7 Nurse Advice Line can provide immediate guidance and help you decide if you need to see a doctor.
5. Explore Special Programs: If you have a chronic condition or are pregnant, inquire about the specific disease management or pregnancy programs available to you.
6. Review Your Preferred Drug List (PDL): Familiarize yourself with the CalViva Health PDL and understand any prior authorization or step therapy requirements for your medications. Remember, most prescriptions are now handled by Medi-Cal Rx.
7. Ask Questions: Don't hesitate to call CalViva Health Member Services at 1-888-893-1569 (TTY 711) if you have any questions about your benefits or need assistance.

Conclusion

Understanding your healthcare benefits is a crucial step towards maintaining your health and well-being. CalViva Health offers comprehensive benefits designed to provide quality, affordable healthcare to eligible residents in Fresno, Kings, and Madera counties, covering everything from routine doctor visits and prescription medications to mental health support, vision, and dental care. By familiarizing yourself with the CalViva Health benefits explained in this guide, you can confidently navigate your healthcare journey and access the services you need.

Don't let healthcare confusion stand in your way. Take charge of your health today by exploring your CalViva Health benefits further. If you have specific questions about your coverage or need assistance finding a provider, reach out to CalViva Health Member Services.

Frequently Asked Questions (FAQ)

Q1: What counties does CalViva Health serve?

CalViva Health serves Medi-Cal beneficiaries in Fresno, Kings, and Madera counties.

Q2: Do I have to pay for services with CalViva Health?

If you qualify for Medi-Cal, most healthcare services received through CalViva Health are provided at no cost, meaning no copays for covered services.

Q3: How do I find a doctor or specialist who accepts CalViva Health?

CalViva Health has a network of over 1,600 caring providers, including doctors, specialists, hospitals, and pharmacies. You can contact CalViva Health Member Services for assistance in finding an in-network provider.

Q4: Does CalViva Health cover prescription drugs?

While most Medi-Cal covered prescriptions are now handled through Medi-Cal Rx (as of January 1, 2022), CalViva Health still has a Preferred Drug List (PDL) for drugs it covers. It's always best to check the current PDL and understand any requirements like prior authorization or step therapy.