Medi-Cal

Frequently Asked Questions

Common questions and answers about CalOptima and Medi-Cal.

If you do not see your question answered here, please call CalOptima’s Customer Service department at the numbers below. We are here to help you and make sure you get access to the best health care possible.

1. What is the difference between a Medi-Cal benefits identification card (BIC) and a CalOptima identification card (CalOptima ID)?

The BIC is a card issued by the County of Orange Social Services Agency. It is used to obtain Medi-Cal covered services. The CalOptima ID card is issued by CalOptima Medi-Cal. The CID card helps to identify you as a CalOptima member. It is important to have all health insurance cards with you and present them to your provider when you access health care services.

2. What if your ID card is lost?

If you lose your BIC, call or visit your local County of Orange Social Services Agency. Click here for a list of offices. If you lose your CalOptima ID card, call CalOptima’s Customer Service department at the numbers below.

3. How do you change your primary care provider (PCP)?

You may change your PCP for any reason every 30 days. Your health network's member services department can assist you in changing PCPs. Their number is on your CalOptima ID card.

If the PCP you selected is not affiliated with your current Health Network, you may have to change your Health Network. Your health network will ask that you call us to change your PCP and health network. If you have questions, please call CalOptima’s Customer Service department at the numbers below.

4. How do you change your health network?

You may change your health network every 30 days. Call CalOptima’s Customer Service department to change your health network. You may have to change your PCP if the health network you selected is not affiliated with your current PCP.

5. What is share-of-cost (SOC)?

Share-of-cost (SOC) is a set amount you must pay to providers each month before you are eligible for Medi-Cal benefits through CalOptima. The County of Orange Social Services Agency will tell you if you have a SOC and how much you will have to pay each month.

6. Are you responsible for any co-pays, premiums, or out of pocket expenses?

If you have a SOC (see question above), you will need to pay that amount each month to your provider. There are no other co-payment, premiums or out of pocket expenses if you see and receive Medi-Cal covered benefits through a Medi-Cal provider.

7. What if you need to see a specialist or need special medical services or medical supplies?

Ask your PCP for a referral. Your health network is responsible for authorizing referrals to specialists, for medical services and for medical supplies. The response time for routine prior authorizations is 5 working days and 24 hours for urgent prior authorizations.

8. How do you check on an authorization request submitted by your doctor or specialist?

Your doctor or specialist should let you know when a decision has been made. You can also call CalOptima’s Customer Service department at the numbers below.

9. What if you get a bill for health care services?

If you received your health care from your CalOptima Medi-Cal provider, you should not be balanced billed for any Medi-Cal covered services. Call the provider who billed you. Give the provider your CalOptima Medi-Cal ID and/or other insurance information. If you get another bill or are sent to collections, call CalOptima’s Customer Service department at the numbers below for help.

10. What if you have other health insurance?

Your other health insurance is the primary payer and is responsible for covering the services you received. CalOptima Medi-Cal is the last payer. First, you have to ask your primary insurance for payment for services before CalOptima (Medi-Cal) will pay.

11. What if you need care when your doctor’s office is closed?

After-hours care is when you need medical attention after your doctor's office is closed. If you need after-hours care:

  • Call your doctor or health network. You should be able to speak to a nurse or someone who can give you medical advice within 30 minutes of your call. You may be asked to go to an urgent care center or to the hospital emergency room.
  • Show your CalOptima Medi-Cal ID card when you get after-hours care.
  • Interpreter services are available to you 24 hours a day, 7 days a week at no cost to you.

12. How do you get emergency or urgent care if you are outside of Orange County?

If you are outside of Orange County and have an emergency or need urgent care:

  • Call 911 or go to the nearest hospital emergency room or urgent care center.
  • If you are not sure if it is an emergency or if you need urgent care, call your doctor or health network.
  • Show your CalOptima Medi-Cal ID card when you go to the hospital emergency room or urgent care center.
  • Ask the hospital or urgent care center staff to call CalOptima Customer Service department within 24 hours.

Do not go to the hospital emergency room for general health care services. Call your doctor about general health care services.

13. How do you get mental health services?

Mental health is also called behavioral health. CalOptima covers mild to moderate behavioral health services. However, specialty mental health services is provided by Orange County Health Care Agency Behavioral Health. Community-based organizations are also available. CalOptima members can access benefits by calling CalOptima Behavioral Health at 1-855-877-3885, 24 hours a day, 7 days a week. We have staff who speak your language. TDD/TTY users can call 1-800-735-2929.

14. What medications are covered?

CalOptima has a list of medications that are covered (paid for) by CalOptima. This list is called the Approved Drug List or Drug Formulary. CalOptima pays for medications on this list when they are filled at one of CalOptima’s network pharmacies at no cost to you. CalOptima’s Pharmacy Directory is included in all new member packets, and is available online here.

If your doctor writes a prescription for a medication that is not on CalOptima’s Approved Drug List, your doctor or pharmacy must ask for prior approval. The approval request form is called a Prior Authorization form. All CalOptima network pharmacies have this form. Your pharmacy sends the form to your doctor. Your doctor fills out the form and sends it back to the pharmacy. The pharmacy will submit it to CalOptima.

15. How do you get prescription coverage if you are outside of Orange County?

In California, you can go to any participating chain pharmacy. Prescriptions filled outside of California need prior approval from CalOptima. Chain pharmacies are listed in the CalOptima Pharmacy Directory. If you have questions, call CalOptima’s Customer Service department at the numbers below.

16. How do you get dental care?

Denti-Cal is the Medi-Cal Dental Program under the guidance of the California Department of Health Care Services. Denti-Cal provides dental care for CalOptima members. To contact Denti-Cal, call toll-free at 1-800-322-6384. TDD/TTY users can call toll-free at 1-800-735-2929.

17. How do you get vision services?

Vision care services are provided to eligible CalOptima members through Vision Service Plan (VSP). To find out if you are eligible, please call CalOptima’s Customer Service department at the numbers below.

18. What if your name changed, you moved or have a new phone number?

We need your correct name, address and phone number to contact you about your health care. If it changed you have to call:

  • Orange County Social Services Agency or the Social Security Administration
  • United States Post Office
  • CalOptima’s Customer Service department

19. What if you need to speak to your doctor in your language?

You can speak with your CalOptima health care providers in the language of your choice. Many of our providers and staff speak your language. Our over-the-phone interpreter service is available to you 24 hours a day at no cost.

You can also ask for a face-to-face interpreter for your health care services. You do not have to ask family members or friends to interpret for you. For example, you can ask for an interpreter to be with you at your doctor visit if your doctor or the office staff does not speak your language. You need to ask for an interpreter at least 5 working days before your doctor’s appointment or at the same time you make the appointment.

If you feel your language needs are not being met, you can file a complaint with CalOptima. For help with interpreter services, call CalOptima’s Customer Service department at the numbers below.

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