Health Plan Basics
Primary Care Physician (PCP)
PCPs can be practitioners of Family, Internal or General Medicine, Pediatricians and in some cases, Obstetricians and Gynecologists. At the time of enrollment, you are required to select a PCP from one of the medical groups in your provider network. Your provider network and medical group are shown on your member ID card. Your PCP is responsible for coordinating all of your medical care. It is extremely important to get established with your doctor as soon as your coverage becomes effective.
Here are a few questions that may be useful to consider when selecting a new PCP:
- What's the most convenient location for your PCP's office--near work or near home?
- Would you prefer a male or female PCP?
- Would you like to see your PCP in a private office or in a setting that offers multiple services under one roof?
- Do you prefer to speak to your PCP in another language or have specific cultural needs?
- Referrals are a great way to find the right PCP. Can your friends or colleagues recommend a doctor?
To obtain covered services, you must see a contracted provider. Our online provider directory at mywha.org/directory is a great tool to get the most up-to-date information about participating PCPs and specialists in your network. You can also search for a provider by name, provider type, location of the practice(s), medical group affiliation or languages spoken. Printed directories are available upon request.
You can change your PCP online by logging into your MyWHA account or by calling Member Services. Your PCP effective date is the first day of the month following your request. You must wait until the effective date before seeking care from your new PCP or the services may not be covered. Upon requesting a change of PCP, WHA will issue you a new ID card confirming your new PCP’s name within 10 to 12 business days. Prior to receiving your card, you can access your ID card from your MyWHA account or from WHA’s MyWHA mobile app.
Health Maintenance Organizations (HMOs) in California must meet timelines for providing care and services to members seeking treatment. The Timely Access Regulations set specific standards for patients to obtain a medical appointment in certain situations.
Visit Timely Access To Care to learn more.
ID cards are mailed to members’ homes no later than two weeks before their effective date. New ID cards are also mailed whenever a change occurs that affects the information on the card, such as a new PCP, a name change or a new medical plan. As a member, you can also access and print your ID card at mywha.org or from WHA’s MyWHA mobile app. A copy of your enrollment form or electronic enrollment confirmation can also be used as temporary proof of coverage.
Access your Western Health Advantage info straight from your smartphone. Quickly find out how to reach your primary care physician (PCP) and get a map to his or her office. Look up details about your plan, such as your copayment or your pharmacy plan. It’s a handy reference, too, for contacting the WHA Member Services Department and the 24-hour nurse advice line. Also keeps an electronic copy of IDs for you and your family. Learn more at mywha.org/digitalresources.
Certain covered services require Prior Authorization from your PCP's affiliated medical group or from WHA in some cases. If Prior Authorization is not obtained, you may be liable for the payment of services or supplies. WHA and your medical group use qualified physicians and nurses to review service requests to confirm medical necessity and appropriateness. You do not need Prior Authorization for Direct Access services, which include annual eye exams and routine gynecological and obstetrical care from participating providers.
Prior Authorization is required for:
- Services from non-Participating Providers except in Urgent Care or Emergency situations
- Behavioral health services except in Urgent Care or Emergency situations
WHA provides routine and complex Case Management (CM) services available for members who qualify for them—generally, those with conditions that require a high level of coordination of care among multiple specialists and other health care providers—at no additional cost. To learn more about our CM services or to determine if you qualify, contact WHA Member Services.
Additionally, Disease Management (DM) programs are available to members to assist with identifying strategies to optimize their health and reach personal health goals for certain members living with chronic conditions. To learn if you qualify for these no-cost DM programs, visit mywha.org/dm or contact WHA Member Services.
WHA has partnered with Optum to provide our members with innovative ways to lead healthy lifestyles.
Through our MyWHA Wellness webpage, you have access to the Optum Health Portal 24/7 interactive decision aide tool that will guide you through making important health decisions. This tool guides you through important health decisions that combines medical information along with your personal values that help you to make informed decisions about medical tests, medicines, surgeries, and other treatments options. Learn more at mywha.org/healthsupport.
A member may request a second medical opinion regarding any diagnosis and/or any prescribed medical procedure. Members may choose any WHA Participating Provider of the appropriate specialty to render the opinion. All opinions performed by non-Participating Providers require Prior Authorization from WHA or its delegated medical group. All requests for second medical opinions should be directed to the member's PCP.
Typically, out-of-network services are not covered unless in an urgent or emergency situation. However, if you are a new member currently undergoing acute treatment with a non-participating provider, you may qualify for Continuity of Care (CoC). For more information or to obtain a Continuity of Care Request Form, contact WHA Member Services. You may also access the CoC Form online
In certain circumstances, members may temporarily continue care with a non-participating provider. If you are being treated by a provider who has been terminated from WHA's network, or if you are a newly enrolled member who has been receiving care from a provider not in WHA's network, you may continue care with that provider if you meet the Continuity of Care (COC) criteria explained below:
- An acute condition: a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.
- A serious chronic condition: a serious chronic condition is a medical condition due to disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure, worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Covered services will be provided for the period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by WHA in consultation with the member and the terminated provider or Non-Participating Provider, consistent with good professional practice. Completion of covered services under this paragraph shall not exceed twelve (12) months from the contract termination date or twelve (12) months from the effective date of coverage for a newly enrolled member.
- A pregnancy. Care will be continued for the duration of the pregnancy and the immediate postpartum period.
- A terminal illness: an incurable or irreversible condition that has a high probability of causing death within one year. Care shall be continued for the duration of the terminal illness.
- Care of a newborn child whose age is between birth and thirty-six (36) months. Care shall be continued for up to twelve (12) months.
- Performance of surgery or other procedure that has been authorized by WHA (or its contracted medical group) as part of a documented course of treatment that is to occur within one hundred eighty (180) days.
If you are a newly enrolled member and you had the opportunity to enroll in a health plan with an out-of-network option, or had the option to continue with your previous health plan or provider, but instead voluntarily chose to change health plans, you are not eligible for Continuity of Care. Please contact Member Services prior to enrollment and no later than thirty (30) days from the effective date of your WHA coverage, or from the date your provider terminated with WHA to request a print copy of the COC form. You may also download an electronic copy of the COC form.
WHA will assist members with transition to other care when benefits end or during transition from pediatric care to adult care.
Transitioning Care When Benefits End
If your benefits are exhausted while you still need care and you are in a case management (CM) or disease management (DM) program, the CM or DM staff can discuss alternatives for continuing care and how to obtain care. If you’re not receiving these health care services, ask to speak to a WHA clinical resource representative who will be happy to assist you. Other alternatives such as Cobra coverage, Conversion/Individual plan, Medi-Cal, ACA Exchange coverage or community resources can be explored to meet your individual needs.
Transitioning from Pediatric to Adult Care
Generally, pediatric patients begin transition of care from a Pediatrician to a Family Practice, Internal Medicine or OB GYN Physician between the ages of 19 to 26 years. However, there are chronic conditions that may warrant a patient to continue their relationship and health care services within the pediatric setting.
WHA encourages members and their families to discuss this important transition with their individual physicians, as this decision should be based on each individual’s health care needs.
A WHA clinical resource representative is available to help should you need assistance in transitioning your health care services or have any questions. For more information, call member services and ask to speak with a Clinical Resource Nurse.
WHA encourages its practitioners to practice open physician-patient communication and to freely discuss available treatment options, including medication treatment options, with their patients regardless of the patient's benefit coverage limitations. Practitioners shall not be penalized for discussing medically necessary or appropriate care and the available options with their patients.
WHA's physician reviewers make coverage decisions related to appropriateness of care and services using available medical information about the patient and criteria that are based on recognized standards of medical practice. During these reviews, health plan benefits and individual circumstances of the patient are also considered.
Financial incentives or compensation are not linked to these decisions or to the withholding of care. If you would like to learn more about WHA's utilization management processes or receive information about the criteria or guidelines used by WHA to make care and treatment decisions, please contact WHA's member services department.
Utilization Management Criteria
Criteria primarily used by WHA’s physician reviewers to make medical necessity decisions at the health plan level include the following sources:
- MCG® (formerly Milliman Care Guidelines) – Acute, Ambulatory & Chronic Care guidelines
- UpToDate® – Evidence-based physician authored clinical decision support resource
- Hayes New Technology Assessment guidelines – Experimental guidelines
- Optum Complete Guide to Medicare Coverage Issues
Most criteria and guidelines are protected by copyright, however if a service is denied for medical necessity reasons, you will receive written rationale with excerpts or references to the criteria that was used to make the decision. You will also be provided with information on how to submit an appeal or a request for re-review of your case by another physician if you do not agree. To obtain more information about the utilization management or appeal processes, decision criteria or pharmaceutical management procedures, please contact Member Services and ask for the Medical Management department.
While your PCP will treat most of your health care needs, if your PCP determines that you require specialty care, your PCP will refer you to an appropriate provider. You may have options in specialty care outside of your PCP’s medical group. Learn more at mywha.org/referral.
If you or another covered family member has a serious, complicated medical condition requiring multiple specialists and treatments, you may qualify for our Case Management program. If you qualify, a nurse will personally assist you to obtain the necessary pre-approvals and services you need, as well as provide health plan and community resource information to help you effectively manage your situation.
If you or a family member is experiencing a catastrophic health situation and you think you might benefit from CM assistance, please discuss your concerns with your PCP and ask him or her to make a referral on your behalf. Visit Case Management to learn more.
Urgent and Emergency Care
WHA covers you for Urgent Care and Emergency Care services wherever you are in the world. Please note that emergency room visits are not covered for non-Emergency situations.
If an Urgent Care situation arises while you are in WHA's Service Area, call your PCP. You can call your doctor at any time of the day, including evenings and weekends. Explain your condition to your PCP or the physician on call and he/she will direct your care. In the event you are not able to reach your PCP, you should go to an Urgent Care facility affiliated with your medical group.
If an Emergency situation arises whether you are in WHA's Service Area or outside of the Service Area, call "911" immediately or go directly to the nearest hospital emergency room. If you are hospitalized at a non-participating facility because of an emergency, WHA must be notified within twenty-four (24) hours or as soon as possible. If you are unable to make the call, have someone else make it for you, such as a family member, friend, or hospital staff member.
Follow-up care after an emergency room visit is not considered an Emergency situation. If you receive Emergency treatment from an emergency room physician or non-participating provider and you return for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost of the service. Contact your PCP for all follow-up care.
Visit Urgent and After-Hours Care to learn more.
WHA covers urgent care and emergency care services wherever you are in the world. If you are hospitalized at a non-participating facility because of an emergency, WHA or your PCP must be notified within 24 hours of the emergency or as soon as possible. Please note that emergency room visits are not covered for non-emergency situations. Also, call your PCP for all follow-up care to your emergency treatment. If you return to the emergency room or a non-participating provider for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost of the service. If your emergency health problem requires a specialist, your PCP will refer you to an appropriate participating provider as needed.
As a member, you and/or your dependents must live or work within the WHA service area zip code. For WHA’s service area map, visit mywha.org/servicearea. If a member or dependent no longer lives in the WHA Service Area, they will no longer be eligible for coverage through WHA. It is important to understand that you must choose a PCP from the WHA network and that you are required to receive all routine and preventive services there. This includes care you may require for routine illnesses such as colds, flu, headaches, minor sprains and other illnesses and injuries that are not classified as urgent or emergency care.
Note: For members with a group plan, please refer to your Evidence of Coverage/Disclosure Form (EOC/DF) and Copayment Summary(ies) for a detailed description of coverage benefits and limitations.
If your dependent child lives outside of our service area, he or she is eligible for in-network coverage only if a full-time student. Note: Those students who reside outside the service area must obtain all routine, preventive and follow-up care from WHA network providers. When outside the service area, these students are covered only for urgent or emergency care.
WHA and our providers support your right to obtain accessible health care. If you have needs with regard to your culture, language, or a disability, please contact your physician’s office first or call WHA’s Member Services.
If you need assistance in a language other than English, WHA offers interpretation services in many languages, including Spanish and American Sign Language, free of charge. Let your physician’s office know when you call for an appointment if you would like this assistance. The deaf and hard of hearing may use WHA’s TTY line at 888.877.5378.
Spanish language versions of all vital and critical plan documents are available to our membership on our website or through WHA Member Services. Translated documents in languages other than Spanish, in large print, in braille, and other formats may be requested through your doctor’s office or WHA’s Member Services Department.