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Find answers to the most commonly asked questions

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  • General questions
  • Benefits
  • Getting care
About Sharp Health Plan

What is a Plan Medical Group (PMG)

Sharp Health Plan has several medical groups (called Plan Medical Groups or PMGs) from which you choose your primary care physician (PCP) and through which you receive specialty physician care or access to hospitals and other facilities. You receive covered benefits from doctors who are affiliated with your PMG and who are part of the Performance Plan Network. To find out which plan doctors are affiliated with your PMG, refer to the Performance provider directory for your Plan Network or call Customer Care.


What is a Plan Network?

A Plan Network is the group of doctors, medical groups and hospitals that are available to you as a Sharp Health Plan member. CalPERS members have access to the Performance Network. You can select your PCP and Plan Medical Group from that network. You will find the name of your Plan Network on your member ID card.


What is Performance? 

Performance is one of Sharp Health Plan’s Plan Networks. The Performance network includes Sharp Community Medical Group, Sharp Rees-Stealy Medical Group, Arch Health Partners, and Children’s Physicians Medical Group. You will find the name of your Plan Network on your member ID card.


How does Sharp Health Plan protect my privacy? 

We understand the importance of keeping your personal information confidential and work to ensure that all privacy regulations are followed. The Health Insurance Portability and Accountability Act’s (HIPAA) privacy regulations govern the use and release of a member's personal health information, also known as protected health information (PHI). Under the HIPAA privacy regulations, members must be informed about how their PHI will be used and given the opportunity to object to or restrict the use or release of their information. You can find a copy of Sharp Health Plan’s Notice of Privacy Practices (PDF, 27KB) here and in the Evidence of Coverage.


Covered benefits - HMO plan

If hospitalization is necessary, which hospital will I use? 

Sharp Health Plan’s Performance network includes many hospitals throughout San Diego. View the full list of hospitals. Primary Care Providers (PCPs) and specialists work with specific hospitals. If hospitalization is necessary, your doctor will admit you to a hospital that is affiliated with your Plan Medical Group. If you want to make sure that you can use a particular hospital, you should select a medical group that is affiliated with that hospital. Customer Care can advise you about which hospitals are used by our Plan Medical Groups.

To find the hospital closest to you, use our search tool.


How can I access chiropractic services?

Sharp Performance Plus Medicare members have access to chiropractic services. Contact American Specialty Health (ASH) at (800) 678-9133 to find a provider. No referral from Sharp Health Plan or your Primary Care Physician is required.


How can I access vision services? 

Contact Vision Service Plan (VSP) at www.VSP.com to find a provider, or call VSP Member Services at (800) 877-7195.

Simply call your VSP doctor and make an appointment, letting the doctor know that you are a VSP Member. You will also need to provide your name, date of birth and the covered Member’s identification number. (The covered Member is the person whose group provides your vision coverage; CalPERS employee or retiree). Once you make your appointment, your doctor and VSP will handle the rest.

You can also select to receive an eye exam from a non-VSP provider and VSP will reimburse you up to $45. Services obtained through non-VSP providers are subject to the same copayments and limitations as services obtained through VSP doctors. Be aware that your out-of-network provider reimbursement rate does not guarantee full payment, and VSP cannot guarantee patient satisfaction when services are received from a non-VSP provider. You may be required to pay the entire bill when you see the non-VSP provider.


Am I covered for infertility services? 

All Sharp Health Plan members are covered for diagnosis and treatment of infertility. CalPERS members also have coverage for artificial insemination. Ask your primary care physician about referral to an appropriate specialist for infertility diagnosis and treatment. Members pay a copayment equal to 50% of the contracted rate for all infertility and artificial insemination services.


Am I covered for physical therapy, speech therapy or occupational therapy?

All Sharp Health Plan members are covered for outpatient and inpatient rehabilitation services, including occupational, physical and speech therapy. Services must be medically necessary and will be reviewed periodically to determine if continued therapy is needed.

Ask your primary care physician about referral to an appropriate specialist for therapy services. Members pay a copayment for each therapy visit. The copayment amount is listed on the benefits summary available by logging into SharpConnect or by calling Customer Care.


Are breast pumps a covered benefit? 

CalPERS members are covered for a breast pump with no copayment, if requested within 365 days after delivery. (Breast pumps are not covered prior to delivery.) You are not required to have a prescription from your doctor. Contact Customer Care for information on how to order a breast pump. Breast pumps are not covered if purchased from a non-contracted supplier.


Which services are covered under Sharp Health Plan HMO

Sharp Health Plan HMO is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services include doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Check your Benefits to find out which services are covered under your plan.


Where can I get a summary of my benefits?

A summary of benefits is mailed to all new members. The Sharp Connect secure member website will also allow you to view a medical benefits summary and other plan documents online. If you prefer, you can call Customer Care to have a benefits summary sent to you.


How do I get authorization for medical care?

Except for PCP services, emergency services and obstetric and gynecologic services, you must obtain prior authorization from your PCP prior to receiving care, for covered benefits. If authorization is approved, take note of the expiration date for the authorization and arrange to receive care prior to that date.

Sharp Health Plan uses evidence-based guidelines for authorization, modification or denial of services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Sharp Health Plan’s medical director, the Quality Management Committee and appropriate physicians. You can request a copy of Sharp Health Plan’s medical policy for a particular service or condition by contacting Customer Care.


Spouse, partner and dependent coverage

Can my spouse/partner and dependents be covered under Sharp Health Plan? 

Contact your human resources department for more information.


Will my child be covered under my health plan while going to school out of state?

If your dependent child is traveling for less than 90 days in the coming year, or is enrolling in college as a full-time student, he or she may continue on your health insurance policy. In situations where your child is expected to be out of the service area (San Diego County), we want to be sure you know the options for accessing health care services:

  • Urgent care and emergency services are covered the same as when home.
  • Basic care can be accessed through any MinuteClinic®, the walk-in medical clinic inside select CVS/pharmacy® locations. A $40 co-pay will apply in most cases except flu shots which have a co-pay of just $10. Visit cvs.com/minuteclinic/clinic-locator for a list of locations.
  • All other covered benefits are available only in Sharp Health Plan's service area and when approved by your Primary Care Physician (PCP).

It's a good idea for your child to keep his or her PCP informed about any care received while away from home. Medical advice is also available through Sharp Nurse Connection—where our specially trained nurses can provide guidance after hours on weekdays and 24 hours a day on weekends. And, if your child is more than 100 miles away or out of the country and needs assistance seeking emergency medical services, we’ve contracted with Assist America® to help. Visit assistamerica.com for more information; our reference number is 01-AA-SHP-09073.

For college-bound children who will be going to school outside San Diego County, we encourage parents to investigate what the college offers in terms of free or low cost health services. Parents may want to consider purchasing supplemental health insurance to provide coverage for non-emergency or urgent services while their children are away from home.

Keep in mind that dependent children must maintain their primary residence or work within Sharp Health Plan’s service area unless they are full-time students or in cases where coverage is provided under a medical support order. A child’s residence will no longer be considered a primary residence if (a) the child moves out of the service area without intent to return or (b) the child is absent from the residence for more than 90 days in any 12-month period and is not a full-time student.


Can my child’s spouse and children enroll in Sharp Health Plan?

No, your child’s spouse and children are not eligible to enroll in Sharp Health Plan.


Prescription drugs

How do I know which medications are covered under my plan?

As a Sharp Health Plan CalPERS member, OptumRx will provide your pharmacy benefits. You can access all of your pharmacy benefits online by visiting the OptumRx website.


Member ID card

When will I get a member ID card?

ID cards are mailed to members' homes within a week of enrollment. You will receive an ID card for each member of your family who is enrolled in Sharp Health Plan. If you haven’t received your ID card yet, but you have a doctor’s appointment, you can log in to Sharp Connect to print a temporary ID card.

New ID cards are mailed whenever a change occurs that affects the information on the card, such as a new PCP, a name change or a new physician phone number. Be sure to use only your most current ID card, and show any new ID cards at your next office visit.


How can I get a new ID card?

You can get a new ID card by logging on to SharpConnect to order an ID card or to view and print a temporary member ID. If you prefer, you can call Customer Care at (855) 995-5004 to request a new ID card. Your new card will arrive within 7-10 business days.


Medical bills / reimbursement

What if I get a bill? 

As a Sharp Health Plan member, you will not normally receive a bill from a provider. You are responsible only for paying any copayment due at the time of your visit. However, sometimes a bill for covered services may be sent to you in error. If you receive a bill in error, don’t worry. Just call Customer Care toll-free at (855) 995-5004 as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.


How can I request reimbursement for medical expenses that I have paid?

As a Sharp Health Plan member, you will not normally receive a bill from a provider. You are responsible only for paying any copayment due at the time of your visit. However, sometimes a bill for covered services may be sent to you in error. If you receive a bill in error, don’t worry. Just call Customer Care toll-free at (855) 995-5004 as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.


How can I request reimbursement for smoking cessation that I paid for?

If you complete a smoking cessation program you can request reimbursement (PDF, 21KB) from Sharp Health Plan. We will need a copy of the receipt or Certificate of Completion. You will be reimbursed up to $100 for approved services. Call Customer Care if you have any questions about the reimbursement process.


Emergency and urgent care services

Where and when can I access urgent care services?

Sharp Health Plan has urgent care centers throughout San Diego County. Get location information for Sharp Health Plan's urgent care centers or call Customer Care. You must contact your PCP for authorization before going to an urgent care center, unless you are assigned to Sharp Rees-Stealy Medical Group (SRS). SRS members do not need authorization before going to SRS urgent care centers. Check the Plan Medical Group on your member ID card to see if you are assigned to Sharp Rees-Stealy.


What if I have an emergency situation?

Sharp Health Plan members have direct access to emergency room treatment, whether in San Diego or anywhere worldwide. If you are not sure whether your situation is an emergency, call your PCP. They can help decide the best way to get treatment and can arrange for prompt emergency care. Members also have access to Sharp Nurse Connection®, Sharp’s nurse advice line, for medical assistance during evenings and weekends. To contact Nurse Connection, call Customer Care toll-free at (855) 995-5004 and select the appropriate prompt.


How can I receive medical advice outside normal office hours?

Health concerns may arise at any hour of the day. Sharp Nurse Connection® is an after-hours nurse advice line. Nurse Connection puts you in contact with registered nurses who can assess your medical situation, suggest self-care or address your problem until you can see your doctor, and advise you where to seek care. To contact Nurse Connection, call Customer Care toll-free at (855) 995-5004 and select the appropriate prompt.


Am I covered when I am outside Sharp Health Plan’s service area?

You are covered for emergency and urgent care when you are outside Sharp Health Plan’s service area. If you are admitted to a hospital because of an injury or life-threatening medical emergency, you (or someone acting for you) should immediately notify Sharp Health Plan. In other cases, you should contact your PCP within 48 hours after receiving emergency care. Sharp Health Plan members who need help finding emergency or urgent care services out of the service area can contact Assist America® (PDF, 380KB). These services are available if you face a medical emergency while traveling 100 miles or more away from your permanent residence or in a foreign country. For San Diegans that can mean travel to destinations as close as Los Angeles or Mexico. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services. Call Assist America at (800) 872-1414 and provide reference number 01-AA-SHP-09073.


Mental health services

Which mental health services are covered?

Sharp Health Plan provides coverage for the medically necessary diagnosis and treatment of mental illnesses in members of any age. Mental health benefits include inpatient hospital services, partial hospital services and outpatient services when ordered and performed by a participating mental health professional.


How do I access mental health services?

Members have direct access to Sharp Health Plan providers of mental health services without obtaining a PCP referral. Please call Psychiatric Centers at San Diego toll-free at (877) 257-7273 whenever you need mental health services.


Wellness

Are the Sharp Health Plan wellness programs covered under my plan? 

Sharp Health Plan members have access to comprehensive online resources for wellness, including a wellness assessment, personal report, multi-week wellness programs on various health topics, customized exercise and meal plans, food logs, health trackers and much more. Additionally, members have access to a health coaching program and can work one-on-one with a coach to reach personal health goals. See the Best Health wellness program page for more information.


Are my dependents eligible for the wellness programs?

Your enrolled dependents ages 18 and up, are eligible for the online Sharp Health Plan wellness programs. Only CalPERS employees and retirees are eligible for the wellness incentive.


Primary care physician (PCP)

What is a primary care physician (PCP)?

A PCP is your personal doctor who is familiar with your health history and who provides or arranges for quality health care for you. If a specialist is needed, your PCP refers you and keeps in contact with your specialist to ensure continuity of care. Doctors who specialize in family practice, internal medicine, general practice and pediatrics are considered PCPs. Your PCP is listed on your member ID card.


How do I choose a PCP? 

Selecting your PCP is a very important and personal choice. We encourage you to select a PCP who best suits your needs. However, if you are unable to select a PCP at the time you enroll in Sharp Health Plan, we will select one for you so that you can access care immediately. For the most up-to-date information on PCPs, go to our Find a Doctor tool or call Customer Care.


Can I choose a different PCP for different members of my family?

Yes. Each covered family member may choose a different PCP from a different Plan Medical Group. All family members must stay in the Performance Plan Network.


Can I change my PCP?

Yes. In general, it is a good idea to stay with a PCP so that they can get to know your health needs and history. However, with Sharp Health Plan, you may change to a different PCP in the Performance Plan Network whenever you like. If you wish to make a change, you can log in to SharpConnect to use the online Change PCP Form, or you can call Customer Care and we will help you select a new PCP over the telephone. The change will be effective on the first day of the following month.


Specialists

What is a specialist?

A specialist is a doctor who focuses on one area of medicine. A specialist is trained as an expert in his or her particular field, such as cardiology, neurology or urology. When you need specialty care, your PCP will refer you to a specialist to ensure that you receive proper medical attention and follow-up.


Does my PCP make the decision about which specialist I see, or am I able to make that decision?

Your PCP will make recommendations for you to consider. Together, you and your doctor will determine the most appropriate specialist for your particular needs. In some cases, you may be able to see a specialist directly without a referral from your PCP. Women have direct and unlimited access to participating obstetricians and gynecologists within their Plan Medical Group for obstetric and/or gynecological services. In addition, members who choose Sharp Rees-Stealy for their PMG have direct access to specialists in allergy treatment, ophthalmology, otolaryngology (ear, nose and throat) and podiatry. Check the Plan Medical Group on your member ID card to see if you are assigned to Sharp Rees-Stealy. If you have any questions about access to a specialist, call Customer Care.


If you can't find an answer to your question, please send us a message or call Customer Care at (855) 995-5004.
We're here to help.