Frequently asked questions

What should I do if I do not receive my member ID card?

If you are a new member, it can take up to 3 business days after Sharp Health Plan gets your information from your human resources department to receive your new member ID card.

If you are currently enrolled in benefits with Sharp Health Plan, and recently made a benefit change, made a demographic change (i.e., changed your name or gender), or selected a new primary care physician (PCP), you will automatically be sent a new member ID card. It can take up to 7 business days after making one of these changes to receive your new member ID card in the mail. If you plan includes three or more covered family members, those cards will be mailed separately.

If you lost your member ID card and have requested a replacement, please allow up to 7 business days to receive your new one in the mail. In the meantime, you can print a temporary member ID card through the Sharp Connect member portal.

I received my member ID card in the mail, but other covered family members’ cards were missing. What should I do?

If your plan includes three or more covered family members, those cards will be mailed separately.

What should I do if the name on my member ID card is incorrect?

If you or one of your dependents received a member ID card with the incorrect personal information on it (like your name), you can request a replacement online by logging into your Sharp Connect member portal. From within the portal, you will be able to review your personal information, update your information if necessary, and request a new member ID card.

What should I do if the primary care physician listed on my member ID card is incorrect?

If you receive a member ID card with the wrong primary care physician (PCP) listed on the front, please log into your Sharp Connect member portal to verify the PCP that we have on record for you. Please note that if you are a Sharp Rees-Stealy member, your ID card will not list your PCP’s name, only the location of the Sharp Rees-Stealy Medical Center where they see patients. We know choosing the right PCP is a personal decision, which is why we make it easy for you to change your selection at any time. Please visit calpers.sharphealthplan.com/findadoctor to find a list of doctors. Once you’ve made your selection, you can update your PCP through the member portal. Please note that PCP changes will be effective the first of the following month. Upon making your selection, we will mail you a new member ID card.

What should I do if my primary care physician isn’t listed on member ID card at all?

If you are a Sharp Rees-Stealy member, by default the name of your primary care physician (PCP) will not display on the front of your new member ID card, only Sharp Rees-Stealy and the phone number for your designated location.

What should I do if my new member ID card shows the wrong effective date?

The effective date on your ID card does not affect your ability to access care or fill prescriptions. The effective date listed on the ID card is based on contract updates in the Sharp Health Plan system. If you enrolled in Sharp Health Plan before 1/1/16, your ID card will list that effective date. If you enrolled after 1/1/16, you will have a later effective date.

What should I do if I'm not being prompted to re-register for my Sharp Connect account?

If you are accessing Sharp Connect through a bookmark you created to the portal, you will not be prompted to re-register. To re-register for the new, upgraded Sharp Connect portal, you will have to visit sharphealthplan.com/calpers/login. Please note that you may need to refresh your web browser, or clear your web cache and/or history to display the most up-to-date log-in screen.

When do I need to start using my member ID card?

Your member ID card is your key to accessing care and filling prescriptions. Please carry it with you at all times and present it whenever getting care.

What will my member ID card look like?

The front of your member ID card will include your name, date of birth, account information, primary care physician’s name or affiliated medical group location, medical deductible (if applicable) and certain cost share information. The back of your new card will include important contact information. To see samples of what the new ID cards look like, view or print this CalPERS member ID PDF.

Who do I contact with questions?

If you have additional questions, please contact Customer Care at customer.service@sharp.com. Basic HMO plan members can call us at 1-855-995-5004. Medicare members can call us at 1-833-346-4322. We are available to assist you 7 am – 8 pm, seven days a week.

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, 77KB) here and in the Evidence of Coverage.

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 1-800-678-9133 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 1-800-877-7195.

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 Sharp Connect 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.

What is an EOB?

An explanation of benefits (EOB) is a statement you get from your health insurance company after getting care. It is not a bill. Your EOB breaks down the cost of services you received, showing how much you saved, what your health plan paid, and how much you may owe. If you do owe anything, you will get a bill from your doctor or health care provider(s). We are required to send you an EOB for each month you access care. This information is also available on Sharp Connect.

What does “allowed amount” mean?

Allowed amount is the maximum amount Sharp Health Plan will pay for a covered health care service.

Why does my claim say “amount you saved”?

This shows discounts negotiated by Sharp Health Plan to save you money.

What is a claim?

A claim is a payment request your provider submits to Sharp Health Plan when you receive services you think are covered.

What is a deductible?

A deductible is the amount you pay for covered health care services before Sharp Health Plan starts to pay. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.

What is coinsurance?

Coinsurance is a percentage of costs of a covered health care service you pay (20%, for example). As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.

What is a copay?

A copay is a fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

What does “out-of-pocket maximum” mean?

The out-of-pocket maximum is the most you have to pay for covered services in a health plan year including deductibles, copays and coinsurance. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.

Who is the patient?

A patient is the name of the person for whom services were rendered.

What are the dates of service?

Dates of service show the days you received your medical care.

What is a summary?

The summary highlights your financial information, such as the amount billed, your total benefits approved and the amount you owe.

What is a patient account?

A patient account is the number assigned by the service provider.

What’s a CPT code?

CPT stands for Current Procedural Terminology. It is a medical code used to report medical, surgical and diagnostic services.

What does “amount not covered” mean?

The amount not covered is the portion of the claim not covered by your health insurance.

What’s a remark code?

A remark code relates to the charges not covered amount.

What’s a remark code description?

A remark code description is an additional explanation of the remark code. See the explanation of the remark code above.

What's OTC?

Over-the-counter (OTC) drugs are medicines sold directly to a consumer without a prescription from a health care professional.

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 1-855-995-5004 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 1-855-995-5004 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.

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.

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. Learn more about out-of-town coverage for children.

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.

Which behavioral health services are covered?

Sharp Health Plan provides coverage for the medically necessary diagnosis and treatment of mental illnesses in members of any age. Behavioral health benefits include inpatient hospital services, partial hospital services and outpatient services when ordered and performed by a participating behavioral health professional. To see your plan coverage details, please log in to your Sharp Connect account to view your member handbook and benefits summary.

How do I access behavioral health services?

As a member, you can access behavioral health services without a referral from your primary care physician. You can choose a behavioral health provider from our online provider directory. If you need assistance picking a provider, please contact Customer Care at 1-800-359-2002. We are available to assist you Monday through Friday, 8 am to 6 pm.

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 1-855-995-5004 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 1-855-995-5004 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, 254 KB). 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 1-800-872-1414 and provide reference number 01-AA-SHP-09073.

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 Sharp Connect 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.

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.

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.