Frequently asked questions

What is monkeypox?

Monkeypox is a viral infection caused by the monkeypox virus, which is in the same family of viruses that causes smallpox. It’s less contagious than smallpox and usually spreads through close, personal contact. Generally, it does not cause severe illness, and most monkeypox cases resolve on their own. That said, a small number of reported cases have resulted in severe illness and death.

Due to the high number of cases, the World Health Organization has declared the current monkeypox outbreak a global health emergency. And the Centers for Disease Control and Prevention (CDC) has confirmed cases of monkeypox in most parts of the U.S., including San Diego. For more information, please visit the CDC’s website.

How is monkeypox spread?

Monkeypox usually spreads through direct skin-to-skin contact with someone who has a monkeypox rash. It can also be spread by sharing surfaces, clothing, or bedding with an infected person along with blood and/or bodily fluids. Monkeypox can spread from the time symptoms start until the rash has healed, all scabs have fallen off, and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.

What are the symptoms of monkeypox?

According to the CDC, symptoms of monkeypox can include:

• Fever
• Headache
• Muscle aches and backache
• Swollen lymph nodes
• Chills
• Exhaustion
• Respiratory symptoms (e.g. sore throat, nasal congestion or cough)
• A rash that may be located on or near the genitals or anus but could also be on other areas like the hands, feet, chest, face or mouth. The rash will go through several stages, including scabs, before healing. The rash can look like pimples or blisters and may be painful or itchy.

Monkeypox symptoms usually start within 3 weeks of exposure to the virus. If someone has flu-like symptoms, they will usually develop a rash 1-4 days later.

Is there a monkeypox vaccine?

Yes. The County of San Diego is currently prioritizing vaccination for individuals 18 or older who:

• Have been identified as intimate with or otherwise close contacts of a person diagnosed with monkeypox.
• Have been intimate or otherwise had skin-to-skin contact with a person who has a monkeypox-like rash.
• Have attended an event where a diagnosed case has been reported.
• Are part of a community in which monkeypox infections have been reported. At this time, this includes members of the LGBTQ+ community, including gay, bisexual and other men who have sex with men and have had more than one sex partner in the last month.

For more information on the monkeypox vaccine, visit Sharp HealthCare’s website.

How do I protect myself against monkeypox?

Along with vaccination — recommended for people who have been in close contact with individuals who have monkeypox or who had multiple sexual partners in the past 14 days in an area with known monkeypox cases — the CDC recommends you:

• Avoid close, skin-to-skin contact with people who have a rash that looks like monkeypox.
• Do not touch the rash or scabs of a person with monkeypox.
• Do not kiss, hug, cuddle or have sex with someone with monkeypox.
• Do not share eating utensils or cups with a person with monkeypox.
• Do not handle or touch the bedding, towels or clothing of a person with monkeypox.
• Wash your hands often with soap and water or use an alcohol-based hand sanitizer.

What should I do if I think I may have monkeypox?

If you think you may have monkeypox contact your primary care physician and follow the CDC's isolation guidelines:

• Do not share items that have been worn, used or handled with other people or animals.
• Wash and disinfect items that have been worn or handled and surfaces that have been touched.
• Avoid close physical contact with other people.
• Avoid crowds and congregate settings, such as residential facilities, dormitories and prisons.
• Wash your hands often with soap and water or use an alcohol-based hand sanitizer, especially after direct contact with the rash.

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, SCMG Palomar Health Medical Group, 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 your Sharp Health Plan online account 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. Your online account 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 explanation of benefits?

An explanation of benefits, or EOB, is a statement you get from your health plan to let you know a claim was paid and processed. An explanation of benefits is not a bill. We provide two types of EOB statements in your Sharp Health Plan online account: Summary EOBs and Individual EOBs .

What do I do when I get an explanation of benefits?

When you get an explanation of benefits, read it through. The purpose of an EOB is to help you understand how much your health plan covers for medical or pharmacy services you had.

What’s the difference between a claim and an EOB?

A claim is a request for payment. Your provider submits a claim to us after you receive a health care service from them.

An explanation of benefits is a statement that shows you claim and service details from a specific period, usually one month.

Can I opt in to paperless EOBs?

Yes. You can opt in to paperless EOBs through your Sharp Health Plan online account. Simply log in or create an online account and go to the Claims tab. If you're using the mobile app, tap Medical. From there you can follow the prompts to sign up for paperless EOBs.

Can I opt out of paperless EOBs?

Yes. You can opt out of paperless EOBs at any time through your Sharp Health Plan online account. Simply log in or create an online account and go to the Claims tab. If you're using the mobile app, tap Medical. From there you can select 'cancel paperless EOBs'.

What do “allowed” and “approved” mean?

“Allowed” and “approved” is the maximum amount we will pay for covered health care services.

What does “in plan savings” mean?

“In plan savings” are discounts we negotiated to save you money. This information is shown on any Individual EOB statements in your online account.

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.

What are the dates listed under my claim details?

The dates are when you had a health care service.

What is a reference number?

A reference number is what your provider can use to look up your specific claim.

What does CPT mean?

CPT stands for current procedural terminology. It is a medical code used to report medical, surgical and diagnostic services.

What does “not covered” mean?

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

What’s a reason code?

A reason code relates to the “not covered” amount.

What’s a code summary?

A code summary helps explain any reason codes listed.

What does OTC mean?

Over-the-counter drugs, or OTC, are medicines sold directly to consumers, no prescription needed.

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 Health Plan online 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 finding a provider, please contact Customer Care at 1-844-483-9013. If you are enrolled in a Sharp Direct Advantage^® plan, visit our online behavioral health directory here.

How do I get reimbursed for behavioral health services that I paid for?

If you receive care from an out of network behavioral health provider, you may be asked to pay for those services.  If that occurs, you can contact Magellan Healthcare at 1-844-483-9013, to request reimbursement. Magellan will provide a form that outlines the information needed for reimbursement including important reimbursement request deadlines.  Magellan will need a copy of the itemized bill showing all services received from the provider and a copy of your Sharp Health Plan ID card in order to determine if the services are covered.  Applicable co-payments will apply.

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, 1 MB). 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 price transparency?

Price transparency helps patients better understand the costs of the health care services they receive.

What is the Transparency in Coverage rule? 

The Transparency in Coverage rule is a federal price transparency rule that requires health plans to share health care costs with members and the general public. There are two main phases of the rule.

The first phase went live July 1, 2022, and it requires health plans to publish machine-readable files on their websites. Our machine-readable files are published here in JSON format as required by the rule. JSON files are intended for researchers and application developers — not the general public — and are not easily accessible without special software.

The second phase will go live Jan. 1, 2023. For this phase, we're developing a self-service price tool on your Sharp Health Plan online account. It will allow members to look up specified services, then get an out-of-pocket estimate based on their provider and benefit plan. We’ll share details as we get closer to launching the new tool.

What other resources can Sharp Health Plan members use to check their cost for covered benefits?

Members can log in to their online account today to access their coverage documents, including a summary of benefits matrix that lists the cost shares of their benefit plan. Members who get care at Sharp HealthCare can also request price estimates for shoppable services from certain Sharp providers. For estimates from other hospitals and health care providers, members should contact the hospital or provider directly.

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 your Sharp Health Plan online account, or you can call Customer Care. 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.