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Welcome to the Path to Health Program. This Member Guide provides important information about your Path to Health benefit coverage and how to obtain covered health care services. Please review this Member Guide to learn about your benefit coverage and how to contact Advanced Medical Management (AMM), the administrator for Path to Health medical benefits, if you have questions. This Member Guide also provides information on how to get prescription medications that are covered under your Path to Health benefits and how to contact MedImpact Healthcare Systems, Inc. (MedImpact), the pharmacy benefit administrator for the Path to Health Program. AMM does not administer Path to Health pharmacy benefits.
Your Path to Health ID Card is enclosed with this Member Guide. You will use this ID card when you seek health care services under the Path to Health Benefit. Below is an example of a Path to Health Benefit Member ID Card:
Your ID card includes the “benefit period” which are the dates your coverage is valid for Path to Health. If you want to re-apply, you can do so within thirty days prior to the end of your benefit period so you don’t have a gap in coverage. You re-apply through your assigned clinic organization where you originally applied for Path to Health. You’ll receive a new ID card when you complete the re-application process with a new “benefit period” of up to 6 months.
Please be sure to also keep your State of California Benefits Identification Card (BIC). You received this card separately from the State of California. You will use your BIC for any emergency services.
You should always carry both your Path to Health ID Card and your BIC with you. It is your responsibility to show your providers both your Path to Health ID Card and your BIC at the time you receive services. Your providers will use these cards to identify you and verify your eligibility in the Path to Health program.
In an emergency, get care immediately, even if you do not have your ID cards with you. Remember to tell the emergency provider that you are covered by Emergency Medi-Cal and show the provider your BIC as soon as possible after you have received care.
Your Path to Health ID Card must be used only by you. Your Path to Health Benefits may be reduced or your eligibility with Path to Health may be discontinued if you let someone else use your Path to Health ID Card. You may also be referred to law enforcement for prosecution.
How to Use Your Path to Health Benefit
Your Assigned Clinic for Path to Health Coverage: Your Path to Health ID Card lists your assigned clinic organization to receive covered benefits. Make sure that you are getting Path to Health covered health care services from the clinic you are assigned to. Please note, situations in which emergency medical attention is needed are exempt from this requirement as your eligibility with Emergency Medi-Cal offers health coverage in emergent situations. Path to Health does not cover and will not pay for medical services provided by any providers except the clinic you are assigned to. If you have any questions or issues regarding your assigned clinic, you can also call AMM Customer Service at 1-877-283-PATH (7284) for assistance.
Restriction on Non-Assigned Providers: Path to Health will NOT pay for, or reimburse you for any medical services provided to you when it is provided by a provider outside of your assigned clinic organization or at an out-of-network pharmacy.
Your benefit includes physicals, checkups, or other (non-emergency) medical office visits: You can schedule visits with your assigned clinic at no cost to you. Be sure to bring your Path to Health ID Card and your BIC with you to your medical appointment. See the Appendix for covered services.
Lab Testing and Procedures: A defined set of screening labs are part of the Path to Health covered benefit at no cost to you. These tests must be done through your assigned clinic. See Appendix for a list of these covered services.
Prescriptions: Prescription drugs listed on the Path to Health drug formulary are a covered Path to Health benefit at an in-network pharmacy with a $5.00 copay per prescription (up to a maximum of $1500 in prescription drug benefits per eligibility period and $500 per claim). Prescription drug services are administered by MedImpact. You may contact MedImpact at 1-800-788-2949 regarding this coverage or to locate an in-network pharmacy. You can also find out which pharmacies accept Path to Health at http://mypathtohealth.org.
How to Resolve a Problem with AMM, MedImpact or Path to Health
Important Phone Numbers
Advanced Medical Management, Inc. Customer Service
TTY Line for members with hearing or speech loss
MedImpact Healthcare Systems, Inc. Prescription Drug Services*
If you have a question, complaint or grievance about services with AMM or your Path to Health clinic provider, call AMM’s Customer Service department at (877) 283-PATH (7284), Monday through Friday, 8 a.m. to 5 p.m. In addition, we can also help you fill out a grievance or complaint form or mail a form to you. The form is also available on the AMM website at: http://pathtohealth.amm.cc/Home/Members.
Appeals: If we send you a letter telling you that we are denying a service and you do not agree with our decision, you can file an appeal. Your authorized representative or provider can also file an appeal for you with your written permission. You must request an appeal in writing or by phone within 60 calendar days of the notification by AMM of the denied, reduced or terminated service. The AMM Appeals department may be reached at:
Path to Health - Advanced Medical Management
Attention: Care Management - Member Appeals
5000 Airport Plaza Drive, Suite 150
Long Beach, CA 90815-1260
To Request a Medical Benefit Hearing: If you file an appeal with Advanced Medical Management, Inc. (AMM) regarding a denial, reduction or termination of service by AMM and you are not satisfied with how AMM has resolved your appeal under the AMM appeals procedures, you have the right to request a Medical Benefit Hearing with the CMSP Governing Board. You must request a Medical Benefit Hearing within 30 calendar days of the notification by AMM of the appeal decision. You can request a Medical Benefit Hearing from the CMSP Governing Board at:
CMSP Governing Board
Attention: Medical Benefit Hearing
1545 River Park Drive, Suite 435
Sacramento, CA 95815
Phone: 1-916-649-2631, Option 3
Third Party Liability: Please notify Path to Health at (877) 283-7284 of any health care services you receive as a result of an accident or injury caused by some other person’s action or failure to act. This is called third party liability.
Path to Health Benefit coverage includes the following benefits (limitations may apply):
|Screening for depression, alcohol misuse, obesity counseling (performed by a physician)
||Screenings for HIV, HPV, Hepatitis B & C, STI Screenings
Tobacco use counseling and intervention
(performed by a physician)
||Routine screening laboratory testing
Preventative health screenings
||Specified X-rays of head, neck, chest, trunk, upper and lower extremities
||Colorectal cancer screening
EKG, Osteoporosis, DEXA Scan
||Prescription medications with a $5 copay per prescription (up to $500 per claim and $1500 maximum benefit limit)
For a complete list of covered benefits, please visit the AMM website at:
Specific services that are NOT covered by the Path to Health Benefit include:
|Acupuncture, including podiatry-related acupuncture services
||Methadone maintenance services
Breast and cervical cancer treatment services when covered by other coverage (Breast
and Cervical Cancer Treatment Program/Medi-Cal)
||Optometry services and eye appliances
Public transportation, such as airplane, bus,
car or taxi rides
||Pregnancy-related and infertility services
||Services by a Psychologist, LCSW, MFT or substance use disorder counselor
Family planning services when covered by another coverage (F-PACT)
||Any medical service provided at a location other than your assigned clinic as well as any prescription drug provided at an out-of-network pharmacy
In addition, Path to Health is the “payer of last resort” and is the secondary payer to state and federal health coverage programs. If you have HIV or AIDS, want family planning or infertility services, have Hepatitis C, or have breast or cervical cancers:
California AIDS Drug Assistance Program (ADAP) for HIV and AIDS medications (Call 1-844-421-7050)
Family Planning, Access, Care and Treatment (Family PACT) for family planning and infertility treatment (Call 1-800-942-1054)
Assistance Program for Hepatitis C medications (Visit https://www.pparx.org)
Breast and Cervical Cancer Treatment Program (BCCTP) for breast and cervical cancer treatment services (Call 1-800-824-0088)
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