Find answers to the most commonly asked questions

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Understanding open enrollment with Covered California

How do you know if you need to change your health plan? What should you consider?

You can change your health plan during the open enrollment period, which runs from November 1 to January 31. There are two common reasons why you may choose to change your plan:

  1. You are planning to access care more frequently throughout the year. In this instance, you may want to switch to a Platinum or Gold plan where you pay a higher monthly premium, but have a lower deductible and lower copays for medical care.
  2. You want to change your plan network (Premier Network 1 or Performance Network) to visit a particular doctor. Learn more about Sharp Health Plan’s networks under "Compare networks and plans."

To change your plan, you should log in to your account on CoveredCA.com or call them directly at 1.800.300.1506.


I understand there are new out-of-pocket limits this year for Covered California. What are the changes and how might they affect people who get insurance through Covered California? 

Some plan designs through Covered California have increased maximum out-of-pocket (MOOP) limits, a feature that caps how much you will pay out of pocket each year when accessing care. This limit guarantees that in addition to your monthly premium, you will never pay more than the MOOP in a given year. 


What is open enrollment? When does it take place in 2016 and what are the deadlines? If you want coverage for Jan. 1, 2017, when must you have a plan in place? 

Open enrollment is a period of time each year when you have the opportunity to enroll in health insurance or make changes to your current plan. Open enrollment for the individual and family (IFP) market starts on November 1, 2016 and ends on January 31, 2017. You must apply by December 15, 2016 to have coverage effective on January 1, 2017. The open enrollment window is the only time of year when you can enroll in health insurance unless you have a “qualifying event” such as having a new baby, getting married or losing coverage through your work. 


Who should take part in open enrollment -- those without insurance, with insurance, or both? 

Whether you have insurance or not, it’s wise to participate in open enrollment to explore your options. If you don’t have coverage, you could be assessed a tax penalty for not carrying health insurance. Even if you do have coverage, it’s an opportunity to review available options to make sure they still meet the needs of you and your family. Open enrollment is the only time that changes can be made unless a “qualifying event” occurs. 


For those who've not had insurance before, do you have any advice on what to look for or consider when picking a plan? Where do you go to get started with comparing plans? 

Whether you are shopping for insurance for the first time or renewing your policy, the most important advice is to find a high-quality health plan at the best value. Many individuals don’t realize that there’s a difference in quality ratings between health plans. Covered California uses Members’ experiences to rate the quality of its participating health plans. Their rating system has one to four stars, with four stars being the top rating. Also, the National Committee for Quality Assurance (NCQA) has different levels of accreditation status for health plans. NCQA awards its highest accreditation status of “Commendable” to health plans that meet or exceed rigorous requirements for quality improvement.

To review the benefit plan options that are available, you can search plans on CoveredCA.com using their “Preview Plans” tool. This tool allows you to preview plans and prices from multiple insurance companies and tells you whether you may qualify for government subsidies to help pay for health insurance. Or, you can shop the specific plans offered by a particular insurance company using its website. Either way, you can do it on your own, or get help from a licensed insurance broker.

Although insurance companies differ in quality ratings, those who participate in Covered California offer the exact same benefit designs arranged in four categories or metal tiers (Bronze, Silver, Gold and Platinum). Platinum plans have the highest monthly premiums, but the lowest costs when accessing care. Bronze plans have the lowest monthly premiums, and the highest costs when accessing care. Gold and Silver plans strike a balance between the two. For example, if you are healthy and only visit the doctor once a year, you may benefit from a Silver or Bronze plan that carries a lower monthly premium but higher out-of-pocket costs when accessing care. If you see your doctor more frequently, then you may consider a Platinum or Gold plan.

Lastly, make sure your doctor or specialist (if you have one) participates in the provider network of the health plan that you select. 


For those who are already insured and happy with their current plan, what - if anything - do they need to do during open enrollment, especially if they get insurance through their employer? 

Even if you are insured and happy, it’s always a good idea to review your health coverage options each year. Health insurance benefits will sometimes change from one year to the next. 


What about those who get insurance through the healthcare marketplace? What should they do during open enrollment to make sure their coverage continues? 

Insurance companies with Covered California will send renewal notices highlighting benefit and rate changes for the coming year. If you want to make changes to your plan or switch insurance companies, you’ll need to do so by December 15, 2016 for a January 1, 2017 effective date. Because rates and plans tend to change annually, you will want to review which options are best for you and your family. If you purchased coverage through Covered California, it’s important to update any income changes that may affect subsidies for health insurance as this could impact your taxes. In the meantime, keep paying your monthly bill to make sure your current coverage continues. 

Please note if you have employer-sponsored coverage, you would not be eligible for a premium subsidy through Covered CA. 


Our service area

What is Sharp Health Plan’s service area?

Sharp Health Plan is San Diego’s only non-profit locally based commercial health plan. We serve employers and individuals based in San Diego and southern Riverside Counties. See a list of all zip codes included in Sharp Health Plan’s service area.

Sharp Health Plan connects Members to thousands of physicians and 13 local hospitals through four networks: Choice, Value, Performance and Premier. Learn more about our networks and their coverage area.

Search for a doctor to determine if a specific physician is part of Sharp Health Plan’s provider network.


Getting care outside of San Diego

Can Sharp Health Plan Members get covered care outside of San Diego?

Yes, as a Sharp Health Plan Member, you are covered for urgent care and emergency care wherever you are, although routine care is only covered at home in our service area. If you need help finding urgent or emergency services outside of our service area, our partner, Assist America, can help. Assist America services are available when Members face a medical emergency while traveling 100 miles or more away from their permanent residence, or when visiting a foreign country. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services.

Learn more about how we cover care outside of San Diego.


Seeing specialists

With Sharp Health Plan, will I be able to choose my own specialists or will my Primary Care Physician make that decision for me?

Together, you and your doctor will determine the best specialist for your particular needs. Women can see participating obstetricians and gynecologists within their Plan Medical Group for obstetric and/or gynecological services without a referral from their Primary Care Physician (PCP).


Our networks explained

What is the Premier Network?

The Premier network, also known as Network 1 in the Covered California marketplace, is a high-performing, select network. Although narrower in size than other Sharp Health Plan networks, Premier's quality of care is comprehensive. It's also the most affordable of our four provider networks. This network features more than 1,100 doctors, six hospitals and two medical groups, including:

  • Sharp Rees-Stealy Medical Group (SRS)
  • Sharp Community Medical Group (SCMG)

The Premier network, or Network 1, is a great option for Members who live in central San Diego County. If you are a Member of this network, you will find the Premier listed on your Member ID card.


What is the Performance Network?

The Performance network, also known as Network 2 in the Covered California marketplace, is our largest network for individual and family plans. It's an affordable network that covers all of San Diego County. Performance features more than 1,600 doctors, 10 hospitals and six medical groups, including:

  • Sharp Rees-Stealy Medical Group (SRS)
  • Sharp Community Medical Group (SCMG)
  • SCMG Arch Health Partners
  • SCMG Graybill Medical Group
  • SCMG Inland North Medical Group
  • Rady Children’s Health Network/CPMG

The Performance network, or Network 2, is a great option for Members who live anywhere in San Diego County. If you are a Member of this network, you will find Performance listed on your Member ID card.


What is the Value Network?

The Value network is a large network of medical professionals, devoted to giving its Members the best possible care and value. This network features a large selection of specialty doctors, medical groups and hospitals in San Diego County. The network has more than 1,820 doctors, 10 hospitals and eight medical groups, including:

  • Sharp Rees-Stealy Medical Group (SRS)
  • Sharp Community Medical Group (SCMG)
  • SCMG Arch Health Partners
  • SCMG Graybill Medical Group
  • SCMG Inland North Medical Group
  • Rady Children’s Health Network/CPMG
  • Greater Tri-Cities IPA
  • Primary Care Associates Medical Group

This network is available with certain employer-sponsored benefit plans. If you are a Member of this network, you will find Value listed on your Member ID card.


What is the Choice Network?

The Choice network is the largest network of Sharp Health Plan’s four provider networks. Members can choose from a wide range of quality doctors and conveniently located facilities. The Choice network features more than 2,240 doctors, 12 hospitals and eight medical groups, including:

  • Sharp Rees-Stealy Medical Group (SRS)
  • Sharp Community Medical Group (SCMG)
  • SCMG Arch Health Partners
  • SCMG Graybill Medical Group
  • SCMG Inland North Medical Group
  • Rady Children’s Health Network/CPMG
  • Greater Tri-Cities IPA
  • Primary Care Associates Medical Group

It also includes doctors who are contracted directly with Sharp Health Plan, as part of the Independent Plan Medical Group. This network is available with certain employer-sponsored benefit plans. If you are a Member of this network, you will find Choice listed on your Member ID card.


Wellness programs

Does Sharp Health Plan provide any wellness programs?

As a Member, you get comprehensive resources through our nationally accredited Best Health™ wellness program. You can take a personal health assessment, get a wellness score and report, enjoy multi-week wellness programs on various health topics, and much more. You can even take advantage of our health coaching program and work one-on-one with a coach to reach your personal health goals. Visit the Prevention and Wellness Center for more information.


Covered benefits — HMO plan

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 always include coverage for medically necessary doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Coverage for other services varies depending upon the benefit plan you are enrolled in. Log in to SharpConnect to check your Member handbook, benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.


Where can I get a summary of my benefits?

Log in to your SharpConnect account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.


How do I get authorization for medical care?

Except for PCP services, emergency services and obstetric and gynecologic services, you are responsible for obtaining valid authorization before you receive covered benefits. Contact your PCP prior to receiving care, and request prior authorization for those covered benefits. If authorization is approved, obtain the expiration date for the authorization. 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 Utilization Management Committee and appropriate physicians. You can request a copy of Sharp Health Plan’s medical policy for a particular service or condition by calling Customer Care at 858.499.8300 or 1.800.359.2002.


Covered benefits — POS plan

Where can I get a summary of my benefits?

Log in to your SharpConnect account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.


Which services are covered under Sharp Health Plan POS?

Sharp Health Plan’s Point of Service Plan (POS) is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services always include coverage for medically necessary doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Coverage for other services varies depending upon the benefit plan you are enrolled in. Log in to SharpConnect to check your Member Handbook, benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.


What is the difference between the POS and HMO plan? 

Except for PCP services, emergency services, and obstetric and gynecologic services, you are responsible for obtaining valid authorization before you receive covered benefits at the Tier 1 – HMO Benefit Level. Contact your PCP prior to receiving care, and request prior authorization for those covered benefits. If authorization is approved, obtain the expiration date for the authorization. Some Tier 2 - Aetna/or Out-of-Network services require precertification before you receive services.

It is your responsibility to make sure that you receive precertification. Check your benefit summary to find out which services require precertification. If you do not receive required precertification, you may be required to pay 50% of the amount Sharp Health Plan pays the provider for that service rather than the coinsurance amount listed, even if the services are approved as medically necessary. The 50% payment will not count toward your deductible or annual out-of-pocket maximum.


HMO vs. POS

What is the difference between the POS and HMO plan? 

In a health maintenance organization (HMO) plan, you must select a Primary Care Physician. Your Primary Care Physician will coordinate all your medical care. All care is typically received by in-network physicians.

In a point-of-service (POS) plan, you choose your Primary Care Physician in network but have the option to go out of network. Going out of network will cost you more.


Hospitalization

If hospitalization is necessary, which hospital will I use?

Sharp Health Plan’s network includes many hospitals throughout San Diego. View the full list of hospitals. Primary Care Physicians (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. Contact us to find out which hospitals are used with your Plan Medical Group, or search for a hospital and narrow your search results by your Plan Medical Group. 

Additional information for POS plan Members

If you are a POS Member, you may also obtain care from any licensed provider not affiliated with the Plan Medical Group you selected. Your costs will be higher and you will usually pay a deductible and coinsurance when using Tier 2 - Aetna/or Out-of-Network benefits. To find the Tier 1 - HMO Benefit Level hospital closest to you, use the Find a Doctor tool and select "Facility" in the "Type" dropdown menu.


Covered medications

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

The Sharp Health Plan drug formulary lists all covered medications. View the Drug List or call us at 1.800.359.2002 to find out if your medication is included on Sharp Health Plan’s formulary.


What is a drug formulary?

A formulary is a list of covered medications for Sharp Health Plan doctors to use when prescribing medicines for you. A formulary improves the quality of care by encouraging use of prescription medications that are demonstrated to be safe, effective and produce superior clinical outcomes. Our goal is to include drugs that are supported by medical research and have the most potential to improve Members' health, while also keeping health care coverage affordable.


Who decides which drugs are on the formulary?

Sharp Health Plan's Pharmacy and Therapeutics Committee, composed of doctors and pharmacists, meets quarterly to evaluate the formulary. The Committee considers newly developed drugs and recommendations from plan Members, doctors and pharmacists for possible changes to the formulary. 

How are medications chosen to be included on the drug formulary?

The Pharmacy and Therapeutics Committee reviews a variety of materials in the medical literature, such as peer review journals and independent clinical studies. To be included on the formulary, drugs must be approved by the Food and Drug Administration and supported by medical research to have the most potential to improve Members' health.


What is a generic drug?

A generic drug is identical to a brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. The Food and Drug Administration certifies that generic drugs are safe and effective, and therapeutically equivalent to their brand-name offering. Generic drugs, when available, are usually the best value, providing the same clinical benefits for substantially less cost. These savings help keep the cost of health care coverage more affordable. For Sharp Health Plan Members, most generic drugs have a lower copayment.


Does the formulary include both branded drugs and generics?

Yes, Sharp Health Plan’s formulary includes many commonly prescribed medications, both brand-name drugs and generics. When a generic equivalent is available, it must be dispensed instead of the brand-name drug, unless your doctor specifies that the brand-name drug is medically necessary. Most generic drugs have lower copayments than brand-name drugs.


Can I get any drug on the formulary?

The formulary is a tool for your doctor to use when determining the most appropriate course of treatment. The presence of a drug on the formulary does not guarantee that your doctor will prescribe it for a particular condition. In some cases, prior authorization from Sharp Health Plan may be required before a drug is approved. View the Drug List online or call Customer Care at 1.800.359.2002 to find out if your medication requires prior authorization.


What if my medication is not on the formulary?

Sharp Health Plan’s Drug List includes information on alternative medications that are in the same drug class. If your medication is not listed on the formulary, ask your doctor if a formulary alternative would be appropriate for you.

You must receive prior authorization for non-formulary drugs. To do this, you must:

  • Contact your PCP.
  • Request prior authorization for those non-formulary drugs. Authorization requests for outpatient prescription drugs are reviewed by Sharp Health Plan.
  • If authorization is approved, you will be notified of the approved provider and the expiration date for the authorization.
  • If authorization is denied, you will be informed of the reason for denial and your appeal rights.


Prescription refills and mail order delivery

Can I order prescription medications through the mail?

Yes, mail order is a convenient, cost-effective way to obtain maintenance drugs. Maintenance drugs are medications prescribed to treat or stabilize chronic conditions such as arthritis or hypertension. Maintenance drugs are available for up to a 90-day supply through our prescription home delivery service. View more information about mail order services for prescription drugs or call us at 1.800.359.2002.


My Wellpartner prescription was transferred to a local pharmacy. How do I get it transferred to CVS Caremark for mail order services?

You can call toll free at 1.800.930.5190 to move your prescription to CVS Caremark. You will need to provide your Sharp Health Plan ID number, medicine name, payment information and mailing address. CVS Caremark can contact your doctor for a new prescription if requested.


I have not used mail order pharmacy before. How do I get started?

You can call toll free at 1.800.930.5190 to move your prescription to CVS Caremark.  You will need to provide your Sharp Health Plan ID number, medicine name, payment information and mailing address.  CVS Caremark can contact your doctor for a new prescription if requested.

You can also log on to www.caremark.com/faststart. Going online is a quick and easy way to start using mail service. Once you provide the requested information, Caremark CVS will contact your doctor for a 90-day prescription. If you haven’t registered yet on Caremark.com, be sure to have your Sharp Health Plan ID number handy when you register for the first time.


What can you tell me about CVS Caremark?

CVS Caremark offers mail services representing approximately 70.3 million people and dispensed 39.2 million mail service prescriptions. They provide convenient, responsive service with a two-day processing turnaround time for most prescriptions and include an educational member advisory letter with all prescriptions. They offer telephone or internet refill ordering including toll-free pharmacist consultation 24 hours a day, 7 days a week. They have supportive services for special needs populations such as the elderly, sight and hearing impaired. In addition, CVS Health’s messaging platform can support automated alerts regarding order status, refill reminders, health updates, etc. via the member’s preferred method of contact (phone, email, text messaging, etc.). Information about how to start using mail order pharmacy services with CVS Caremark can be found here.


How does a provider submit a prescription to CVS Caremark for delivery through mail order?

Prescriptions can be sent electronically through the prescriber’s electronic medical record by choosing:

Mail CVS Caremark Service Electronic
NCPDP ID 322038 9501
East Shea Blvd
Scottsdale, AZ 85260

Prescriptions can be faxed to CVS Caremark Mail Service Pharmacy using this form: https://www.caremark.com/portal/asset/NewRX_Fax_Form_v91.pdf

Prescriptions can also be called in to CVS Caremark at 1.800.930.5190.


When can I refill my prescription?

Sharp Health Plan allows you to refill your prescription after you have used at least 70% of the prescribed amount. For a 30-day supply, this means you can get a refill 22 days after you last filled the prescription. For a 90-day supply, you can get a refill 64 days after you last filled the prescription. If you try to order a refill at the pharmacy too soon, you will be asked to wait until the allowable refill date. 

You can find out when you last filled your prescription by logging in to SharpConnect and selecting "Prescription History" to check your drug history. If you have any questions about when your prescription can be refilled, ask your pharmacy for assistance or call Customer Care at 1.800.359.2002.


Diplomat transition to CVS for specialty medications

Why are we moving away from Diplomat?

Beginning March 1, 2017, Diplomat will no longer be available in the pharmacy network provided to Sharp Health Plan through our partnership with MedImpact.


Why are we moving to CVS for specialty medications?

Using CVS for specialty medications allows for more choices:

  • Receive specialty medications by mail through the CVS Specialty by Mail Pharmacy
  • Pick up specialty medications at any of the 140+ CVS and Target pharmacies throughout San Diego County


What do I need to do to change to CVS?

You do not need to do anything. You can continue to use Diplomat Specialty Pharmacy for your specialty mediations until February 24, 2017. On February 25,2017, remaining Diplomat prescriptions will then be digitally transferred to CVS Specialty. If you choose this method, you can call CVS Specialty at 1-800-237-2767 any time after February 27, 2017 to obtain your prescription. You will need to have your Sharp Health Plan member ID number when calling. 

If you want to transition to Diplomat immediately, you can move your prescriptions to CVS Specialty through one of the following methods: 

  1. Ask your doctor to send new specialty medications prescriptions to CVS Specialty. Your doctor can: 
    • Fax in specialty prescription(s) at 1.800.323.2445
    • e-Prescribe specialty prescription(s) to CVS Specialty or CVS pharmacy
    • Call specialty prescription(s) in to 1.800.237.2767
  2. Call Diplomat pharmacy at the number on the prescription bottle and transfer your prescription to the CVS pharmacy of your choice. You will need to have the CVS pharmacy phone number available for Diplomat.
  3. A CVS representative will call you in the coming weeks to welcome you to the new service. During this call, give him or her permission to call Diplomat pharmacy and/or your doctor to transfer your specialty medications to CVS Specialty. You will need to be prepared to give your Sharp Health Plan member ID number, medication names and your doctor’s contact information. 

Once established with CVS Specialty, you can either choose to have your prescription mailed to you or arrange to pick up your medication at any of the 140+ CVS retail pharmacy locations in San Diego County, including those within Target stores.


Prescription copays and pre-authorizations

How do I know what my copay is for a prescription medication?

Your benefits summary lists the copayments for prescription drug benefits. To find out the copayment for a specific drug, log in to SharpConnect and select Drug List under My Health Plan.


Why do some drugs require prior authorization?

Some drugs require prior authorization by Sharp Health Plan to ensure that you are receiving the appropriate medication for your condition based on a review of medical criteria. Your doctor will provide the necessary information to Sharp Health Plan for the prior authorization review. If you have any questions regarding the prior authorization process, please call us at 1.800.359.2002.


Deductibles

How do I request a deductible?

Sharp Health Plan will give you a credit toward your Sharp Health Plan deductible for approved amounts that were applied toward your deductible with your previous health plan (for the same calendar year). Keep in mind, we can’t give you credit for deductible amounts paid for outpatient prescription drugs. To request a deductible:

  1. Download and send the completed form and the required attachments to Sharp Health Plan within 90 days of the start of your Sharp Health Plan coverage. We will not process Deductible Credit Request Forms received more than 90 days after your start date.
  2. List the deductible amount met by each family Member separately. You only need to fill out one Deductible Credit Request Form for all family Members covered by Sharp Health Plan.
  3. Attach a copy (front and back) of the most current explanation of benefits (EOB) from your previous health plan. The EOB must list all deductible amounts you are requesting as credit.


Emergency and urgent care services

Where and when can I get urgent care services?

Sharp Health Plan has urgent care centers throughout San Diego and southern Riverside Counties. You can search for an urgent care center or call us at 1.800.359.2002. In most cases, you must contact your Primary Care Physician for authorization before going to an urgent care center. Sharp Rees-Stealy (SRS) Members do not need authorization before going to SRS urgent care centers and Sharp Community Medical Group (SCMG) Members do not need authorization before going to an urgent care center affiliated with SCMG. Check the Plan Medical Group on your Member ID card.


What if I have an emergency situation?

As a Member, you can visit any emergency room, whether in San Diego or anywhere worldwide. If you are not sure whether your situation is an emergency, call your Primary Care Physician. Your Primary Care Physician can help you decide on the best course of action. You can also talk to a nurse after hours with Sharp Nurse Connection® for medical assistance during evenings and weekends. To talk to a nurse call toll-free at 1.855.995.5004 from 5 p.m. - 8 a.m., M-F, and 24 hours a day on weekends.


How can I get 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 talk to a nurse, call toll-free at 1.855.995.5004 from 5 p.m. - 8 a.m., M-F, and 24 hours a day on weekends.


Care while traveling outside of the San Diego area

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 (San Diego and southern Riverside Counties). 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 your Primary Care Physician or Sharp Health Plan within 48 hours or at the earliest time reasonably possible. This will allow your doctor to share your medical history with the hospital and help coordinate your care.


How can I get care outside Sharp Health Plan’s service area?

Sharp Health Plan Members who need help finding emergency or urgent care services out of the service area can contact Assist America®. 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.

Learn more about getting care outside of San Diego.


Women’s health services

What kind of women’s health services do you cover?

From well woman exams to breast cancer screenings and pregnancy care to one-on-one health coaching, Sharp Health Plan connects you to the best women’s health services. Your specific coverage depends on your benefit plan; log in to SharpConnect to see your coverage details.

Learn more about our women’s health services.


Am I covered for infertility services?

Depending on your plan, you might have coverage for the diagnosis and treatment of infertility and/or coverage for Assisted Reproductive Technologies (ART). These services may include artificial insemination, IVF or GIFT, and are determined based on your specific benefit plan.

If your benefit plan includes coverage for infertility services, ask your Primary Care Physician about a 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 reproductive technology services.


Where can I find out about my plan’s infertility care coverage details?

How to find out if you have infertility service coverage

Check your Member handbook and summary of benefits to determine if your benefit plan includes coverage for infertility diagnosis and treatment. Log in to SharpConnect or contact us to find out if your benefit plan includes coverage for infertility treatment or reproductive technologies.

Information for POS plan Members
Infertility services (the diagnosis and treatment of the underlying condition) are only covered on the Tier 1: HMO Benefit Level and not on the Tier 2: Aetna/or Out-of-Network Level.


Are breast pumps a covered benefit?

Most 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.) Your OB/Gyn can provide you with a referral for a breast pump. Call us at 1.800.359.2002 or email customer.service@sharp.com for information on how to order a breast pump. Breast pumps are not covered if purchased from a non-contracted supplier.

Learn more about pregnancy care.


Physical, speech, and occupational therapy

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.


Do I need a referral and copay?

Ask your Primary Care Physician about referral to an appropriate specialist for therapy services. The Member’s share of cost for therapy services could be deductible, copay and/or coinsurance for each therapy visit. The copayment amount is listed on the benefits summary available by logging in to SharpConnect or by calling Customer Care at 1.800.359.2002, or emailing customer.service@sharp.com.

Information for POS plan Members

Ask your Primary Care Physician about referral to an appropriate specialist for therapy services at the Tier 1 — HMO Benefit Level. You may also obtain care from any licensed provider not affiliated with the Plan Medical Group you selected. Your costs will be higher and you will usually pay a deductible and coinsurance when using Tier 2 - Aetna/or Out-of-Network benefits.


Mental health services

Which mental health services are covered?

Sharp Health Plan provides coverage for the diagnosis and treatment of severe mental illnesses in Members of any age and serious emotional disturbances in children. Mental health benefits include inpatient hospital services, partial hospital services and outpatient services when ordered and performed by a participating mental health professional. Members may also have coverage for treatment of other mental health conditions. For detailed descriptions, please log in to your account to view your Member Handbook and benefits summary.


How do I get mental health services?

As a Member, you can get mental health services without a referral from your Primary Care Physician. Please call Psychiatric Centers at San Diego toll-free at 1.877.257.7273 whenever you need mental health services. You can visit sharphealthplan.com to learn more about care for mental health.


Vision care

How can I get vision care?

Log in to SharpConnect or contact us to find out if your benefit plan includes coverage for vision services.

If you currently have vision coverage

If your benefit plan includes vision services, call your Vision Service Plan (VSP) doctor and make an appointment, letting the doctor know that you are a VSP Member. You will also need to provide your ID, date of birth and the covered Member’s identification number. (The covered Member is the eligible employee or family leader who signed up for your insurance coverage; it will be either you, your spouse/domestic partner or your parent.) Once you make your appointment, your doctor and VSP will handle the rest.

Getting services from a non-VSP provider

In some cases, you may also select to receive services from a non-VSP provider and VSP will reimburse you for part of the cost. Any service you get from a non-VSP provider is 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. Call VSP Member Services at 1.800.877.7195 to find out if your coverage includes non-VSP providers.

Learn more about getting vision care.


Dental care

How can I get dental care?

How can I get dental care?

If you have dental coverage through your policy, contact our dental care partner, Premier Access Dental. Visit premierelife.com, call 888.715.0760 or email customerservice@premierelife.com to find a provider.  


If you currently have dental coverage

If your benefit plan includes dental services, call your Premier Access dentist and make an appointment, letting the them know that you are a Premier Access Dental Member. You will also need to provide your ID, date of birth and the covered Member’s ID number. (The covered Member is the eligible employee or family leader who signed up for your insurance coverage; it will be either you, your spouse/domestic partner or your parent.) Once you make your appointment, your dentist and Premier Access Dental will handle the rest.

Learn more about getting dental care.


Acupuncture and chiropractic care

How can I get acupuncture treatment?

How to get services

If acupuncture services are covered through your benefit plan, search for a provider or call1.800.678.9133 to speak with an American Specialty Health (ASH) representative for assistance.

How to find out if you have acupuncture services

Log in to your SharpConnect account to see your Member Handbook and Summary of Benefits to determine if your benefit plan includes coverage for acupuncture services. For more information, please call Customer Care at 1.800.359.2002, or email customer.service@sharp.com.

Learn more about getting acupuncture care.


How can I get chiropractic care?

If chiropractic services are covered through your benefit plan, search for a provider or call1.800.678.9133 to speak with an American Specialty Health representative for assistance. No referral from Sharp Health Plan or your Primary Care Physician is required.

How to find out if you have chiropractic coverage
Log in to your SharpConnect account to see your Member Handbook and summary of benefits to determine if your benefit plan includes coverage for chiropractic services. For more information, please call Customer Care at 1.800.359.2002, or email customer.service@sharp.com.

Learn more about getting chiropractic care.

Get discounted services
For Members who do not have this coverage (or who may have used all their allotted benefits during the current year), Sharp Health Plan partners with American Specialty Health (ASH) and its affiliate, Healthyroads, Inc., to provide discounts on alternative care services. Receive 25% off usual provider rates on services from an extensive, credentialed network of chiropractors, acupuncturists, massage therapists and dietitians. You may visit any of these providers directly, without a physician referral.

Receive 15 to 40% off suggested retail prices on more than 2,400 health and wellness products, including vitamins, minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, DVDs, fitness products and skin care items.

For assistance with ordering wellness products or locating an alternative care provider, please contact our health discounts partner, American Specialty Health at 1.877.335.2746.


Wellness

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

As a Member, you get 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 can get health coaching program and can work one-on-one with a coach to reach personal health goals. See the Health & Wellness center for more information.


Are my dependents eligible for the wellness programs?

Yes, your enrolled dependents are eligible for the Sharp Health Plan wellness programs.


How can I get information about alternative health care programs?

The alternative health care programs from Sharp Health Plan offer you discounts of up to 25% off usual provider rates on services from an extensive, credentialed network of chiropractors, acupuncturists, massage therapists and dietitians. You may visit any of these providers directly without a physician referral.

You can also get discounts of 15-40% off suggested retail prices on more than 2,400 health and wellness products, including vitamins, minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, CDs, DVDs, fitness products and skin care items.

You can find more information on these services at Choose Healthy or by calling 1.877.335.2746.


Primary care physicians (PCP)

What is a Primary Care Physician (PCP)?

A Primary Care Physician (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 Primary Care Physician (PCP)?

We encourage you to select a Primary Care Physician (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 you can access care immediately. For the most up-to-date information on available PCPs, call Customer Care at 1.800.359.2002.


Can I choose a different Primary Care Physician (PCP) for different Members of my family?

Yes, each covered family Member may choose a different Primary Care Physician (PCP) from a different Plan Medical Group. All family Members must stay in the same Plan Network.


Can I change my Primary Care Physician (PCP)?

Yes, in general it is a good idea to stay with a Primary Care Physician (PCP) so he or she can get to know your health needs and history. However, with Sharp Health Plan, you may change to a different PCP in your 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 at 1.800.359.2002 and we will help you select a new PCP. 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 Primary Care Physician (PCP) will refer you to a specialist to ensure that you receive proper medical attention and follow-up. Your PCP will refer you to a specialist in your Plan Medical Group (PMG). In most cases, each PMG includes a different set of PCPs, specialists, urgent care centers and other providers.


Does my Primary Care Physician (PCP) make the decision about which specialist I see, or am I able to make that decision?

Your Primary Care Physician (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 can see 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 how to see a specialist, call Customer Care at 1.800.359.2002.


Member ID cards

When will I get a Member ID card?

ID cards are mailed to Members' homes within a week of enrolling. You will receive an ID card for each Member of the 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 SharpConnect 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 or replacement ID card?

You can get a new or replacement ID card by logging in to SharpConnect to order an ID card or to view and print a temporary Member ID. If you prefer, you can call to request a new ID card at 1.800.359.2002. Your new card will arrive within 7 to 10 business days.


Coverage for spouses and partners

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

Yes, if your employer provides coverage for dependents and you are enrolled in Sharp Health Plan or if you are enrolled in an individual/family plan, your legally married spouse or registered domestic partner and your children are eligible. Some employers also cover non-registered domestic partners. Contact your human resources department for more information.

Learn more about adding or removing dependents.


If my spouse loses health coverage through his or her employer, can he or she be covered under my Sharp Health Plan?

In most cases, yes. If you are a Sharp Health Plan Member when your spouse loses group coverage through your spouse’s employer, your spouse may enroll as a dependent under Sharp Health Plan, so long as enrollment occurs within 30 days for large groups and 60 days for small groups and IFP plans from the date that coverage ended under the former health plan.

Learn more about adding or removing dependents.


Can I add or remove my spouse or partner to my Sharp Health Plan coverage if open enrollment is over?

Yes, as long as there has been a qualified family change, such as marriage. Enrollment must occur within 30 days for large groups and 60 days for small groups and IFP plans from the time your dependents first become eligible to join (that is, within the marriage or domestic partnership).

Learn more about qualifying events.


Coverage for dependents living outside of San Diego

Can I enroll my dependents living outside Sharp Health Plan's service area?

In most cases, all eligible family Members must live or work in San Diego County to enroll in Sharp Health Plan. 


Can my child who lives outside of San Diego enroll in Sharp Health Plan if I have a medical support order?

Yes, as long as there is a valid medical support order in place. If you are enrolled in an HMO plan, your child will be covered for emergency and urgent care services while outside the plan’s service area. If you are enrolled in a POS plan, your child may obtain care from any licensed provider but the costs using Tier 2 - Aetna/or Out-of-Network benefits will be higher and your child will usually pay a deductible and coinsurance.


Coverage for students

Does my child have to be a full-time student to enroll in Sharp Health Plan?

If your benefit plan is provided by your employer, check with your employer to find out if you can enroll your dependents. If your employer includes coverage for dependents or you have an individual/family plan, your child is eligible for enrollment up to age 26 regardless of student status.


Can my child who attends school outside of San Diego County enroll in Sharp Health Plan?

Yes, as long as your child retains a permanent residence in Sharp Health Plan’s service area. If you are enrolled in an HMO plan, your child will be covered for emergency and urgent care services while they are away at school. They receive routine and preventive care services from doctors affiliated with their Plan Medical Group while they are back at home. If you are enrolled in a POS plan, your child may obtain care from any licensed provider but the costs using Tier 2 - Aetna/or Out-of-Network benefits will be higher and your child will usually pay a deductible and coinsurance.


Coverage for newborns and newly adopted children

How can I get coverage for my newborn or newly adopted child?

If your benefit plan is provided by your employer, contact your employer’s human resources department for instructions and an enrollment change form to add your newborn. If you are enrolled in an individual/family plan, contact Sharp Health Plan Customer Care at 1.800.359.2002 for instructions and an enrollment change form. An eligible newborn is covered automatically for the birth month, but must be enrolled within 30 days to be covered after the birth month. Adopted children are covered from the date of birth if enrolled within 30 days.


Coverage for adult children

How long can my child be enrolled in Sharp Health Plan?

In most cases your child can be enrolled in Sharp Health Plan until the last day of the month of their 26th birthday.


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 under your policy; however, your child’s spouse and children may be eligible to enroll in their own individual/family plan through Sharp Health Plan.


Can my child enroll in Sharp Health Plan if he/she is married?

If your benefit plan is provided by your employer, check with your employer to find out if you can enroll your dependents. If your employer includes coverage for dependents or you have an individual/family plan, your child is eligible for enrollment up to age 26 regardless of marital status.


Medical bills and reimbursements

What if I get a bill for medical services?

As a Sharp Health Plan Member, you will not normally receive a bill from a provider unless you have not paid your copay or deductible. You are responsible only for paying any copayment or deductible 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. Contact Customer Care at 1.800.359.2002 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?

If you receive emergency or urgent care services outside of San Diego County, you may be asked to pay for those services. If that occurs, you can request reimbursement from Sharp Health Plan. 

Learn how to request a reimbursement.


How can I request reimbursement for prescription drugs that I paid for?

In some cases, you may be asked to pay for prescription drugs that are normally covered by Sharp Health Plan. An example is when you are traveling outside of California and urgently need to fill a prescription. You can request reimbursement for covered prescription drugs from us. To determine if the medication is covered, we will need a copy of the print out from the pharmacy showing the medication you received and a receipt showing proof of payment. Applicable copayments will apply. 


Networks vs. medical groups

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. In the Choice network, you can also select a PCP who is contracted directly with Sharp Health Plan. If you choose one of these PCPs, your PMG will be part of the Independent PMG.

You receive covered benefits from doctors who are affiliated with your PMG and who are part of your Plan Network. In most cases, each PMG includes a different set of PCPs, specialists, urgent care centers and other providers. In addition, your selection may impact the primary hospital in which services are delivered. To find out which plan doctors are affiliated with your PMG and part of your Plan Network, refer to the provider directory for your Plan Network or call Customer Care at 1.800.359.2002.


What is a Plan Network?

A Plan Network is the group of doctors, medical groups and hospitals available to you as a Sharp Health Plan Member. There are four Plan Networks: Choice, Value, Performance and Premier. You select your PCP and Plan Medical Group from the Plan Network you are assigned. You will find the name of your Plan Network on your Member ID card.


Our networks explained

What is the Performance Network?

Performance is one of Sharp Health Plan’s Plan Networks. The Performance network includes Sharp Community Medical Group (SCMG), Sharp Rees-Stealy Medical Group, Rady Children’s Health Network/CPMG, SCMG Graybill Medical Group, SCMG Inland North Medical Group, and SCMG Arch Health Partners. You will find the name of your Plan Network on your Member ID card.


What is the Premier Network?

Premier is one of Sharp Health Plan’s Plan Networks. The Premier network includes Sharp Community Medical Group and Sharp Rees-Stealy Medical Group. You will find the name of your Plan Network on your Member ID card.


Privacy policy

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 here and in the Member Handbook.


Selling Sharp Health Plan

What are the small group underwriting requirements for Sharp Health Plan?

Sharp Health Plan’s underwriting requirements are available here for your reference: Small Group Underwriting Matrix. 


How can I start selling with Sharp Health Plan?

To sell Sharp Health Plan, you are only required to maintain appropriate state licensing credentials. Please contact your Sharp Health Plan representative to review a group quote at 858.499.8300.


How do I get a group quote?

Sharp Health Plan has teamed up with Health Connect to offer small group quotes for employers. You may also contact your Sharp Health Plan representative to get group quotes at 858.499.8300.


How do I order marketing materials?

Marketing materials are available through our online Materials Request Form or by contacting your Sharp Health Plan representative. 


Grandfathered status under healthcare reform

What is a grandfathered health plan?

A grandfathered health plan is a plan that has maintained the same health coverage in effect when the health care reform law was enacted on March 23, 2010. A grandfathered health plan is exempt from the following changes otherwise required by health care reform:

  • Coverage of preventive health services with no copayments. Sharp Health Plan already covers preventive health services, but our grandfathered benefit plans include some level of copayments for those services. Eliminating the copayments may increase premiums.
  • Other requirements became effective in 2014. These include restrictions on premium differences based on age and require coverage of all “essential health benefits” with specified cost sharing. These requirements may result in increased premiums for benefit plans that did not maintain their grandfathered status.


What kinds of changes would cause my benefit plan to lose its grandfathered status?

Changes that can cause an employer’s benefit plan to lose its grandfathered status include, but are not limited to:

  • At renewal, selecting a benefit plan other than the one that was in effect on March 23, 2010.
  • A decrease of more than 5% in the percentage of premiums paid by the employer.


How do I keep my grandfathered benefit plan?

You may keep your grandfathered benefit plan by renewing with the same benefit plan you had in place on March 23, 2010. You may change your provider network and still maintain your grandfathered status.


Will my grandfathered health plan always have a lower premium than a non-grandfathered benefit plan?

Not necessarily, although grandfathered benefit plans are exempt from certain requirements under the law, you may choose a non-grandfathered benefit plan during your renewal that has a lower premium due to other benefit changes.


Are there any health care reform requirements that apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans, whether grandfathered or not, must provide the following benefits to their customers for plan years starting on or after September 23, 2010:

  • No lifetime limits on the dollar value of “essential health benefits.” All Sharp Health Plan HMO plans already provide this benefit.
  • No coverage exclusions for children with pre-existing conditions. Sharp Health Plan HMO plans do not include any pre-existing condition clauses for children or adults.
  • No annual limits on the dollar value of “essential health benefits.” Sharp Health Plan HMO plans do not have any annual dollar limits on “essential health benefits.”


What does “essential health benefits” mean? Which benefits are included in “essential health benefits”?

Essential health benefits include the following categories of services: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorders including behavioral health treatment, prescription drugs, rehabilitative and rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including dental and vision care.


For employers: dependent coverage under healthcare reform

What changes did health care reform require for dependent coverage?

If you provide dependent coverage, you must offer coverage to dependents up to 26 years of age, regardless of marital or student status.


Does the change in dependent coverage apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans that provide coverage to dependents must offer coverage up to age 26, regardless of grandfathered or non-grandfathered status.


Which of my employee’s dependents can enroll in Sharp Health Plan?

An employee’s child (naturally born or adopted), stepchild or children for whom the employee is the legal guardian may enroll in Sharp Health Plan.


Does an employee’s dependent have to live with them to enroll in Sharp Health Plan?

No, an employee’s dependent does not have to live with them to enroll in Sharp Health Plan, but he/she must live or work within Sharp Health Plan’s service area (San Diego and southern Riverside Counties).


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

No, the employee's child’s spouse and children are not eligible to enroll in Sharp Health Plan under the employee's policy; however, the spouse and children may be eligible to enroll in their own individual/family plan through Sharp Health Plan.


Contact information

Who can my customers contact with questions?

Your may contact your Sharp Health Plan representative with questions about the administration of their health plan.

Members may contact Customer Care at 1.800.359.2002, or email customer.service@sharp.com. Customer Care representatives are available 8 am - 6 pm, Monday to Friday.


Who can I contact with questions?

Your Sharp Health Plan account representative can answer your questions or connect you to the right person. Call our sales department at 858.499.8229 for assistance or send us a message


Sharp Health Plan service area

What is Sharp Health Plan’s service area?

Sharp Health Plan is San Diego’s only locally based commercial health plan. We serve employers based in San Diego and southern Riverside Counties. See a list of all ZIP codes included in Sharp Health Plan’s service area.


Which providers and hospitals are available through Sharp Health Plan?

Sharp Health Plan connects Members to thousands of physicians and 13 local hospitals through four networks: Choice, Value, Performance and Premier. Search for a doctor to determine if a specific physician is part of Sharp Health Plan’s provider network.

Learn more about our networks and their coverage area.


Sharp Health Plan products

Which health plan products are available through Sharp Health Plan?

Sharp Health Plan provides a wide variety of HMO options, POS and HDHP-HSA plans, supplemental riders and value-added enhancements to meet your customers’ health plan needs.

Check out all of our group plan options.


Which wellness programs are available to Sharp Health Plan Members?

Best Health is our comprehensive wellness program, which provides our Members with a variety of resources from meal plans and exercising routines to one-on-one personalized health coaching.


About our plans

What is a Point of Service (POS) Plan?

Members with a POS plan option can choose the provider(s) and the level of coverage that works best for them. If Members choose providers who are not part of their Plan network (Out of Network, OON), their out-of-pocket costs will be higher. No referral from the Primary Care Physician (PCP) is required for OON services, but some services do require a pre-certification.

The Member or the OON provider is responsible for obtaining pre-certification prior to services being rendered. The deductible, copayments and coinsurance for the HMO Benefit Level and the OON Benefit Level of the POS plans are listed on the Health Plan Benefits and Coverage Matrix.


Claims and reimbursements

How can I find out the status of my claim?

For services provided to Members assigned to one of the following Plan Medical Groups, providers should contact the group directly:

  • SCMG Arch Health Partners Medical Group: 858.499.2565
  • Children’s Physicians Medical Group: 858.309.6280
  • Greater Tri-Cities IPA: 760.941.7309, option 3
  • Primary Care Associates Medical Group: 909.476.1575 ext. 63007
  • Rady Children’s Health Network/CPMG: 800.387.1103
  • SCMG Inland North Medical Group: 858.499.2550
  • SCMG Graybill: 760.291.6621
  • Sharp Community Medical Group: 858.499.2550
  • Sharp Rees-Stealy Medical Group: 858.499.2410
  • Providers who are contracted directly with Sharp Health Plan and providers outside San Diego County can call Customer Care at 858.499.8300 for information regarding claims status


I can’t locate my Sharp Health Plan provider contract. How can I find out my contract rate of reimbursement?

Physicians who are contracted directly with Sharp Health Plan can contact our Network Development / Provider Support Department.  


Provider directory

How do I get a provider directory?

You can browse or search our provider directory online. To request a paper copy of Sharp Health Plan’s provider directory, call Customer Care at 858.499.8300.


Checking patient eligibility

How do I check patient eligibility?

Sharp Health Plan provides two online options for checking eligibility: SharpConnect and the ACES web-based application. Call Network Development / Provider Support at 858.499.8352 to find out more. For a one-time eligibility check, call Customer Care at 858.499.8200. You can verify eligibility 24 hours a day using a touchtone phone; just select the option to verify eligibility. Providers may also speak directly to a Member of the Customer Care team, Monday through Friday, 8 a.m. - 6 p.m.


How can I get a listing of Sharp Health Plan patients assigned to me?

Physicians who are contracted directly with Sharp Health Plan may contact Network Development / Provider Support to request a list of their assigned Members.


Electronic funds transfer (EFT)

How do I sign up for direct deposit?

Complete the Electronic Funds Transfer Authorization Agreement and return it along with a voided check or savings deposit slip to:

     Sharp HealthCare
     Attn: EDI MCA Operations
     8695 Spectrum Center Blvd., 3rd Floor
     San Diego, CA 92123


When will my direct deposit begin?

Please allow two weeks from the date we receive your EFT Authorization Agreement to process your request. We will contact you at the phone number you provide on the form to confirm receipt of your information. You may also call EDI MCA Operations at 858.499.5573 if you have any questions about the application process.


How will I know when my payment has been deposited into my account?

Contact your bank or check online if you are set up to do so. Please allow two business days from the date the payment is issued for the deposit to appear in your account. Claims payments are issued every Tuesday. Payments will be posted into your account that Thursday.


When are claims payments generated?

Claims payments are issued every Tuesday unless Tuesday falls on a holiday. In those cases, payments will be issued on Wednesday. If you have any questions about when your payment will be deposited, please contact EDI MCA Operations at 858.499.5573.


How will my information be safeguarded?

All banking information will be kept confidential and secured in a locked, private area.


How will I get my Evidence of Benefits (EOBs) or other payment documents?

All reports and supporting documents will be mailed through U.S. mail one to two days after your payment has been generated. This is the same process currently in place with paper checks.


What happens if I change banks or checking/savings account numbers?

We will need to deactivate your current account information and disable your electronic funds transfer if you make any changes to the following: Tax Identification Number (TIN), medical group affiliation, banking institution or account numbers for your checking/savings account.

If you have any changes in this information, complete a new EFT Authorization Agreement, checking the “Revision to Current Authorization” box. Be sure to include the effective date of the change. Please allow 30 days to process your new information to resume your direct deposit. Until the change process is complete, you will receive a paper check.


How do I cancel direct deposit?

Call EDI MCA Operations at 858.499.5573 to cancel direct deposit. If you prefer, check the "Cancel EFT" box on your copy of the EFT Authorization Agreement, write the date you want to cancel direct deposit, and return the form to:

     Sharp HealthCare 
     Attn: EDI MCA Operations 
     8695 Spectrum Center Blvd. 3rd Floor 
     San Diego, CA 92123


Who do I contact if I have questions?

Please contact EDI MCA Operations at 858.499.5573 or email EDI_MCA.Operations@sharp.com.


Wellness program

Where can my patients find more information about wellness programs available to Sharp Health Plan Members?

Members have direct access to a variety of wellness programs offered through Sharp Health Plan, including online self-management tools, trackers, workshops and telephone-based health coaching.

Visit our Health & Wellness section.


Becoming a Sharp Health Plan provider

How can I become a contracted provider with Sharp Health Plan?

Physicians interested in participating in our network may contract with Sharp Health Plan independently or through a contracted medical group. Sharp Health Plan requires a physician to go through a credentialing process before becoming a contracted provider.


What is credentialing?

Credentialing is a systematic approach to the collection and verification of a practitioner applicant’s professional qualifications. It considers factors such as relevant training, licensure and certification and/or registration to practice in a health care field. Credentialing requires that a physician:

  • Be board certified or have satisfactorily completed a residency in his or her practice specialty.
  • Have a current California medical license.
  • Have a current, unrestricted Drug Enforcement Agency (DEA) registration number (as applicable).
  • Have admitting privileges at a Sharp Health Plan contracted hospital affiliated with his or her physician’s medical group. Exceptions may be made for certain types of physicians who do not normally obtain admitting privileges or if the physician has arrangements with another Sharp Health Plan credentialed physician to admit on his or her behalf.
  • Be free of any Medical Board of California restrictions.
  • Provide 24-hour-a-day coverage for all Plan Members with another participating physician or with another on-call physician who agrees to abide by the guidelines of the Plan.
  • Have professional liability insurance in the minimum amount of $1 million per occurrence and $3 million annual aggregate.

The credentialing process also includes primary source verification of all information on the application, a practice site and medical record-keeping evaluation, and approval by Sharp Health Plan's Peer Review Committee. Credentialing may be performed directly by Sharp HealthCare’s Centralized Credentialing Department or by the contracted medical group.


Grandfathered status under health care reform

What is a grandfathered health plan?

A grandfathered health plan maintains the same health coverage that was in effect when the health care reform law was enacted on March 23, 2010. A grandfathered health plan is exempt from the following changes otherwise required by health care reform:

  • Coverage of preventive health services with no copayments. Sharp Health Plan already covers preventive health services, but our grandfathered benefit plans include some level of copayments for those services. Eliminating the copayments may increase premiums.
  • Other requirements went into effect in 2014. These include restrictions on premium differences based on age and required coverage of all “essential health benefits” with specified cost sharing. These requirements may have resulted in increased premiums for benefit plans that did not maintain their grandfathered status.


What kinds of changes would cause my benefit plan to lose its grandfathered status?

Changes that can cause an employer’s benefit plan to lose its grandfathered status include, but are not limited to:

  • At renewal, selecting a benefit plan other than the one that was in effect on March 23, 2010.
  • A decrease of more than 5% in the percentage of premiums paid by the employer.


How do I keep my grandfathered benefit plan?

You may keep your grandfathered benefit plan by renewing with the same benefit plan you had in place on March 23, 2010. You may change your provider network from Blue Choice to Gold Value and still maintain your grandfathered status.


Will my grandfathered health plan always have a lower premium than a non-grandfathered benefit plan?

Not necessarily, although grandfathered benefit plans are exempt from certain requirements under the law, you may choose a non-grandfathered benefit plan during your renewal that has a lower premium due to other benefit changes.


Are there any health care reform requirements that apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans, whether grandfathered or not, must provide the following benefits to their customers for plan years starting on or after September 23, 2010:

  • No lifetime limits on the dollar value of “essential health benefits.” All Sharp Health Plan HMO plans already provide this benefit.
  • No coverage exclusions for children with pre-existing conditions. Sharp Health Plan HMO plans do not include any pre-existing condition clauses for children or adults.
  • No annual limits on the dollar value of “essential health benefits.” Sharp Health Plan HMO plans do not have any dollar annual limits on “essential health benefits.”


What are “essential health benefits”?

The health care reform law lists the following categories as “essential health benefits”:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorders
  • Behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care


Small business premium tax credit

Am I eligible for the premium tax credit under health care reform?

If you are a small employer with fewer than 25 full-time equivalent employees that pays an average wage of less than $50,000 a year, and pays at least half of employee health insurance premiums, then you may qualify for the tax credit. Details are available on the IRS website.


How much is the premium tax credit?

Info about the tax credit can be found on the IRS website


How do I claim the premium tax credit?

You must use IRS Form 8941, Credit for Small Employer Health Insurance Premiums, to calculate the premium tax credit. If you are a small business employer, you may be able to carry the credit backward or forward. And if you are a tax-exempt employer, you may be eligible for a refundable credit. Contact your tax professional for information regarding your specific circumstances.


Dependent coverage under healthcare reform

What changes does health care reform require for dependent coverage?

If you provide coverage for dependent children, you must offer coverage to dependents up to 26 years of age, regardless of marital or student status.


Does the change in dependent coverage apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans that provide coverage to dependent children must offer coverage up to age 26, regardless of grandfathered or non-grandfathered status.


Which of my employee’s dependents can enroll in Sharp Health Plan?

An employee’s child (naturally born or adopted), stepchild or children for whom the employee is the legal guardian may enroll in Sharp Health Plan.


Does an employee’s dependent have to live with them in order to enroll in Sharp Health Plan?

No, an employee’s dependent does not have to live with them to enroll in Sharp Health Plan, but he/she must live or work within Sharp Health Plan’s service area (San Diego and southern Riverside Counties).


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

No, the employee’s spouse and children are not eligible to enroll in Sharp Health Plan under the employee's policy; however, the spouse and children may enroll in their own individual/family plan through Sharp Health Plan.


Contact information

Who can I contact with questions?

You may contact your Sharp Health Plan representative to ask questions about the administration of your health plan. Call us at 858.499.8300 for assistance or send us a message.


Who can my employees contact with questions?

Members can contact Customer Care at 858.499.8300 or toll-free at 1.800.359.2002, or email customer.service@sharp.com. Customer Care representatives are available from 8 a.m. - 6 p.m., Monday through Friday.


Who can I contact regarding billing questions?

Log in to SharpConnect to view your most recent billing activity online. If you have any questions about your premium bill, you can contact your Sharp Health Plan representative at 858.499.8229 for assistance or send us a message


About Sharp Health Plan

Which providers and hospitals are available through Sharp Health Plan?

Sharp Health Plan connects your employees to thousands of physicians and 13 local hospitals throughout San Diego County. Access will vary depending on the network you choose. Compare networks for more details.

You can search our directory to determine if a specific physician is part of Sharp Health Plan’s provider network.


Which wellness programs are available to Sharp Health Plan Members?

Sharp Health Plan Members have direct access to a variety of wellness programs, including online self-management tools, trackers, workshops and telephone-based health coaching.

Visit the Health and Wellness section for more information.


Our networks explained

What is the Performance Network?

Performance is one of Sharp Health Plan’s Plan Networks. The Performance network includes Sharp Community Medical Group (SCMG), Sharp Rees-Stealy Medical Group, Rady Children’s Health Network/CPMG, SCMG Graybill Medical Group, SCMG Inland North Medical Group, and SCMG Arch Health Partners. You will find the name of your Plan Network on your Member ID card.


What is the Premier Network?

Premier is one of Sharp Health Plan’s Plan Networks. The Premier network includes Sharp Community Medical Group and Sharp Rees-Stealy Medical Group. You will find the name of your Plan Network on your Member ID card.


Administration of Sharp Health Plan coverage

Does Sharp Health Plan provide administrative support to manage my health plan benefits?

Your Sharp Health Plan representative is available to address any questions you have about the plan. In addition, Sharp Health Plan issues a Group Administration Manual upon your group’s enrollment.

The manual includes information about:

  • Enrollment cancellation procedures
  • Membership changes
  • Coordination of benefits
  • Continuation of coverage
  • Billing procedures
  • Terms and definitions


Does Sharp Health Plan send detailed benefits information to my employees?

Sharp Health Plan provides a Member ID card and welcome letter with information on where to find a Member’s summary of benefits and Member Handbook online. 


How do I order new employee packets and additional forms?

You may contact your Sharp Health Plan representative to order additional employee packets. Call us at 858.499.8300 for assistance. 


How do I enroll or remove an employee from our plan?

Log in to SharpConnect to complete enrollment and disenrollment online.

For paper enrollment, the new employee will need to complete the enrollment application once he or she has fulfilled your group’s waiting period. This form must be received by Sharp Health Plan within 30 days of the eligibility date.

To disenroll an employee on paper, you must complete the appropriate section of the complete the appropriate section of the enrollment application or by contacting your Sharp Health Plan representative. The application must be received by Sharp Health Plan by the end of the month in which coverage is to end. 


Payments

When is my premium due each month?

Premium payments are due by the first day of each coverage month.


How can I make my monthly payment?

We offer several options to make your monthly premium payment. You can:

  • Make a payment online at sharphealthplan.com 
  • Call our Customer Care department to make a payment by phone at 1.800.359.2002
  • Send your payment by mail to us at:

Sharp Health Plan
P.O. Box 57248
Los Angeles, CA 90074-7248

  • Pay in person Monday through Friday from 8 a.m. to 5 p.m. at:

Sharp Health Plan
8520 Tech Way, Suite 200
San Diego, CA 92131


What forms of payments does Sharp Health Plan accept?

We accept:

Credit cards (Visa® and MasterCard®)
Debit cards (endorsed by Visa or MasterCard)
Check or money orders
Cash
Bank wire
ACH payments


How to make one-time or recurring payments online

Do I need to create an account to make a one-time payment?

No, you do not need to create an account to make a one-time payment. However, creating an account will allow you to view your online payment history, and set up recurring payments. Signing up is easy.


Why do I need to provide my email address when making a one-time payment?

 

After you make a payment, we use your email address to send you a payment receipt.


What is the difference between the Responsible Party Information and the Member Information?

Member means a person who is enrolled for coverage with Sharp Health Plan. The Responsible Party is the cardholder who is making the payment. This may be the Member or the person who will be making payments on behalf of a Member(s).


Where can I find my Account ID number?

If you are an existing Member, you can find your Sharp Member ID number at the top left corner of your Member ID card. The Member ID number is also listed on the premium billing statements mailed to you each month. If you do not have a Sharp Member ID, you can enter one of the following ID numbers when making an online payment:

  • The Reference ID number found on the first billing statement you received from Sharp Health Plan.
  • The Sharp Application ID you were provided when you applied for coverage through the Sharp Health Plan small group resources website.
  • The Covered CA ID you were provided when you completed your Covered California online application.


Is making an online payment secure?

The Sharp Health Plan payment portal is a safe and secure way to pay your premium online. We use Payment Card Industry (PCI) compliant software with a secure payment gateway.


Will I get confirmation after making my online payment?

After making your online payment, you will receive an on-screen receipt number. You will also receive an emailed confirmation of your payment including the receipt number and payment amount.


Can I set up automatic payments?

Yes, setting up automatic payments is simple. You must first create an account on the payment portal. To set up automated recurring payments, select the Member, payment method and enter the amount of each payment. Select a start and end date* for the payments.

*Note: Recurring payments should only be set up for the current coverage year. Payments can only be scheduled to occur between the 1st and 28th of each month. It is important that you renew the auto payments each January.


How do I cancel an automated payment?

To cancel automated payments, first log in to your profile. Under "Existing Automated Payments" click on the "Cancel" button link located to the right of the scheduled recurring payment.


How can I view any previous payments I made?

You can create an account to view your previous online payments.


How long will it take for my account to be updated after I make a payment?

Your account will be updated within two business days of making your online payment.


Managing/Updating my information in the payment portal

How do I change my Payment Portal email address?

If you have an account: 
You must contact Customer Care at 858.499.8300 or 1.800.359.2002 to change your email address.

If you do not have an account:
If you entered your email address when making a one-time payment, simply use the new email address the next time you make a one-time payment. We request your email address to send you a one-time payment receipt.


How do I update or change a credit card?

 If your credit card information changes, log into the payment portal and select Profile. Under the Payment Method section, simply delete the old credit card and add the new credit card information.

If you update the credit card information used for your recurring payments, you must delete the current recurring payment setup and establish a new recurring payment setup.


Late payments

What happens to my coverage if I don’t pay my bill on time?

On Exchange (Plans through Covered California)

Subsidy Members (receiving a premium tax credit): If you do not pay your premiums when due, Sharp Health Plan will mail you a notice of payment delinquency. If you have previously paid at least one full month’s premium during the benefit year, we will provide you with a grace period of 3 consecutive months to pay the premium owed. If you do not pay your premium after the first 30 days of the grace period, your coverage for months 2 and 3 will be suspended. If this occurs, Sharp Health Plan will notify your providers that your coverage has been suspended and your providers will not be obligated to treat you. If you pay the full premium owed during the grace period, your enrollment will be reinstated to the last day of paid coverage and your enrollment information will be updated so that your providers will know that you are eligible to receive covered benefits once again.

Non-subsidy Members (those NOT receiving a premium tax credit): If you do not pay your premiums when due, then coverage for you and your dependents will end at the end of your 30-day grace period, effective on the 31st day after notice for nonpayment of premiums. Sharp Health Plan will mail you a grace period notice at least 30 calendar days before any cancellation of coverage. The 30-day grace period will not begin until after the end of any coverage period for which Sharp Health Plan has received full payment. This Prospective Notice of Cancellation will provide information to you regarding the consequences of your failure to pay the Premiums due within 30 days of the date the notice was mailed. If payment is not received from you within 30 days of the date the Prospective Notice of Cancellation is mailed, Sharp Health Plan will cancel the Membership Agreement and mail you a Notice Confirming Termination of Coverage, which will provide you with the following information:

• That the Membership Agreement has been cancelled for non-payment of Premiums.
• The specific date and time when your coverage ended.
• Sharp Health Plan’s telephone number to call to obtain additional information.

Once a Member pays the bill, the coverage will be reinstated retroactively.


 

If you can't find an answer to your question, please send us a message or call Customer Care at 858.499.8300. We're here to help.



 

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