Alameda Alliance for Health (Alliance) A comprehensive local health plan covering Alameda County. Alliance Network The health care providers who have joined the Alliance to provide members with high quality services and medical care. Authorization The requirement that certain services be approved by the Alliance or Primary Care Provider in order to be Covered Services. Beneficiary A person(s) receiving health care benefits. Benefits (Covered Services) The health services and medicines paid for under this plan. Child A person who is under 19 years of age. Co-payment The Member's share of the costs to be paid at the time certain services are received. Denti-Cal The program for Medi-Cal dental services in California. Disability An injury, or an illness, or a condition; however, all injuries sustained in any one accident will be considered one disability; all illnesses existing simultaneously which are due to the same or related causes will be considered one disability; if any illness is due to causes which are the same as or related to the causes of any prior illness, the succeeding illness will be considered a continuation of the previous disability and not a separate disability. Disenrollment To stop using the health plan, either because you lose eligibility or because you quit the health plan. You must sign a form that says you do not want to use the health plan any longer. This is when you are no longer a member of the Alliance health plan, for whatever reason. When you disenroll, you can no longer use our services. Emergency A sudden, serious and unexpected illness, injury or condition that requires immediate diagnosis and treatment, or could lead to death or disability. Exclusion Any medical, surgical, hospital, or other treatment for which the Alliance offers no coverage. Fee-for-service Medi-Cal Another name for "regular" Medi-Cal. It is a health care system for Medi-Cal beneficiaries. This is not a managed care system. With "regular" Medi-Cal, beneficiaries may go to any doctor, clinic, or provider they find who will take Medi-Cal patients. Formulary A chosen list of drugs approved by Alameda Alliance for Health that your doctor may prescribe for you. Health Care Options The company who works for the Medi-Cal program to help you choose your managed care health plan in Alameda County. They can also help you fill out the Medi-Cal Choice Form, and enroll or disenroll with health plans. Their telephone number is 1-800-430-4263. Healthy Families Program A low-cost health coverage program that provides health, dental and vision coverage to children from birth to 19 years of age with family incomes below 250% of the federal poverty level. Hospital A facility providing treatment and inpatient and outpatient care from doctors and nurses. Inpatient Care administered to an individual by admission into a hospital as a registered bed patient. In these circumstances, an individual receives Covered Services under the direction of a Physician. Managed Care A system of health care that provides a comprehensive way to help you stay healthy and treat you when you are sick. Managed care services are centered on a Primary Care Provider. He or she personally directs your care and helps you stay well. Medi-Cal A state and federally funded comprehensive health coverage plan for individuals that provides health, dental and vision coverage. Medi-Cal members are within 100% of the Federal Poverty Level (FPL) income guidelines. Medi-Cal Managed Care Health Plan A program to deliver health services to Medi-Cal beneficiaries. A Plan uses only certain doctors, specialists, clinics, pharmacies, and hospitals. If you become a member of a Medi-Cal Managed Care Health Plan or Medi-Cal Health Plan, you get your care using the health care providers who are part of the plan's network. You choose a Primary Care Provider from a Provider List. In most situations, you must visit your Primary Care Provider first. Alameda Alliance for Health is an example of a Medi-Cal Managed Care Health Plan. Medi-Cal Provider Doctors, specialists, clinics, pharmacies, and hospitals that provide health care services to Medi-Cal beneficiaries. Medically Necessary A medical condition that your doctor feels requires treatment. Member (also Subscriber, Enrollee or Customer) A person who joined a managed care health plan, like the Alliance, to receive his or her health care. Mental Health Services Psychoanalysis, psychotherapy, counseling, medical management, or other services most commonly provided by a psychiatrist, psychologist, licensed clinical social worker, or marriage, family, and child counselor for diagnosis or treatment of mental or emotional disorders or the mental or emotional problems associated with an illness, injury, or any other condition. Outpatient Care Healthcare services provided that do not require a patient to be admitted in a hospital or other facility. Plan Provider A physician, hospital, Skilled Nursing Facility, or other licensed health professional, licensed facility, or licensed home health agency who, or which, at the time care is rendered to a Member, has a contract in effect with Alameda Alliance for Health to provide covered services to its members. Preventive Health Care Health care to keep you from getting a disease or to keep you from getting sick. For example, immunizations for children are preventive health care. A complete physical examination is also preventive health care. Primary Care Provider (PCP) The doctor you have chosen to provide you with most of your health care. He or she helps you get the care you need and must approve any care ahead of time, unless it's an emergency. Prior Authorization When both Alameda Alliance for Health and your health care provider agree that the service or care you get is needed before you get the service or care. Specialist or Specialty Care Physician A doctor who only treats certain kinds of health problems like a broken bone, allergies, or heart trouble. In a managed care health plan, your Primary Care Provider usually must send you to the right specialty care doctor. Urgent Care Services for the treatment of a non-life threatening condition that requires prompt medical attention to minimize severity and prevent complications.