activities · 15
what they do
direct service · 15
- Allows continuation of care with out-of-network providersPermits members to continue care with out-of-network providers for specific conditions including acute and chronic illnesses, pregnancy, maternal mental health, newborn care, terminal illness, and scheduled surgeries.
- Applies consistent utilization management criteria Integrated Care & Case ManagementApplies uniform clinical review standards across medical/surgical, mental health, and substance use disorder services, incorporating diagnosis, severity, age, comorbidities, treatment history, and psychosocial context.
- Delivers health education programs and resources Community Health Education & Wellness PromotionOffers health education classes on various topics and provides web-based screening tools to support member health literacy and prevention.
- Offers annual vision benefits Vision and Hearing Aids ProvisionProvides annual vision benefits covering one pair of lenses and frames, up to $500 per year for Medi-Cal members and $300 for Medicare Advantage members.
- Offers comprehensive dental benefitsProvides comprehensive dental services with an annual maximum of $2,500 for Medi-Cal members and up to $2,300 for Medicare Advantage members for services in San Diego County not covered by Medi-Cal Dental Program.
- Offers specialized Medicare Advantage plans Union and Association Health Benefits AdministrationProvides a targeted Medicare Advantage plan for individuals with cardiovascular disorders, chronic heart failure, and/or diabetes.
- Operates online Member Portal for member self-serviceManages a digital Member Portal that enables members to update personal information, change their primary care provider, and print their member ID card.
- Partners on diabetes prevention programs Chronic Disease Self-Management EducationCollaborates with the Skinny Gene Project to deliver a no-cost diabetes prevention program to members.
- Processes claims within 15 working days Nonprofit Insurance Claims Processing & ResolutionProcesses claims on average within 15 working days to ensure timely reimbursement and service continuity.
- Provides 24/7 member support services Member Support and Guidance ServicesOffers round-the-clock member services to answer questions and address concerns.
- Provides Medi-Cal health coverage in San Diego County Sliding Fee Scale Healthcare ServicesOffers a no-cost health plan with no copayments, deductibles, or annual or lifetime maximums to residents of San Diego County through its Medi-Cal program.
- Provides no-cost interpretation and translation services Language Interpretation and Translation ServicesOffers 24/7 interpretation and translation services in multiple languages including Spanish, Vietnamese, Tagalog, Arabic, Chinese, Farsi, and American Sign Language, with accessible materials available in braille, audio, and large print.
- Provides over-the-counter medication benefitOffers a benefit of $200 every three months ($800 annually including sales tax) for over-the-counter medications to members.
- Provides worldwide emergency services coverage Group Life and AD&D InsuranceOffers worldwide emergency services coverage with a $50,000 annual maximum per incident for members, excluding transportation back to the U.S.
- Publishes multilingual member newsletters Bilingual Health Education Materials ProductionProduces and distributes a member newsletter tailored by health plan and available in multiple languages, including Spanish, to support informed healthcare engagement.
strategies · 7
how they think
Theories of action extracted from this org's own source material. Click any to see the full field of orgs running the same approach.
- Chronic Condition-Focused Special Needs Plan chronic_special_needs_planTargets individuals with specific chronic conditions such as cardiovascular disorders, chronic heart failure, and diabetes through a Chronic Special Needs Plan (C-SNP) model to deliver tailored, effective care.
- Comprehensive Member Support and Access member_support_and_accessEnsures members have continuous access to support services, including 24/7 Member Services Representatives and multilingual interpretation in over 200 languages, to remove barriers to care.
- Health Education Integration health-educationSupplements clinical care with health education classes to improve member health knowledge, empowering individuals to manage their conditions and make informed health decisions.
- Integrated Medicare-Medicaid Model integrated_medicare_medicaidIntegrates Medicare and Medi-Cal benefits into a single health plan, simplifying access and expanding coverage with additional benefits at no extra cost to members.
- Integrated and Evidence-Based Utilization Management integrated_utilization_managementApplies a consistent, integrated approach to utilization management across medical, mental health, and substance use services, with medical necessity decisions grounded in evidence-based guidelines and national clinical standards.
- Managed Care Coordination managed_careUses a managed care model to coordinate healthcare through networks of doctors and hospitals, enabling early access to care by streamlining service delivery and provider collaboration.
- Person-Centered, Community-Based Care community-based_careDelivers personalized, community-based care that incorporates social and environmental factors into clinical decisions, leveraging local presence and relationships to improve health outcomes.
named programs · 6
what they call their work
CommuniCare Advantage
HMO D-SNP plan integrating Medicare and Medi-Cal benefits for dual-eligible beneficiaries with chronic conditions
Community Supports (CS)
Referral-based program connecting members to social and community-based services
Community y Más
Comprehensive Medicare plan tailored for individuals with chronic care needs
Enhanced Care Management (ECM)
Program providing coordinated care for members with complex health and social needs
Medi-Cal
Comprehensive health plan for low-income individuals in San Diego County, covering medical, dental, vision, pharmacy, and transportation services with no cost-sharing
Medi-Cal Plan
Managed care health plan providing comprehensive medical, dental, vision, and transportation services to low-income individuals in San Diego County
relationships · 16
who they work with
- Agency for Healthcare Research and Quality Government — Consults AHRQ as a source for clinical guidelines in utilization management decisions.
- American Diabetes Association Network — Uses guidelines from American Diabetes Association in medical necessity determinations.
- American Heart Association Network — Uses guidelines from American Heart Association in medical necessity determinations.
- American Lung Association Network — Uses guidelines from American Lung Association in medical necessity determinations.
- Case Management Society of America Government — Uses CMSA Standards of Practice for Case Management in utilization review decisions.
- Centers for Disease Control Government — Consults CDC as a source for clinical guidelines in utilization management decisions.
- DHCS Government — References the DHCS eligibility page for Medi-Cal qualification guidelines.
- Food and Drug Administration Government — Consults FDA as a source for clinical guidelines in utilization management decisions.
- Health Care Options Government — Works with Health Care Options (HCO) to confirm member enrollment in CHG’s Medi-Cal plan.
- Medi-Cal Government — Integrated with CommuniCare Advantage to provide combined benefits for eligible members.
- Medicare Government — Integrated with CommuniCare Advantage to provide combined benefits for eligible members.
- Member Services Partner — Unit providing direct member support, including interpretation services and health plan management assistance.
- National Committee for Quality Assurance Network — Uses NCQA standard quality markers in utilization management processes.
- National Institutes of Health Government — Consults NIH as a source for clinical guidelines in utilization management decisions.
- San Diego County Government — Collaborates with San Diego County for Medi-Cal enrollment and services.
- Skinny Gene Project Partner — Partner organization delivering a diabetes prevention program for CHG members.