You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.
In accordance with state and federal laws and regulations to ensure members have adequate accessibility to available services, Gold Coast Health Plan (GCHP) adheres to the following time and distance standards:
- Primary care, both adult and pediatric: 10 miles or 30 minutes from any member or anticipated member’s residence.
- Specialty care (including OB/GYN), both adult and pediatric: 30 miles or 60 minutes from any member or anticipated member’s residence.
- Hospitals: 15 miles or 30 minutes from any member or anticipated member’s residence.
- Outpatient mental health (non-psychiatry): 30 miles or 60 minutes from any member or anticipated member’s residence.
- Pharmacy: 10 miles or 30 minutes from any member or anticipated member’s residence.
In cases where GCHP is unable to meet time and distance standards for any zip code within Ventura County, an Alternate Access Standards (AAS) request is submitted to the state Department of Health Care Services (DHCS) on an annual basis.
The approved AAS as of December 2021 are:
County: Ventura
Zip Code: 93252
Provider Type: Nephrology
Adult, Pediatric, or N/A: Pediatric
Approved Max Time (minutes): 145
Approved Max Distance (miles): 105
County: Ventura
Zip Code: 93252
Provider Type: PCP
Adult, Pediatric, or N/A: Adult
Approved Max Time (minutes): 110
Approved Max Distance (miles): 85
County: Ventura
Zip Code: 93252
Provider Type: PCP
Adult, Pediatric, or N/A: Pediatric
Approved Max Time (minutes): 110
Approved Max Distance (miles): 85
If your zip code and provider type are listed, you have a right to call GCHP's Member Services Department at 1.888.301.1228, TTY 711 for help finding an appointment with a specialist that is closer to you. If GCHP cannot find you an appointment with a specialist that is closer to you, GCHP will arrange transportation for you to see the specialist.
Los Robles Hospital and Medical Center
215 W. Janss Road
Thousand Oaks, CA 91360
1.805.497.2727
losrobleshospital.com
Ojai Valley Community Hospital (CMH)
1306 Maricopa Highway
Ojai, CA 93023
1.805.646.1401
cmhshealth.org
Santa Paula Hospital (VCMC)
825 N. 10th St.
Santa Paula, CA 93060
1.805.933.8600
vchca.org/hospitals/santa-paula-hospital
Simi Valley Hospital and Health Care Services
2975 N. Sycamore Drive
Simi Valley, CA 93065
805.955.6000
simivalleyhospital.com
St. John's Pleasant Valley Hospital
2309 Antonio Ave.
Camarillo, CA 93010
1.805.389.5800
stjohnshealth.org
St. John's Regional Medical Center
1600 N. Rose Ave.
Oxnard, CA 93030
1.805.988.2500
stjohnshealth.org
Ventura County Medical Center (VCMC)
3291 Loma Vista Road
Ventura, CA 93003
1.805.652.6000
vchca.org/hospitals/ventura-county-medical-center
Gold Coast Health Plan's (GCHP) grievance and appeals process provides a mechanism for members to report complaints regarding their health care benefits. Please use the Member Grievance & Appeals Form to submit your complaint.
Member Grievance & Appeals Form
Submit your completed forms to:
Gold Coast Health Plan
Attn: Member Grievance & Appeals
P.O. Box 9176
Oxnard, CA 93031
The County of Ventura Human Services Agency provides a broad array of services that include the protection of children and vulnerable adults and support for those needing assistance with food, housing, healthcare and employment. Access the Medi-Cal site.
Mammogram services are a free benefit for Gold Coast Health Plan (GCHP) members. A mammogram is an X-ray used to check breasts for breast cancer. Mammograms play a key role in finding breast cancer in its early stages. Finding cancer early can help give you a head start on treatment.
Talk to your doctor about ordering your screening. For a list of contracted imaging centers for mammograms, click here.
This Member Handbook tells you about your coverage under GCHP. Please read it carefully and completely. It will help you understand and use your benefits and services. It also explains your rights and responsibilities as a member of GCHP. If you have special health needs, be sure to read all sections that apply to you.
This Member Handbook is also called the Combined Evidence of Coverage (EOC) and Disclosure Form. It is a summary of GCHP rules and policies and based on the contract between GCHP and state Department of Health Care Services (DHCS). If you would like more information, call GCHP at 1-888-301-1228. If you use a TTY/TDD, call 711.
2023 Member Handbook (English and Spanish)
2023 Member Handbook Changes
On May 1, 2023, the following changes were made to the Member Handbook:
- Added language about California Cancer Equity Act Referral
This new language is found under Section 3: How to get care. - The removal of the word “brief” under cognitive health assessments
This change is found under Section 4: Benefits and services.
Both changes are below for your reference.
3. How to get care
Referrals
Your PCP or another specialist will provide you a referral to visit a specialist within the time frame listed in the “Timely access to care” section of this handbook, if you need one. A specialist is a doctor who has extra education in one area of medicine. Your PCP will work with you to choose a specialist. Your PCP’s office can help you set up a time to go to the specialist.
Other services that might need a referral include in-office procedures, X-rays, lab work.
Your PCP may give you a form to take to the specialist. The specialist will fill out the form and send it back to your PCP. The specialist will treat you for as long as they think you need treatment.
If you have a health problem that needs special medical care for a long time, you may need a standing referral. This means you can go to the same specialist more than once without getting a referral each time.
If you have trouble getting a standing referral or want a copy of the GCHP referral policy, call 1-888-301-1228 (TTY 1-888-310-7347 or 711).
You do not need a referral for:
- PCP visits
- Obstetrics/Gynecology (OB/GYN) visits
- Urgent or emergency care visits
- Adult sensitive services, such as sexual assault care
- Family planning services (to learn more, call Office of Family Planning Information and Referral Service at 1-800-942-1054)
- HIV testing and counseling (12 years or older)
- Sexually transmitted infection services (12 years or older)
- Chiropractic services (a referral may be required when provided by out-of-network FQHCs, RHCs and IHCPs)
- Initial mental health assessment
- Podiatry services
Minors can also get certain outpatient mental health services, sensitive services and substance use disorder services without parent’s consent. For more information read “Minor consent services” and “Substance use disorder treatment services” in this handbook.
California Cancer Equity Act Referrals
Effective treatment of complex cancers depends on many factors including getting the right diagnosis and getting timely treatment from cancer experts.
If you are diagnosed with a complex cancer, the new California Cancer Care Equity Act allows you to ask for a referral from your doctor to get cancer treatment specifically from an in-network National Cancer Institute (NCI)-designated cancer center, NCI Community Oncology Research Program (NCORP)-affiliated site, or qualifying academic cancer center.
If GCHP does not have an in-network NCI-designated cancer center, GCHP will allow you to ask for a referral to get cancer treatment from one of these out-of-network centers in California, if one of the out-of-network centers and GCHP agree on payment, unless you choose to see a different cancer treatment provider.
If you have been diagnosed with cancer, contact GCHP to see if you qualify for services from one of these cancer centers.
4. Benefits and services
Medi-Cal benefits covered by GCHP
Outpatient (ambulatory) services
Cognitive health assessments
GCHP covers an annual brief cognitive health assessment for members who are 65 years of age or older, and are otherwise not eligible for a similar assessment as part of an annual wellness visit under the Medicare Program. A cognitive health assessment looks for signs of Alzheimer’s disease or dementia.
Gold Coast Health Plan (GCHP) values the health of its members. To encourage healthy behavior, GCHP offers incentives to members who complete these preventive care exams:
- Annual Well-Care Exam: Members 3 to 21 years of age who have a well-care visit in 2023 can receive a $25 gift card. Download the form. Read more about well-care visits with GCHP's guide, Well-Care Visits: What to Expect (English and Spanish).
- Breast Cancer Screening: Female members 50 to 74 years of age who have a breast cancer screening (mammogram) in 2023 can receive a $40 gift card. Download the form.
- Cervical Cancer Screening: Members 21 to 64 years of age who have a cervical cancer screening (Pap test) in 2023 can receive a $25 gift card. Download the form.
- Lead Screening: Members 0 to 2 years of age can earn a $25 gift card for completing a blood lead test on or before their second birthday within the calendar year. Download the form.
To learn more, view the Member Rewards flyer. (English and Spanish)
Tri-Counties Regional Center (TCRC) helps people with developmental disabilities of any age with services and support for living, working, learning and recreating in our community.
If you are receiving TCRC services and need help with getting care for a medical problem, talk to your Primary Care Provider (PCP). Your PCP can ask Gold Coast Health Plan's (GCHP) Care Management nurses to work with TCRC and the PCP to help ensure your care needs are met.
TCRC offices in Ventura County:
Oxnard
2401 E. Gonzales Road, Suite 100
Oxnard, CA 93036
1.805.485.3177 or 1.800.664.3177
Fax 1.805.988.9521
Simi Valley
1900 E. Los Angeles Ave., Second Floor
Simi Valley, CA 93065
1.805.522.8030 or 1.800.517.2524
Fax 1.805.522.8142