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
What Happens After I File a Grievance?
Within 5 calendar days of getting your complaint, GCHP will send you a letter telling you we got it. Within 30 days, we will send you another letter that tells you how we resolved your problem. If you call GCHP about a grievance that is not about health care coverage, medical necessity, or experimental or investigational treatment, and your grievance is resolved by the end of the next business day, you may not get a letter.
If you have an urgent matter involving a serious health concern, we will start an expedited (fast) review. We will give you a decision within 72 hours. To ask for an expedited review:
- Call us at 1.888.301.1228 (TTY 711).
Within 72 hours of getting your complaint, we will decide how we will handle your complaint and whether we will expedite it. If we find that we will not expedite your complaint, we will tell you that we will resolve your complaint within 30 days. You may contact the California Department of Health Care Services directly for any reason, including if you believe your concern qualifies for a fast review, GCHP does not respond to you within the 72-hour period, or if you are unhappy with GCHP’s decision.
Complaints related to Medi-Cal Rx pharmacy benefits are not subject to the GCHP grievance process or eligible for Independent Medical Review. To submit complaints about Medi-Cal Rx pharmacy benefits:
- Call 1.800.977.2273. If you use a TTY, call 1.800.977.2273 (press 7) or call 711.
- Or go to the Medi-Cal Rx website: https://medi-calrx.dhcs.ca.gov/home/.
What to Do if You Do Not Agree with an Appeal Decision
If you requested an appeal and got a letter telling you we did not change our decision, or you never got a letter and it has been past 30 days, you can ask for a State Hearing from the California Department of Social Services (CDSS) and a judge will review your case.
- Call CDSS’ toll-free telephone number is 1.800.743.8525 (TTY 1.800.952.8349).
- You can also ask for a State Hearing online at https://www.cdss.ca.gov.
You will not have to pay for a State Hearing. The Member Handbook has more information on how to ask for a State Hearing.
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.
This Member Handbook tells you about your coverage as a member of 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. 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 is 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.
2025 Member Handbook Changes
On April 1, 2025, information about Physician Administered Drugs or Medical Drug Benefit was updated. This change is under Section 4: Benefits and services:
4. Benefits and services
Physician Administered Drugs or Medical Drug Benefit
GCHP covers certain medications (drugs) that you get at your doctor’s office or hospital, such as an injection. These medications are called Physician Administered Drugs (PAD) and are covered by GCHP’s Medical Drug Benefit. Some medicines need a Prior Authorization Treatment Request Form submitted by your doctor for review and approval. The list of medicines that need approval from GCHP is called the PAD list. You can find the PAD list, and what is needed to cover your medicines, on the GCHP website at www.goldcoasthealthplan.org/for-members/pharmacy-services/medical-drug-benefit.
You can also find updates and changes to the PAD list on the website. The information is updated about four times a year. If you have any questions or want a copy of the PAD list and what GCHP needs to cover the medicines through this benefit, call GCHP’s Member Services Department at 1.888.301.1228, Monday through Friday, 8 a.m. to 5 p.m. (except holidays). If you use a TTY, call 711.
Certain medical services require referrals and/or prior authorizations. To learn more please see below.
Referrals
If you need a specialist for your care, your Primary Care Provider (PCP) or another specialist will refer you to one. A specialist is a doctor who focuses on one type of health care service. The doctor who refers you will work with you to choose a specialist.
To help make sure you can go to a specialist in a timely way, the state Department of Health Care Services (DHCS) sets time frames for members to get appointments. These time frames are listed in the Member Handbook. Your PCP’s office can help you set up an appointment with a specialist.
You might need a referral for:
- In-office procedures
- X-rays
- Lab work
Your PCP might 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 as long as they think you need treatment.
If you have a health problem that needs special medical care for a long time, you might 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, Monday through Friday, 8 a.m. to 5 p.m. (except holidays). If you use a TTY, call 711.
You do not need a referral for:
- PCP visits
- Obstetrics / Gynecology (OB/GYN) visits
- Urgent care or emergency department (ED) visits
- Adult sensitive services, such as sexual assault care
- Family planning
- HIV testing and counseling (12 years or older)
- Sexually transmitted infection (STI) care (12 years or older)
- Chiropractor services (a referral may be required when done out-of-network like at Federally Qualified Health Center [FQHCs], Rural Health Clinics [RHCs], and Indian Health Care Provider [IHCPs])
- Initial mental health assessment
- Podiatry
- Eligible dental care
Minors can also get certain outpatient mental health services, sensitive services, and substance use disorder services without their parent’s consent.
Prior Authorization
For some types of care, your PCP or specialist will need to ask GCHP for permission before you get the care. This is called asking for prior authorization. It means GCHP must make sure the care is medically necessary (needed).
Medically necessary services are reasonable and necessary to protect your life, keep you from getting seriously ill or disabled, or reduce severe pain from a diagnosed disease, illness, or injury. For members under 21 years of age, Medi-Cal services include care that is medically necessary to fix or help relieve a physical or mental illness or condition.
You need a prior authorization, even if you get them from a provider in the GCHP network for:
- Hospitalization, if not an emergency
- Care out of the GCHP service area, if not urgent or an emergency
- Outpatient surgery
- Long-term or skilled nursing care at a nursing facility
- Specialized treatments, imaging, testing, and procedures
- Medical transportation when it is not an emergency
Emergency ambulance services do not require prior authorization.
Under Health and Safety Code Section 1367.01(h)(1), GCHP has seven business days from when GCHP gets the information reasonably needed to decide (approve or deny) prior authorization requests. If a provider or GCHP finds that following the standard time frame could seriously endanger your life, health, or ability to attain, maintain, or regain maximum function, GCHP will make an expedited (fast) prior authorization decision. GCHP will give you notice as quickly as your health condition requires and no later than 72 hours after getting the request for services.
Clinical or medical staff, such as doctors and nurses, review prior authorization requests. GCHP does not influence the reviewers’ decision to deny or approve coverage or services in any way.
If GCHP does not approve the request, we will send you a Notice of Action (NOA) letter. The NOA will tell you how to file an appeal if you do not agree with the decision.
GCHP will contact you if more information or time is needed to review your request.
You never need prior authorization for emergency care, even if it is out of the network or your service area. This includes labor and delivery if you are pregnant. You do not need prior authorization for certain sensitive care services.
For questions about prior authorization, call 1.888.301.1228, Monday through Friday, 8 a.m. to 5 p.m. (except holidays). If you use a TTY, call 711.
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