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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

20-932 Give Timely Flu Shots to Help Keep Members Healthy

Date: 11/16/20

Availability through providers, local health clinics or network pharmacies can help remove barriers to access the flu vaccine

The flu vaccine is critical to keeping the most vulnerable patients from having the flu and COVID-19 at the same time.

Encouraging the flu vaccine among members can also help conserve health care system resources during the COVID-19 crisis and reduce the prevalence of illness caused by the flu, thereby reducing outpatient visits or hospital admissions.

The flu vaccine is a covered benefit

As a reminder, California Health & Wellness Plan (CHWP) and delegated at-risk independent practice associations (IPAs) must cover the flu vaccine for all members as an essential preventive services benefit. It is not subject to prior authorization or cost share.

As a preventive measure, providers are encouraged to offer members the flu vaccine during an appointment. If you do not have access to the vaccine, you can refer members to a local health department, health clinic, retail clinic or network pharmacy (dependent on the member’s plan). Please inform member that out-of-pocket costs may apply if they receive the flu vaccine at these other locations.

You may use the VaccineFinder website as a resource to find a location close to a member’s home. Be sure to verify flu vaccine coverage for any location pursuant to the member’s plan.

If you need help finding a participating provider for a member, please contact the Provider Services Center at 1-877-658-0305.

Responsibilities of delegated entities

Delegated IPAs that have risk for the flu vaccine are required to cover the flu vaccine for members. Please also ensure:

  • Members have timely access to the vaccine without the need for prior authorization or cost share.
  • Members are referred to alternative sites for flu vaccine in the event the vaccine is not available through their provider or network.
  • Arrangements are made to avoid any out-of-pocket costs for members.

Delegated at-risk IPAs are required to cover the costs of the flu vaccine for members who may be referred to out an out-of-network provider or pharmacy during the COVID-19 state of emergency. Such flu vaccines paid by CHWP or paid out-of-pocket by the member will be deducted from the IPA’s next capitation payment, where applicable.

How to bill the vaccine

The Vaccines for Children program provides free pediatric flu vaccines for Medi-Cal providers. You can bill the administration of the vaccine to Health Net or the IPA, as applicable. Providers can submit a claim for the administration of the vaccine to CHWP or your IPA. Reimbursement corresponds to the Division of Financial Responsibility between CHWP and the IPA, and is in accordance with the terms in your CHWP Provider Participation Agreement (PPA) or your contract with the IPA, as applicable.

Additional information

Providers are encouraged to access CHWP’s provider portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.