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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

Contract Termination: Rideout Memorial Hospital and Freemont Medical Center

Date: 03/27/17

On March 17, 2017 California Health & Wellness terminated its contract with Rideout Memorial Hospital and Freemont Medical Center. Per the DMHC approval of the termination:

1)    California Health & Wellness (The Plan) will allow our providers and provider groups to continue referring services to the Rideout Memorial Hospital and Freemont Medical Center (Terminating Hospital) after the termination date, and allow all enrollees to receive the following services at the Terminating Hospital after the termination date:

a)    Any medically necessary services that cannot be scheduled at an Alternate Hospital or other hospital, within a reasonable geographic distance, in a timely manner consistent with good professional practice,

b)    Any medically necessary services that are available at the Terminating Hospital, but not available at any other contracted or non-contracted hospital within a reasonable geographic distance, including, but not limited to, Neonatal ICU, Labor and Delivery Services, Acute Neonatal Services, and

c)    Any medically necessary services, when due to an insufficient number of providers or hospitalists with active admitting privileges at the Alternate Hospitals, an enrollee may not be admitted to an Alternate Hospital or other hospital within a reasonable geographic distance, in a timely manner consistent with good professional practice.

2)    For Plan members accessing Rideout Memorial Hospital and Freemont Medical Center under conditions above, the Terminating Hospital will continue to be deemed a participating, in-network provider. For these members accessing the Terminating Hospital, the copayment, deductible and percentage coinsurance or any other cost sharing components for care accessed under the aforementioned conditions shall be no greater than the financial responsibility the member would have had, if the member received the services from the Terminating Hospital prior to the Termination Date.

If a dispute arises between the Plan and the Terminating Hospital concerning the reasonable and customary value of the provider's service, the Plan shall protect and hold the enrollee harmless for any amount above the member’s in-network copay, deductible, and/or coinsurance.

3)    For Members accessing the Terminating Hospital under conditions (1) one above, the Plan will pay, directly to the Terminating Hospital, as applicable:

a.     The amount required by any post-termination rates set forth in the contract between the Plan and the Terminating Hospital,

b.    The amount set forth in any negotiated letter of agreement or other negotiated arrangement between the Plan and the Terminating Hospital regarding the services, or

c.     The reasonable and customary value of the hospital's services, less the enrollee's established in-network copay, deductible, and/or coinsurance.

4)    The Plan will not take any adverse action, financial or other, against the Terminating Hospital with regards to the services identified in these conditions (this does not preclude either the Plan, or the Terminating Hospital, from utilizing any dispute resolution mechanism that would otherwise be available). In addition, the Plan will not take any adverse action, financial or other, against any contracted provider for admitting affected enrollees to the Terminating Hospital in order to receive services required by these conditions.

5)    With respect to these conditions, “deemed to be a participating in-network provider” does not apply to emergency services or post-stabilization services rendered to Plan members at the Terminating Hospital following the Termination Date, nor does it affect any existing statutory and/or regulatory payment obligations with respect to these services.

6)    The Plan shall ensure, with respect to enrollees who are approved to receive Completion of Covered Services from the Terminating Hospital, that the copayment or percentage copayment and any other cost sharing components for such care is no greater than the financial responsibility the enrollee would have had, if he or she received the services from the Terminating Hospital prior to the Termination Date.