Benefits Guide

Acupuncture

L.A. Care covers acupuncture services to prevent, modify, or alleviate the perception of severe, persistent chronic pain resulting from a generally recognized medical condition. Outpatient acupuncture services (with or without electric stimulation of the needles) are limited to two services in any one month, and additional services can be provided through L.A. Care pre-approval (prior authorization) as medically necessary.

Alcohol/Drug Abuse

L.A. Care covers screening and brief interventions for substance abuse by primary care providers (PCP).  For more intensive substance use disorder services, including residential services, your PCP or mental health specialist may refer you to Los Angeles County Substance Abuse Prevention and Control (SAPC).  You do not need a referral to request services from Los Angeles County.  You can call SAPC at 844-804-7500.

Asthma Services

L.A. Care covers these asthma services for members when medically necessary:

  • Nebulizers (including face mask and tubing)
  • Inhaler spacers and peak flow meters for management and treatment of asthma
  • Member education on proper use of nebulizers, inhaler spacers and peak flow meters for asthma

Learn more about the L.A. Cares About Asthma® education program.

Behavioral Health Treatment

Behavioral health treatment (BHT) includes services and treatment programs, such as applied behavior analysis and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual. BHT is designed to help children and teens who have autism spectrum disorder, a condition that affects how a person relates to others.

BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of a targeted behavior. BHT services are based on reliable evidence and are not experimental.

BHT services include:

  • Behavioral interventions
  • Cognitive behavioral intervention packages
  • Comprehensive behavioral treatment
  • Applied behavioral analysis

BHT services must be medically necessary, prescribed by a licensed doctor or psychologist, approved by L.A. Care, and provided in a way that follows the approved treatment plan.

Cancer Screening

L.A. Care covers the following cancer screening services:

  • All generally medically accepted cancer screening tests, including coverage for screening and diagnosis of prostate cancer
  • Colon cancer screening
  • Mammography for breast cancer screening
  • Pap exam
  • Cervical cancer screening test, including:
    • Human Papilloma Virus (HPV) screening
    • HPV vaccinations including, but not limited to, Gardasil for girls and young women ages 9 through 26

Cancer clinical trials. If you have cancer, you may be able to be part of a cancer clinical trial. A cancer clinical trial is a research study with cancer patients to find out if a new cancer treatment or drug is safe and treats a member’s type of cancer.

Cardiac Rehabilitation

L.A. Care covers inpatient and outpatient cardiac rehabilitative services.

Chiropractic Services

L.A. Care covers two chiropractic services per month, limited to the treatment of the spine by manual manipulation.

Diabetic Services

L.A. Care covers these diabetic services when medically necessary:

  • Medical equipment
  • Prescription drugs on the L.A Care formulary
  • Diabetes-related supplies:
    • Blood glucose monitors and blood glucose testing strips
    • Blood glucose monitors designed to assist the visually impaired for insulin dependent, non-insulin dependent and gestational diabetes
    • Insulin pumps and all related necessary supplies
    • Ketone urine testing strips
    • Lancets and lancet puncture devices
    • Pen delivery systems for the administration of insulin
    • Podiatric devices of the feet (such as special footwear or shoe inserts) to prevent or treat diabetes related complications
    • Insulin syringes
    • Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin
  • Training and health education for self-management
  • Family education for self-management

Learn more about the L.A. Cares About Diabetes® program.

Drugs/Medications

Prescription drugs and over-the-counter drugs on the L.A. Care formulary are covered. Drugs on the formulary are safe and effective. A group of doctors and pharmacists update this list.  You can view the formulary by visiting the Pharmacy Services page.

Sometimes L.A. Care needs to approve a drug that the provider prescribed. L.A. Care will review and decide on these requests within 24 hours.

  • A pharmacist or hospital emergency room may give you a 72-hour emergency supply if they think you need it. L.A. Care will pay for the emergency supply.
  • If L.A. Care says no to the request, L.A. Care will send you a letter that lets you know why and what other drugs or treatments you can try.
Durable Medical Equipment (DME)

L.A. Care covers medically necessary DME that is ordered by an L.A. Care doctor or other provider. DME is equipment that is used over and over again by a person who is ill or injured. L.A. Care will decide whether to rent or buy DME. The rental costs must not be more than the cost to buy. L.A. Care covers the repair of medical equipment.

Examples of DME:

  • Apnea monitors
  • Blood glucose monitors, including monitors for the visually impaired, for insulin dependent, non-insulin dependent and gestational diabetes
  • Hearing Aides (including implanted hearing devices)
  • Incontinent Creams and Washes
  • Insulin pumps and all related supplies
  • Nebulizer machines, Pulmo-Aides and related supplies
  • Orthotics (shoe inserts)
  • Ostomy bags
  • Oxygen and oxygen equipment
  • Prosthesis
  • Spacer devices for metered dose inhalers
  • Tubing and related supplies
  • Urinary catheters and related supplies
Emergent or Urgent Care

For emergency care, call 911 or go to the nearest emergency room (ER).

Emergency services are covered 24 hours a day, seven days a week, anywhere.

You do not need pre-approval (prior authorization).

Emergency Care

Emergency Care is for emergency medical conditions. It is for an illness or injury that a reasonable layperson (not a health care professional) with average knowledge of health and medicine could expect that, if you do not get care right away, your health (or your unborn baby’s health) could be in danger, or a body function, body organ or body part could be seriously harmed. Examples include:

  • Active labor
  • Broken bone
  • Severe pain, especially in the chest
  • Severe burn
  • Drug overdose
  • Fainting
  • Severe bleeding
  • Psychiatric emergency condition such as someone who is a danger to himself/herself

Urgent Care

Urgent care is care you need within 24 hours, but it is not an emergency or life threatening. Urgent care needs could be a cold or sore throat, fever, ear pain or a sprained muscle.

Family Planning

Family planning services are provided to members of childbearing age to help them to determine the number and spacing of children. These services include all methods of birth control approved by the Food and Drug Administration. As a member, you pick a doctor who is located near you and will give you the services you need.

L.A. Care’s PCP and Ob/Gyn specialists are available for family planning services. For family planning services, members may also pick a doctor or clinic not connected with L.A. Care without having to get pre-approval from L.A. Care. L.A. Care will pay that doctor or clinic for the family planning services you get.

Health Education Services

L.A. Care has health education materials, programs and services to help members stay healthy. These programs are free. Health education services can help members by:

  • Promoting health: Learn to develop life-long healthy habits
  • Preventing diseases: Learn how to prevent and care for life-threatening illnesses.
  • Helping you manage chronic diseases

Learn more about these topics by talking to your doctor or through health education services:

  • Asthma
  • Dental Health
  • Diabetes
  • Drug and Alcohol Programs
  • Exercise/Fitness
  • Family Planning/Birth Control
  • HIV
  • Healthy Foods
  • High Blood Pressure
  • Immunization (Shots)
  • Parenting/Child Health
  • Prenatal Health
  • Safety Tips
  • Sexually Transmitted Diseases (STDs)
  • Tobacco Use (how to quit or prevent smoking)
  • Weight Problems
  • Violence/Abuse

Health education services include:

  • Written materials (booklets)
  • Tapes, DVDs, CDs or videos
  • Referrals to health education classes or programs
  • Counseling (one-on-one teaching, phone or group)
  • Support groups
  • Online community resource and health education information

To learn more, visit our health education page.

Workshops and classes are also available at a Family Resource Center near you. You can view the calendar of classes for each Family Resource Center. 

Hearing Aids

L.A. Care covers hearing aids if you are tested for hearing loss and receive a prescription from your doctor. L.A. Care may also cover hearing aid rentals, replacements and batteries for your first hearing aid.

HIV Testing

L.A. Care covers these confidential services for Human Immunodeficiency Virus (HIV):

  • Screening
  • Prevention
  • Testing
  • Diagnosis; and after diagnosis
  • Treatment

Examples of where you can get confidential HIV testing include:

  • Your PCP doctor,
  • Los Angeles County Department of Health Services,
  • Family planning services providers, and
  • Prenatal clinics.

Please call L.A. Care 1-888-4LA-CARE (1-888-452-2273) to request a list of testing sites.

Home Health

L.A. Care covers these health services provided in your home, when they are medically necessary and prescribed by your doctor.  These services include:

  • Short-term physical, occupational and speech therapy,
  • Respiratory therapy

Home health providers include:

  • Registered Nurses (RNs),
  • Licensed Vocational Nurses (LVNs),
  • Home health aides,
  • Medical social services

If a service can be provided in more than one location, L.A. Care will work with the provider to choose the location.

Hospice Care

L.A. Care covers hospice care for eligible members.  Hospice is care to reduce physical, emotional, social and spiritual discomforts for a member with a terminal illness (not expected to live for more than 6 months).

If you decide to receive hospice care, you may not receive other benefits for the terminal illness while you are in hospice. You can choose to receive hospice for up to two (2) periods of 90 days each. After that, you may choose to receive hospice for unlimited periods of 60 days each.

If you are under the age of 21, L.A. Care will offer and pay for covered services related to your terminal illness even if you choose to receive hospice care.

Hospital Care

L.A. Care covers hospital care that includes:

  • Inpatient services
  • Intensive care
  • Outpatient services
  • Surgical services (Bariatric, Reconstructive Surgery, Mastectomy, etc.)
Lab Services

L.A. Care covers these services:

  • Blood work
  • Urine tests
  • Throat cultures
  • X-rays

Services must be provided at a network:

  • Doctor’s office,
  • Hospital,
  • Laboratory
Long-term services and supports (LTSS)

L.A. Care covers these LTSS benefits for members who qualify:

  • Skilled nursing facility services (91+ days)
  • Personal care services
  • Self-directed personal assistance services
  • Community First Choice Option
  • Home and Community Based Services
  • Institutional Long-term Care
Maternity | Prenatal | Newborn Care

L.A. Care covers these maternity, prenatal and newborn services:

  • Breastfeeding Education
  • Delivery and Postpartum care
  • Nurse midwife services
  • Prenatal Care
    • Regular doctor visits during your pregnancy (called prenatal visits)
    • Prenatal supplements
    • Diagnostic and genetic testing
  • Birthing center services
  • Care of a newborn child (for the month of birth and the following month)

If you are pregnant, call us at 1-888-4LA-CARE (1-888-452-2273) right away. We want to make sure you get the care you need. 

L.A. Care will help you choose your maternity care doctor from a doctor in your network. Ask your doctor to find out more.

Minor Consent Services

There are some services adolescent members (children ages 12 to 21) can get without a parent’s okay. Minors can decide to get these services through their doctor or from other qualified providers not with L.A. Care’s network.

The following services are covered:

  • Counseling and surgical procedures to end pregnancy (abortion),
  • Drug and alcohol abuse services for members 12 years of age or older,
  • Family planning services,
  • Outpatient mental health treatment and counseling,
  • Pregnancy related services,
  • Sexual assault services (including rape),
  • Sexually transmitted disease (STD) services for members 12 years of age or older
  • Outpatient mental health treatment and counseling for minors (12 to 21 years of age) who are not mature enough to participate, and where:
    • There is danger of serious physical or mental harm to themselves or to others; or
    • They are a victim of incest or child abuse.
Obstetrical/Gynecological (Ob/Gyn)

L.A. Care members who are pregnant do not need a referral or okay from their doctor or L.A. Care to see an Ob/Gyn who works in their network. Please call L.A. Care if you have any questions.

Orthotics/prostheses

L.A. Care covers orthotic and prosthetic appliances and services that are medically necessary and prescribed by your doctor.

Podiatry (services for the feet)

L.A. Care covers podiatry services that are medically necessary.  Some podiatry services will require pre-approval (prior authorization) except when received on an emergency basis.  Services are limited to:

  • Treatment for disorders for the feet, ankles, or tendons that insert into the foot,
  • Complicating chronic medical diseases, and
  • The ability to walk.
Pulmonary Rehabilitation

L.A. Care covers pulmonary rehabilitation that is medically necessary and prescribed by a doctor. Pulmonary rehabilitation is a program of exercise, education, and support to help members learn to breathe and function at the highest level possible.

Reconstructive Surgery

L.A. Care covers reconstructive surgery when medically necessary.  Reconstructive surgery fixes problems that can be caused, by a birth defect, disease, or injury.

Sexually Transmitted Disease (STD) Services

L.A. Care covers the following STD services:

  • Preventive care
  • Screening
  • Testing
  • Diagnosis
  • Counseling
  • Treatment and
  • Follow-up

Members can get confidential STD services from any doctor or clinic. Members do not need a referral or okay from your doctor.

Temporomandibular Joint (TMJ) disease

L.A. Care covers treatment of TMJ.  TMJ is a disease of the temporomandibular joint (“TMJ”) that connects the lower jaw to the skull. TMJ disease is covered only for medically necessary surgery or treatment to realign the jaw, and not for a dental disorder.

Therapy - Occupational, Physical and Speech

Occupational Therapy

L.A. Care covers the following physical therapy services when medically necessary:

  • Evaluation,
  • Treatment planning,
  • Treatment,
  • Instruction and consultative services

Physical Therapy

L.A. Care covers the following physical therapy services when medically necessary:

  • Physical therapy evaluation,
  • Treatment planning (treatment, instruction, consultative services), and
  • Application of topical medications

Speech Therapy

L.A. Care covers speech therapy that is medically necessary.  You may have limitations as to how many visits you get per month.

Transgender Services

L.A. Care covers these services when medically necessary for members who qualify:

  • Psychotherapy
  • Continuous hormonal therapy
  • Laboratory testing to monitor hormone therapy, and
  • Gender reassignment surgery that is not cosmetic in nature
Transportation

IMPORTANT: For emergency transportation services, call 911

L.A. Care members are eligible for both emergency and non-emergency transportation benefits. Depending on your plan and the service needed, prior authorization may be required. Always consult your plan handbook or call Member Services at 1-888-839-9909 (TTY 711) for complete details.

Non-Emergency Medical Transportation (NEMT)

This transportation type can include transport by ambulance, litter van, wheelchair van medical transportation services, and/or coordinating with para transit.
The forms of transportation are authorized when:

  • Your medical and/or physical condition does not allow you to travel by bus, passenger car, taxicab, or another form of public or private transportation, and
  • Transportation is required for the purpose of obtaining needed medical care.

Non- Medical Transportation (NMT)

This benefit allows for transportation to approved medical services by passenger car, taxi, or other forms of public/private transportation.
The forms of transportation are authorized when:

  • Medically necessary covered services.
  • Members picking up drug prescriptions that cannot be mailed directly to the member.
  • Members picking up medical supplies, prosthetics, orthotics and other equipment.
Vision Care

L.A. Care covers the following vision services:

  • Eyeglasses for members under the age of 21 who qualify, as determined by L.A. Care
  • Eyeglasses for pregnant women through postpartum
  • Routine eye exam once in 24 months

If you have questions about what is covered or not covered, please call L.A. Care at 1-888-839-9909 (TTY 711).

Medi-Cal provides medical, dental, and vision coverage. All covered benefits are free.

  • Doctor visits
  • Dental and mental health services*
  • Prescription drugs
  • Vision care
  • Hospital care
  • Emergency room care
  • Shots (immunizations), and more

*L.A. Care will help give you information on how you can get these services.

All services require prior authorization unless the benefit says that it does not require prior authorization. “Prior authorization” means that your doctor and L.A. Care agree that services and care are necessary. Call our Member Services Department at 1-888-839-9909 (TTY 711) if you have any questions.

Description of Medi-Cal Benefits

You should read your Member Handbook for a full description of coverage benefits and limitations. You can find your member handbook in the resources section on the right side of this page.

Click on one of the topics below to learn more about that benefit.

If you have questions about what is covered or not covered, please call L.A. Care at 1-888-839-9909 (TTY 711).