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Common Questions
Common Questions
If you would like paper copies of any of this information please contact us at 1-888-4LA-CARE (1-888-452-2273).
View recent changes to your Healthy Families Member Handbook:
Below are some health-related topics that are frequently discussed. Click on a topic for more information about it.
- Quality Improvement Program
- Disease Management Program
- How to contact health plan staff if you have questions about Utilization Management issues
- Case management services and how to self refer
- Our policy about financial incentives for providers and staff
- Your rights and responsibilities as a health plan member
- What benefits and services are covered
- What benefits and services are not covered
- Co-payments and other charges
- How to get care from your primary care physician (PCP) doctor
- How to change your primary care physician (PCP) doctor
- What services you can and cannot get outside of Los Angeles County
- What to do if you get a bill
- How to get prescriptions filled and other pharmacy procedures
- How to get information about doctors and specialists who work with your health plan
- How to get specialty care when you need it, like services that require a referral, behavioral health services and hospital services
- How to get care when the office is closed, like weekends, holidays and evenings
- How to get emergency care, like when to go to the emergency room or call 911
- How to complain when you are unhappy about care or service you get
- How to appeal a decision or ask for an independent review if you are denied services, coverage or benefits; or if you are disenrolled from your health plan
- How your health plan evaluates new technology to decide if it should be a covered benefit
- Our notice of privacy practices and how we use and disclose your personal health information (PDF)
- How you can access your personal health information, request restrictions on use and disclosure of your personal health information, request an amendment to your personal health information, request an accounting of our disclosures of your personal health information (PDF)
- How L.A. Care protects oral, written and electronic personal health information and discloses personal health information to health plan sponsors or employers (PDF)
- Your right to authorize or deny release of personal health information beyond uses for treatment, payment or health care operations (PDF)
L.A. Cares About Asthma and L.A. Cares About Diabetes are programs that help people with asthma and diabetes stay healthy. These free programs are staffed by a team of doctors, nurses and other health care team members. We want members and their families to be part of the health care team, too. As part of these programs you will get:
- Information on what causes asthma or diabetes and how you can stay healthy
- Tips on how to control your asthma or diabetes
- A chance to talk to a nurse or educator. We can talk about ways to get you the best care.
Members are signed up for these programs when our records show that you have asthma or diabetes. If you want to be taken out of the program, call us at the phone numbers below.
- Call (888) 200-3094 (TTY/TDD 1-888-448-6894) if you have questions about asthma or want to self refer or enroll yourself into L.A. Cares About Asthma.
- Call (866) 756-2048 (TTY/TDD 1-866-782-7237) if you have questions about diabetes or want to self refer or enroll yourself into L.A. Cares About Diabetes.
How to contact health plan staff if you have questions about Utilization Management issues
When L.A. Care makes a decision to approve or deny your care, this is called Utilization Management (UM). If you have questions about UM or our UM Process, you can call L.A. Care during business hours:
- Monday through Friday, 8 a.m. to 5 p.m.
- The number to call is 1-888-452-2273. This call is free.
To learn more about how decisions about your care are made and services that need an OK, see your Member Handbook (also called “A Helpful Guide to Your Health Care Benefits”).
L.A. Care Health Plan provides access to staff for members and practitioners seeking information regarding the Utilization Management process and the authorization of care.
- UM staff is available during normal business hours Monday through Friday, 8:00 a.m. – 5:00 p.m. After hours staff is available for urgent requests and assistance to members and practitioners.
- Members and practitioners may use the toll-free number to communicate with UM staff. The toll free number is (877) 431-2273.
- Collect calls regarding UM issues are accepted.
Additional instructions on how to obtain authorizations and communicate with UM staff are listed in your Member Handbook or L.A. Care Provider Manual.
Case management services and how to self refer
Care Management is a special program for helping members with chronic conditions or special health care needs such as diabetes, heart conditions, cancer or other medical or physical disabilities. Care Managers and Care Coordinators can help you
- Make a plan for your care with your doctor
- Understand your health care benefits
- Organize your doctor and specialist appointments
- Locate community resources
For more information about care management, or to make a referral, call the L.A. Care UM Department at 1- 877- 431-2273 and ask to speak with a Care Manager.
Our policy about financial incentives for providers and staff
When L.A. Care makes a decision to approve or deny your care, this is called Utilization Management (UM). L.A. Care Health Plan wants you to know that decisions about your health care are based on two things:
- If the care and/or service is right for your condition and
- If your benefits cover the care and/or service.
L.A. Care doctors and other health care staff do not get money or other rewards when making decisions about your care. L.A. Care does not reward staff to make decisions that result in less care than what is requested.
The following health benefits are excluded under the health plan:
- Any services or items specifically excluded in the “Benefit Descriptions” section.
- Any benefits in excess of limits specified in the “Benefit Descriptions” section.
- Services, supplies, items, procedures or equipment which are not medically necessary, unless otherwise specified in the “Benefit Descriptions” section.
- Any services which were received prior to the member’s effective date of coverage. This exclusion does not apply to covered services to treat complications arising from services received prior to the member’s effective date.
- Any services received after coverage ends.
- Experimental or investigational services, including any treatment, therapy, procedure or drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supply which is not recognized as being in accordance with generally accepted professional medical standard or for which the safety and efficacy have not been determined for use in the treatment of a particular illness, injury or medical condition for which the item or service in question is recommended or prescribed.
- Medical services that are received in an emergency care setting for conditions that are not emergencies if you reasonably should have known that an emergency care situation did not exist.
- Eyeglasses, except for those eyeglasses or contact lenses necessary after cataract surgery which are covered under the “Cataract Spectacles and Lenses” benefit.
- The diagnosis and treatment of infertility is not covered unless provided in conjunction with covered gynecological services. Treatments of medical conditions of the reproductive system are not excluded.
- Long-term care benefits including long-term skilled nursing care in a licensed facility and respite care are excluded except when L.A. Care Health Plan determines they are a less costly, satisfactory alternatives to the basic minimum benefits. This section does not exclude short-term skilled nursing care or hospice benefits as provided pursuant to “Skilled Nursing Care” and “Hospice” benefits.
- Treatment for any bodily injury or sickness arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which benefits are provided or payable under any worker’s compensation benefit plan. L.A. Care Health Plan shall provide services at the time of need and the member or member’s legal guardian shall cooperate to assure that L.A. Care Health Plan is reimbursed for such benefits.
- Services which are eligible for reimbursement by insurance or covered under any other insurance or health care service plan. L.A. Care Health Plan shall provide services at the time of need and the member or member’s legal guardian will cooperate to assure that L.A. Care Health Plan is reimbursed for such benefits.
- Cosmetic surgery that is solely performed to alter or reshape normal structure of the body in order to improve appearance.
- Acupuncture services
- Chiropractic services
- Biofeedback services
You will be required to pay a small amount of money for some services. This is called a co-payment. The maximum amount of money you are required to pay out in one benefit year per household is $250. All co-payments paid for Healthy Families Program members in your household apply to the $250 maximum.
Make sure that you keep all receipts from your doctors’ visits and prescriptions for all family members enrolled in the Healthy Families Program. As soon as you have paid $250 in a benefit year, you should photocopy the receipts and send the original receipts to:
L.A. Care Health Plan
1055 West 7th Street
Los Angeles, CA 90017
Attention: Member Services Department
When L.A. Care Health Plan receives your receipts, then no Healthy Families Program members in your household will have to pay co-payments for the rest of the benefit year. You will still need to pay co-payments until L.A. Care Health Plan receives proof that you have paid $250. L.A. Care Health Plan will provide you with a “Co-payment Certification” letter, which will verify that you are no longer required to make co-payments for the remainder of the benefit year. Keep the “Co-payment Certification” letter with you whenever you obtain care and show it whenever you are asked about paying a co-payment. If you need assistance with a co-payment problem, contact your PCP or L.A. Care Health Plan Member Services at 1-888-839-9909.
No co-payment will be charged for routine examinations and preventive care. Additionally, no co-payment will be charged to members 24 months of age and younger for well baby care, health examinations and other office visits. There are no co-payments for members who are determined under Healthy Families Program rules to be American Indians or Alaskan Natives. For information pertaining to co-payment waivers for American Indians or Alaskan Natives, please refer to the Healthy Families Program Handbook or contact the Healthy Families Program toll-free at 1-800-880-5305
How to get care from your primary care physician (PCP) doctor
The L.A. Care Health Plan provider directory is a list of all doctors, hospitals, pharmacies and mental health services in L.A. Care Health Plan’s network. The provider directory lists the addresses, telephone numbers, hours of service and languages spoken at our health care providers and pharmacies in our service area. Keep these guides handy and refer to them when you need to access care. You should have received a copy in your welcome packet with this Member Handbook. If you would like to change providers, contact your Primary Care Provider (called a “PCP”) or L.A. Care Health Plan Member Services at 1-888-839-9909.
When you need a checkup or if you get sick, you need to go to your PCP doctor. Call your PCP doctor. The phone number is on your ID card.
Start getting your care now! Call your PCP doctor for a checkup.
It is important for a new member to get a checkup even if you are not sick. Be sure to schedule this checkup soon after becoming an L.A. Care member. Call your PCP doctor today to make an appointment for a “new member checkup.”
How to change your primary care physician (PCP) doctor
Subscribers may change their L.A. Care Health Plan primary care site or provider on a monthly basis. If you would like to transfer to another medical group and Primary Care Provider, please contact L.A. Care Health Plan Member Services at 1-888-839-9909. The request must be received by the 20th day of the month to be effective the first day of the next month. If the request is received after the 20th day of the month, it will be effective one month later.
If your new PCP works with a different Participating Provider Group (PPG), this may also change the hospitals, specialists and other health care providers from whom you may receive health care.
You can change your PCP doctor for any reason if you are not happy. To change your PCP doctor, call L.A. Care. You may choose a PCP doctor within the first 30 calendar days of enrollment and change at least monthly after that.
Things to remember if you choose a new PCP doctor:
· Some doctors work within a group of doctors with certain specialists, hospitals and other health care providers. If you need a specialist, your PCP doctor may send you to these providers. If you are going to a specialist already or want to use a specific hospital, talk with the PCP doctor you are choosing.
· A PCP is a doctor or even a clinic. You can pick one PCP doctor for all members of your family in Healthy Families. Or, you can pick a different PCP doctor for each member of your family in Healthy Families. Women may choose an Ob/Gyn or family planning clinic as their PCP doctor.
· Ask about office access if you or a family member has a disability.
The PCP doctor you choose may not agree to treat you and may ask L.A. Care to make a change. This can happen if:
· you are disruptive or disrespectful to your doctor or your doctor’s office staff; or
· you do not follow your doctor’s treatment plan; or
· the service or care you need are not within the doctor’s scope of care (like a high-risk pregnancy)
What services you can and cannot get outside of Los Angeles County
If you are outside of Los Angeles County, you do not need to call your PCP doctor or get prior authorization before getting urgent care services. Be sure to let your PCP doctor know about this care. You may need follow-up care from your PCP doctor.
Members can submit provider bills or statements directly to our claims department to the following address:
L.A. Care Health Plan — Claims Department
P.O. Box 712129, Los Angeles, CA 90071
You can call L.A. Care Member Services at 1-888-839-9909 (TTY line for the hearing impaired at 1-866-522-2731). This call is free.
How to get information about doctors and specialists who work with your health plan
We’re proud of our doctors and their professional training. If you have questions about the professional qualifications of network doctors and specialists, call L.A. Care. We can tell you about the medical school they attended, their residency or board certification.
How to get specialty care when you need it, like services that require a referral, behavioral health services and hospital services
Your Primary Care Provider will refer you to a specialist or hospital. Your PCP may decide to refer you to a physician who is a specialist to receive care for a specific medical condition. For most covered services not directly provided by your primary care provider; including specialty, non-emergency hospital, laboratory and x-ray services; the services must be authorized in advance by your primary care provider. In consultation with you, your PCP will choose a participating specialist physician, participating hospital or other participating provider from whom you may receive services. For a list of specialists, call L.A. Care Member Services at 1-888-839-9909 (TTY line for the hearing impaired at 1-866-522-2731).
Behavioral Health Care
Specialized mental health and chemical dependency services are provided by L.A. Care Health Plan and you may receive services with or without a referral from your PCP. Mental health drugs listed on the formulary and prescribed by a licensed mental health provider are covered by L.A. Care Health Plan, if medically necessary; you may also get a mental health drug not on the formulary.
Members can access behavioral health services through any of the following ways:
- Call our behavioral health toll-free number at 1-877-344-2858 (TTY line for the hearing impared at 1-877-344-2848).
- Self-refer directly to a mental health provider listed in our provider directory.
- Call L.A. Care Member Services.
- Ask your PCP to recommend a mental health provider listed in our provider directory
How to get care when the office is closed, like weekends, holidays and evenings
If you need care when your PCP doctor’s office is closed (like after normal business hours, on the weekends or holidays), call your PCP doctor’s office. Ask to speak to your PCP doctor or to the doctor on call. A doctor will call you back.
For urgent care (this is when a condition, illness or injury is not life-threatening, but needs medical care right away) call or go to your nearest urgent care center. Many of L.A. Care’s doctors have urgent care hours in the evening, on weekends, or during holidays.
How to get emergency care, like when to go to the emergency room or call 911
Emergency services are covered 24-hours a day, seven days a week, anywhere. Emergency care is a service that a member reasonably believes is necessary to stop or relieve:
- Sudden serious illnesses or symptoms
- Injury or conditions requiring immediate diagnosis and treatment
Emergency services and care include ambulance, medical screening, exam and evaluation by a doctor or appropriate personnel. Emergency services include both physical and psychiatric emergency conditions.
Examples of emergencies include but are not limited to:
- Having trouble breathing
- Seizures (convulsions)
- Lots of bleeding
- Unconsciousness/blackouts (will not wake up)
- In a lot of pain (including chest pain)
- Swallowing of poison or medicine overdose
- Broken bones
- Head injury
- Eye injury
- Thoughts or actions about hurting yourself or someone else
If you think you have a health emergency, call 911. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine health care.
What to do in an emergency
Call 911 or go to the nearest emergency room if you have an emergency. Emergency care is covered at all times and in all places.
How to complain when you are unhappy about care or service you get
What is a Grievance?
A grievance is a complaint. This complaint is written down and tracked. You might be unhappy with the health care services you get or how long it took to get a service, and have the right to complain. Some examples are complaints about:
- The service or care your PCP doctor or other providers give you
- The service or care your PCP doctor’s medical group gives you
- The service or care your pharmacy gives you
- The service or care your hospital gives you
- The service or care L.A. Care gives you
How to File a Grievance
You have many ways to file a grievance. You can do any of the following:
- Write, visit or call L.A. Care. You may also file a grievance here.
L.A. Care Health Plan
Member Services Department
1055 West 7th Street
Los Angeles, CA 90017
1-888-839-9909
TTY Service: 1-866-LACARE1 (1-866-522-2731)
www.lacare.org
- Fill out a grievance form at your doctor’s office.
L.A. Care can help you fill out the grievance form. Or, we can send you a form for you to fill out and send back to us.
Within five (5) calendar days of receiving your grievance, you will get a letter from L.A. Care saying we have your grievance and are working on it. Then, within 30 calendar days of receiving your grievance, L.A. Care will send you a letter explaining how the grievance was resolved.
Filing a grievance does not affect your medical benefits. If you file a grievance you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call L.A. Care.
If you Don’t Agree with the Outcome of your Grievance
If you do not hear from L.A. Care within 30 calendar days, or you do not agree with the decision about your grievance, you may file a grievance with the Department of Managed Health Care (DMHC).
How to File a Grievance for Health Care Services Denied or Delayed as not Medically Necessary
If you believe a health care service has been wrongly denied, changed, or delayed by L.A. Care because it was found not medically necessary, you may file a grievance. This is known as a disputed health care service.
Within five calendar days of receiving your grievance, you will get a letter from L.A. Care Health Plan saying we have received your grievance and that we are working on it. The letter will also let you know the name of the person working on your grievance. Then, within 30 calendar days you will receive a letter explaining how the grievance was resolved.
Filing a grievance does not affect your medical benefits. If you file a grievance you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call L.A. Care.
If you Don’t Agree with the Outcome of your Grievance for Health Care Services Denied or Delayed as not Medically Necessary
If you do not hear from L.A. Care within 30 calendar days, or you do not agree with the decision about your grievance, you may file a grievance with DMHC.
How to File a Grievance for Urgent Cases
Examples of urgent cases include:
- Severe pain
- Potential loss of life, limb or major bodily function
- Immediate and serious deterioration of your health
In urgent cases, you can request an “expedited review” of your grievance. You will receive a call and/or a letter about your grievance within 24 hours. A decision will be made by L.A. Care within three calendar days (or 72 hours) from the day your grievance was received.
You have the right to file an urgent grievance with DMHC without filing a grievance with L.A. Care.
If you Don’t Agree with the Outcome of your Grievance for Urgent Cases
If you do not hear from L.A. Care within three (3) calendar days (or 72 hours), or you do not agree with the decision about your grievance, you may file a grievance with the Department of Managed Health Care (DMHC).
How to appeal a decision or ask for an independent review if you are denied services, coverage or benefits; or if you are disenrolled from your health plan
When to File an Independent Medical Review (IMR)
You may file an IMR if you meet the following requirements:
- Your doctor says you need a health care service because it is medically necessary and it is denied; or
- You received urgent or emergency services determined to be necessary and they were denied; or
- You have seen a network doctor for the diagnosis or treatment of the medical condition, even if the health care services were not recommended.
- The disputed health care service is denied, changed or delayed by L.A. Care based in whole or in part on a decision that the health care service is not medically necessary, and
- You have filed a grievance with L.A. Care and the health care service is still denied, changed, delayed or the grievance remains unresolved after 30 days.
You must first go through the L.A. Care grievance process, before applying for an IMR. In special cases, the DMHC may not require you to follow the L.A. Care grievance process before filing an IMR.
The dispute will be submitted to a DMHC medical specialist if it is eligible for an IMR. The specialist will make an independent decision on whether or not the care is medically necessary. You will receive a copy of the IMR decision from DMHC. If it is decided that the service is medically necessary, L.A. Care will provide the health care service.
Non-urgent cases
For non-urgent cases, the IMR decision must be made within 30 days. The 30-day period starts when your application and all documents are received by DMHC.
Urgent cases
If your grievance is urgent and requires fast review, you may bring it to DMHC’s attention right away. You will not be required to participate in the health plan grievance process.
For urgent cases the IMR decision must be made within three calendar days from the time your information is received.
Examples of urgent cases include:
- Severe pain
- Potential loss of life, limb or major bodily function
- Immediate and serious deterioration of your health
Independent Medical Review for Denials of Experimental/ Investigational Therapies
You may also be entitled to an Independent Medical Review, through the Department of Managed Health Care, when we deny coverage for treatment we have determined to be experimental or investigational.
- We will notify you in writing of the opportunity to request an Independent Medical Review of a decision denying an experimental/ investigational therapy within five (5) business days of the decision to deny coverage.
- You are not required to participate in L.A. Care Health Plan’s grievance process prior to seeking an Independent Medical Review of our decision to deny coverage of an experimental/ investigational therapy.
- If a physician indicates that the proposed therapy would be significantly less effective if not promptly initiated, the Independent Medical Review decision shall be rendered within seven (7) days of the completed request for an expedited review.
Review by the Department of Managed Health Care
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against L.A. Care Health Plan, you should first telephone L.A. Care Health Plan at 1-888-839-9909 (TDD/TTY for the hearing impaired at 1-866-522-2731) and use L.A. Care Health Plan’s grievance process before contacting the department. Using this grievance procedure does not prohibit any legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by L.A. Care Health Plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial view of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency and urgent medical services. The Department of Managed Health Care has a toll-free telephone number, 1 (888) HMO-2219, to receive complaints regarding health plans. The hearing and speech impaired may use the department’s TDD line (1-877-688-9891) number, to contact the department. The Department’s Internet website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online.
L.A Care Health Plan’s grievance process and DMHC’s complaint review process are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.
How your health plan evaluates new technology to decide if it should be a covered benefit
L.A. Care follows changes and advances in health care. We study new treatments, medicines, procedures, and devices. We call all of this “new technology.” We review scientific reports and information from the government and medical specialists. Then we decide whether to cover the new technology. Members and providers may ask L.A. Care to review new technology.
