Benefits & Services
Your doctor must arrange and approve all your care before you receive services. Services are covered only if they are medically necessary. Emergency room and out of area urgent care services do not require prior authorization.
Call our Member Services Department at 1-888-839-9909 if you have any questions.
Click here to access the Healthy Kids Member Handbook. (PDF)
Healthy Kids 6-18 Program Member Handbook/Evidence of Coverage Changes Effective July 1, 2010 (PDF)
Summary of Benefits
Services described in the table below are brief descriptions. For a full explanation of your benefits, please see the Plan Benefits pages in your Member Handbook.
| Benefits | Covered Services | Member Pays |
| Alcohol /Drug Abuse Services – Inpatient | Hospitalization to remove toxic substances from the system.
Call L.A. Care's toll-free behavioral health hotline at 1-866-908-0677. We will help you find the kind of help that is right for you. |
No co-payment |
| Alcohol/Drug Abuse Services – Outpatient | Crisis intervention and treatment of alcoholism or drug abuse.
Call L.A. Care's toll-free behavioral health hotline at 1-866-908-0677. We will help you find the kind of help that is right for you. |
$5 per visit
Benefit is limited to 20 visits per benefit year. |
| Blood and Blood Products | Inpatient and outpatient processing, storage, and administration and collection, and storage of autologous blood, when medically necessary. | No co-payment |
| Cancer Clinical Trials | Coverage for a member’s participation in a cancer clinical trial, phase I through IV, when the member’s physician has recommended participation in the trial and member meets certain requirements. | $5 per visit
Co-payment for prescriptions as described in the “Prescription Drug Program” |
| Cataract Spectacles and Lenses | Cataract spectacles and lenses, cataract contact lenses or intraocular lenses that replace the natural lens of the eye after cataract surgery. | No co-payment |
| Dental Services | Covered by SafeGuard Dental(1-800-766-7775) | No co-payment |
| Diabetic Care | Equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes and gestational diabetes as medically necessary, even if the items are available without prescription. | $5 per visit
Co-payment for prescriptions as described in “Prescription Drug Program” |
| Diagnostic, X-Ray and Laboratory Services |
Therapeutic radiological services, ECG, EEG, mammography, other outpatient diagnostic laboratory and radiology tests. | No co-payment |
| Durable Medical Equipment | Equipment for home used as medically necessary. | No co-payment |
| Emergency Care Services | Health care services which a prudent lay person would consider necessary to relieve a serious illness or symptom, injury, severe pain, or condition requiring immediate diagnosis. Offered 24 hours a day, seven days a week. | $5 per visit (waived if member is admitted to the hospital) |
| Eye Exams/Supplies | Eye refraction to determine the need for corrective lenses, dilated retinal eye exams, cataract spectacles and lenses. | No co-payment |
| Family Planning Services | Voluntary family planning services. | No co-payment |
| Health Education Services | Effective health education services and materials for diabetes outpatient self-management training, education and nutrition counseling. Other education services also offered through designated L.A. Care health education providers, such as weight management and asthma classes. | No co-payment |
| Hearing Aids/Services | Hearing evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, repairs. | No co-payment |
| Home Health Care Services | Services provided at the home by health care personnel. | No co-payment except: $5 per visit for physical, occupational and speech therapy in an outpatient setting |
| Hospice | Medically necessary skilled care; counseling; medical supplies; short term inpatient care; pain control and symptom management; bereavement services; physical, speech and occupational therapies; medical social services; and respite care. | No co-payment |
| Hospital Services – Inpatient | Room and board, nursing care and all medically necessary ancillary services. | No co-payment |
| Hospital Services – Outpatient | Diagnostic, therapeutic and surgical services performed at a hospital or outpatient facility.
• Physical, occupational and speech therapy performed on an outpatient basis • Emergency health care services (waived if the member is hospitalized) |
No co-payment
$5 per visit
$5 per visit |
| Medical Transportation | Ambulance transportation when medically necessary. | No co-payment |
| Mental Health Care – Inpatient | L.A. Care will limit days per year for illnesses that meet the criteria for Serious Emotional Disturbance (SED) of a child, to 30 days per benefit year. For SED children, L.A. Care will refer these members to the Los Angeles County Department of Mental Health for continued treatment of the condition. L.A. Care will provide services with no visit limits for Severe Mental Illnesses (SMI). L.A. Care may limit coverage to 30 days per benefit year for mental illnesses that do not meet the criteria for SMI/SED.
With the agreement of the member or guardian, if appropriate, each day of inpatient hospitalization may be substituted for any of the following outpatient mental health services: • Two days of residential treatment • Three days of day care treatment (care in which patients participate during the day, returning to their home or other community placement during the evening and night) • Four outpatient visits Call L.A. Care's toll-free behavioral health hotline at 1-866-908-0677. We will help you find the kind of help that is right for you. |
No co-payment |
| Mental Health Care – Outpatient | L.A. Care will provide coverage for up to 20 visits per benefit period for mental conditions or illnesses that do not meet the criteria for SMI and SED. There is no limitation on treatment for SMI and SED.
Call L.A. Care's toll-free behavioral health hotline at 1-866-908-0677. We will help you find the kind of help that is right for you. |
$5 per visit |
| Pediatric Asthma Care | Coverage for medically necessary supplies and equipment relating to the management and treatment of asthma, including inhaler spacers, nebulizers (including face masks and tubing), peak flow meters and education on the proper use of these items. | $5 co-payment per office visit
Co-payment for prescriptions as described in “Prescription Drugs”, under “Plan Benefits” |
| Phenylketonuria (PKU) | Testing and treatment of PKU. | No co-payment |
| Physical, Occupational and Speech Therapy | Therapy may be provided in a medical office or other appropriate outpatient setting. | $5 per visit when performed in an outpatient setting.
No co-payment for inpatient therapy |
| Prescription Drug Program | Drugs prescribed by a licensed practitioner:
• 30-day supply for brand name or generic drugs • 90-day supply of maintenance drugs •Prescription drugs provided in an inpatient setting • Drugs administered in the doctor’s office or in an outpatient facility • FDA-approved contraceptive drugs and devices • Respiratory devices for the management and treatment of asthma Call Member Services for mail order or for a list of participating pharmacies at 1-888-839-9909. |
$5 per prescription
$5 per prescription
No co-payment
No co-payment
No co-payment
|
| Preventive Care Services | • Immunizations, STD tests, and cytology exams on a reasonable periodic basis
• Periodic health exams • Well-baby and well-child visits |
No co-payment |
| Professional Services – Inpatient |
Licensed hospital, skilled nursing facility, hospice, mental health facility. | No co-payment |
| Professional Services – Outpatient | • Office or home visit
• Chemotherapy, dialysis, surgery, anesthesiology, or radiation |
$5 per visit
No co-payment |
| Prosthetics and Orthotics | Prosthetics and orthotics as prescribed by L.A. Care providers | No co-payment |
| Reconstructive Surgery | Reconstructive surgery repairs abnormal body parts, improves body function, or brings back a normal look.
Note: Medical or surgical condition that would qualify for services under CCS should be referred to that program. |
No co-payment |
| Skilled Nursing Care | Services provided in a licensed skilled nursing facility.
Benefit is limited to a maximum of 100 days per benefit year. |
No co-payment |
| Transplants | Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ | No co-payment |
| Vision Services | Covered under VSP (1-800-877-7195) | No co-payment |
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