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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).

For enrolled L.A. Care Healthy Kids members, click here for a copy of your member handbook (also called evidence of coverage). (PDF)

Frequently Discussed Topics

Below are some health-related topics that are frequently discussed. Click on a topic for more information about it.

Disease Management Program

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 if you have questions about asthma or want to self refer or enroll yourself into L.A. Cares About Asthma.
Call (866) 756-2048 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 doctors and other health care staff do not get money or other rewards to deny care. L.A. Care does not reward staff to make decisions that result in less care that what is requested.

Exclusions and Limitations

California Children’s Services (CCS)

Children needing specialized medical care may be eligible for the California Children’s Services (CCS) program.

CCS is a California medical program that treats children with certain physical conditions and who need specialized medical care. This program is available to all children in California whose families meet certain medical, financial and residential eligibility requirements. Services provided through the CCS program are coordinated by the local county CCS office.

If a member’s PCP suspects or identifies a possible CCS eligible condition, he/she may refer the member to the local county CCS program. The CCS program (local or the CCS Regional Office) will determine if the member’s condition is eligible for CCS services.

If determined to be eligible for CCS services, a Healthy Kids member continues to stay enrolled in the Healthy Kids program. He or she will be referred and should receive treatment for the CCS eligible condition through the specialized network of CCS providers and/or CCS approved specialty centers. These CCS providers and specialty centers are highly trained to treat CCS eligible conditions. L.A. Care will continue to provide primary care and prevention services that are not related to the CCS eligible conditions, as described in this document. L.A. Care will also work with the CCS program to coordinate care provided by both the CCS program and the plan. L.A. Care will continue to provide all other medical services not related to CCS diagnosis.

The CCS office must verify residential status for each child in the CCS program. If your child is referred to the CCS program, you will be asked to complete a short application to verify residential status, financial eligibility and ensure coordination of your child’s care after the referral has been made.

Additional information about the CCS program can be obtained by calling the Los Angeles County CCS program at 1-800-288-4584 for more information.

The following services are not covered benefits.

Any health care services which L.A. Care excludes in the Member Handbook which cost more than L.A. Care states it will pay in this Member Handbook.
Any services received before a member’s starting date with L.A. Care.
Cosmetic surgery that is solely performed to alter or reshape normal structures of the body in order to improve appearance.
Emergency facility services for non-emergency services.
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 time or service in question is recommended or prescribed. If L.A. Care denies your request for services based on the determination that the services are experimental or investigational, you may request an Independent Medical Review.
Long-term care benefits. Includes long-term skilled nursing care in a licensed facility, and respite care. (For short-term skilled nursing care or hospice benefits, please see Skilled Nursing Care under the “Plan Benefits” section.)
Non-medically necessary health care services. Any health care services, supplies, comfort items, procedures, or equipment that is not medically necessary. This includes private rooms in a hospital, unless medically necessary.
Other insurance. Services covered by any other insurance or health care service plan. L.A. Care will provide the services at the time of need.
Acupuncture services
Chiropractic services
Biofeedback services

How to get care from your primary care physician (PCP) doctor

All L.A. Care members must have a Primary Care Physician (PCP). The name and phone number of your child’s PCP is found on his/her L.A. Care ID card. Except for emergency services, your child’s PCP will arrange all your health care needs, refer you to specialists, and make hospital arrangements.

Each PCP works with a Participating Provider Group (PPG), which is another name for medical group. Each PPG works with certain specialists, hospitals, and other health care providers. The PCP you choose determines which health care providers are available to you.

Scheduling Appointments

Step 1: Call your PCP

Step 2: Explain why you called

Step 3: Ask for an appointment

Your PCP’s office will tell you when to come in and how much time you will need with your PCP.

How to change your primary care physician (PCP) doctor

We will send you a letter in the mail if your primary care physician (PCP) stops working with L.A. Care. We will do this 60 days before the date your PCP stops working with L.A. Care. You can ask to keep seeing this doctor (including specialists and hospitals) if the doctor agrees and has been treating you for anything listed below:

Acute condition – For the duration of the condition.
Serious chronic (long-term) condition – For a period of time necessary to complete a course of treatment and arrange for a safe transfer to another provider.
Pregnancy – Includes the rest of the pregnancy and immediate postpartum care.
Terminal illnesses/conditions – For the length of the illness.
Children from birth to age 36 months – For up to 12 months.
You have a surgery or other procedure that has been authorized by the plan as part of a documented course of treatment.

New members can also ask to keep seeing their current doctor or hospital for these conditions if they have just joined L.A. Care.If you have one of the conditions listed, ask your doctor if you can keep seeing him/her. You can also call L.A. Care Member Services at 1-866-4LA-KIDS (1-866-452-5437) on how to request continuity of care.

You need to know that the continuity of care benefit will not apply to you if:

1. You are a new member in L.A. Care and your old health plan offered to let you keep receiving care from an out-of-network provider.

2. You had the choice to keep receiving care from your previous provider, but you decided to change health plans.

Doctors who are not contracted with L.A. Care may be required to agree to the same terms and conditions as contracted providers. If the doctor does not agree, then L.A. Care is not required to provide the services through that doctor.

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.

What to do if you get a bill

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 Health Plan Member Services at 1-888-839-9909 (TDD/TTY 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

You may get a list on the availability, education, and board certification of a participating provider in a geographical area of your choice by calling L.A. Care.

How to get specialty care when you need it, like services that require a referral, behavioral health services and hospital services

Specialists are doctors with training, knowledge, and practice in one area of medicine. For example, a cardiologist is a heart specialist who has years of special training to deal with heart problems.

Your child’s PCP will ask for prior authorization if he or she thinks your child should see a specialist.

Mental Health Care – Inpatient

Mental health benefits will be provided on the same basis as other illnesses. These benefits include outpatient services, inpatient hospital services, and partial hospitalization services and prescription drugs.

Description: Mental health inpatient treatment ordered in a participating hospital by a participating mental health provider for the treatment of a mental health condition. Severe Mental Illnesses (SMI) include, but are not limited to:

Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Schizophrenia
Schizoaffective disorder
Bipolar disorder (manic-depressive illness)
Major depressive disorders
Panic disorders
Obsessive-compulsive disorder
Pervasive developmental disorder or autism
Anorexia nervosa
Bulimia nervosa
Psychosis

L.A. Care will also provide coverage for up to 30 days of treatment per benefit period for mental conditions or illnesses that do not meet the criteria for Severe Mental Illness (SMI) and Severe Emotional Disturbance (SED). There is no limitation on days of treatment for SMI and SED.

Mental Health Care – Outpatient

Description: Mental health outpatient treatment when ordered by a participating mental health professional. This includes the treatment of children who have experienced family dysfunction or trauma, including child abuse and neglect, domestic violence, substance abuse in the family, or divorce and bereavement.

Family members may be involved in the treatment to the extent that L.A. Care determines it is appropriate for the health and recovery of the child.

L.A. Care will provide up to 20 visits per benefit year, for illnesses that do not meet the criteria for Serious Emotional Disturbance (SED) and Severe Mental Illnesses (SMI). L.A. Care may elect to provide additional visits and may provide group therapy at a reduced co-payment.

Additional visits require:

Medical necessity
PCP referral
Prior authorization

L.A. Care provides services with no visit limits for SMI. SMI includes, but is not limited to:

Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Schizophrenia
Schizoaffective disorder
Bipolar disorder (manic-depressive illness)
Major depressive disorders
Panic disorder
Obsessive-compulsive disorder
Pervasive developmental disorder or autism
Anorexia nervosa
Bulimia nervosa
Psychosis

When a child is determined to have SED, L.A. Care will provide services for the member until he or she has been evaluated and receives a referral for services through L.A. County Department of Mental Health. Services coordinated may include individual and/or family therapy or counseling assistance with medication related to the mental health condition and day programs.

Mental Health Care Benefits Substitution Choices

With the agreement of the member and/or member’s parent 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 in the evening and night)
Four outpatient visits

Hospital Services – Inpatient

The following inpatient hospital services are covered when authorized by L.A. Care and provided at a participating hospital. Any hospital may be used in case of an emergency.

A hospital room of two or more beds with standard furnishings and equipment, meals, including special diets as medically necessary, and general nursing care.
Intensive care, coronary care, and definitive observation unit services as medically necessary.
Operating room and related facilities.
Surgical, anesthesia, and oxygen supplies.
Special duty nursing, as medically necessary.
Discharge planning and planning of continuing care.
Devices implanted surgically.
Hospital ancillary services in connection with hospital inpatient services, including:
- Laboratory,
- Inhalation and respiratory therapy,
- Pathology,
- Imaging and radiation therapy,
- Radiology and cardiology, and
- Other diagnostic, therapeutic and rehabilitative services as appropriate.
Drugs, medications, and biologicals, which are approved by the FDA and are supplied by and used in the hospital.
Administration of blood and blood products.
Rehabilitative therapy services. This includes physical, occupational, speech, and other therapy services as appropriate.
Hemodialysis
Inpatient hospital services (including general anesthesia) for dental procedures are covered when hospitalization is necessary due to a member’s medical condition and/or clinical status, or because of the severity of the dental procedure. L.A. Care will coordinate these services with the member’s dental plan. Services of the dentist or oral surgeon are not covered by L.A. Care.

Exclusions: A private room in a hospital or personal or comfort items are excluded, unless medically necessary as determined by L.A. Care.

Hospital Services – Outpatient

The following outpatient services are covered when authorized by L.A. Care and provided at a participating hospital or outpatient facility: Diagnostic, therapeutic, and surgical services done at a hospital or outpatient facility. This includes physical, occupational, and speech therapy as appropriate, and hospital services, which can reasonably be provided on an ambulatory basis. Related services and supplies include:

Operating room,
General anesthesia,
Treatment room,
Ancillary services, and
Medications which are given by the hospital or facility for use during the member's treatment at the facility.

General anesthesia for dental procedures is covered when performed at a hospital or surgery center because of a member’s medical condition, clinical status, or the severity of the dental procedure. L.A. Care will coordinate such services with the member’s dental plan. Services of the dentist or oral surgeon are not covered by L.A. Care.

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.

L.A. Care covers emergency care services 24 hours a day, seven days a week. If you believe your child has a life threatening emergency condition that needs immediate treatment, please go to the nearest emergency room.

Emergency care services are medically necessary covered services, including ambulance and mental health services, which a prudent layperson would consider necessary to stop or relieve:

Serious illness or symptom,
Injury or severe pain, or
Conditions that need immediate diagnosis and treatment.

Emergency services and care include a medical screening, exam, and evaluation by a doctor or other appropriate personnel. Emergency services also include both physical and mental emergency conditions. Examples of some emergencies include, but are not limited to:

Breathing problems
Seizures (convulsions)
Lots of bleeding
Unconsciousness/blackouts (will not wake up)
Severe pain (including chest pain)
Swallowing of poison or medicine overdose
Broken bones
Head injury
Eye injury

What to do in an emergency

Call 911 or go to the nearest emergency room for treatment.

You should call your child’s PCP within 48 hours of the emergency, unless L.A. Care decides that it was not reasonably possible to call. In such cases, notice must be given as soon as possible. You should go to the nearest L.A. Care participating hospital for emergency care when possible.

In an emergency, you may be admitted to a hospital where your PCP may or may not work. If your PCP does not work with the hospital, L.A. Care may transfer you to a hospital your PCP works with when it is medically safe.

If you are unsure if you need emergency care:

Step 1: Call your child’s PCP.

Step 2: Tell him or her about your condition.

Step 3: Follow the doctor’s instructions.

Call 911 if you are not able to reach your child’s PCP.

After you receive emergency care

Step 1: Follow the instructions of the emergency room doctor.

Non-emergency services given after the emergency has been treated need an authorization from L.A. Care.

Step 2: Call to make an appointment with your PCP for all follow-up care.

DO NOT USE THE EMERGENCY ROOM FOR ROUTINE HEALTH CARE SERVICES.

Non-Qualified Services

Non-qualified services are any non-emergency services received in the emergency room. L.A. Care will review all emergency room services provided to members based on the prudent lay person’s definition of emergency services. The member’s family must pay for the cost of any non-qualified services. (Please refer to the “Emergency Services” section of your member handbook for more information.)

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 online through L.A. Care’s Web site at www.lacare.org.
L.A. Care Health Plan
Member Services Department
555 West Fifth Street
Los Angeles, CA 90013
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.

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.

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