Benefits & Services
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 you 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 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.
Click here to access the L.A. Care Medi-Cal Member Handbook. (PDF)
Or, click here to access a Member Handbook if you belong to one of our Plan Partners.
Click on one of the topics below to learn more about that benefit.
- Services that do not require prior authorization
- Alcohol/Drug Abuse
- Asthma Services
- Cancer Screening
- Diabetic Services
- Doctor Office Visits
- Drugs/Medications
- Durable Medical Equipment
- Emergency Services
- Family Planning
- Health Education Services
- Hearing Aids
- HIV Testing
- Home Health
- Hospice Care
- Hospital Care
- Incontinent Creams and Washes
- Lab Services
- Mastectomy
- Maternity Care
- Minor Consent Services
- Newborn Care
- Obstetrical/Gynecological (Ob/Gyn))
- Podiatry
- Prenatal Care
- Reconstructive Surgery
- Sexually Transmitted Disease (STD) Services
- Skilled Nursing Facility Services
- Temporomandibular Joint (TMJ) disease
- Therapy – Occupational, Physical and Speech
- Transportation
- Vision Care
- X-ray Services
Services that do not require prior authorization
- PCP doctor visits,
- emergency services,
- urgently needed services when outside of Los Angeles County,
- family planning services,
- preventive service,
- basic prenatal care,
- sexually transmitted disease services,
- HIV testing,
- Certified Nurse Midwife/Ob-Gyn, in network.
- Crisis intervention
- Health education services
- 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
- All generally medically accepted cancer screening tests, including coverage for screening and diagnosis of prostate cancer
- Mammography for breast cancer screening
- 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. See your Member Handbook for more information.If you have a life threatening or weakened condition or were eligible but denied coverage for a cancer clinical trial, you have the right to request an Independent Medical Review (IMR) on the denial. This is talked about in the section, “Complaints: What should I do if I am unhappy?” in your handbook.
- Medical equipment
- Prescription drugs
- 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 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
- All routine visits, exams, treatments, shots and CHDP visits are provided by your doctor.
- Services received from specialist visits
- Any CHDP services from school-based programs or the Los Angeles County Department of Health Services. There is more information about the Child Health Disability Prevention Program (CHDP) under “More benefits: What other services can I get?” in your handbook. You can also call CHDP at 1-800-993-2437.
- Prescription drugs and over-the-counter drugs on the L.A. Care formulary are covered. This is talked about in the section, “Pharmacy Benefits: How do I get prescription drugs?” in your handbook.
Durable Medical Equipment (DME)
DME is medical equipment used over and over again by a person who is ill or injured.
These items are ordered by your doctor.
- Apnea monitors
- Blood glucose monitors, including monitors for the visually impaired for insulin dependent, non-insulin dependent and gestational diabetes
- Insulin pumps and all related supplies
- Nebulizer machines
- Orthotics
- Ostomy bags
- Oxygen and oxygen equipment
- Prosthesis
- Pulmo-Aides and related supplies
- Spacer devices for metered dose inhalers
- Tubing and related supplies
- Urinary catheters and related supplies
Emergency services are covered 24 hours a day, seven days a week, anywhere.
Emergency care is a service that a “prudent layperson” believes is necessary to stop or relieve
- sudden serious illnesses or symptoms
- injury or conditions requiring immediate diagnosis and treatment.
A “prudent layperson” is a non-medical person with an average knowledge of health and medicine but has awareness or information to make a good decision.
Emergency services and care include ambulance, medical screening, exam and evaluation by a doctor or appropriate personnel. Emergency services cover physical and psychiatric emergency conditions, and active labor. These are talked about in “Emergency Care: How do I get care in an emergency?” in your handbook.
Family planning services are provided to members of child bearing age to help them choose the number and spacing of children.
These services include all methods of birth control approved by the Food and Drug Administration (FDA). You may receive family planning services and FDA-approved contraceptives from any health care provider licensed to provide these services.
Family planning services also include counseling and surgical procedures for the termination of pregnancy (called an abortion). Please call L.A. Care to find out more.
The California Department of Health Services (CDHS), Office of Family Planning, can also answer questions or give you a referral for family planning services. You may reach them at 1-800-942-1054.
L.A. Care has programs to help you stay healthy and take care of yourself. These programs are free.
Health education services help members by:
- promoting health,
- preventing diseases,
- helping manage chronic diseases (such as asthma, heart disease and diabetes),
- providing information on tobacco, alcohol and drug abuse. Health education services are delivered through:
- literature (booklets),
- tapes,
- classes,
- counseling (one-to-one learning or counseling),
- support groups,
- diabetic self-management education programs that include nutrition and counseling.
Ask your doctor for health education materials and classes. You can also call L.A. Care.
- Hearing aids are covered when ordered by your doctor.
You can get confidential HIV testing from any health care provider licensed to provide these services. You do not need a referral or okay from your doctor or health plan for confidential HIV testing.
Examples of where you can get confidential HIV testing include:
- your doctor,
- Los Angeles County Department of Health Services,
- family planning services providers,
- prenatal clinics.
Please call L.A. Care to request a list of testing sites.
These services are provided in the home by health care personnel for all of the following:
- short-term physical, occupational and speech therapy,
- respiratory therapy when prescribed by a licensed practitioner acting within the scope of his or her licensure.
Home health services ordered by your doctor are provided by home health personnel such as:
- 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.
Care is limited to terminally ill members expected to live 12 months or less. If you decide to receive hospice benefits, you are waiving all rights to all other benefits for the terminal illness for the duration of the hospice election. The hospice election may be made up to two periods of 90-days each, one subsequent period of 30 days, and one 180-day extension of the 30-day period. Hospice services are not covered for more than 390 days
Includes, but is not limited to:
- inpatient services
- intensive care
- outpatient services
Provided at no cost when there is a medical need
- blood work
- urine tests
- throat cultures
Services must be provided at a network:
- doctor’s office,
- hospital,
- laboratory
- Mastectomy is a surgery to remove a breast due to cancer
- Mastectomy
- Prosthesis
- Reconstructive surgery — See “Reconstructive Surgery” in this section for more information
You and your doctor decide how long you need to stay in the hospital after the surgery based on medical necessity.
Maternity care includes:
- regular doctor visits during your pregnancy (called “prenatal” visits),
- diagnostic and genetic testing,
- nutrition counseling,
- labor and delivery care,
- health care six weeks after delivery (called “postpartum” care),
- inpatient hospital care for at least 48 hours after a normal vaginal delivery, or for at least 96 hours after a cesarean section. Coverage for inpatient hospital care may be less than 48 hours or 96 hours if:
- the decision is made by the mother and treating physician, and
- a post-discharge follow up visit for the mother and newborn is made within 48 hours of discharge.
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.
After giving birth, you will receive breastfeeding education and special equipment if needed. Ask your doctor, or call L.A. Care if you have any questions. Go to “Women, Infants and Children (WIC) Program” under “More Benefits: What other services can I get?” in your handbook for information about nutrition and food stamps.
There are some services adolescent members (children ages 12 to 18) can get without a parent’s okay. Minors may choose 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,
- family planning services,
- outpatient mental health treatment and counseling,
- pregnancy related services,
- sexual assault services,
- sexually transmitted disease (STD) services.
Your newborn baby will be covered by L.A. Care for the month of birth and the following month. When you have a baby, it is important to do three things:
- Please call L.A. Care at 1-888-452-2273. We want to make sure you and your baby get the care you need right away. We also have a gift for you!
- Contact your eligibility worker at DPSS toll free at 1-877-481-1044 to enroll your baby in Medi-Cal. This is important so that your baby can continue to receive Medi-Cal benefits!
- Take your baby to the doctor within three days after you go home from the hospital. An L.A. Care doctor in your network should see your newborn baby within a few days after birth. Call L.A. Care.
Newborn baby screenings for certain treatable genetic disorders are covered. These genetic disorders include:
- Phenylketonuria (PKU)
- Galactosemia
- Hypothyroidism
- Sickle cell disease
- Related blood disorders
Babies with these conditions will be referred to California Children’s Services (CCS) for treatment or to L.A. Care if the treatment is not covered by CCS. This is talked about in the section, “More Benefits: What other services can I get? in your handbook.
Obstetrical/Gynecological (Ob/Gyn)
Pregnant members do not need a referral or okay from their doctor or L.A. Care to see an Ob/Gyn who works in their network
Podiatry (services for the feet)
Podiatry services are limited and require prior authorization except when received on an emergency basis.
- Regular doctor visits during your pregnancy (called “prenatal” visits)
- Prenatal supplements
- Diagnostic and genetic testing
- Reconstructive surgery repairs abnormal body parts, improves body function or brings back a normal look.
Sexually Transmitted Disease (STD) Services
STD services include:
- preventive care,
- screening,
- testing,
- diagnosis,
- counseling,
- treatment,
- follow-up.
You can get confidential STD services from any doctor or clinic. You do not need a referral or okay from your doctor.
Skilled Nursing Facility Services
- A facility licensed to provide medical services for non-acute conditions
If you need long-term skilled nursing facility services, you may be disenrolled from L.A. Care and provided these services through Medi-Cal or another state program.
Temporomandibular Joint (TMJ) disease
- 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 is used to improve and maintain a patient’s daily living skills because of a disability or injury.
- Physical therapy uses exercise to improve and maintain a patient’s ability to function after an illness or injury.
- Speech therapy is used to treat speech problems.
Includes non-emergency transportation for the transfer of a member from a hospital to another hospital or facility, or facility to home when the transportation is:
- medically necessary, and
- requested by the doctor, and
- authorized in advance by L.A. Care.
Exclusion: Coverage for public transportation including transportation by airplane, passenger car, taxi, or other forms of public conveyance.
Eye exams are covered by L.A. Care. You are limited to one pair of eyeglasses every two years unless your prescription changes. This includes lenses and covered frames for eyeglasses when authorized.
These services will be provided when ordered by your doctor from a network:
- doctor’s office
- hospital
- laboratory
What benefits and services are not covered
The following is a list of services not covered by L.A. Care or by the regular ("fee-for-service") Medi-Cal program:
- All services excluded from Medi-Cal under state and/or federal law
- Routine circumcision, unless medically necessary
- Cosmetic surgery (surgery performed to alter or reshape normal structures of the body in order to improve your appearance)
- Custodial care. Some custodial care may be covered under regular (fee-for-service) Medi-Cal. For more information about custodial care covered under regular Medi-Cal, call DPSS. You can find DPSS' phone number under the "Important Phone Numbers" section of your handbook.
- Experimental and investigational services. This is talked about in “IMRs for Experimental and Investigational Therapies (IMR-EIT)” under “Complaints: What should I do if I am unhappy?” section of your handbook.
- Infertility
- Immunizations (shots) for work or travel
- Personal comfort items such as a phone, television or guest tray when in the hospital
- Dental
- Chiropractic
- Acupuncture
- Psychiatry Services
- Under the age of 21
- Living in a skilled nursing facility (Level A or B. This includes subacute care facilities.)
- Pregnant (If you are pregnant, you can continue to receive pregnancy-related benefits and services. You can also receive other benefits and services listed above to treat conditions that, if left untreated, might cause difficulties for the pregnancy. This includes dental exams, cleanings and gum treatment. Dental and other benefits and services may also be available up to 60 days after the baby is born.)
- Receiving benefits through the California Children’s Services program
- Receiving benefits through a Program of All-Inclusive Care for the Elderly
- Speech therapy services
- Podiatric services
- Audiology services
- Incontinence creams and washes
- Annual optometry exam for diabetic members
If you have questions about what is covered or not covered, please call L.A. Care at 1-888-839-9909.
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