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How to Join | Find a Doctor | Getting Care | How to Get Prescriptions Filled | Medical Bills | General Information Through the Healthy Families program, L.A. Care offers health care coverage to children who do not qualify for Medi-Cal and their families cannot afford private insurance. L.A. Care offers services for Healthy Families members through a large network of provider groups, hospitals, independent pharmacies and other health care providers. If you would like paper copies of any
of this information, please contact us at 1-888-4LA-CARE
(1-888-452-2273).
What are the program benefits?
How much will I pay? Healthy Families members pay from $4 per child to a maximum of $45 per family. Monthly premiums depend on your family income, size, and the health plan you choose. There are $5 copayments for most services. Some services, like check ups, are free. The most a family will have to pay in copayments for each benefit year (July 1 – June 30) is $250.
How do I apply? L.A. Care can help you find out which programs you and your children may qualify for. We can even help you with the application. Call 1-888-4LA-KIDS (1-888-452-5437) for more information.
Below are some health-related topics that are frequently
discussed.
Click on a topic for more information about it.
Quality improvement is how L.A. Care Health Plan helps you improve your health care. It is a program to make sure you are getting the best health care possible. Here’s what we’re doing in 2007 to make sure you get the best health care:
How L L.A. Care respects each member’s culture. In 2006, we won an award for tools we created to help our members manage their weight. These tools were made in different languages so more of our members can use them.
What are L.A. Care’s goal is do better than what our regulatory agencies expect from us.
What Else is • Tracks the health care services
you get through a survey of our doctors called HEDIS. • Asks how well we serve you
through a survey of members every year called CAHPS. • Makes changes to improve the health care services you get by starting new quality improvement projects.
Asthma L.A. Care
tracks:
What we do to
help:
How we are
doing:
Diabetes
L.A. Care tracks:
What we do to
help:
How we are
doing:
Preventing illness -
Childhood immunizations What we track: The number of members age 2 years and below who get the shots they need.
What we do to help: Remind you of
the shots that you should be getting.
How we’re doing: In 2006, 75% of members age two and under got the shots they needed.
Preventive Health Visits
for Well Child 0 – 15 months What we track: The number of members ages 0 – 15 months who have had 6 preventive health visits in the first 15 months of life.
What we do to
help: ·
Teach
providers the value of preventive health visits ·
Give a
gift to members to go for their health visits
How we are doing: In 2006, 47% of our members had gone for all 6 visits, which is better than 2005.
Preventive Health Visits
for Well Child 3 – 6 years What we track: The number of members ages 3 – 6 years who have had 1 preventive health visit in the year.
What we do to
help: ·
Teach
providers the value of preventive health visits ·
Give a
gift to members to go for their health visits
How we are doing: In 2006, 77% of our members had one visit during the year, which is better than 2005.
Breast Cancer Screening What we track: The number of
members ages 40 – 65 years who had a mammogram in the last 12 months.
What we do to help:
How we are doing:
Access to
Care What
we track: ·
Members’ access to medical care.
What we do to help:
·
Look
for areas to improve access to care for the members.
How we are
doing: ·
97% of
members were able to plan a non-urgent visit with their PCP within 10
days. · 97% of members were able to plan a preventive health visit within 30 days.
If you would like a paper copy of this information, please call the QI Department of L.A. Care at 1-213-694-1250 x4027.
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:
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.
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:
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.
Additional
instructions on how to obtain authorizations and communicate with UM staff are
listed in your Member Handbook or
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:
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:
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.
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 Choosing a Primary Care Provider It is important that you choose your Primary Care Provider
(PCP). If you do not choose a PCP at the time of enrollment, a PCP will be
assigned to you to make sure that all your health care needs are met. When L.A.
Care Health Plan selects a PCP for you, L.A. Care Health Plan makes sure that
eligible family members are assigned to the same provider, the location of the
primary care clinic/doctor office is in your zip code or within a 10 mile radius
from your home, the provider does not have more patients than allowed by L.A.
Care Health Plan so that you can get an appointment within a reasonable time and
the provider meets your language and health care needs. Also, your age and
gender are taken into consideration when L.A. Care Health Plan assigns your
provider. If you would like to change providers, contact your PCP or
You have the right to choose an OB/GYN as your PCP. You may
also choose to receive your regular health care from a non-physician health care
practitioner (nurse practitioner, physician’s assistant or nurse mid-wife), if
available, under the oversight of a supervising physician. L.A. Care Health Plan Subscribers receive their regular health
care from the L.A. Care Health Plan PCP, clinic or doctor’s office they have
selected or been assigned. Your PCP will: •
Provide primary health care and coordinate other health care. •
Provide “well care,” including physical examinations. •
Provide prescriptions for medicine and medical supplies.
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 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.
What services you can and cannot get outside of L.A. Care Health Plan does not cover medical services that
are received in an emergency or urgent care setting for conditions that are not
emergencies or urgent if you reasonably should have known that an emergency or
urgent care situation did not exist. You will be responsible for all charges
related to these services.
Members can submit provider bills or statements directly to
our claims department to the following address: You can call
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.
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 Behavioral Health Care Members can access behavioral health services through any
of the following ways: •
Call our behavioral health toll-free number at 1-866-908-0677. •
Self-refer directly to a mental health provider listed in our provider
directory. •
Call • 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 online through L.A. Care’s Web site at www.lacare.org. Member Services Department 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. |
