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L.A. Care’s Healthy Kids Program™
Member Rights and Responsibilities /Benefits /How and Where to Get Prescriptions
Healthy Kids offers low-cost health coverage for children under age 19 years to families who don’t qualify for Medi-Cal or Healthy Families, but meet other eligibility and income requirements. The program is offered by L.A. Care Health Plan and is sponsored by First 5 LA and the Children's Health Initiative of Greater Los Angeles.
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 Kids members pay between $0 and $6 a month for each child, depending on family income. There is a $5 co-payment for most services. Some services like checkups are free.
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 ages 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.
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 Primary Care Physician (PCP) Please read the following information so you will know from
whom or what group of providers health care may be obtained. 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. (Please see the “Summary of Benefits”
section to know which services require co-payments).
How to
change your primary care physician (PCP) doctor Each enrolled child may have a different PCP. If you did
not choose a PCP when you enrolled your child in the Healthy Kids program, L.A. Care will choose one for you
based on the following: •
The language you speak •
How far from the PCP you live. It is best if you live or work within 10
miles of the PCP, and •
Specialty care most appropriate for the member’s age. If you would like to change your child’s PCP, call L.A.
Care 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 PPG, this may also
change the hospitals, specialists, and other health care providers from whom
your child may receive health care.
What services you can and cannot get outside of 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 nonqualified services.
If You Receive a Bill 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 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.
Specialists are doctors with training, knowledge, and
practice in one area of medicine. For example, a cardiologist is a heart specialist and 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 Benefits 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. 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. 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 which 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. 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. |