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| Benefits | Medi-Cal is a federal and state funded health insurance program for low-income, elderly and disabled persons who qualify for help. Medi-Cal provides no-cost, comprehensive health, dental and vision benefits for people who qualify. Medi-Cal beneficiaries do not pay premiums, and they do not have any co-payments for services.
When you join L.A. Care, you can choose to get your health
care from L.A. Care or one of the other fine health plans we work with for
Medi-Cal in L.
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 Medi-Cal members, click below for a copy of your member handbook (also called evidence of coverage).
What are the program benefits?
How much will I pay? L.A. Care is free for families who qualify. There are no monthly premiums or co-pays.
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.
If you are a
Medi-Cal member enrolled with Blue Cross, Kaiser Permanente, Care 1st or CHP,
please refer to your member handbook for more information on disease
management.
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 L.A. Care
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 does not reward staff to make decisions
that result in less care than what is requested.
There is no cost to you when you get services covered by
Medi-Cal.
How to
get care from your primary care physician (PCP) doctor You were asked to choose a primary care physician (PCP)
doctor and a health plan when you filled out the Medi-Cal enrollment form.
Sometimes we cannot give you the PCP doctor you choose. Some of the reasons
are:
If you did not get the PCP doctor or health plan you chose,
call L.A. Care at 1-888-839-9909 to see if that PCP doctor or health plan is
available. Each member has a PCP doctor. A PCP doctor can even be a
clinic. You can pick one PCP doctor for all members of your family in Medi-Cal.
Or, you can pick a different PCP doctor for each member of your family in
Medi-Cal. Women can choose an Ob/Gyn or family planning clinic as their PCP
doctor. Your PCP doctor Your PCP doctor gives you “primary” — or basic medical
care. Health care services you can get from your PCP doctor include:
When you need a checkup or if you get sick, you need to go
to your PCP doctor. Call your PCP doctor. The phone number is on your ID
card. Start getting your care now! Call your PCP doctor for a
checkup. It is important for a new member to get a checkup even if
you are not sick. Be sure to schedule this checkup soon after becoming an L.A.
Care member. Call your PCP doctor today to make an appointment for a
“new member checkup.”
How to
change your primary care physician (PCP) doctor If you didn’t choose a PCP doctor when you enrolled in
Medi-Cal, a PCP doctor was chosen for you by L.A. Care. Your PCP doctor was
chosen for you based on: ·
the language you speak ·
your age ·
how close you live to the PCP doctor’s office It is best to keep the same PCP doctor. Your PCP doctor
gets to know your health history and health needs. But sometimes you cannot stay
with your PCP doctor.
You can choose a PCP doctor from the L.A. Care network shown in the
provider directory mailed to you with this handbook. Call L.A. Care for another
copy of the provider directory or to help you choose another PCP doctor. You can change your PCP doctor for any reason if you are
not happy. To change your PCP doctor, call Things to remember if you choose a new PCP doctor: ·
Some doctors work within a group of doctors with certain
specialists, hospitals and other health care providers. If you need a
specialist, your PCP doctor may send you to these providers. If you are going to
a specialist already or want to use a specific hospital, talk with the PCP
doctor you are choosing. ·
A PCP is a doctor or even a clinic. You can pick one PCP
doctor for all members of your family in Medi-Cal. Or, you can pick a different
PCP doctor for each member of your family in Medi-Cal. Women may choose an
Ob/Gyn or family planning clinic as their PCP doctor. ·
Ask about office access if you or a family member has a
disability. The PCP doctor you choose may not agree to treat you and
may ask L.A. Care to make a change. This can happen if: ·
you are disruptive or disrespectful to your doctor or your
doctor’s office staff; or ·
you do not follow your doctor’s treatment plan; or ·
the service or care you need are not within the doctor’s
scope of care (like a high-risk pregnancy)
What services you can and cannot get outside of
If you travel outside of
As a member of L.A. Care, your service area is Routine care is not covered out of service area. Emergency
and urgent care services are covered outside of
Outside of If you have an emergency when you are not in If you are admitted to a hospital not in L.A. Care’s
network or to a hospital your PCP doctor or other provider does not work at,
L.A. Care has the right to move you to a network hospital as soon as medically
safe. Your PCP doctor must provide follow-up care when you leave
the hospital.
You may get a bill if you go to a doctor that does not work
with L.A. Care or is located outside of
How to get information about doctors and specialists who
work with your health plan We are 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. L.A. Care can tell you about the
medical school they attended, their residency or board certification.
How to get care from a
specialist Your PCP doctor will refer you to a specialist or
hospital. Your
PCP doctor is the doctor who makes sure you get the care you need when you need
it. Sometimes your PCP doctor will send you to a specialist. A “specialist” is a
type of doctor who is an expert in some kind of health care. These specialists
are within your PCP doctor and L.A. Care’s network. If you need care from a
specialist, your PCP doctor must approve these services before you receive them.
Routine referrals to a specialist take up to five working days and rush
referrals cannot take more than three calendar days (for example, when you need
medical care right away or have an urgent condition). Female members who need Ob/Gyn care don’t need their PCP
doctor’s okay to go to an Ob/Gyn or family planning doctor with L.A. Care. Behavior Health Care Mental health services. Mental health services may include
treatment for anxiety, behavior health problems, or depression. Your PCP doctor
will provide you with some outpatient mental health services, within the scope
of their training and practice. Specialized mental health services may be needed
for services beyond your PCP doctor’s training and practice. Specialized mental
health services are provided through the Los Angeles County Department of Mental
Health (LACDMH). You may receive services from LACDMH with or without a referral
from your doctor. LACDMH may be reached toll free at 1-800-854-7771.
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 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 Complaints: What should I do if I am unhappy? If you are not happy, are having problems or have questions
about the service or care given to you, let your PCP doctor know. Your PCP
doctor may be able to help you or answer your questions. If you are still not
happy, you may file a grievance with L.A. Care. 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 |
