If you have questions about what is covered or not covered, please call L.A. Care at 1-888-839-9909.
Benefits Guide
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.
The following services do not require prior authorization. Click on one of the topics below to learn more about that benefit.
Alcohol/Drug Abuse
- Crisis intervention
- Health education services
Asthma 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
Cancer Anchor Screening
- 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.
Diabetic Services
- 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 of the feet (such as special footwear or shoe inserts) 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
Doctor Office Visits
- All routine visits, exams, treatments, required immunization shots, and Child Health Disability Prevention Program (CHDP) visits are provided by your doctor.
- Services from a specialist
- 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.
Drugs/Medications
- 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 (shoe inserts)
- 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
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
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.
Examples of family planning providers include:
- Your PCP doctor
- Clinics
- Certified Nurse Midwives and Certified Nurse Practitioners
- OB/GYN specialists (doctors who specialize in female reproductive health care)
- Planned Parenthood clinics
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.
Many of our doctors who provide family planning services are also OB/GYN specialists. Women may pick a PCP doctor from a list of family planning clinics located near them. Please call L.A. Care to find out more.
Women have the right to family planning services given by a family planning provider who is not in L.A. Care's network. You do not need an okay from your PCP to do this. L.A. Care will pay that doctor or clinic for the family planning services you get.
The California Department of Health Services (DHCS), 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.
Health Education Services
L.A. Care has health education materials, programs and services to help you stay healthy and take care of yourself. These programs are free. Health education services can help members by:
- Promoting health: Learn to develop life-long healthy habits
- Preventing diseases: Learn how to prevent and care for life-threatening illnesses.
- Helping you manage chronic diseases
Learn more about these topics by talking to your doctor or through health education services:
- Asthma
- Dental Health
- Diabetes
- Drug and Alcohol Programs
- Exercise/Fitness
- Family Planning/Birth Control
- HIV
- Healthy Foods
- High Blood Pressure
- Immunization (Shots)
- Parenting/Child Health
- Prenatal Health
- Safety Tips
- Sexually Transmitted Diseases (STDs)
- Tobacco Use (how to quit or prevent smoking)
- Weight Problems
- Violence/Abuse
Health education services include:
- Written materials (booklets)
- Tapes, DVDs, CDs or videos
- Referrals to health education classes or programs
- Counseling (one-on-one teaching, phone or group)
- Support groups
- Online community resource and health education information
For health education services information, visit L.A. Care online at www.lacare.org.
Ask your doctor for health education materials and classes. You can also call L.A. Care.
Hearing Aids
- Hearing aids are covered when ordered by your doctor.
HIV Testing
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 PCP doctor,
- Los Angeles County Department of Health Services,
- family planning services providers,
- prenatal clinics.
Please call L.A. Care 1-888-4LA-CARE (1-888-452-2273) to request a list of testing sites.
Home Health
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.
Hospice Care
Hospice care is limited to members who have been certified as terminally ill and are expected to live six (6) 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 of up to two (2) periods of 90 days each and an unlimited number of subsequent periods of 60 days each during the individual's lifetime.
If you are under the age of 21, L.A. Care will offer and pay for covered services related to your terminal illness even if you choose to receive hospice care.
Hospital Care
Includes, but is not limited to:
- inpatient services
- intensive care
- outpatient services
Incontinent Creams and Washes
Provided at no cost when there is a medical need.
Lab Services
- blood work
- urine tests
- throat cultures
Services must be provided at a network:
- doctor’s office,
- hospital,
- laboratory
Mastectomy
Mastectomy is a surgery to remove a breast due to cancer.
- Prosthesis (replacing a missing body part with an artificial one)
- 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
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 (6) 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.
Minor Consent Services
There are some services adolescent members (children ages 12 to 21) can get without a parent’s okay. Minors can decide 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 for members 12 years of age or older,
- Family planning services,
- Outpatient mental health treatment and counseling,
- Pregnancy related services,
- Sexual assault services (including rape),
- Sexually transmitted disease (STD) services for members 12 years of age or older
- Outpatient mental health treatment and counseling for minors (12 to 21 years of age) who are not mature enough to participate, and where:
- There is danger of serious physical or mental harm to themselves or to others; or
- They are a victim of incest or child abuse.
Newborn Care
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 1-888-839-9909. 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 (3) days of getting home from the hospital after delivery. An L.A. Care doctor in your network should see your newborn baby within a few days after birth. Call L.A. Care for more information on getting an appointment.
Newborn baby screenings for certain treatable genetic disorders are covered. These genetic disorders include:
- Phenylketonuria (PKU)
- Galactosemia
- Hypothyroidism
- Hemoglbinopathies
- Sickle cell disease
- Thalassemia
- Amino acid disorder
- Organic acid oxidation disorders
- Fatty acid oxidation disorders
- Congenital adrenal hyperplasia (CAH)
- 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.
Treatment of PKU includes medically prescribed formulas and special food products. PKU cases are followed by a health care professional who consults with a doctor specializing in PKU-related issues.
You can learn more about this in “More Benefits: What other services can I get? section 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. Please call L.A. Care if you have any questions.
Podiatry (services for the feet)
Podiatry services are limited and require prior authorization except when received on an emergency basis.
Prenatal Care
- Regular doctor visits during your pregnancy (called prenatal visits)
- Prenatal supplements
- Diagnostic and genetic testing
Reconstructive Surgery
- 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.
Topical Fluoride Varnish
Topical fluoride varnish helps prevent an control tooth decay. Topical application of fluoride is a Medi-Cal benefit for children younger than six (6) years of age, up to three (3) times in a 12-month period.
Transportation
Emergency transportation for a member that believes it is necessary to stop or relieve sudden serious illnesses or symptoms, or injury or conditions requiring immediate diagnosis and treatment. Emergency transportation (ambulance) or ambulance transport services provided through the "911" emergency response system will be covered in a medical emergency when medically necessary.
Non-emergency medical transportation to medical facilities is covered when your medical and physical condition does not allow you to take regular means of public or private transportation (car, bus, etc.,) and you have a written prescription from your doctor. Examples of non-emergency medical transportation include, but are not limited to, litter vans and wheelchair vans. Also includes non-emergency transportation for the transfer of a member from a hospital to another hospital or facility, or facility to home when the transport 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.
Vision Care
Eye exams are covered by L.A. Care for members of all ages. Members who are under 21 years of age, pregnant or living in a nursing home are covered for one pair of eyeglasses every two (2) years unless the prescription changes. This includes lenses and covered frames for eyeglasses when authorized.
To find out more about eye exams or vision care coverage call Vision Service Plan at 1-800-877-7195 (TTY/TDD 1-800-428-4833). No-cost interpreting services, including American Sign Language, are available.
X-ray Services
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
The following is a list of services not covered for some L.A. Care Medi-Cal members over the age of 21 (Please see the "Medi-Cal Benefit Changes" section of below):
- Dental
- Chiropractic
- Acupuncture
- Psychiatry Services
Medi-Cal Benefit Changes
The state recently cut a few benefits from the Medi-Cal program. These changes only affect some adults age 21 and older who are on Medi-Cal. These changes do not affect members under 21 years of age. Medi-Cal benefits for members under 21 remain the same.
These benefits will NOT change for Medi-Cal members who are:
- 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
However, L.A. Care feels that five (5) benefits the state cut are important to our members and will still provide these benefits when there is a medical need.
As an L.A. Care Medi-Cal member, you will keep getting:
- Speech therapy services
- Podiatric services
- Audiology services
- Incontinence creams and washes
- Annual optometry exam for diabetic members