Healthy Kids Program

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					 Healthy Kids
 Program

          A Helpful Guide to
    Your Health Care Benefits




L.A. Care Health Plan offers the Healthy Kids program through funding
  from First 5 LA and Children’s Health Initiative of Greater Los Angeles.
                                                                                                                            A Helpful Guide to Your Health Care Benefits




Thank you for your membership with L.A. Care Health Plan.
When you join, and then every year, you will get this package of important information in the mail. It is
about your health coverage. We need you to read and understand it.
This Member Handbook you are reading contains the Evidence of Coverage and Disclosure Form
(EOC). It has the terms and conditions of your health benefits, summarizes the L.A. Care Health Plan
(L.A. Care) policies and rules, and tells you how to get health care. The Member Handbook is broken
down into the following sections:
   • Combined Evidence of Coverage and Disclosure Form  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . p . 3
   • How to Get Your Prescription Drugs  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . p . 45
   • Preventive Health Guidelines – How to Keep Your Child or Teen Healthy  .  .  .  .  .  .  .  .  .  .  .  .  .  . p . 47
   • Notice of Privacy Practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . p . 51
   • Nurse Advice Line – List of Audio Health Topics  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . p . 55
The information listed below can be found in this Member Handbook:
Basic Information
  •	 What benefits and services are covered
  •	 What benefits and services are not covered
  •	 How does my health plan make decisions about new treatments
  •	 What care you can and cannot get when you are out of Los Angeles County
  •	 How to access care when you are out of Los Angeles County
  •	 How to change or get care from your primary care physician (PCP)
  •	 How to get information about doctors
  •	 How to get a referral
  •	 What to do when you need care right away or when the office is closed
  •	 What do I do if I have an emergency
  •	 How to get prescriptions filled and other pharmacy information
  •	 Co-payments and other charges
  •	 What to do if you get a bill
Special Programs
  •	 How L.A. Care makes sure you get good health care
  •	 Programs for people with disease, like diabetes or asthma
How decisions are made about your care
  •	 How our doctors and staff make decisions about your care
  •	 How to reach us if you want to know more about how decisions are made about your care
  •	 How to appeal a decision about your care
Member Issues
  •	 Your rights and responsibilities as a health plan member
  •	 How to complain when you are unhappy
  •	 What to do if you are disenrolled from your plan
  •	 How L.A. Care protects and uses your personal health information
You may view this Member Handbook before enrollment in the Healthy Families Program. Be sure
to see our Web site www.lacare.org, or call us at 1-888-839-9909 if you would like paper copies.
Please read the following information so that you will know
how and where to get care.



In Your Language

  The Civil Rights Act of 1964 is a law which protects you if you do not speak English. The hearing
impaired, disabled, aged, and blind are also protected by the Americans with Disabilities Act (ADA)
of 1990.
  The doctor’s office, clinic, or hospital cannot deny services because you do not speak English or
are disabled. You have the right to free face-to-face interpreter services to explain your child’s health
problem and understand treatments. You may also request documents translated into your language.
Call L.A. Care Member Services toll-free at 1-888-839-9909. Members who have hearing loss or
are deaf/hearing impaired can call L.A. Care at 1-866-LACARE1 (1-866-522-2731).
                                                                                                       Healthy Kids Member Handbook




                Healthy Kids Program
                Combined Evidence of Coverage and Disclosure Form




Healthy Kids is sponsored by First 5 LA and the Children’s Health Initiative of Greater Los Angeles and is administered by L.A. Care Health Plan.
                                                                                                                                                iii
Table of Contents

     Customer Service                                                                                                                         6   Grievance & Appeals                                                                                                             20
      Welcome  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   6    L .A . Care Grievance Process  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
      Health Information Privacy  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                   6    How to File a Grievance  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
      Identification Card (ID Card)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                   7    How to File a Grievance for Urgent Cases  .  .  .  .  .  .  .  .  .  . 21
      The Provider Directory  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                           7    Independent Medical Review  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
      Language and Interpreter Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                                    7    Review by the Department of
                                                                                                                                                       Managed Health Care  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22
      Hearing Impaired Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                    7
                                                                                                                                                   Eligibility and Enrollment  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
      Vision Impaired Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                               7
      Health Care Access for Patients with Disabilities  .  .  .  .  .                                                                        7
      Service Area  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .       7   Payment Responsibilities                                                                                                        24
      Helpful information at www .lacare .org                                                                                                      Monthly Family Contributions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
         on the Internet  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                   8    Annual Co-payment Maximum  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
                                                                                                                                                   Member Liability  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
     Definitions                                                                                                                              9
                                                                                                                                                  Summary of Benefits                                                                                                             25
     Member Bill of Rights                                                                                                              14
      Member Rights  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14                   Plan Benefits                                                                                                                   29
      Member Responsibilities  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14                                     Alcohol/Drug Abuse Services – Inpatient  .  .  .  .  .  .  .  .  .  . 29
                                                                                                                                                   Alcohol/Drug Abuse Services – Outpatient  .  .  .  .  .  .  .  . 29
     How to Get Care                                                                                                                    15         Blood and Blood Products  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
      Primary Care Physician (PCP)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15                                            Cataract Spectacles and Lenses  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
      Scheduling Appointments  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15                                           Cancer Clinical Trials  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
      Initial Health Assessment .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15                                    Dental Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
      Referrals and Prior Authorizations  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15                                                     Diagnostic X-Ray and Laboratory Services  .  .  .  .  .  .  .  .  . 29
      Referrals to Specialty Physicians  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16                                                Durable Medical Equipment (DME)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
      Standing Referrals  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16                        Emergency Care Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
      Second Opinions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16                        Emergency Contraception  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31
      How to Find a Pharmacy  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17                                      Family Planning Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31
      Emergency and Urgent Care Services  .  .  .  .  .  .  .  .  .  .  .  .  . 17                                                                 Health Education Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32
      Non-Qualified Services .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19                                 Home Health Services .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32
      Continuity of Care  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19                        Hospice  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32




iv
                                                                                                                                                                                                Healthy Kids Member Handbook




 Hospital Services – Inpatient  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32                                     Regional Community Advisory Committees
 Hospital Services – Outpatient  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33                                            (RCACs)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
 Medical Transportation  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33                             Notice of Information Practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
 Mental Health Care – Inpatient  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33                                          Governing Law  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
 Mental Health Care – Outpatient  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34                                               New Technology  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
 Pediatric Asthma Care  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34                           Natural Disasters, Interruptions, Limitations  .  .  .  .  .  .  .  . 41
 Phenylketonuria (PKU)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34
 Physical, Occupational, and Speech Therapy  .  .  .  .  .  .  . 35                                                                    Important Phone Numbers                                                                                                  42
 Prescription Drugs  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 35
 Preventive Care Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 35
 Professional Services, Office Visits and
                                                                                                                                       Service Area Map                                                                                                         43
    Outpatient Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
 Prosthetics and Orthotics  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
 Reconstructive Surgery  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
 Skilled Nursing Care  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
 Transplants  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 37
 Vision Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 37
 Exclusions and Limitations  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 37


General Information                                                                                                         39
 Benefit Program Participation  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
 Notifying You of Changes in Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
 Termination of Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
 Disenrollment and Cancellation  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
 How A Provider Gets Paid  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
 Reimbursement Provisions – If you Receive a Bill  .  .  . 39
 Independent Contractors  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
 Review by the Department of
    Managed Health Care (DMHC) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
 Coordination of Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
 Third Party Liability  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
 Public Policy Participation  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40




                                                                                         Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731.                                                                                                  v
Customer Service

    Welcome!                                                           L.A. Care may get this information from any of these
      Welcome to L.A. Care Health Plan (L.A. Care).                  sources:
    L.A. Care Health Plan is a public entity whose official           •	 You
    name is Local Initiative Health Authority for Los Angeles         •	 Another	health	plan
    County. L.A. Care is an independent public managed care           •	 Your	child’s	doctor
    health plan licensed by the state of California. L.A. Care
    works with doctors, clinics, hospitals, and other providers to    •	 Your	child’s	application	for	the	health	care	program
    offer you quality health care services.                           •	 Your	child’s	health	records
                                                                       Before L.A. Care gives your child’s health information
    Health Information Privacy                                       to another person or group, we need your written consent.
      At L.A. Care, we value the trust you have in us. We want       This may happen when:
    to keep you as a L.A. Care member. That’s why we want             •	 A	court,	arbitrator,	or	similar	agency	needs	your	child’s	
    to share with you the steps L.A. Care takes to keep health           health information
    information about you and your family private.                    •	 A	subpoena	or	search	warrant	is	requested
      To keep health information about you and your family            •	 A	coroner	needs	your	child’s	health	information	
    private, L.A. Care:
                                                                      •	 Your	child’s	health	information	is	needed	by	law
      •	 Uses	secure	computer	systems
                                                                       L.A. Care may give your child’s health information to
      •	 Handles	health	information	the	same	way,	every	time
                                                                     another health plan or group to:
      •	 Reviews	the	way	it	handles	health	information
                                                                      •	 Make	a	diagnosis or treatment
      •	 Follows	 all	 laws	 about	 the	 privacy	 of	 health	
                                                                      •	 Make	payment	for	your	child’s	health	care
         information
                                                                      •	 Review	the	quality	of	your	child’s	health	care
      All L.A. Care staff who have access to your child’s health
    information are trained on privacy laws. They follow               Sometimes, we may also give your child’s health
    L.A. Care guidelines. They also sign an agreement that           information to:
    they will keep all health information private. L.A. Care          •	 Groups	who	license	health	care	providers
    does not give out health information to any person or             •	 Public	agencies
    group who does not have a right to it by law.
                                                                      •	 Investigators
      L.A. Care needs some information about your child so
                                                                      •	 Probate	courts
    that we can give her or him good health care services. This
    information includes:                                             •	 Organ	donation	groups
      •	 Name                                                         •	 Federal	or	state	agencies	as	required	by	law
      •	 Gender                                                       •	 Disease	management	programs
      •	 Date	of	birth                                                 If you have any questions or would like to know
      •	 Language	you	speak                                          more about your child’s health information, please call
      •	 Home	address                                                L.A. Care Member Services at 1-888-839-9909.
      •	 Home	or	work	telephone	number
      •	 Health	history
6
                                                                                                 Healthy Kids Member Handbook




Identification Card (ID Card)                                         1-888-839-9909 to ensure that you can obtain the health
  You will receive an ID card that shows your child is an             care services that you need.
L.A. Care member. Keep your child’s ID card with you
at all times. Show the ID card to the doctor, pharma-                 Language and Interpreter Services
cy, hospital, or other health care provider when you
                                                                        L.A. Care provides free 24-hour interpreter services for
seek care.
                                                                      those members who speak a different language than their
  Never	 let	 anyone	 use	 your	 child’s	 L.A.	Care	 ID	 card.	       health care provider. You do not need to use your family
Letting someone else use your child’s L.A. Care ID card               members or friends to interpret for you. You have the right
with your knowledge is fraud.                                         to file a grievance with L.A. Care if you do not receive
                                                                      your services in the language you request. If you have any
The Provider Directory                                                questions, please call L.A. Care.
  The provider directory is a list of all doctors, hospitals,
pharmacies, and mental health services in L.A. Care’s                 Hearing Impaired Services
network. The provider directory lists the languages spoken              If you are hearing impaired, you can call toll-free at
at each provider’s	 office.	 New	 members	 should	 have	              1-866-LACARE1	(1-866-522-2731).	
received a provider directory in your welcome packet with
                                                                        You may also ask for free sign language interpretive
this Member Handbook. You can also request a provider
                                                                      services for your child’s health visits.
directory by calling Member Services at 1-888-839-9909
or you can visit L.A. Care’s Web site, www.lacare.org, to
find a provider.                                                      Vision Impaired Services
  You may also get a list on the availability, education,               You may ask for this document and other materials in
and board certification of a participating provider in a              large print formats. Please call L.A. Care if you have any
geographical area of your choice by calling L.A. Care.                questions, at 1-888-839-9909.
  Some hospitals and other providers may have a moral
objection to provide some services and some hospitals and             Health Care Access for Patients with Disabilities
other providers do not provide one or more of the following
                                                                        L.A. Care sees to it that provider offices may be accessed
services that may be covered under your plan contract and
                                                                      by the disabled. If you cannot find a provider who meets
that you or your family member might need:
                                                                      your needs, please call L.A. Care.
  •	 Family	Planning
                                                                        If you believe that L.A. Care or its Participating Provider
  •	 Contraceptive	services	including	emergency	contraception         Groups	(PPGs)	have	not	met	your	disability access needs,
  •	 Sterilization,	 including	 tubal	 ligation	 at	 the	 time	 of	   you may file a grievance with L.A. Care.
     labor and delivery
  •	 Infertility	treatments                                           Service Area
  •	 Abortion                                                           You must live in Los Angeles County (including Catalina
  You should obtain more information before you enroll.               Island) in order to receive services through L.A. Care.
Call your prospective doctor, medical group, independent              You must choose a Primary Care Physician (PCP) in
practice association, or clinic, or call Member Services at           Los Angeles County.


                                            Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731.         7
      Please see the “Emergency Services” section for more
    details on emergency care.


    Helpful information at
    www .lacare .org on the Internet
      Do you use the Internet? Our Web site www.lacare.org is
    a great resource. You can:
      •	 Find	a	doctor
      •	 Learn	about	your	benefits
      •	 Learn	more	about	privacy	rights
      •	 Find	out	about	your	rights	and	responsibilities
      •	 File	a	complaint	(called	a	“grievance”)
      You can also check your eligibility for medical coverage.
    You can even request to change your doctor or medical
    group. Since this information is private, you will need to log
    in.	Go	to	www.lacare.org	and	then	click	“I	Am	A	Member”	
    to find out what to do. (Be sure to have your ID card ready
    as we ask for your member ID number.)




8
Definitions

  Acute refers to a health effect that is brief and/or of high      Capitation is a set flat rate paid each month to providers
intensity.                                                        for covered services provided to L.A. Care members.

  Americans with Disabilities Act (ADA) of 1990 is law              Cardiology is the medical specialty of the diagnosis and
that protects people with disabilities from discrimination        treatment of heart disease.
and ensures equal opportunity for persons with disabilities
in employment, state and local government services. For             Chemotherapy is the treatment of a disease using
more	information,	call	the	U.S.	Department	of	Justice	at	         chemical substances or drugs.
1-800-514-0301	(voice)	or	1-800-514-0383	(TTY).	
                                                                    Chiropractic is the practice of locating, detecting and
  Anesthesia loss of sensation due to a pharmacological           assisting in correcting vertebral subluxation. This is done
depression of nerve function.                                     by hand only with an adjustment.

   Applicant is a person who applies for the Healthy Kids           Civil Rights Act of 1964 (Title 6) is a law that protects
program on his/her own behalf. An applicant is also a             limited English speaking members by requiring health
person who applies on behalf of a child for whom he or she        care providers who receive federal government money
is responsible.                                                   to offer language services that include interpretations
                                                                  and	 translations.	 For	 more	 information,	 call	 the	 U.S.	
  Qualified health care professional is a PCP, specialist,        Department of Health and Human Services, Office of
or other licensed health care provider who is acting within       Human	 Rights	 at	 1-800-368-1019	 (voice)	 or	 1-800-537-
his/her scope of practice. A qualified health care professional   7697	(TTY).
also has a clinical background in the illness, disease, or
condition(s). Clinical background includes training, and            Contraindicated is the showing that a method of
expertise or a high degree of skill and knowledge.                treatment that would normally be used is not advisable due
                                                                  to the special circumstances of an individual case.
  Authorize/Authorization is the requirement that
covered services be approved.                                       Co-payment is the amount a member is required to pay
                                                                  for certain covered services.
  Benefits, Plan Benefits, or Covered Services are those
services, supplies, and drugs a member is entitled to receive       Covered Services, Plan Benefits, or Benefits are those
according to the Healthy Kids program.                            services, supplies, and drugs a member is entitled to receive
                                                                  according to the Healthy Kids program.
  Benefit Year is the 12-month period based on
anniversary.                                                        Credential is a certificate showing that a person is
                                                                  entitled to treat a member.
  California Children’s Services (CCS) is a statewide health
care program open to persons under the age of 19 with               Custodial Care is a long-term care that does not require
a handicapping condition. Call the Los Angeles County             skilled nursing.
CCS	program	at	(626)	858-2100	for	more	information.
                                                                    Diagnosis the decision of the nature of a disease.
  Cancer Clinical Trial is a research study with cancer
patients, to find out if a new cancer treatment or drug is          Diagnostic testing is the use of tests to reach a
safe and works with the type of cancer that you have.             diagnosis.



                                          Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731.       9
       Dialysis is a form of filtration to separate smaller              Family Premium is the monthly family payment.
     molecules from larger ones in a solution. This is achieved by
     placing a semipermeable membrane between the solution               Federally Qualified Health Centers (FQHCs) are
     and water.                                                        health centers that receive a Public Health Services (PHS)
                                                                       grant. FQHCs are located in areas without a lot of health
       Disability is a physical or mental problem that totally or      care services.
     seriously limits one or more of your major life activities.
                                                                         Formulary is a list of drugs approved by L.A. Care. A
       Disenrollment is when you leave L.A. Care for any               formulary is a list of drugs that are generally accepted in
     reason.                                                           the medical community as safe and effective.

       Drug Formulary (formulary) is a list of drugs approved            Generally medically accepted is a term used for tests
     by L.A. Care. A formulary is a list of drugs that are generally   or treatments that are commonly used by doctors for the
     accepted in the medical community as safe and effective.          treatment of a specific disease or diagnosis.

       Durable Medical Equipment (DME) is medical                        Grievance is the term used when you are not happy
     equipment used repeatedly by a person who is ill or               with the health care service you receive. A grievance may
     injured.                                                          be administrative or clinical. You may file a grievance over
                                                                       the phone or in writing.
       Eligible/Eligibility means to meet certain requirements,
     in order to take part in or receive program benefits.               Healthy Families Program is a health care program
                                                                       that offers low-cost health, dental, and vision coverage for
       Emergency Care/Services are medically necessary                 children. The Healthy Families Program is administered by
     covered services, including ambulance and mental health           the	Managed	Risk	Medical	Insurance	Board	(MRMIB).
     services, which a prudent layperson would have considered
     necessary to stop or relieve a serious illness or symptom,          Healthy Kids is a health care program that offers low-
     injury or severe pain, or conditions requiring immediate          cost health, dental, and vision coverage for children.
     diagnosis and treatment.
                                                                        Hemodialysis is the dialysis of soluble substances and
       Emergency Contraceptive Drugs contain the same                  water from the blood by diffusion through a semipermeable
     medication as regular birth control drugs and help prevent        membrane.
     pregnancy.
                                                                         Hospice is care and services provided in a home or
       Enrollee is a person who has joined L.A. Care Health            facility, by a licensed or certified professional, to relieve
     Plan. Also see “member.”                                          pain and provide support to persons who have received a
                                                                       diagnosis for a terminal illness.
       Enrollment is the act of beginning your participation in
     a program like the Healthy Kids program.                            Hospital is a place you can get inpatient and outpatient
                                                                       care from doctors or nurses.
       Evidence of Coverage (also called “Member
     Handbook”) is the document you are reading. It tells you            Immunizations help your immune system attack
     what services are covered or not covered and how to use           organisms that can cause disease. Some immunizations are
     L.A. Care’s services.                                             given in a single shot or oral dose. Others require several
                                                                       shots over a length of time.
       Experimental or Investigational in Nature are medical
     services that are used on humans in testing and trial centers       Infertility is a diminished or absent ability to conceive,
     and will require special authorization from government            and produce offspring after unprotected sexual relations on
     agencies, like the Federal Food and Drug Administration           a regular basis for more than twelve months.
     (FDA).




10
                                                                                           Healthy Kids Member Handbook


  Inpatient Care Services are services provided to a              Medicare is a federal health insurance program for
patient admitted to a hospital.                                 persons	 age	 65	 and	 older,	 persons	 who	 have	 permanent	
                                                                kidney failure, and certain persons with disabilities.
  Interpreter is a person who speaks the languages of two
people who would like to speak with each other, but cannot        Member is a person who is enrolled in the Healthy Kids
because of language differences. The interpreter transfers      program through L.A. Care.
from one language to the other the meaning of what is
heard without changing what is being said.                        Member Services Department is the department
                                                                in L.A. Care that can help members with questions and
  Intraocular Lens is the lens within your eyeball.             concerns.

  Laboratory is the place equipped for the running of             Mental Health Care is the diagnosis or treatment of
tests, experiments, and investigative procedures.               mental or emotional disorders or the mental or emotional
                                                                problems associated with an illness, injury, or any other
  L .A . Care Health Plan is a non-profit managed health        condition.
care organization that takes part in the Healthy Kids
program.                                                          Negligence is the doing of some act which a person
                                                                of ordinary prudence would not have done under similar
  Liable/Liability is the responsibility of the party; or       circumstances, or failure to act which a person of ordinary
obligation one is bound by law or justice to perform.           prudence would have done under similar circumstances.
  Lien is a claim or charge on property, which a creditor         Network is the doctors, hospitals, pharmacies, and
(one who is owed money) has as security for a debt or charge    mental health services contracted with L.A. Care to provide
that is owed to him/her.                                        covered health care services for members.
  Life Threatening tells about a disease or condition that         Occupational Therapy is the treatment provided by a
may put a person’s life in high danger if the course of the     licensed professional, using arts, crafts, or other training
disease is not stopped.                                         in daily living skills, to improve and maintain a patient’s
                                                                ability to function after an illness or injury.
  Maintenance Drug is any drug taken continuously for
a chronic medical problem.                                        Office of Civil Rights handles complaints about
                                                                discrimination against minorities or the disabled.
  Managed Risk Medical Insurance Board (MRMIB)
is the state agency that manages the Healthy Families             Orthotics is a device used to support, align, prevent,
Program, and determines eligibility, benefits, and premium      correct, or improve the function of movable body parts.
payments.
                                                                  Outpatient is the medical treatment in a hospital or
  Medi-Cal is a state health insurance program that             clinic but you do not have to stay overnight.
provides health care coverage to low-income families.
                                                                  Participating Hospital is a hospital approved by
  Mediation is a process where a neutral person tries to help   L.A. Care to provide covered services to its members.
individuals resolve a dispute. The results of the mediation
are not binding.                                                  Participating Provider is a doctor, hospital, pharmacy,
                                                                or other health care professional approved by L.A. Care to
   Medical Group is a physician group your doctor or PCP        provide covered services to its members.
is	a	part	of.	Also	see	“Participating	Provider	Group.”
                                                                  Participating Provider Group is a physician group your
  Medically Necessary are those services provided to treat      doctor or PCP is a part of. Also see “medical group.”
an illness or injury according to established and accepted
medical practice standards.

                                                                                                                     >>
                                         Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 11
       Participating Specialist is a doctor with specialized             Provider Directory is a list of doctors, hospitals,
     training, who has been approved by L.A. Care to provide           pharmacies, and mental health services contracted with
     covered services to its members.                                  L.A. Care to provide covered health care services for
                                                                       members.
      Pharmacy is a licensed retail pharmacy. It is a place
     where you can get your prescription filled.                         Prudent Layperson is an individual who does not belong
                                                                       to a particular profession or specialty, but has awareness or
       Phenylketonuria (PKU)	is	a	rare	disease.	PKU	can	cause	         information to make a good decision.
     mental retardation and other neurological problems if
     treatment is not started within the first few weeks of life.        Radiology the use of radiation to diagnose and treat a
                                                                       disease.
       Physical Therapy is the treatment provided by a licensed
     professional, using physical agents, such as ultrasound,            Reconstructive Surgery repairs abnormal body parts,
     heat and massage, and exercise to improve and maintain a          improves body function, or brings back a normal look.
     patient’s ability to function, after an illness or injury.
                                                                         Referral is the process by which your PCP directs you to
       Physician is a doctor.                                          other providers to seek and obtain covered services, which
                                                                       require prior authorization by L.A. Care.
       Plan Benefits, Benefits, or Covered Services are those
     services, supplies, and drugs a member is entitled to receive       Rehabilitative Services are the services used to restore
     according to the Healthy Kids program.                            the ability to function in a normal or near normal way,
                                                                       after a disease, illness, or injury.
       Prescription is a written order issued by a licensed
     prescriber.                                                          Respiratory Therapy is the treatment provided by a
                                                                       licensed professional, to improve a patient’s breathing
       Primary Care Physician (PCP) is a doctor who acts as            function.
     your family doctor and manages your health care needs.
                                                                         Routine Patient Care Costs are ordinary or normal
       Prosthesis is an artificial device, used to replace a missing   costs for patient care services.
     part of the body.
                                                                         Screenings protect your health by detecting disease
       Provider(s) are the persons contracted with L.A. Care           early and when it may be easier to treat.
     to provide covered health care services for members. These
     people include:                                                     Second Opinion is a visit with another doctor when
       •	 Doctors                                                      you:
       •	 Hospitals                                                      •	 Question	a	diagnosis,	
       •	 Skilled	nursing	facilities                                     •	 Do	not	agree	with	your	PCP’s	treatment	plan,	or	
       •	 Home	health	agencies                                           •	 Would	like	to	confirm	your	treatment	plan.
       •	 Pharmacies                                                     Seriously Debilitating tells about a disease or condition
       •	 Medical	transportation	companies                             that may not be possible to stop or change and may cause
       •	 Laboratories                                                 death.
       •	 X-ray	facilities
       •	 Durable	medical	equipment	suppliers
       •	 Others




12
                                                                                               Healthy Kids Member Handbook


  Serious Emotional Disturbance (SED) is a mental con-               Third Party includes insurance companies, individuals,
dition in children under the age of 19 years. As said by           or government agencies.
the most recent edition of the Diagnostic and Statistical
Manual of Mental Disorders, children with this disorder              Third Party Liability is the liability of a party other than
have serious problems in at least two of the following areas:      the State of California, L.A. Care, or a member.
self-care, school functioning, family relationships, ability
to function in the community; and meets other require-               Urgent Services are health services needed to prevent
ments; and either of the following occur:                          an illness or injury from becoming worse with delay of
                                                                   treatment.
  a) The child is at risk of being removed or has been
      removed from the home; or                                       Urgent Grievance is when you are not happy with the
  b) The mental disorder and problems have been present            health care service and feel that any delay with decision
      for more than six months or are likely to continue for       could lead to a life-threatening or debilitating condition.
      more than one year without treatment.                        Urgent	grievances	include,	but	are	not	limited	to:
                                                                     •	 severe	pain
 Service Area is the Los Angeles County, including
Catalina Island.                                                     •	 potential	loss	of	life,	limb,	or	major	bodily	function

   Severe Mental Illnesses (SMI) include, but are not                Venereal relates to or is the result of sexual intercourse.
limited to: Attention Deficit Disorder (ADD), Attention
Deficit Hyperactivity Disorder (ADHD), schizophrenia,                Vision Impaired is when your ability to see is reduced.
schizoaffective disorder, bipolar disorder (manic-depressive
illness), major depressive disorders, panic disorder, obsessive-
compulsive disorder, pervasive developmental disorder or
autism, anorexia nervosa, bulimia nervosa.

  Skilled Nursing Facility is a facility licensed by the
California State Department of Health Services (SDHS)
to provide specialized nursing services.

  Specialist is a doctor with specialized training, who has
been approved by L.A. Care to provide covered services for
members.

  Speech Therapy is the treatment provided by a licensed
professional, to treat speech problems.

  Standing Referral is a referral approved by your PCP
for more than one visit to a specialist or specialty care
center for continued or long-term treatment of a medical
condition.

  State Department of Health Services (SDHS) is a
California state agency with the purpose to protect and
improve the health status of all Californians.

  Therapeutic Services are the services for the treatment,
remediating, or curing of a disorder or disease.



                                                                                                                          >>
                                           Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 13
Member Bill of Rights

     As a Member of L .A . Care Health                                Service and information in your language. You have
     Plan, you have a right to…                                     a right to request an interpreter at no charge and not use a
                                                                    family member or a friend to translate for you. You have the
       Respectful and courteous treatment. You have the             right to get the Member Handbook and other information
     right to be treated with respect, dignity and courtesy from    in a language or format you understand.
     L.A. Care providers and staff. You have the right to be
     free from retaliation or force of any kind when making
     decisions about your care.                                     As a Member of L .A . Care Health Plan,
       Privacy and confidentiality. You have a right to have        you have a responsibility to…
     a private relationship with your provider and to have your       Act courteously and respectfully. You are responsible
     medical record kept confidential. You also have a right to     for treating your L.A. Care doctor and all our providers
     receive a copy of and request corrections to your medical      and staff with courtesy and respect. You are responsible for
     record. If you are a minor, you have a right to certain        being on time for your visits or calling your doctor’s office
     services that do not need your parent’s okay.                  at least 24 hours before the visit to cancel or reschedule.
       Choice and involvement in your care. You have the              Give up-to-date, accurate and complete information.
     right to receive information about L.A. Care and our           You are responsible for giving correct information to all
     services. You have the right to choose your Primary Care       of your providers. You are responsible for getting regular
     Physician (doctor) from the doctors and clinics listed in      check-ups and telling your doctor about health problems
     L.A. Care’s provider directory. You also have the right to     before they become serious. You are responsible for
     get appointments within a reasonable amount of time.           notifying L.A. Care as soon as possible if you are billed by
     You have a right to talk with your doctor about any care       mistake by a provider.
     your doctor provides or recommends. You have the right
     to a second opinion. You have a right to information about       Follow your Doctor’s advice and take part in your
     treatment regardless of the cost or what your benefits are.    care. You are responsible for talking over your health care
     You have the right to say “no” to treatment. You have a        needs with your doctor and following the treatment you
     right to decide in advance how you want to be cared for in     both agree on.
     case you have a life-threatening illness or injury.
                                                                      Use the Emergency Room only in an emergency. You
       Voice your concerns. You have the right to complain          are responsible for using the emergency room in cases of an
     about L.A. Care or our providers without fear of losing        emergency or as directed by your doctor or L.A. Care’s 24-
     your benefits. L.A. Care will help you with the process. If    hour, free nurse advice line. If you are not sure you have an
     you don’t agree with a decision, you have a right to ask to    emergency, you can call your doctor or call our free nurse
     for a review. You have a right to disenroll from L.A. Care     advice line at 1-800-249-3619.
     whenever you want.
                                                                      Report wrongdoing. You are responsible for reporting
       Service outside of L.A. Care’s provider network. You         health care fraud or wrongdoing to L.A. Care. You can
     have a right to receive emergency or urgent services as well   report without giving your name by calling the L.A. Care
     as family planning and sexually transmitted disease services   Fraud and Abuse Hotline toll-free at 1-800-400-4889.
     outside L.A. Care’s provider network. You have the right to
     receive emergency treatment whenever and wherever you
     need it.

14
How to Get Care
Please read the following information so that you will know how and where to get care.



Primary Care Physician (PCP)                                       If you would like to change your child’s PCP, call
                                                                 L.A. Care at 1-888-839-9909. Or, you can go to the
  Please read the following information so you will know
                                                                 L.A. Care Web site, www.lacare.org. Click on each of the
from whom or what group of providers health care may be
                                                                 following:
obtained.
                                                                   •	 I Am A Member
  All L.A. Care members must have a Primary Care
Physician (PCP). The name and phone number of your                 •	 Click on this sentence to sign into
child’s PCP is found on his/her L.A. Care ID card. Except             L.A. Care Connect.
for emergency services, your child’s PCP will arrange all
                                                                    Follow the instructions to change your child’s doctor.
your health care needs, refer you to specialists, and make
                                                                 The request must be received by the 20th day of the month
hospital arrangements.
                                                                 to be effective the first day of the next month. If the request
  Each PCP works with a Participating Provider Group             is received after the 20th day of the month, it will be effective
(PPG),	which	is	another	name	for	medical group.	Each	PPG	        one month later.
works with certain specialists, hospitals, and other health
                                                                   If	your	new	PCP	works	with	a	different	PPG,	this	may	
care providers. The PCP you choose determines which
                                                                 also change the hospitals, specialists, and other health care
health care providers are available to you.
                                                                 providers from whom your child may receive health care.

Scheduling Appointments
                                                                 Initial Health Assessment
  Step 1: Call your PCP
                                                                   You should take your child to the PCP for an Initial
  Step 2: Explain why you called                                 Health Assessment (IHA) within three months of becoming
  Step 3: Ask for an appointment                                 a L.A. Care member. An IHA is a complete medical history
                                                                 and physical exam and will help your PCP know your
  Your PCP’s office will tell you when to come in and how        child’s health care needs. Your child should also see his/her
much time you will need with your PCP. (Please see the           PCP once a year for health check-ups and well-child visits.
“Summary of Benefits” section to know which services             There is no co-payment for these visits.
require co-payments).

                                                                 Referrals and Prior Authorizations
How to change your PCP
                                                                    A referral is a request for health care services that are not
  Each enrolled child may have a different PCP. If you           usually provided by your PCP. All health care services must
did not choose a PCP when you enrolled your child in the         be	approved	by	your	PCP’s	PPG	before	you	get	them.	This	
Healthy Kids program, L.A. Care will choose one for you          is called prior authorization. Prior authorization is required
based on the following:                                          for all in-network and out-of-network providers.
  •	 The	language	you	speak                                        There are different types of referral requests with different
  •	 How	far	from	the	PCP	you	live.	It	is	best	if	you	live	or	   timeframes as follows:
     work within 10 miles of the PCP, and                          •	 Routine	or	regular	referral	–	5	business	days
  •	 Specialty	care	most	appropriate	for	the	member’s age.         •	 Urgent	referral – 24 to 48 hours



                                         Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 15
       •	 Emergency	referral – same day                                   PCP or with a contracted specialty care center.

       Please call L.A. Care if you do not get a response within            The specialist or qualified health care professional will
     the above time frames.                                               develop a treatment plan for your child. The treatment
                                                                          plan will show how often your child needs to be seen. Once
       The following services do not require a prior                      the treatment plan is approved, the specialist or qualified
     authorization.                                                       health care professional will be authorized to provide health
       •	 Emergency	 services	 (go	 to	 Emergency Care Services           services. The specialist will provide health services in his
          section for more information)                                   or her area of expertise and training and based on the
       •	 Preventive	health	services	(including	immunizations)            treatment plan.
       •	 Obstetrician	and	gynecological	services	in-network

       All health care services are reviewed, approved, or                Second Opinions
     denied according to medical necessity. Call L.A. Care if             What is a second opinion?
     you would like a copy of the policies and procedures used             A second opinion is a visit with another doctor when you:
     to decide if a service is medically necessary. The number is
                                                                            •	 Question	a	diagnosis, or
     1-888-839-9909.
                                                                            •	 Do	not	agree	with	the	PCP’s	treatment	plan,	or	
                                                                            •	 Would	like	to	confirm	the	treatment	plan.	
     Referrals to Specialty Physicians
        Specialists are doctors with training, knowledge, and               The second opinion must be from a qualified health care
     practice in one area of medicine. For example, a cardiologist        professional	in	L.A.	Care’s	or	your	PPG’s	network. If there
     is a heart specialist and who has years of special training to       is no qualified health care professional in the network,
     deal with heart problems.                                            L.A.	Care	 or	 your	 PPG	will	make	arrangements	 for	one.	
                                                                          You have the right to ask for and to get a second opinion,
       Your child’s PCP will ask for prior authorization if he or         and to ask for timeliness for making routine and urgent
     she thinks your child should see a specialist.                       opinions available.

     Referral to Non-physician Providers
                                                                          What do you need to do?
       You may get services from non-physician providers who
     work	 in	 your	 PCP’s	 office.	 Non-physician providers may          Step 1: Talk to your PCP or L.A. Care and let him/her
     include, but are not limited to, clinical social workers, family             know you would like to see another doctor and the
     therapists, nurse practitioners, and physician assistants.                   reason why.
                                                                          Step 2: Your PCP or L.A. Care will refer you to a qualified
                                                                                  health care professional.
     Standing Referrals                                                   Step 3: Call the second opinion doctor to make an
        Your child may have a chronic, life-threatening or disabling              appointment.
     condition or disease such as HIV/AIDS. If so, he/she may               If you do not agree with the second opinion, you may file
     need to see a specialist or qualified health care professional for   a grievance	 with	 L.A.	Care.	 Refer	 to	 the	 “Grievance	 and	
     a long length of time. Your child’s PCP may suggest, or you          Appeals” section for more information.
     may ask for, what is called a standing referral.
       A standing referral to a specialist or qualified health care
     professional needs prior authorization. With a standing
     referral, you will not need authorization to visit the
     specialist or qualified health care professional. You may ask
     for a standing referral to a specialist that works with your


16
                                                                                             Healthy Kids Member Handbook


How to Find a Pharmacy                                           The L.A. Care formulary includes:
  L.A. Care works with many pharmacies. The drugs                 •	 Approved	prescription drugs
prescribed by your child’s PCP or specialist must be filled at     •	 Diabetic	 supplies:	 Insulin,	 insulin	 syringes,	 glucose	
one of these pharmacies. You can receive a 90-day supply of           test strips, lancets and lancet puncture devices, pen
maintenance medications at certain local pharmacies. Ask              delivery systems such as EpiPens, and Anakits
your doctor to write a 90-day prescription.                        •	 Inhaler	extender	devices
To find a pharmacy near you:                                       •	 Emergency Contraceptive Drugs: You may get emergency
  Look in the Participating Pharmacies section of the Pro-            contraceptive drugs from your doctor or pharmacy
vider Directory to find a pharmacy in your neighborhood.              with a prescription from your doctor. You may also
Or, visit the L.A. Care Web site, www.lacare.org. Click               get emergency contraceptive drugs from a certified
on each of the following:                                             pharmacist without a prescription.
  •	 I Am A Member                                                 For information on pharmacies offering emergency
  •	 Healthy Kids                                                contraceptive drugs from certified pharmacists without a
                                                                 prescription, please call L.A. Care Member Services at
  •	 Find a Pharmacy Close to Home
                                                                 1-888-839-9909.
  You can also click on How to Get Your Prescriptions
                                                                   Emergency contraceptive drugs are covered also when you
Filled for more information.
                                                                 receive emergency care services. You may receive emergency
  Be sure to show your L.A. Care ID card when you fill           care services from doctors, hospitals, pharmacies or other
your prescriptions at the pharmacy.                              health care professionals whether or not they are contract-
                                                                 ed with L.A. Care Health Plan.
What drugs are covered?
   L.A. Care uses a formulary of approved drugs. A for-          Non-formulary drugs
mulary is a list of drugs that are generally accepted in the       Sometimes, the doctor may prescribe a drug that is
medical community as safe and effective. The formulary           not on the formulary. This will require that the doc-
is reviewed and approved by a committee of L.A. Care’s           tor get authorization from L.A. Care. To decide if the
participating physicians and pharmacists on a quarterly          non-formulary drug will be covered, L.A. Care may ask
basis. You may call L.A. Care to ask for a copy of the for-      the doctor and/or pharmacist for more information.
mulary or to ask if a specific drug or drugs are included.       L.A. Care will reply to the doctor and/or pharmacist with-
You can also view the formulary on L.A. Care’s Web site,         in 24 hours or one business day after getting the requested
www.lacare.org. Click on each of the following:                  medical information.
  •	 I Am A Member                                                 The doctor or pharmacist will let you know if the drug
  •	 Healthy Kids                                                is approved. After approval, you can get the drug at a
                                                                 pharmacy in your network.
  •	 Find a Pharmacy Close to Home
                                                                   If the non-formulary drug is denied, you have the right
  •	 Click on this sentence to view the list of approved
                                                                 to file a grievance.	(Please	see	the	“Grievance	and	Appeals”	
     drugs for the Healthy Kids Program.
                                                                 section for more information.)
  Your doctor will prescribe drugs from the formulary. A
drug may be included on the formulary, but your doctor
may still not prescribe that drug, depending on your health      Emergency and Urgent Care Services
status. L.A. Care covers both brand name and generic ver-
                                                                 Urgent Care Services
sions of any prescribed drug. Members are responsible for
the co-payment.                                                    There is a difference between needing care urgently and
                                                                 an	emergency.	Urgent	care	is	when	a	condition,	illness	or	

                                                                                                                         >>
                                          Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 17
     injury is not life-threatening, but needs medical care right      •	 Broken	bones
     away. Many of L.A. Care’s doctors have urgent care hours          •	 Head	injury
     in the evening, on weekends, or during holidays.
                                                                       •	 Eye	injury
                                                                       •	 Thoughts	or	actions	about	hurting	yourself	or	someone	
     How to get urgent care                                               else
      1. Call your PCP doctor. You may speak to an operator            If you think you have a health emergency, call 911.
         who answers calls for your PCP doctor’s office when         You are not required to call your doctor before you
         closed (like after normal business hours, on the            go to the emergency room. Do not use the emergency
         weekends or holidays).                                      room for routine health care.
       2. Ask to speak to your PCP doctor or the doctor on
          call. A doctor will call you back. If your PCP doctor      What to do in an emergency:
          is not available, another doctor may answer your call.       Call 911 or go to the nearest emergency room if you
          A doctor is available by phone 24 hours a day, seven       have an emergency. Emergency care is covered at all times
          days a week, and also on the weekends and holidays.        and in all places.
       3. Tell them about your condition and follow their
          instructions.
                                                                     Post Stabilization and
       If you are outside of Los Angeles County, you do not          Follow-up Care After an Emergency
     need to call your PCP doctor or get prior authorization           Once your child’s emergency medical condition has
     before getting urgent care services. Be sure to let your PCP    been treated at a hospital and an emergency no longer
     doctor know about this care. You may need follow-up care        exists because your child’s condition is stabilized, the
     from your PCP doctor.                                           doctor who is treating your child may want your child to
                                                                     stay in the hospital for a while longer before your child can
                                                                     safely leave the hospital. The services your child receives
     Emergency services
                                                                     after an emergency condition is stabilized are called “post-
       Emergency services are covered 24-hours a day, seven days     stabilization services.”
     a week, anywhere. Emergency care is a service that a member       If the hospital where your child received emergency
     reasonably believes is necessary to stop or relieve:            services is not part of L.A. Care Health Plan’s contracted
       •	 sudden	serious	illnesses	or	symptoms                       network (“non-contracted hospital”), the non-contracted
       •	 injury	 or	 conditions	 requiring	 immediate	 diagnosis	   hospital will contact L.A. Care to get approval for your
          and treatment                                              child to stay in the non-contracted hospital.
                                                                       If L.A. Care approves your child’s continued stay in
       Emergency services and care include ambulance, medical        the non-contracted hospital, you will not have to pay for
     screening, exam and evaluation by a doctor or appropriate       services.
     personnel. Emergency services include both physical and
     psychiatric emergency conditions, and active labor.               If L.A. Care has notified the non-contracting hospital
                                                                     that your child can safely be moved to one of L.A. Care’s
       Examples of emergencies include but are not limited to:       contracted hospitals, L.A. Care will arrange and pay for
       •	 Having	trouble	breathing                                   your child to be moved from the non-contracted hospital
                                                                     to a contracted hospital.
       •	 Seizures	(convulsions)
                                                                       If L.A. Care determines that your child can be safely
       •	 Lots	of	bleeding                                           transferred to a contracted hospital, and you, your spouse or
       •	 Unconsciousness/blackouts	(will	not	wake	up)               legal guardian do not agree to your child being transferred,
       •	 In	a	lot	of	pain	(including	chest	pain)                    the non-contracted hospital must give you, your spouse or
                                                                     legal guardian a written notice stating that you will have
       •	 Swallowing	of	poison	or	medicine	overdose

18
                                                                                                Healthy Kids Member Handbook


to pay for all of the cost for post-stabilization services             	New	members	can	also	ask	to	keep	seeing	their	current	
provided to your child at the non-contracted hospital after          doctor or hospital for these conditions if they have just
your child’s emergency condition is stabilized.                      joined L.A. Care.
  Also, you may have to pay for services if the non-contracted           If you have one of the conditions listed, ask your doctor
hospital cannot find out what your name is and cannot                if you can keep seeing him/her. You can also call L.A. Care
get L.A. Care’s contact information to ask for approval to           Member Services at 1-888-839-9909 on how to request
provide services once your child(ren) are stable.                    continuity of care.
  If you feel that you were improperly billed for post-                You need to know that the continuity of care benefit will
stabilization services that your child received from a               not apply to you if:
non-contracted hospital, please contact the L.A. Care                   (1) You are a new member in L.A. Care and your old
Member Services at 1-888-839-9909.                                   health plan offered to let you keep receiving care from an
                                                                     out-of-network provider.
Non-Qualified Services                                                 	OR
  Non-qualified	 services	 are	 any	 non-emergency	 services	           (2) You had the choice to keep receiving care from your
received in the emergency room. L.A. Care will review all            previous provider, but you decided to change health plans.
emergency room services provided to members based on the               Doctors who are not contracted with L.A. Care may
prudent lay person’s definition of emergency services. The           be required to agree to the same terms and conditions
member’s family must pay for the cost of any non-qualified           as contracted providers. If the doctor does not agree, the
services.	(Please	refer	to	the	“Emergency	and	Urgent	Care	           L.A. Care is not required to provide the services through
Services” section for more information.)                             that doctor.


Continuity of Care
   We will send you a letter in the mail if your primary care
physician (PCP) stops working with L.A. Care. We will do
this 60 days before the date your PCP stops working with
L.A. Care. You can ask to keep seeing this doctor (includ-
ing specialists and hospitals), if the doctor agrees and has
been treating you for anything listed below:
  •	 Acute	condition	–	For	the	duration	of	the	condition.
  •	 Serious	chronic	(long-term)	condition	–	For	a	period	of	
     time necessary to complete a course of treatment and
     arrange for a safe transfer to another provider.
  •	 Pregnancy	 –	 Includes	 the	 rest	 of	 the	 pregnancy	 and	
     immediate postpartum care.
  •	 Terminal	 illnesses/conditions	 –	 For	 the	 length	 of	 the	
     illness.
  •	 Children	from	birth	to	age	36	months	–	For	up	to	12	
     months.
  •	 You	 have	 a	 surgery	 or	 other	 procedure	 that	 has	 been	
     authorized by the plan as part of a documented course
     of treatment.



                                            Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 19
Grievance & Appeals

     L .A . Care Grievance Process                                           •	 Fill	out	a	grievance	form	at	your	doctor’s	office
     Complaints: What should I do if I am unhappy?                            L.A. Care can help you fill out the grievance form. Or,
        If you are not happy, are having problems or have ques-            we can send you a form for you to fill out and send back to
     tions about the service or care given to you, you can con-            us. Within five calendar days of receiving your grievance,
     tact your PCP doctor and let your PCP know. Your PCP                  you will get a letter from L.A. Care saying we have your
     doctor may be able to help you or answer your questions.              grievance and are working on it. Then, within 30 calendar
     However, you may file a grievance with L.A. Care at any-              days of receiving your grievance, L.A. Care will send you
     time and do not have to contact your PCP doctor before                a letter explaining how the grievance was resolved.
     filing a grievance with L.A. Care.                                       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
     What is a grievance?
                                                                           more about continuing a medical service, call L.A. Care.
       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             If you don’t agree with the outcome of your grievance
     service, and have the right to complain. Some examples                   If you do not hear from L.A. Care within 30 calendar
     are complaints about:                                                 days, or you do not agree with the decision about your
       •	 The	service	or	care	your	PCP	doctor	or	other	providers	          grievance, you may file a grievance with the Department
          give you                                                         of Managed Health Care (DMHC). For information on
       •	 The	service	or	care	your	PCP	doctor’s	medical	group	             how	to	file	a	grievance	with	DMHC,	go	to	“Review	by	the	
          gives you                                                        Department of Managed Health Care (DMHC)” section.

       •	 The	service	or	care	your	pharmacy	gives	you
       •	 The	service	or	care	your	hospital	gives	you                      How to file a grievance for health care services
                                                                           denied or delayed as not medically necessary
       •	 The	service	or	care	L.A.	Care	gives	you
                                                                             If you believe a health care service has been wrongly
                                                                           denied, changed, or delayed by L.A. Care because it was
     How to File a Grievance                                               found not medically necessary, you may file a grievance.
                                                                           This is known as a disputed health care service.
       You have many ways to file a grievance. You can do any
     of the following:                                                       Within five calendar days of receiving your grievance,
                                                                           you will get a letter from L.A. Care saying we have
       •	 Write,	 visit	 or	 call	 L.A.	 Care.	 You	 may	 also	 file	 a	   received your grievance and that we are working on it.
          grievance online through L.A. Care’s Web site at                 The letter will also let you know the name of the person
          www.lacare.org.                                                  working on your grievance. Then, within 30 calendar days
           L.A. Care Health Plan                                           you will receive a letter explaining how the grievance was
           Member Services Department                                      resolved.
           555	West	Fifth	Street
           Los Angeles, CA 90013-3036
           1-888-839-9909
           TTY	Service:	1-866-LACARE1	(1-866-522-2731)
           www.lacare.org
20
                                                                                            Healthy Kids Member Handbook




   Filing a grievance does not affect your medical bene-       If you don’t agree with the outcome of
fits. If you file a grievance you may be able to continue      your grievance for urgent cases
a medical service while the grievance is being resolved.          If you do not hear from L.A. Care within three calendar
To find out more about continuing a medical service, call      days	(or	72	hours),	or	you	do	not	agree	with	the	decision	
L.A. Care.                                                     about your grievance, you may file a grievance with the
                                                               Department of Managed Health Care (DMHC). For
                                                               information on how to file a grievance with DMHC, go
Dental and Vision Grievances                                   to	“Review	by	the	Department	of	Managed	Health	Care	
  For dental	grievances	please	call	SafeGuard	Dental	toll-     (DMHC)” section.
free	at	1-800-766-7775.
  For vision grievances please call VSP toll-free at 1-800-
877-7195.                                                      Independent Medical Review
                                                                 You	 may	 request	 an	 Independent	 Medical	 Review	
If you don’t agree with the outcome of your                    (IMR)	 from	 DMHC.	 You	 have	 up	 to	 six	 months	 from	
grievance for health care services denied                      the	date	of	denial	to	file	an	IMR.	You	will	receive	infor-
or delayed as not medically necessary                          mation	 on	 how	 to	 file	 an	 IMR	 with	 your	 denial	 letter.	
    If you do not hear from L.A. Care within 30 calendar       You may reach DMHC toll-free at 1-888-HMO-2219 or
days, or you do not agree with the decision about your         1-888-466-2219.
grievance, you may file a grievance with DMHC. For               There	 are	 no	 fees	 for	 an	 IMR.	 You	 have	 the	 right	 to	
information on how to file a grievance with DMHC, go           provide	information	to	support	your	request	for	an	IMR.	
to	“Review	by	the	Department	of	Managed	Health	Care	           After	the	IMR	application	is	submitted,	a	decision	not	to	
(DMHC)” section.                                               take	part	in	the	IMR	process	may	cause	you	to	lose	certain	
                                                               legal rights to pursue legal action against the plan.
How to File a Grievance for Urgent Cases
  Examples of urgent cases include:                            When to File an Independent Medical Review (IMR)
  •	 Severe	pain                                                 You	 may	 file	 an	 IMR	 if	 you	 meet	 the	 following	
                                                               requirements:
  •	 Potential	loss	of	life,	limb	or	major	bodily	function
                                                                 •	 Your	doctor	says	you	need	a	health	care	service	because	
  •	 Immediate	and	serious	deterioration	of	your	health             it is medically necessary and it is denied; or
   In urgent cases, you can request an “expedited review”        •	 You	received	urgent	or	emergency	services	determined	
of your grievance. You will receive a call and/or a letter          to be necessary and they were denied; or
about your grievance within 24 hours. A decision will            •	 You	 have	 seen	 a	 network	 doctor	 for	 the	 diagnosis	 or	
be	made	by	L.A.	Care	within	three	calendar	days	(or	72	             treatment of the medical condition, even if the health
hours) from the day your grievance was received.                    care services were not recommended.
  You have the right to file an urgent grievance with            •	 The	disputed	health	care	service	is	denied,	changed	or	
DMHC without filing a grievance with L.A. Care. For                 delayed by L.A. Care based in whole or in part on a
information on how to file a grievance with DMHC, go                decision that the health care service is not medically
to	“Review	by	the	Department	of	Managed	Health	Care	                necessary, and
(DMHC)” section.
                                                                                                                         >>
                                         Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 21
       •	 You	 have	 filed	 a	 grievance	 with	 L.A.	 Care	 and	 the	              denying an experimental/ investigational therapy
          health care service is still denied, changed, delayed or                 within	 five	 (5)	 business	 days	 of	 the	 decision	 to	 deny	
          the grievance remains unresolved after 30 days.                          coverage.

       You must first go through the L.A. Care grievance                         •	 You	are	not	required	to	participate	in	L.A.	Care	Health	
     process,	 before	 applying	 for	 an	 IMR.	 In	 special	 cases,	                Plan’s grievance process prior to seeking an Independent
     the DMHC may not require you to follow the L.A. Care                           Medical	Review	of	our	decision	to	deny	coverage	of	an	
     grievance	process	before	filing	an	IMR.	                                       experimental/ investigational therapy.

        The dispute will be submitted to a DMHC medical                          •	 If	a	physician	indicates	that	the	proposed	therapy	would	
     specialist	 if	 it	 is	 eligible	 for	 an	 IMR.	 The	 specialist	 will	        be significantly less effective if not promptly initiated,
     make an independent decision on whether or not the care                        the	 Independent	 Medical	 Review	 decision	 shall	 be	
     is	medically	necessary.	You	will	receive	a	copy	of	the	IMR	                    rendered	within	seven	(7)	days	of	the	completed	request	
     decision from DMHC. If it is decided that the service is                       for an expedited review.
     medically necessary, L.A. Care will provide the health
     care service.
                                                                               Review by the Department of
                                                                               Managed Health Care
     Non-urgent cases                                                             The California Department of Managed Health Care
       For	non-urgent	cases,	the	IMR	decision	must	be	made	                    is responsible for regulating health care service plans. If
     within 30 days. The 30-day period starts when your                        you have a grievance against L.A. Care Health Plan, you
     application and all documents are received by DMHC.                       should first telephone L.A. Care Health Plan at 1-888-839-
                                                                               9909	(TTY	for	the	hearing	impaired	at	1-866-522-2731)	
                                                                               and use L.A. Care Health Plan’s grievance process before
     Urgent cases                                                              contacting	 the	 department.	 Using	 this	 grievance	 proce-
       If your grievance is urgent and requires fast review, you               dure does not prohibit any legal rights or remedies that
     may bring it to DMHC’s attention right away. You will                     may be available to you. If you need help with a grievance
     not be required to participate in the health plan grievance               involving an emergency, a grievance that has not been sat-
     process.                                                                  isfactorily resolved by L.A. Care Health Plan, or a griev-
       	For	urgent	cases	the	IMR	decision	must	be	made	within	                 ance that has remained unresolved for more than 30 days,
     three calendar days from the time your information is                     you may call the department for assistance. You may also
     received.                                                                 be	eligible	for	an	Independent	Medical	Review	(IMR).	If	
                                                                               you	are	eligible	for	an	IMR,	the	IMR	process	will	provide	
       Examples of urgent cases include:
                                                                               an impartial view of medical decisions made by a health
       •	Severe	pain                                                           plan related to the medical necessity of a proposed ser-
       •	Potential	loss	of	life,	limb	or	major	bodily	function                 vice or treatment, coverage decisions for treatments that
                                                                               are experimental or investigational in nature and payment
       •	Immediate	and	serious	deterioration	of	your	health
                                                                               disputes for emergency and urgent medical services. The
                                                                               Department of Managed Health Care has a toll-free tele-
     Independent Medical Review for Denials of                                 phone, 1-888-HMO-2219, to receive complaints regard-
     Experimental/ Investigational Therapies                                   ing health plans. The hearing and speech impaired may
       You may also be entitled to an Independent Medical                      use	the	department’s	TTY	line	(1-877-688-9891)	to	con-
     Review,	 through	 the	 Department	 of	 Managed	 Health	                   tact the department. The Department’s Internet website
     Care, when we deny coverage for treatment we have                         (http://www.hmohelp.ca.gov)	has	complaint	forms,	IMR	
     determined to be experimental or investigational.                         application forms and instructions online.

       •	 We	 will	 notify	 you	 in	 writing	 of	 the	 opportunity	 to	          L.A Care Health Plan’s grievance process and DMHC’s
          request	an	Independent	Medical	Review	of	a	decision	                 complaint review process are in addition to any other



22
                                                                                             Healthy Kids Member Handbook


dispute resolution procedures that may be available to you,       Annual Eligibility Review
and your failure to use these processes does not preclude           The Healthy Kids Program has an annual renewal process
your use of any other remedy provided by law.                     to determine if your child is still eligible for the program.
                                                                  You will receive a notice when it is time for you to go
                                                                  through this process.
Eligibility and Enrollment
Requirements for Member Eligibility
                                                                  Notification of Eligibility Changes
  In order to be eligible to participate in the Healthy Kids
                                                                   It is your responsibility to notify L.A. Care Health Plan
program your child must be all of the following:
                                                                  within 31 days of all changes in eligibility.
  •	 From	 birth	 through	 age	 18;	 members	 are	 no	 longer	
     eligible after their 19th birthday
                                                                  Appealing Enrollment Decisions
  •	 Live	in	Los	Angeles	County
                                                                    If you believe that L.A. Care made a mistake in deciding
  •	 Have	an	annual	or	monthly	Household	Income	at	or	
                                                                  whether you child is eligible, you can file an appeal with
     below 300% of the Federal Poverty Level
                                                                  L.A. Care. Please call us at 1-888-839-9909.
  •	 Not	 eligible for no-cost Medi-Cal or the Healthy
     Families
  •	 Not	eligible for job-based health insurance
  •	 Not	 covered	 by	 any	 other	 publicly	 sponsored	 health	
     insurance plan.

  Children who are covered through an independently
purchased health coverage are not eligible to enroll.


Application Process
  To apply for the Healthy Kids program, you have to
submit to L.A. Care all information, documentation
and declarations required to determine eligibility. This
information should include:
  •	 Name	 and	 address	 of	 all	 the	 children	 for	 whom	
     enrollment is requested
  •	 Statement	of	the	household	income
  •	 Statement	indicating	which	child/children	is	currently	
     enrolled in an employer-sponsored health insurance
     plan.


Starting Date of Coverage
  You will receive a notice from L.A. Care letting you
know when your child is approved for the program and
when coverage will begin.
  Generally,	coverage	begins	the	first	month	after	eligibility	
for the program is determined.



                                          Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 23
Payment Responsibilities

     Monthly Family Contributions                                         •	 Immunizations
       Your monthly premium is determined by family size and              •	 Well-child	visits
     income. Your premium will range from $0 to $6 for each               Call us if you believe you have a large number of co-
     child. The family maximum for all children in a family             payments and need help with your co-payments. We will
     enrolled in the Healthy Kids program is $12.                       work	with	your	PPG	to	try	and	set	up	a	payment	plan.
       You have the option of paying six months of premiums                Please refer to the “Summary of Benefits” section for a
     in	advance.	If	you	choose	this	option,	you	will	get	a	25%	         listing of services and co-payments.
     discount.
      The first payment must be paid with a cashier’s check or          Annual Co-payment Maximum
     money order. Make your payments to:
                                                                          The annual co-payment maximum amount for the Healthy
         L.A. Care Health Plan–Healthy Kids Program                     Kids program	is	$250.	The	annual	co-payment maximum is
                       P.O.	Box	515388                                  the highest total co-payment amount your family is required
                  Los	Angeles,	CA	90051-9788                            to pay during one benefit year.
                                                                          Step 1: Save your receipts.
       Once your child is enrolled in the Healthy Kids program,
     you will receive a monthly bill in the mail. Your payment            Step 2:	 Call	us	when	the	receipts	total	$250.	You	may	
     will	 be	 due	 to	 L.A.	Care	 Health	 Plan	 on	 the	 15th of the              not have to pay co-payments for the rest of the
     month.                                                                        benefit year.

       Use	one	of	the	following	methods	to	pay:
                                                                        Member Liability
       •	 Cashier’s	check
                                                                          Members must pay required co-payments. Other than
       •	 Money	order                                                   required co-payments, participating providers may not ask
       •	 Personal	check                                                for payments from or assert a lien on a member’s family
                                                                        for covered services. If you think you are being asked to
       L.A. Care will not increase your premium amount unless           pay a co-payment that you feel you should not have to
     you have been given 30 days written notice sent by postage         pay, please call the L.A. Care Fraud and Abuse Hotline at
     prepaid,	regular	U.S.	Mail	to	your	most	current	address	of	        1-800-400-4889.
     record with L.A. Care.
                                                                           Please	 see	 “Third	 Party	 Liability,”	 in	 the	 “General	
       In the event that you are unable to pay your child’s             Information” section for more information on member
     monthly premium, please call L.A. Care. We will help you           liability.
     apply for the premium assistance program.
                                                                          Members are only eligible to get health care services that
       Important: If your address changes, call L.A. Care               are covered services in the Healthy Kids program. Even if
     right away, at 1-888-839-9909.                                     your doctor recommends that you get health care servic-
                                                                        es that are not covered services, these health care services
     Co-payments                                                        are not covered plan benefits for members. Members are
       A	 $5	 co-payment is required for some health care               only able to get covered services as described in this Mem-
     services.                                                          ber Handbook. If you have any questions about what are
       Co-payments are not needed for preventive care services.         covered services, please call L.A. Care Member Services at
     Preventive care includes:                                          1-888-839-9909.

24
Summary of Benefits
Services are covered only if they are medically necessary.

  The table below is a summary of your Healthy Kids             at 1-888-839-9909 if you have any questions. Exception:
program covered benefits and co-payments. Only services         Emergency room and out of area urgent care services do
described as plan benefits in the Member Handbook are           not require prior authorization.
covered by L.A. Care. Services are covered only according         Services described in the table below are brief descriptions.
to the procedures described in this Member Handbook,            For a full explanation of your benefits, please see the pages
including all authorizations and referrals.                     following this table.
  Your PCP must arrange and approve all your care before
you receive services. All health care services are reviewed,
approved or denied according to medical necessity. It is        Annual or Lifetime Benefit Maximum
important that you learn about your benefits before you           There is no annual or lifetime benefit maximum under
need them. Please call the L.A. Care Member Services            the Healthy Kids program.


           Benefits                                   Covered Services                                 Member Pays

 Alcohol /Drug Abuse Services –   Hospitalization to remove toxic substances from the             No	co-payment
 Inpatient                        system.
                                  Call L.A. Care’s toll-free behavioral health hotline at
                                  1-866-908-0677.	We	will	help	you	find	the	kind	of	help	
                                  that is right for you.

 Alcohol/Drug Abuse Services –    Crisis intervention and treatment of alcoholism or drug         $5	per	visit
 Outpatient                       abuse.                                                          Benefit is limited to 20
                                  Call L.A. Care’s toll-free behavioral health hotline at         visits per benefit year.
                                  1-866-908-0677.	We	will	help	you	find	the	kind	of	help	
                                  that is right for you.

 Blood and Blood Products         Inpatient and outpatient processing, storage, and               No	co-payment
                                  administration and collection, and storage of autologous
                                  blood, when medically necessary.

 Cancer Clinical Trials           Coverage for a member’s participation in a cancer clinical      $5	per	visit
                                  trial, phase I through IV, when the member’s physician has      Co-payment for
                                  recommended participation in the trial and member meets         prescriptions as
                                  certain requirements                                            described in the
                                                                                                  “Prescription Drug
                                                                                                  Program”

 Cataract Spectacles and Lenses   Cataract spectacles and lenses, cataract contact lenses or      No	co-payment
                                  intraocular lenses that replace the natural lens of the eye
                                  after cataract surgery

 Dental Services                  Covered	by	SafeGuard	Dental	(1-800-766-7775)                    $5	for	certain	services.		
                                                                                                  Call	SafeGuard	Dental	
                                                                                                  for more information.

                                        Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 25
               Benefits                                  Covered Services                               Member Pays

     Diabetic Care                   Equipment and supplies for the management and                 $5	per	visit
                                     treatment of insulin-using diabetes, non-insulin-using        Co-payment for
                                     diabetes and gestational diabetes as medically necessary,     prescriptions
                                     even if the items are available without prescription.         as described in
                                                                                                   “Prescription Drug
                                                                                                   Program”

     Diagnostic, X-Ray and           Therapeutic	radiological	services,	ECG,	EEG,	                 No	co-payment
     Laboratory Services             mammography, other outpatient diagnostic laboratory
                                     and radiology tests

     Durable Medical Equipment       Equipment for home used as medically necessary                No	co-payment

     Emergency Care Services         Health care services which a prudent lay person would         $5	per	visit
                                     consider necessary to relieve a serious illness or symptom,   (waived if member is
                                     injury, severe pain, or condition requiring immediate         admitted to the hospital)
                                     diagnosis. Offered 24 hours a day, seven days a week.

     Eye Exams/Supplies              Eye refraction to determine the need for corrective lenses,   $5	Exam
                                     dilated retinal eye exams, cataract spectacles and lenses.    $5	Materials/Supplies
                                     Covered	by	VSP	(1-800-877-7195).

     Family Planning Services        Voluntary family planning services                            No	co-payment

     Health Education Services       Effective health education services and materials for      No	co-payment
                                     diabetes outpatient self-management training, education
                                     and nutrition counseling
                                     Other education services also offered through a designated
                                     L.A. Care health education providers, such as weight
                                     management and asthma classes.

     Hearing Aids/Services           Hearing evaluations, hearing aids, supplies, visits for       No	co-payment
                                     fitting, counseling, adjustments, repairs

     Home Health Care Services       Services provided at the home by health care personnel        No	co-payment	except:
                                                                                                   $5	per	visit	for	physical,	
                                                                                                   occupational and speech
                                                                                                   therapy in an outpatient
                                                                                                   setting

     Hospice                         Medically necessary skilled care; counseling; medical sup-      No	co-payment
                                     plies; short term inpatient care; pain control and symptom
                                     management; bereavement services; physical, speech and oc-
                                     cupational therapies; medical social services; and respite care

     Hospital Services – Inpatient   Room	and	board,	nursing	care	and	all	medically	necessary	 No	co-payment
                                     ancillary services


26
                                                                                           Healthy Kids Member Handbook


          Benefits                                  Covered Services                                   Member Pays

Hospital Services – Outpatient   Diagnostic, therapeutic and surgical services performed at No	co-payment
                                 a hospital or outpatient facility
                                 •	physical,	occupational	and	speech	therapy	performed	on	 $5	per	visit
                                    an outpatient basis
                                 •	 emergency	health	care	services	(waived	if	the	member	is	
                                                                                             $5	per	visit
                                    hospitalized)

Medical Transportation           Ambulance transportation when medically necessary                No	co-payment

Mental Health Care –             L.A. Care will limit days per year for illnesses that meet the No	co-payment
Inpatient                        criteria for Serious Emotional Disturbance (SED) of a child,
                                 to 30 days per benefit year. For SED children, L.A. Care will
                                 refer these members to the Los Angeles County Department
                                 of Mental Health for continued treatment of the condition.
                                 L.A. Care will provide services with no visit limits for Severe
                                 Mental Illnesses (SMI). L.A. Care may limit coverage to 30
                                 days per benefit year for mental illnesses that do not meet
                                 the criteria for SMI/SED.
                                 With the agreement of the member or guardian, if
                                 appropriate, each day of inpatient hospitalization may
                                 be substituted for any of the following outpatient mental
                                 health services:
                                 •	Two	days	of	residential	treatment
                                 •	Three	days	of	day	care	treatment	(care	in	which	patients	
                                   participate during the day, returning to their home or other
                                   community placement during the evening and night)
                                 •	Four	outpatient visits
                                 Call L.A. Care’s toll-free behavioral health hotline at
                                 1-866-908-0677.	We	will	help	you	find	the	kind	of	help	
                                 that is right for you.

Mental Health Care –             L.A. Care will provide coverage for up to 20 visits per          $5	per	visit
Outpatient                       benefit period for mental conditions or illnesses that
                                 do not meet the criteria for SMI and SED. There is no
                                 limitation on treatment for SMI and SED.
                                 Call L.A. Care’s toll-free behavioral health hotline at
                                 1-866-908-0677.	We	will	help	you	find	the	kind	of	help	
                                 that is right for you.

Pediatric Asthma Care            Coverage for medically necessary supplies and equipment          $5	co-payment	per	office	
                                 relating to the management and treatment of asthma,              visit
                                 including inhaler spacers, nebulizers (including face masks      Co-payment for
                                 and tubing), peak flow meters and education on the proper        prescriptions as described
                                 use of these items                                               in “Prescription Drugs”,
                                                                                                  under “Plan Benefits”

Phenylketonuria (PKU)            Testing	and	treatment	of	PKU                                     No	co-payment

                                       Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 27
                                                                                                                               >>
                Benefits                              Covered Services                               Member Pays

     Physical, Occupational and   Therapy may be provided in a medical office or other           $5	per	visit	when	
     Speech Therapy               appropriate outpatient setting.                                performed in an
                                                                                                 outpatient setting
                                                                                                 No	co-payment	for	
                                                                                                 inpatient therapy

     Prescription Drug Program    Drugs prescribed by a licensed practitioner
                                  •	30-day	supply	for	brand	name	or	generic	drugs                $5	per	prescription
                                  •	90-day	supply	of	maintenance	drugs                           $5	per	prescription
                                  •	 Prescription	drugs	provided	in	an	inpatient	setting         No	co-payment
                                  •	 Drugs	administered	in	the	doctor’s	office	or	in	an	         No	co-payment
                                     outpatient facility
                                  •	 FDA-approved	contraceptive	drugs	and	devices                No	co-payment
                                  •	 Respiratory	devices	for	the	management	and	treatment	       No	co-payment
                                     of asthma
                                  Call Member Services for mail order form or for a list of
                                  participating pharmacies at 1-888-839-9909.

     Preventive Care Services     •	Immunizations, STD tests, and cytology exams on a            No	co-payment
                                    reasonable periodic basis
                                  •	Periodic	health	exams
                                  •	Well-baby	and	well-child	visits	

     Professional Services –      Licensed hospital, skilled nursing facility, hospice, mental   No	co-payment
     Inpatient                    health facility

     Professional Services –      •	Office	or	home	visit                                          $5	per	visit
     Outpatient                   •	Chemotherapy, dialysis, surgery, anesthesiology, or radiation No	co-payment

     Prosthetics and Orthotics    Prosthetics and orthotics as prescribed by L.A. Care           No	co-payment
                                  providers

     Reconstructive Surgery       Reconstructive surgery repairs abnormal body parts,            No	co-payment
                                  improves body function, or brings back a normal look.
                                  Note:	Medical	or	surgical	condition	that	would	qualify	for	
                                  services under CCS should be referred to that program.

     Skilled Nursing Care         Services provided in a licensed skilled nursing facility.     No	co-payment
                                  Benefit is limited to a maximum of 100 days per benefit year.

     Transplants                  Medically necessary organ and bone marrow transplant;          No	co-payment
                                  medical and hospital expenses of a donor or prospective
                                  donor; testing expenses and charges associated with
                                  procurement of donor organ

     Vision Services              Covered	under	VSP	(1-800-877-7195)                             No	co-payment

28
Plan Benefits

Alcohol/Drug Abuse Services – Inpatient                                If your child has a life-threatening or debilitating
                                                                    condition, or was eligible, but denied coverage for a cancer
  Hospitalization for alcoholism or drug abuse as medically
                                                                    clinical trial, you have the right to request an Independent
necessary to remove toxic substances from the system.
                                                                    Medical	 Review	 or	 denial.	 Go	 to	 the,	 “When	 to	 file	 an	
                                                                    Independent	Medical	Review”	section.	
Alcohol/Drug Abuse Services – Outpatient
  Crisis intervention and treatment of alcoholism or drug           Dental Services
abuse on an outpatient basis as medically necessary.
                                                                      Dental benefits	are	provided	through	SafeGuard	Dental	
Limitation: 20 visits per benefit year. Additional visits may       at	1-800-766-7775.	A	member’s eligibility for dental benefits
be covered if approved and authorized by L.A. Care.                 begins on the first day after the member’s eligibility for the
                                                                    Healthy Kids program is approved.
Blood and Blood Products
  Processing, storage, and administration of blood and              Diagnostic X-Ray and Laboratory Services
blood products in inpatient and outpatient settings.                  •	 Laboratory tests for the management of diabetes,
Includes the collection and storage of autologous blood                  including at a minimum: cholesterol, triglycerides,
when medically indicated.                                                microalbuminuria, HDL/LDL and Hemoglobin A-1C
                                                                         (Glycohemoglobin),	
Cataract Spectacles and Lenses                                        •	 Diagnostic	 laboratory services, diagnostic and
  Cataract spectacles, cataract contact lenses, or intraocular           therapeutic radiological (x-ray) services necessary to
lenses that replace the natural lens of the eye after cataract           evaluate, diagnose, treat, and follow-up on the care of
surgery are covered. Also one pair of eyeglasses or contact              members.
lenses is covered if necessary after cataract surgery with            •	 Other	diagnostic	services,	which	shall	include,	but	not	
insertion of an intraocular lens.                                        limited	 to,	 electrocardiography	 (EKG)	 and	 electro-
                                                                         encephalography	(EEG).	
Cancer Clinical Trials
  If your child has cancer, he or she may be able to be part        Durable Medical Equipment (DME)
of a cancer clinical trial that meets certain requirements,           Durable medical equipment (DME) is medically necessary
when referred by your child’s L.A. Care PCP or treating             equipment appropriate that is ordered by your physician
provider. The cancer clinical trial must have a meaningful          and for use in the home, which is:
potential to benefit your child, and be approved by one of the
following:	the	National	Institute	of	Health	(NIH),	the	Food	          •	 Intended	for	repeated	use
and	Drug	Administration	(FDA),	the	U.S.	Department	of	                •	 Generally	 not	 useful	 to	 a	 person	 without	 illness	 or	
Defense	 or	 the	 U.S.	 Veteran’s	 Administration.	 If	 you	 are	        injury
part of an approved cancer clinical trial, L.A. Care will             •	 Primarily	serves	a	medical	purpose
provide coverage for all routine patient care costs related to
the clinical trial.                                                   L.A. Care will decide whether to rent or purchase DME.
                                                                    Repair	or	replacement	of	DME	is	covered	unless	the	DME	
                                                                    has been misused or lost. All equipment purchased or
                                                                    rented must be authorized by L.A. Care.


                                           Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 29
       Examples include:                                                    •	 an	injury	or	severe	pain,	or	
       •	 Apnea	monitors                                                    •	 a	 condition	 that	 needs	 immediate	 diagnosis and
       •	 Blood	 glucose	 monitors,	 including	 monitors	 for	 the	            treatment.
          visually impaired for insulin dependent, non-insulin
                                                                            Emergency services include a medical screening, exam,
          dependent, and gestational diabetics
                                                                          and evaluation by a doctor or other appropriate personnel.
       •	 Insulin	pumps	and	all	related	supplies                          Emergency services also include both physical and mental
       •	 Nebulizer	machines                                              emergency conditions.
       •	 Ostomy	bags                                                       Examples of some emergencies include, but are not
                                                                          limited to:
       •	 Oxygen	and	oxygen	equipment
                                                                            •	 Breathing	problems
       •	 Podiatric	 devices	 to	 prevent	 or	 treat	 diabetes	
          complications                                                     •	 Seizures	(convulsions)
       •	 Pulmoaides	and	related	supplies                                   •	 Extreme	bleeding
       •	 Spacer	devices	for	metered	dose	inhalers                          •	 Unconsciousness/blackouts	(will	not	wake	up)
       •	 Tubing	and	related	supplies                                       •	 Severe	pain	(including	chest	pain)
       •	 Urinary	catheters	and	supplies                                    •	 Swallowing	of	poison	or	medicine	overdose
       •	 Visual	 aids,	 excluding	 eyewear	 to	 assist	 the	 visually	     •	 Broken	bones
          impaired with proper dosing of insulin
                                                                            Non-emergency	 services	 given	 after	 the	 medical	
       Exclusions:                                                        screening exam and the services needed to stabilize the
       •	 Coverage	for	comfort	or	convenience	items                       condition, require that the provider get an authorization
                                                                          from L.A. Care.
       •	 Disposable	 supplies	 except	 ostomy	 bags	 and	 urinary	
          catheters and supplies consistent with Medicare                   If your child is admitted to a non-participating hospital
          coverage guidelines                                             or to a hospital that your child’s PCP or other participating
                                                                          provider cannot work at, L.A. Care has the right to transfer
       •	 Exercise	and	hygiene	equipment
                                                                          you to a participating hospital as soon as it is medically safe.
       •	 Experimental	or	research	equipment
                                                                            If an emergency occurs while out of the service area,
       •	 Devices	not	medical	in	nature	such	as	sauna	baths	and	          your child may receive emergency services at the nearest
          elevators                                                       emergency facility (doctor, clinic or hospital). You must
       •	 Modifications	to	the	home	or	car                                report such services to L.A. Care within 48 hours. Any
                                                                          treatment given that is not authorized by your child’s PCP
       •	 Deluxe	equipment
                                                                          or L.A. Care, and which is later determined by L.A. Care
       •	 More	than	one	piece	of	equipment	that	serves	the	same	          not to be for emergency services will not be covered.
          function.
                                                                            Your child’s PCP must provide the follow-up care for
                                                                          emergency services. You will be reimbursed for all charges
     Emergency Care Services                                              paid by you for covered emergency services, including
       L.A. Care covers emergency care services 24 hours a day,           medical transportation services, provided by non-
     seven days a week. Emergency care services are medically             participating providers.
     necessary covered services, including ambulance and mental
     health services, which a prudent layperson in good faith,
     would have considered necessary to stop or relieve:
       •	 a	serious	illness	or	symptom,	



30
                                                                                              Healthy Kids Member Handbook


Post Stabilization and Follow-                                   Emergency Contraception
up Care After an Emergency
                                                                   You may get emergency contraceptive drugs from:
  Once your child’s emergency medical condition has
been treated at a hospital and an emergency no longer              •	 your	doctor
exists because your child’s condition is stabilized, the           •	 a	pharmacy	without	a	prescription	if	they	participate	in	
doctor who is treating your child may want your child to              the Pharmacy Access Program in L.A. Care’s network
stay in the hospital for a while longer before your child can      •	 a	 pharmacy	 not	 in	 L.A.	Care’s	 network	 if	 they	
safely leave the hospital. The services your child receives           participate in the Pharmacy Access Program. If this
after an emergency condition is stabilized are called “post-          is the case, you will be asked to pay for the service.
stabilization services.”                                              L.A. Care will reimburse you for this cost.
  If the hospital where your child received emergency
services is not part of L.A. Care Health Plan’s contracted
                                                                   Call L.A. Care for a list of pharmacies that participate
network (“non-contracted hospital”), the non-contracted
                                                                 in the Pharmacy Access Program. You may also call your
hospital will contact L.A. Care to get approval for your
                                                                 pharmacy and ask if they participate in the Pharmacy
child to stay in the non-contracted hospital.
                                                                 Access Program.
  If L.A. Care approves your child’s continued stay in
the non-contracted hospital, you will not have to pay for
services.
                                                                 Family Planning Services
                                                                   Voluntary family planning services include:
  If L.A. Care has notified the non-contracting hospital
that your child can safely be moved to one of L.A. Care’s          •	 Counseling	
contracted hospitals, L.A. Care will arrange and pay for           •	 Surgical	 procedures	 for	 sterilization	 as	 permitted	 by	
your child to be moved from the non-contracted hospital               state and federal law
to a contracted hospital.                                          •	 Diaphragms
  If L.A. Care determines that your child can be safely            •	 Coverage	 for	 other	 Food	 and	 Drug	 Administration	
transferred to a contracted hospital, and you, your spouse or         approved devices
legal guardian do not agree to your child being transferred,
                                                                   •	 Contraceptive	 drugs	 according	 to	 prescription drug
the non-contracted hospital must give you, your spouse or
                                                                      benefit, including emergency contraceptives
legal guardian a written notice stating that you will have
to pay for all of the cost for post-stabilization services         Some hospitals and other providers do not provide one or
provided to your child at the non-contracted hospital after      more of the following services that may be covered under
your child’s emergency condition is stabilized.                  your L.A. Care contract, and that you or your family
  Also, you may have to pay for services if the non-contracted   member might need:
hospital cannot find out what your name is and cannot              •	 Family	planning	
get L.A. Care’s contact information to ask for approval to         •	 Contraceptive	services,	including	emergency	
provide services once your child(ren) are stable.                     contraceptives
  If you feel that you were improperly billed for post-            •	 Sterilization	
stabilization services that your child received from
                                                                   •	 Tubal	ligation	at	the	time	of	labor	and	delivery	
a non-contracted hospital, please contact L.A. Care
Member Services at 1-888-839-9909.                                 •	 Infertility treatments or
                                                                   •	 Abortions	

                                                                   You should get more information before you enroll. Call
                                                                 your potential doctor, medical group,	PPG,	or	clinic,	or	call	
                                                                 L.A. Care to make sure you can get the health care services
                                                                 that you need.

                                                                                                                          >>
                                          Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 31
     Health Education Services                                           The hospice benefit may include, at the option of
                                                                       L.A. Care, homemaker services, services of volunteers, and
       Health education services are available through your PCP.
                                                                       short-term inpatient respite care.
     Call	 your	 PPG	 for	 more	 information.	 You	 can	 also	 call	
     L.A. Care Member Services toll-free at 1-888-839-9909.               The hospice benefit is limited to individuals who are
                                                                       diagnosed with a terminal illness with a life expectancy
       Health education services provide support to members to:
                                                                       of 12 months or less, and who elect hospice care for such
       •	 Promote	health                                               illness instead of the traditional services covered by
       •	 Prevent	disease                                              L.A. Care.
       •	 Manage	 chronic	 disease	 (such	 as	 asthma,	 diabetes,	       The hospice benefit includes medical treatment to relieve
          heart disease)                                               pain and other symptoms related to the terminal illness,
       •	 Self-management	 diabetic	 education	 programs	 which	       but does not include efforts to cure the illness. The hospice
          include nutrition and counseling.                            election may be stopped at any time.

       Health education services are delivered through:                Hospital Services – Inpatient
       •	 Classes                                                        The following inpatient hospital services are covered
       •	 Counseling                                                   when authorized by L.A. Care and provided at a
       •	 Support	groups                                               participating hospital. Any hospital may be used in case of
                                                                       an emergency.

     Home Health Services                                                •	 A	 hospital room of two or more beds with standard
                                                                            furnishings and equipment, meals, including special
       Home health services are provided in the home by health              diets as medically necessary, and general nursing care.
     care personnel when prescribed by a licensed practitioner
     acting within the scope of his or her licensure. This includes      •	 Intensive	care,	coronary	care,	and	definitive	observation	
     visits by:                                                             unit services as medically necessary.

       •	 Registered	Nurses,	                                            •	 Operating	room	and	related	facilities.

       •	 Licensed	Vocational	Nurses	and	home	health	aides,	             •	 Surgical,	anesthesia, and oxygen supplies.

       •	 Physical,	occupational	and	speech therapy, if medically        •	 Special	duty	nursing,	as	medically necessary.
          necessary, and                                                 •	 Discharge	planning	and	planning	of	continuing	care.
       •	 Respiratory	therapy                                            •	 Devices	implanted	surgically.

       Services are limited to those authorized by L.A. Care.            •	 Hospital ancillary services in connection with hospital
     If a service can be provided in more than one location,                inpatient services, including:
     L.A. Care will work with the provider to choose the                   - Laboratory,
     location.                                                             - Inhalation and respiratory therapy,
       Exclusions: Custodial care                                          - Pathology,
                                                                           - Imaging and radiation therapy,
     Hospice                                                               -	 Radiology	and	cardiology, and
                                                                           - Other diagnostic, therapeutic and
       The hospice benefit includes nursing care, medical social
                                                                              rehabilitative services as appropriate.
     services, home health aide services, physician services,
     drugs, medical supplies and appliances, counseling and              •	 Drugs,	 medications,	 and	 biologicals,	 which	 are	
     bereavement services. The benefit also includes physical               approved by the FDA and are supplied by and used in
     therapy; occupational therapy, speech therapy, short-term              the hospital.
     inpatient care, pain control, and symptom management.               •	 Administration	of	blood	and	blood	products.



32
                                                                                                Healthy Kids Member Handbook


  •	 Rehabilitative	therapy	services.	This	includes	physical,	      Medical Transportation
     occupational, speech, and other therapy services as
                                                                      Ambulance transportation to the first hospital which
     appropriate.
                                                                    accepts the member for emergency care is covered.
  •	 Hemodialysis                                                   Emergency ambulance transportation and non-emergency
  •	 Inpatient hospital services (including general anesthesia)     transportation to transfer a member to a hospital to another
     for dental procedures are covered when hospitalization         hospital or facility, or facility to home. This includes
     is necessary due to a member’s medical condition and/          ambulance and ambulance transportation services provided
     or clinical status, or because of the severity of the dental   through the 911 emergency response system.
     procedure.                                                       Non-emergency	 transportation	 for	 the	 transfer	 of	 a	
                                                                    member from a hospital to another hospital or facility or
  L.A. Care will coordinate these services with the member’s
                                                                    facility to home is covered when:
dental plan. Services of the dentist or oral surgeon are not
covered by L.A. Care.                                                 •	 Medically necessary, and
  Exclusions: A private room in a hospital or personal or             •	 Requested	by	an	L.A.	Care	provider, and
comfort items are excluded, unless medically necessary as             •	 Authorized	in	advance	by	L.A.	Care.
determined by L.A. Care.
                                                                      Exclusions: Coverage for transportation by airplane,
                                                                    passenger car, taxi or other form of public transportation.
Hospital Services – Outpatient
  The following outpatient services are covered when                Mental Health Care – Inpatient
authorized by L.A. Care and provided at a participating               Mental health benefits will be provided on the same basis
hospital or outpatient facility: Diagnostic, therapeutic, and       as other illnesses. These benefits include outpatient services,
surgical services done at a hospital or outpatient facility.        inpatient hospital services, and partial hospitalization
This includes physical, occupational, and speech therapy as         services and prescription drugs.
appropriate, and hospital services, which can reasonably
                                                                      Description: Mental health inpatient treatment ordered
be	provided	on	an	ambulatory	basis.	Related	services	and	
                                                                    in a participating hospital by a participating mental health
supplies which include:
                                                                    provider for the treatment of a mental health condition.
  •	 Operating	room,	                                               SMI include, but are not limited to:
  •	 General	anesthesia,                                              •	 Attention	Deficit	Disorder	(ADD)
  •	 Treatment	room,	                                                 •	 Attention	Deficit	Hyperactivity	Disorder	(ADHD)
  •	 Ancillary	services,	and	                                         •	 Schizophrenia
  •	 Medications	which	are	given	by	the	hospital or facility          •	 Schizoaffective	disorder
     for use during the member’s treatment at the facility.           •	 Bipolar	disorder	(manic-depressive	illness)
  General	anesthesia for dental procedures is covered when            •	 Major	depressive	disorders
performed at a hospital or surgery center because of a                •	 Panic	disorders
member’s medical condition, clinical status, or the severity          •	 Obsessive-compulsive	disorder
of the dental procedure.
                                                                      •	 Pervasive	developmental	disorder	or	autism
  L.A. Care will coordinate such services with the member’s
                                                                      •	 Anorexia	nervosa
dental plan. Services of the dentist or oral surgeon are not
covered by L.A. Care.                                                 •	 Bulimia	nervosa
                                                                      •	 Psychosis



                                                                                                                            >>
                                            Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 33
       L.A. Care will also provide coverage for up to 30 days of         •	 Obsessive-compulsive	disorder
     treatment per benefit period for mental conditions or ill-          •	 Pervasive	developmental	disorder	or	autism
     nesses that do not meet the criteria for Severe Mental Illness
     (SMI) and Severe Emotional Disturbance (SED). There is              •	 Anorexia	nervosa
     no limitation on days of treatment for SMI and SED.                 •	 Bulimia	nervosa
                                                                         •	 Psychosis	
     Mental Health Care – Outpatient
                                                                         When a child is determined to have SED, L.A. Care
       Mental health benefits will be provided on the same basis       will provide services for the member until he or she has
     as other illnesses. These benefits include outpatient services,   been evaluated and receives a referral for services through
     inpatient hospital services, and partial hospitalization          L.A. County Department of Mental Health. Services
     services and prescription drugs.                                  coordinated may include individual and/or family therapy
       Description: Mental health outpatient treatment when            or counseling assistance with medication related to the
     ordered by a participating mental health professional. This       mental health condition and day programs.
     includes the treatment of children who have experienced
     family dysfunction or trauma, including child abuse and           Mental Health Care Benefits Substitution Choices
     neglect, domestic violence, substance abuse in the family,
                                                                         With the agreement of the member and/or member’s
     or divorce and bereavement.
                                                                       parent or guardian if appropriate, each day of inpatient
       Family members may be involved in the treatment to the          hospitalization may be substituted for any of the following
     extent that L.A. Care determines it is appropriate for the        outpatient mental health services:
     health and recovery of the child.
                                                                         •	 Two	days	of	residential	treatment
        L.A. Care will provide up to 20 visits per benefit year, for
                                                                         •	 Three	 days	 of	 day	 care	 treatment	 (care	 in	 which	
     illnesses that do not meet the criteria for Serious Emotional
                                                                            patients participate during the day, returning to their
     Disturbance (SED) and Severe Mental Illnesses (SMI).
                                                                            home or other community placement in the evening
     L.A. Care may elect to provide additional visits and may
                                                                            and night)
     provide group therapy at a reduced co-payment. Additional
     visits require:                                                     •	 Four	outpatient visits
       •	 Medical	necessity
       •	 PCP	referral                                                 Pediatric Asthma Care
       •	 Prior	authorization                                            Benefit includes nebulizers (including face mask and
                                                                       tubing), inhaler spacers and peak flow meters and education
       L.A. Care provides services with no visit limits for SMI.
                                                                       on the proper use of these items when medically necessary
       SMI include, but are not limited to:                            for management and treatment of asthma.
       •	 Attention	Deficit	Disorder	(ADD)
                                                                       Phenylketonuria (PKU)
       •	 Attention	Deficit	Hyperactivity	Disorder	(ADHD)
                                                                         L.A. Care provides for testing and treatment of
       •	 Schizophrenia
                                                                       Phenylketonuria (PKU), including medically prescribed
       •	 Schizoaffective	disorder                                     formulas and special food products. California Children’s
       •	 Bipolar	disorder	(manic-depressive	illness)                  Services (CCS) eligible newborns with confirmed positive
                                                                       tests	will	be	referred	to	CCS	for	treatment.	PKU	cases	can	
       •	 Major	depressive	disorders
                                                                       be followed by a health care professional who seeks advice
       •	 Panic	disorder                                               from	a	doctor	who	focuses	on	PKU	related	diseases.




34
                                                                                                  Healthy Kids Member Handbook


Physical, Occupational, and Speech Therapy                             With the exception of self-administered injectable drugs
                                                                    listed	in	the	L.A.	Care	formulary	(in	the	“How	to	Get	Your	
  Therapy may be provided in a medical office or other
                                                                    Prescriptions Filled” section) injectable medication must
appropriate outpatient setting, hospital, skilled nursing
                                                                    be administered in a physician facility to be covered.
facility, or home. L.A. Care may require periodic evaluations
as long as medically necessary therapy is provided.                   Exclusions: Experimental or investigational drugs,
                                                                    unless accepted for use by professionally recognized
Prescription Drugs                                                  standards of practice; drugs or medications for cosmetic
                                                                    purposes; patent or over-the-counter medicines, including
   Medically necessary drugs when prescribed by a licensed
                                                                    non-prescription ointments, foams, etc.; medications not
participating provider acting within the scope of his or her
                                                                    requiring a written prescription order (except insulin);
licensure and included on the L.A. Care drug formulary.
                                                                    and dietary supplements (except for medically prescribed
L.A. Care will provide non-formulary medications based
                                                                    formulas or special food products to treat Phenylketonuria
on medical necessity. In cases where the formulary drug
                                                                    [PKU], appetite suppressants or any other diet drugs or
has a medical contraindication, a non-formulary drug will
                                                                    medications as medically necessary for morbid obesity).
be	 provided.	 Non-formulary drugs need to be requested
through a prior authorization approval process. If denied
after the review, the request can be appealed through               Preventive Care Services
the	 L.A.	Care	 Grievance	 and	 Appeals	 process	 and	 will	          Periodic health exams include all routine diagnostic testing
be responded to within 30 days or within three days if              and laboratory services.*
necessary because of your medical condition.
                                                                       •	 Well	 baby	 care	 during	 the	 first	 two	 years	 of	 life,	
   Brand name drugs will not be provided as a plan benefit
                                                                          including newborn hospital visits newborn screenings,
if	FDA-approved	generic	equivalents	are	available.	Unless	
                                                                          health examinations, and other office visits
such generic equivalents are medically contraindicated.
                                                                       •	 Child	immunizations **
  All of the following will be provided to monitor and treat
                                                                       •	 Child	immunizations	required	for	travel	**
insulin dependent and non-insulin dependent, as medically
necessary:                                                             •	 Other	child	age	appropriate	immunizations **
  •	 Injectable	medication	(including	insulin)                         •	 Eye	 examinations;	 for	 children,	 eye	 refractions	 to	
                                                                          determine the need for corrective lenses, and dilated
  •	 Needles	and	syringes
                                                                          retinal eye exams
  •	 Blood	 glucose	 testing	 strips	 for	 the	 monitoring	 and	
                                                                       •	 Hearing	 tests,	 hearing	 aids	 and	 services:	 Hearing	
     treatment of insulin dependent, non-insulin dependent
                                                                          evaluation to measure the extent of hearing loss
     and gestational diabetes
                                                                          and a hearing and evaluation to determine the most
  •	 Ketone	urine	testing	strips	                                         appropriate make and model of hearing aid
  •	 Glucagon                                                          •	 Hearing	 aid:	 Monaural	 or	 binaural	 hearing	 aids	
  •	 EpiPens                                                              including ear mold(s), the hearing aid instrument, the
                                                                          initial battery, cords, and other ancillary equipment.
  •	 Anakits,	lancets,	and	lancet	puncture	devices
                                                                          Visits for fitting, counseling, adjustments, repairs,
                                                                          etc., at no charge for a one year period following the
                                                                          provision of a covered hearing aid



  *
     Consistent with the most current recommendations for Preventative Pediatric Health Care as adopted by the American Academy of
Pediatrics; and consistent with the most current version of the Recommended Childhood Immunization Schedule/United States, adopted by
the Advisory Committee on Immunization Practices (ACIP).
  **
     Consistent with the most current version of the Recommended Childhood Immunization Schedule/United States adopted by the
Advisory Committee on Immunization Practices (ACIP).
                                                                                                                              >>
                                           Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 35
       •	 Cytology	exam,	on	a	reasonable	and	periodic	basis	             •	 For	breast,	cervical	and	prostate	cancer,	L.A.	Care	will	
       •	 Health	education	                                                 provide and or arrange for the provision of services
                                                                            related to these conditions.
       •	 Cancer	 screening:	 All	 generally medically accepted
          cancer screening tests
                                                                       Prosthetics and Orthotics
       Exclusions:                                                       Orthotics and prosthetics, when prescribed and authorized
         – Members will only receive exams related to their            by a L.A. Care licensed provider acting within the scope
           medical needs. For example, a parent’s desire for           of his or her licensure. This includes medically necessary
           physical exam will not be covered.                          replacement orthotics and prosthetic devices. Coverage
         – The purchase of batteries or other ancillary                includes the initial and subsequent prosthetic devices,
           equipment, except those covered under the terms of          installation accessories to restore a method of speaking
           the initial hearing aid purchase, and charges for a         incident to a laryngectomy, and therapeutic footwear for
           hearing aid which exceeds specification prescribed for      diabetics.
           correction of a hearing aid purchase and charges for          Exclusions: Corrective shoes and arch supports, except
           a hearing aid which exceeds specifications prescribed       for therapeutic footwear and inserts for individuals with
           for	correction	of	a	hearing	loss.	Replacement	parts	        diabetes; non-rigid devices such as elastic knee support
           for hearings aids, repair of hearing aid after the          and elastic stockings; dental appliances; electronic voice
           covered one-year warranty period, replacement of            producing machines; or more than one device for the
           a hearing aid more than once in any period of 36            same part of the body. Does not include eyeglasses (except
           months, and surgically implanted hearing devices.           for eyeglasses or contact lenses necessary after cataract
                                                                       surgery).
     Professional Services, Office Visits
     and Outpatient Services                                           Reconstructive Surgery
       Medically necessary services and consultations by physicians
                                                                         Reconstructive surgery repairs abnormal body parts,
     or other licensed health care providers acting within the
                                                                       improves body function, or brings back a normal look.
     scope of his or her license, professional office, inpatient
     hospital, skilled nursing, home, hospice, and urgent care           Exclusion: Cosmetic surgery that is performed to alter or
     visits, when medically necessary.                                 reshape normal structures of the body in order to improve
                                                                       appearance.
       •	 Medically necessary services for:
         – Outpatient or inpatient surgery,
                                                                       Skilled Nursing Care
         – Assistant surgery, and
                                                                         Services prescribed by a L.A. Care physician or nurse
         – Anesthesia.
                                                                       practitioner and provided in a licensed skilled nursing
       •	 Radiation	therapy	and	chemotherapy                           facility when medically necessary. Skilled nursing on a 24
       •	 Allergy	testing	and	treatment                                hour per day basis; bed and board; x-ray and laboratory
                                                                       procedures; respiratory therapy; physical, occupational
       •	 Chronic	 hemodialysis is covered as an outpatient
                                                                       and speech therapy; medical social services; prescribed
          service                                                      drugs and medications; medical supplies; and appliances
       •	 Physician	 services	 for	 second	 opinions	 for	 specific	   and equipment ordinarily furnished by the skilled nursing
          medical conditions are covered when medically necessary      facility. This benefit shall be limited to a maximum of 100
          and appropriate. For further information on how to           days per benefit year.
          obtain a second opinion, please refer to the “Second           Exclusion: Custodial care
          Opinions” section.




36
                                                                                               Healthy Kids Member Handbook


Transplants                                                           receive treatment for the CCS eligible condition
                                                                      through the specialized network of CCS providers
  Coverage for medically necessary organ transplants and
                                                                      and/or CCS approved specialty centers. These CCS
bone marrow transplants which are not experimental or
                                                                      providers and specialty centers are highly trained to
investigational in nature.	Reasonable	 medical	 and	hospital
                                                                      treat CCS eligible conditions. L.A. Care will continue
expenses of a donor or an individual identified as a
                                                                      to provide primary care and prevention services that are
prospective donor if these expenses are directly related to
                                                                      not related to the CCS eligible conditions, as described
the transplant for a member.
                                                                      in this document. L.A. Care will also work with the
  Coverage includes charges for testing of relatives for              CCS program to coordinate care provided by both the
matching bone marrow transplants, charges associated                  CCS program and the plan. L.A. Care will continue to
with the search and testing of unrelated bone marrow                  provide all other medical services not related to CCS
donors	through	a	recognized	Donor	Registry,	and	charges	              diagnosis.
associated with the procurement of donor organs through a
                                                                      The CCS office must verify residential status for each
recognized Donor Transplant Bank, if the expenses directly
                                                                      child in the CCS program. If your child is referred to
related to the anticipated transplant of a member.
                                                                      the CCS program, you will be asked to complete a
                                                                      short application to verify residential status, financial
Vision Services                                                       eligibility and ensure coordination of your child’s care
  Vision benefits are provided through VSP. Its extensive             after the referral has been made.
nationwide network of providers offer professional vision             Additional information about the CCS program can
care to members covered under group vision care plans. If             be obtained by calling the Los Angeles County CCS
you are not able to locate an accessible provider, please call        program	at	1-800-288-4584	for	more	information.
VSP	 toll-free	 at	 1-800-877-7195	 and	 a	 customer	 service	
representative will help you find another provider.                 The following services are not covered benefits.
                                                                    •	 Any	health	care	services	which	L.A.	Care	excludes	in	the	
Exclusions and Limitations                                             Member Handbook which cost more than L.A. Care
  California Children’s Services (CCS)                                 states it will pay in this Member Handbook.
   Children needing specialized medical care may be                 •	 Any	 services	 received	 before	 a	 member’s starting date
   eligible for the California Children’s Services (CCS)               with L.A. Care.
   program.                                                         •	 Cosmetic	 surgery	 that	 is	 solely	 performed	 to	 alter	 or	
    CCS is a California medical program that treats                    reshape normal structures of the body in order to
    children with certain physical conditions and who                  improve appearance.
    need specialized medical care. This program is available        •	 Emergency	 facility	 services	 for	 non-emergency	
    to all children in California whose families meet                  services.
    certain medical, financial and residential eligibility
                                                                    •	 Experimental	or	investigational	services,	including	any	
    requirements. Services provided through the CCS
                                                                       treatment, therapy, procedure or drug or drug usage,
    program are coordinated by the local county CCS
                                                                       facility or facility usage, equipment or equipment
    office.
                                                                       usage, device or device usage, or supply which is not
    If a member’s PCP suspects or identifies a possible                recognized as being in accordance with generally
    CCS eligible condition, he/she may refer the member                accepted professional medical standard or for which the
    to the local county CCS program. The CCS program                   safety and efficacy have not been determined for use in
    (local	 or	 the	 CCS	 Regional	 Office)	 will	 determine	 if	      the treatment of a particular illness, injury or medical
    the member’s condition is eligible for CCS services.               condition for which the time or service in question is
    If determined to be eligible for CCS services, a Healthy           recommended or prescribed. If L.A. Care denies your
    Kids member continues to stay enrolled in the Healthy              request for services based on the determination that
    Kids program. He or she will be referred and should                the services are experimental or investigational, you


                                                                                                                             >>
                                           Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 37
       may	 request	 an	 Independent	 Medical	 Review.	 For	
       information	 about	 the	 Independent	 Medical	 Review	
       process,	 please	 refer	 to	 the	 “Grievance	 and	 Appeals”	
       section on page 21 of this Member Handbook.
     •	 Long-term	 care	 benefits. Includes long-term skilled
        nursing care in a licensed facility, and respite care. (For
        short-term skilled nursing care or hospice benefits, please
        see	 Skilled	 Nursing	 Care	 under	 the	 “Plan	 Benefits”	
        section.)
     •	 Non-medically necessary health care services. Any
        health care services, supplies, comfort items, proce-
        dures, or equipment that are not medically necessary.
        This includes private rooms in a hospital, unless medi-
        cally necessary.
     •	 Other	 insurance.	 Services	 covered	 by	 any	 other	
        insurance or health care service plan. L.A. Care will
        provide the services at the time of need. (Please see the
        “Coordination of Benefits” section for details.)
     •	 Acupuncture	services
     •	 Chiropractic services
     •	 Biofeedback	services




38
General Information

Benefit Program Participation                                      Disenrollment and Cancellation
  L.A. Care will apply the health plan contract and this             Sometimes a member is no longer eligible for the Healthy
Member Handbook to decide your benefits. L.A. Care                 Kids program and will be disenrolled by L.A. Care. Please
will serve the best interests of all persons eligible to receive   refer to “Eligibility and Enrollment”	in	the	“Grievance	and	
benefits.                                                          Appeals” section for more information.
                                                                     If you would like your child to be disenrolled from the
Notifying You of Changes in Benefits                               Healthy Kids program, you have to fill out a disenrollment
  L.A. Care will let you know when there are changes to            form and state the reason for the disenrollment. You can
your benefits. L.A. Care will send you a letter 30 days before     request a disenrollment form at L.A. Care. For more
any changes in benefits, exclusions or limitations take place.     information on disenrollment call L.A. Care Member
Services provided after the date of change in benefits will be     Services at 1-888-839-9909.
based on the new benefits.
                                                                   How A Provider Gets Paid
Termination of Benefits                                              L.A. Care pays your doctor, hospital, or other provider in
  L.A. Care will let you know if any of the benefits are           different ways:
terminated or ended.                                                 •	 A	fee	for	each	service,	or
  Coverage for your child will be terminated without your            •	 Capitation, which is a set amount, regardless of services
consent in the following conditions:                                    provided.
  •	 Midnight	on	the	last	day	of	the	month	in	which	your	            Providers are sometimes rewarded for providing quality
     child turns nineteen                                          care to L.A. Care members. If you have any questions,
                                                                   please call L.A. Care.
  •	 Midnight	on	the	last	day	of	the	month	in	which	your	
     child’s policy expires due to non-response:                     L.A. Care works with a large number of providers to
                                                                   provide health care services to its members. Most of
    - unless L.A. Care receives payment on or before the
                                                                   the doctors are organized into groups (also known as a
      20th day after the due date, at which point the child
                                                                   Participating Provider Groups	 (PPG)	 or	 medical group).
      will be reinstated with original effective date, or
                                                                   PPGs	 cannot,	 except	 for	 collection	 of	 co-payments,	 seek	
    - unless L.A. Care receives payment on or later than           payment from members.
      the 21st day after the due date, at which point the
      child will be reinstated with a revised effective date
                                                                   Reimbursement Provisions – If you Receive a Bill
      and the family will receive written notice, or
                                                                     Members can submit provider bills or statements directly
    - unless you contact L.A. Care Member Services to
                                                                   to our claims department to the following address:
      request and are granted access to the Healthy Kids
      premium assistance fund at which point the child               L.A. Care Health Plan
      will remain in the program.                                    Claims Department
                                                                     P.O.	Box	712129
                                                                     Los	Angeles,	CA	90071


                                                                                                                          >>
                                           Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 39
       You can call L.A. Care Health Plan Member Services at             Third Party Liability
     1-888-839-9909 (TTY for the hearing impaired at 1-866-
                                                                            L.A. Care will provide covered services where an injury
     522-2731). This call is free.
                                                                         or illness is caused by a third party. The term “third party”
                                                                         includes insurance companies, individuals, or government
     Independent Contractors                                             agencies.	Under	California	state	law,	L.A.	Care	or	the	PPG	
       L.A. Care physicians,	 PPGs,	 hospitals, and other health         may assert a lien on any payment or right to payment,
     care providers are not agents or employees of L.A. Care.            which you have or may have received as a result of a third
     Instead, they are independent contractors. Although                 party injury or illness. The amount of this lien claim may
     L.A. Care regularly credentials the doctors who provide             include:
     services to members, L.A. Care does not, itself, provide              •	 Reasonable	and	true	costs	paid	for	health	care	services	
     these services. As such, L.A. Care is not responsible for the            given to you, and
     actions or omissions of any person who does provide these             •	 An	additional	amount	under	California	state	law.
     services to members. This includes any doctor, hospital, or           As a member, you also agree to assist L.A. Care in
     other provider or their employees.                                  recovering payments for services provided. This may
                                                                         require you to sign or provide documents needed to protect
     Review by the Department of Managed                                 the rights of L.A. Care.
     Health Care (DMHC)
       A member may ask for a review by the DMHC if L.A. Care            Public Policy Participation
     cancels or refuses to renew a member’s enrollment, and the            L.A. Care is an independent public managed care health
     member feels that it was due to reasons of health or use of         plan	run	by	a	Board	of	Governors.	The	L.A.	Care	Board	of	
     benefits.                                                           Governors	meets	monthly.	L.A.	Care	encourages	you	to:
       The member can call the DMHC toll-free at                           •	 Attend	Board	of	Governors	meetings
     1-888-HMO-2219 (1-888-466-2219).
                                                                           •	 Offer	 public	 comment	 at	 the	 Board	 of	 Governors	
                                                                              meeting
     Coordination of Benefits                                              •	 Take	 part	 in	 establishing	 policies	 that	 assure	 the	
       L.A. Care will coordinate benefits for members, even in                comfort, dignity and convenience of members, their
     cases when members are eligible for:                                     families, and the public when seeking health care
       •	 Other	 health	 benefits [such as California Children’s              services. (Health and Safety Code 1369)
          Services (CCS)],
       •	 Another	contract,	or	                                          Regional Community Advisory
       •	 Another	government	program.                                    Committees (RCACs)
       L.A. Care will coordinate payments for covered services             There	are	11	L.A.	Care	Regional	Community	Advisory	
     based on California state law and regulations, and                  Committees	(RCACs)	in	Los	Angeles	County.	“RCAC”	is	
     L.A. Care policies.                                                 pronounced	“Rack.”	The	purpose	of	the	RCAC	is	to:
       In the event that L.A. Care covers benefits greater than            •	 Talk	 about	 member issues and concerns, and resolve
     required	 by	 law,	 L.A.	Care	 or	 the	 PPG	 has	 the	 right	 to	        them through L.A. Care Member Services
     recover the excess payment from any person or entity                  •	 Advise	the	L.A.	Care	Board	of	Governors
     which may have benefited from the excess payment. As                  •	 Educate	and	empower	the	community	on	health	care	
     an L.A. Care member, you agree to help L.A. Care in                      issues
     recovering any over payment.




40
                                                                                          Healthy Kids Member Handbook


  RCAC’s	 meet	 once	 a	 month.	 RCAC	 members	 include	
L.A. Care members, member advocates (supporters), and
health care providers.	For	more	information	about	RCACs,	
call L.A. Care Member Services at 1-888-839-9909.

Notice of Information Practices
  The Insurance Information and Privacy Protection Act
states that “L.A. Care may collect personal information
from person(s) other than the person(s) applying for
insurance coverage.” L.A. Care will not disclose any
personal information without written consent. If you have
applied for insurance coverage through L.A. Care, you can
have access to your personal information collected through
the application process.

Governing Law
  L.A. Care must abide by any provision required to be in
this benefit program by any of the laws listed below, even if
they are not found in this Member Handbook or the health
plan contract. [California Knox-Keene Act (Chapter 2.2 of
Division 2 of the California Health and Safety Code), and
Title 28 regulations]

New Technology
  L.A. Care follows changes and advances in health care.
We study new treatments, medicines, procedures, and
devices. We call all of this “new technology.” We review
scientific reports and information from the government
and medical specialists. Then we decide whether to cover
the new technology. Members and providers may ask
L.A. Care to review new technology.

Natural Disasters, Interruptions, Limitations
  In the unfortunate event of a major disaster, epidemic,
war, riot, civil insurrection or complete or partial
destruction	of	facilities,	our	Participating	Medical	Groups	
and hospitals will do their best to provide the services you
need.	 Under	 these	 extreme	 conditions,	 go	 to	 the	 nearest	
doctor or hospital for emergency services. L.A. Care will
later provide appropriate reimbursement.




                                          Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 41
Important Phone Numbers

     California State Services
          California State Department of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-916-445-4171
          Department of Managed Health Care (DMHC) . . . . . . . . . . . . . . .1-888-HMO-2219 (1-888-466-2219)
          Department of Public and Social Services (DPSS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-481-1044
          Supplemental Social Income (SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-772-1213

     Children’s Services and Programs
          Access for Infants and Mothers (AIM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-433-2611
          California Children’s Services (CCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-288-4584
          Child Health and Disability Prevention (CHDP) . . . . . . . . . . . . . .1-800-993-CHDP (1-800-993-2437)
          Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-481-1044
          Healthy Families Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-880-5305

     Dental Plan
          SafeGuard	Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-766-7775

     Disability Services
          American Disabilities Act Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-514-0301
          Hearing Impaired/California	Relay	Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-735-2929	
          California	Relay	Services	(CRS)	—	TTY/TDD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .711

     L .A . Care Health Plan Services
          L.A. Care Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-839-9909
          Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-431-2273
          Pharmacy (MedImpact) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-788-2949
          L.A. Care Behavioral Health Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-866-908-0677
          L.A.	Care	Nurse	Advice	Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-249-3619
          L.A. Care Fraud and Abuse Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-400-4889

     Los Angeles County Services
          Los Angeles County Department of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213-250-8055
          Los Angeles County Department of Mental Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-854-7771
          Women, Infant and Children (WIC) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-942-9675

     Vision Plan
          VSP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-877-7195


42
Service Area Map

                         Healthy Kids




          Questions? Call L.A. Care Member Services at 1-888-839-9909 – TTY 1-866-522-2731. 43
               How to Get Your
               Prescription Drugs
                                                                                                            www.lacare.org

                Sometimes when you are sick or have a health            How to Get a Prescription
                condition like asthma or diabetes, your doctor          Filled at the Pharmacy
                may give you a prescription. Your doctor will give        1. Choose a pharmacy near you that works with
                you a prescription based on your health status.              your health plan.
                For New Prescriptions                                    2. Bring your prescription to the pharmacy.
                If you are filling a prescription for the first time,    3. Give the prescription to the pharmacy with
                you must go to a pharmacy that works with your              your health plan member ID card. This will
                health plan. A list of pharmacies that work with            help the pharmacy fill your prescription.
                your health plan is in the provider directory.           4. Make sure you give the pharmacy your
                For Prescription Refills                                    correct address and phone number.
                If you are refilling a prescription that you already     5. Make sure the pharmacy knows any allergies
                have, you can go to a pharmacy that works with              you have to any medicine.
                your health plan. Also, you can now receive a            6. If you have any questions about your prescrip-
                90-day supply of maintenance medications at                 tion, make sure you ask the pharmacist.
                certain local pharmacies. Please ask your doctor
                                                                         7. Healthy Kids program members pay $5 for
                to write a 90-day prescription for your medication.
                                                                            each prescription.
                L.A. Care partners with pharmacies through-
                out Los Angeles County (including Albertson’s /
                Sav-On, CVS, Rite Aid, Target, Vons, Wal-Mart,
                and Walgreens) to offer this service.

                Pharmacy Information
                To find pharmacies near you or if you would like
                to get a prescription mail order form to have medi-
                cations mailed to your home, please call Member
                Services toll-free at 1-888-839-9909. You can
                also get a prescription mail order form on the
                Internet at www.lacare.org.

                 •	 Click	on	I Am A Member
                 •	 On	the	left,	click	on	Healthy Kids, then
                 •	 On	 the	 left,	click	 on	 Pharmacy Information,
LA0522 09/09




                    scroll down to Prescriptions by Mail, and
                    follow the instructions.
                                                                                                                             45
Preventive Health
Guidelines 2009–2010




              How to Keep Your Child
                     or Teen Healthy




                                   47
                    How to Keep Your Child or Teen Healthy
                    Take your children and teens to the doctor for regular                  If your child or teen is a new member, take them to
                    check-ups to help them stay healthy. This brochure                      the doctor right away for their first check-up. Re-
                    tells you when to take them and what needs to be done                   member, regular check-ups help them stay healthy!
                    during these checkups.
                    Your doctor is always a good resource for advice and
                    education about health topics that are important to
                    your family.


                          Well Care Guidelines for Infants and Young Children*
                                        What will be done                       When to go to the doctor                   When to go to the doctor
                                           Tests/Exams                             Birth to 2 years                            3 to 10 years
                                          Well Care Visit:
                                History, physical exam, screenings         A few days after hospital discharge,
                               for growth, development, and risky            by 1 month, at 2, 4, 6, 9, 12, 15,                      Yearly
                              behaviors, health education, advice on              18, 24 and 30 months.
                                what to expect at your child’s age
                                                                                    At 7 to 9 months,
                                    Blood Test (for anemia)                                                                  At each well child visit
                                                                             13 to 15 months and at 2 years
                                          Urine Test                                                                 At age 4 to 5 and every couple of years
                                        Blood Pressure                                                                     Each year starting at age 3
                                     Tuberculosis (TB) test                                                                TB test between age 4 to 5
                                                                          Ask your doctor if your child is at risk
                                      and risk screening                                                                    required for kindergarten
                                        Lead Screening                         At 12 months and at 2 years                          As needed
                                                                                  Screening at each visit
                                Oral Health (teeth and gums)**                                                               Screening at each visit
                                                                        Get a referral to dentist by age 12 months


                           *Your doctor may order these tests more or less often as needed.
                           ** California law now requires children to have a dental check‑up
                           by a dentist or dental hygienist by May 31 of their first school
                           year (public school kindergarten or first grade level).




                                                              Questions?
                                                              Call 1-888-839-9909
LA0221 06/09




               48
               How to Keep Your Child or Teen Healthy

               Well Care Guidelines for Older Children and Teens*
                                        What will be done                                             When to go to the doctor
                                           Tests/Exams                                                   11 to 19 years
                                         Well Care Visit:
                          History, physical exam, screenings for growth,
                                                                                                               Each year
                       development, and risky behaviors, health education,
                           advice on what to expect at your child’s age
                                                                                                  At least once every 2 to 3 years
                                    Blood Test (for anemia)
                                                                                      Each year for females who have started their periods
                                          Urine Test                                Every couple of years or more often if doctor recommends
                                     Cholesterol Screening                                          When doctor recommends
                                                                                      Pelvic exam and cervical cancer screening by age 21
                                          Pelvic Exam
                                                                                        for all females; more often if doctor recommends
                            Sexually Transmitted Disease Screening
                                                                                               Each year for all sexually active patients
                                     (including Chlamydia)
                                                                                              Ask your doctor if your child is at high risk
                            Tuberculosis (TB) Screening and TB Test
                                                                                                   TB test between age 11 and 16
               *Your doctor may order these tests more or less often as needed.




                  You can also ask to talk with your doctor about these topics:
                  Asthma                                               Parenting
                  Dental Health                                        Prenatal Health
                  Diabetes                                             (for pregnant women)
                  Drug and Alcohol Problems                            Safety Tips
                  Exercise                                             STDs and HIV
                  Family Planning/Birth Control                        Tobacco
                  Healthy Foods                                        Violence and Abuse
                  High Blood Pressure                                  Weight Problems




               Sources for all information in this document: American Academy of Pediatrics
               (AAP); California Department of Health Services, Children’s Medical Services
               Branch, Child Health and Disability Prevention Program (CHDP); 2009
LA0221 06/09




               Advisory Committee on Immunization Practices, Department of Health
               and Human Services, Centers for Disease Control and Prevention.

                                                                                                                                               49
                          How to Keep Your Child or Teen Healthy

                                  Get Your Child the Right Shots at the Right Time
                                  Your child will need shots at different times to stay healthy. Use the guide below to find out about the shots
                                  needed. Ask your doctor about combined vaccines. These can help protect your child with fewer shots. Your
                                  doctor can help you understand what each shot does.


                                                   Age                                                  Your child should get these shots
                                                  Birth                       Hepatitis B** (Some infants may get their first shot at birth)
                                                                              DTaP (#1) Diphtheria, Tetanus, and Pertussis (Whooping Cough)
                                                                              Hepatitis B ***
                                                                              Hib (#1) Haemophilus influenzae type b (Hib Meningitis)
                                                2 Months
                                                                              PCV (#1) Pneumococcal disease
                                                                              Polio (#1)
                                                                              Rotavirus (#1)
                                                                              DTaP (#2)                         PCV (#2)
                                                4 Months                      Hepatitis B***                    Polio (#2)
                                                                              Hib (#2)                          Rotavirus (#2)
                                                                              DTaP (#3)                         PCV (#3)
                                                6 Months                      Hepatitis B***                    Polio (#3)
                                                                              Hib (#3)                          Rotavirus (#3)
                                                                              MMR (#1) Measles, Mumps, and Rubella                                Get a flu shot
                                                                              Varicella-Chickenpox (#1)
                                               12 Months*                     Hib (#4)                                                         each year for babies
                                                                              PCV (#4)
                                                                              Hepatitis A (#1)
                                                                                                                                               6 months and older,
                                               15 Months*                     DTaP (#4) (can be given as early as 12 months)                      and children
                                               18 Months*                     Hepatitis A (#2)                                                  up to 5 years old.
                                                                              DTaP (#5)
                                                                              Polio (#4)
                                                Age 4 to 6                    MMR (#2)
                                          (Before Kindergarten)               Varicella-Chickenpox (#2)
                                                                              Get these shots if they were missed before:
                                                                                 Hep B Series – Hep A Series – Hib
                                                                              MCV4 (Meningitis)
                                                                              Tdap (Tetanus, diphtheria, pertussis)
                                              Age 11 to 12                    HPV (3 doses) Human Papilloma Virus – for girls
                                            (Before 7th Grade)                Get these shots if they were missed before:
                                                                                 Hep B series – Hep A series – Polio series
                                                                                 MMR #2 – Pneumococcal series – Varicella
                                                                              If shots not received at ages 11 to 12:
                                                                                 MCV4 (at age 15)
                                               Age 13 to 18
                                                                                 HPV (3 doses) Human Papilloma Virus – for girls
                                                                                 Tdap
LA0221 06/09




                * Check with your doctor to see if your child needs any “catch‑up” shots.
                ** Your child may get a total of 4 Hepatitis B shots if your doctor uses both single antigen and combination vaccines.
                *** Hepatitis B Vaccine is usually given at 2, 4, and 6–18 months (3 doses).
               50
               Notice of Privacy Practices
               A Message for Healthy Kids Program Members
               Please review it carefully.                                                                                    www.lacare.org




                     This notice describes how medical information about              those who have access. Portable media devices with PHI
                     you may be used and disclosed and how you can get                are encrypted and must have password protections applied.
                                                                                      Computer screen and work stations must have privacy screen
                     access to this information.                                      filters and workstation drawers and cabinets have secure
                                                                                      locks placed on them.
                                                                                         We also must give you this Notice. This Notice tells you
                     What is “Protected Health Information?”                          how we may use and share your information. It also tells you
                                                                                      what your rights are.
                        Your protected health information (“PHI”) is health
                     information that contains identifiers, such as your name,
                     Social Security number, or other information that reveals        Your Information is Personal and Private
                     who you are. For example, your medial record is PHI
                                                                                        We get information about you from the Healthy Kids
                     because it includes your name and other identifiers.
                                                                                      Program after you join our health plan. We also get medical
                        L.A. Care Health Plan provides health care to you for the     information from your doctors, clinics, labs, and hospitals
                     Healthy Kids Program. Your confidentiality is important          so we can approve and pay for your health care.
                     to us. We are required by state and federal law to protect
                     your health information. Our staff follows policies and
                     procedures that protect your health information given to us      Changes to Notice of Privacy Practices
                     in oral, written or electronic ways.                               L.A. Care must obey the Notice that we are using now.
                        Our staff goes through training which covers the inter-       We have the right to change these privacy practices. Any
                     nal ways members’ oral, written and electronic PHI may be        changes in our practices will apply to all of your medical
                     used or disclosed across the organization. All L.A. Care staff   information. Effective April 14, 2003, whenever there is
                     with access to your health information is trained on privacy     an important change in our practices, we will change this
                     and information security laws. Staff has access only to the      Notice and notify you.
                     amount of information they need to do their job.
                        Our computer systems protect your electronic Protected
                     Health Information at all times by using various levels of          If you would like this information in
                     password protection and software technology.                        Armenian, Chinese, Farsi, Khmer, Korean,
                        Our L.A. Care employees follow internal practices, poli-         Russian, Spanish or Vietnamese, please
                     cies and procedures to protect any conversations about your
                                                                                         call L.A. Care at 1-888-839-9909.
                     health information. For example, employees are not allowed
                     to speak about your information in the elevators or hall-
                     ways. Employees must also protect any written or electronic      How We May Use and Share
                     documents containing your health information across the
                     organization.
                                                                                      Information About You
                        Fax machines, printers, copiers, computer screens, work         L.A. Care may use or share your information in order to
                     stations, portable media disks containing your information       provide or arrange for your care. Some of the information
                     are carefully guarded from others who should not have ac-        we use and share is:
                     cess. Employees must ensure member PHI is picked up from           •	 Your	name,
LA0541 09/09




                     fax machines, printers and copiers and only is received by         •	 Address,
                                                                                                                                             51
                      •	 Personal	facts,                                              •	 to	report	problems	with	medications	and	other	medical	
                      •	 Medical	care	given	to	you,                                      products;
                      •	 The	cost	of	your	medical	care,	and                           •	 to	notify	people	of	recalls	of	products	they	may	be	using;	
                      •	 Your	medical	history.                                           and
                                                                                      •	 to	 notify	 a	 person	 who	 may	 have	 been	 exposed	 to	 a	
                      Some actions we take when we act as a health plan
                                                                                         disease or may be at risk for contracting or spreading a
                    include:
                                                                                         disease or condition.
                      •	 Checking	whether	you	are	covered,
                                                                                       We may also tell the appropriate government authority
                      •	 Approving,	giving,	and	paying	for	services,
                                                                                    if we believe you have been the victim of abuse, neglect or
                      •	 Checking	the	quality	of	care	you	receive,                  domestic violence. We will only make this disclosure if you
                      •	 Making	sure	you	get	all	the	care	you	need.                 agree or when required or authorized by law.
                                                                                       We may give out medical information to a health oversight
                      These are some examples of how we may use and share           agency for activities authorized by law. These oversight
                    information about you:                                          activities may include audits, investigations, inspections
                      • For treatment: You may need medical treatment that          and licensure or disciplinary actions. These activities are
                        needs to be approved ahead of time. We will share           necessary for the government to monitor the health care
                        information with doctors, hospitals and others in order     system, government programs, and compliance with civil
                        to get you the care you need.                               rights laws.
                      • For payment: We share your information with other              If you are involved in a lawsuit or dispute, we may give
                        health plans or providers that are responsible for your     out medical information about you in response to a court or
                        care. We may also forward bills to other health plans or    administrative order.
                        providers for payment.                                         We may also give out medical information about you in
                                                                                    response to a subpoena, discovery request, or other lawful
                      •	 For health care operations: We may use information         process by someone else involved in the dispute. We will only
                         in your health record to check the quality of the health
                                                                                    do this if the person asking for the information has tried to
                         care you receive. We may also use this information in
                                                                                    tell you about the request or to obtain an order protecting the
                         audits, programs to stop fraud, planning, and general
                                                                                    information requested.
                         administration.
                                                                                       We may give out medical information if asked to do so
                                                                                    by a law enforcement official. This could include, but not be
                    Other Uses for Your Health Information                          limited to, giving out the information in the following cases:
                      You or your doctor, hospital, and other health care provid-      •	 in	 response	 to	 a	 court	 order,	 subpoena,	 warrant,	 sum-
                    ers may not agree if we decide not to pay for your care. We           mons	or	other	similar	process;
                    may use your health information to review these decisions.         •	 to	identify	or	locate	a	suspect,	fugitive,	material	witness	
                      We may share your health information with groups that               or	missing	person;
                    check how our health plan is providing services.                   •	 about	 the	 victim	 of	 a	 crime	 if,	 under	 certain	 limited	
                      We may share your information with persons involved in              circumstances, we are unable to obtain the person’s
                    your health care, or with your personal representative.               agreement;
                      We must share your health information with the federal           •	 about	a	death	we	believe	may	be	the	result	of	criminal	
                    government when it is checking on how we are meeting                  conduct;	and
                    privacy rules.                                                     •		about	criminal	conduct	at	our	health	plan.
                      We may share your information with other companies that          We may give out medical information to a coroner or med-
                    help us with our work. But we won’t do that unless those        ical examiner. This may be necessary, for example, to identify
                    companies agree in writing to keep your information private.    a deceased person or determine the cause of death. We may
                      We may contact you to provide appointment reminders           also give our medical information about members to funeral
                    or information about treatment alternatives or other health-    directors so they can carry out their duties.
                    related benefits that may be of interest to you.                   If you are an organ donor, we may give your medical infor-
                      We may give out your information for public health            mation to organizations that handle organ and tissue dona-
                    activities. These activities may include, but are not limited   tions to help with the donation and transplantation.
                    to, the following:                                                 Under certain circumstances, we may use and give out
                      •	 to	prevent	or	control	disease,	injury	or	disability;       your medical information for research purposes. All research
                      •	 to	report	births	and	deaths;                               projects are subject to a special approval process.
     LA0541 09/09




                      •	 to	report	child	abuse	or	neglect;                             We may use and give out your medical information when
52
               necessary to stop a serious threat to the health and safety of    fill out the form for you. We may refuse your request if:
               a person or the public. We would only give out this informa-         •	 The	information	is	not	created	or	kept	by	L.A.	Care,	or
               tion to someone who could help stop the threat. We may also          •	 The	 information	 is	 not	 part	 of	 a	 standard	 set	 of	
               use or give out information that is necessary for law enforce-          information kept by us, or
               ment authorities to catch a criminal.
                  If you are a member of the armed forces, we may release
                                                                                   •	 The	 information	has	been	gathered	for	 a	court	 case	 or	
               medical information about you as required by military
                                                                                      other legal action, or
               command authorities. We may also release information
               about foreign military personnel to the appropriate foreign         •	 We	believe	it	is	correct	and	complete.
               military authority.                                                 We will let you know if we agree to make the changes
                  We may give out your medical information to federal            you want. If we don’t agree to make the changes you want,
               officials for national security purposes. We may also give out    we will send you a letter telling you why. You may ask that
               your medical information to federal officials. These officials    we review our decision if you disagree with it. You may also
               would use this information to provide protection to the           send a statement saying why you disagree with our records.
               President, other authorized persons or foreign heads of state,    We will keep your statement with your records.
               or conduct special investigations.
                  We may give out your health information to comply
               with laws related to workers’ compensation or other similar       Important
               programs.
                  L.A. Care staff is trained to protect information given to     L.A. Care does not have complete copies of your medical
               plan sponsors or employers. L.A. Care requires plan sponsors      records. If you want to look at, get a copy of, or change your
               or employers to have the same protections that L.A. Care has      medical records, please contact your doctor or clinic.
               in place. Plan sponsors or employers must agree to protect
               your medical information.
                                                                                   Effective April 14, 2003, whenever we share your health
               When Written Permission is Needed                                 information, you have the right to request a list of:
                  If we want to use your information for any purpose not           •	 Whom	we	shared	the	information	with,
               listed above, we must get your written permission. If you           •	 When	we	shared	it,
               give us your permission, you may take it back in writing at         •	 For	what	reasons,	and
               any time.                                                           •	 What	information	was	shared.
                                                                                   This list will not include when we share information with
               What Are Your Privacy Rights?                                     you, with your permission, or for treatment, payment, or
                                                                                 health plan operations.
                  You have the right to ask us not to use or share your
               personal health care information. We will send you a form to       You have a right to request a printer paper copy of this
               fill out to tell us what you want. Or, we can fill out the form   Notice of Privacy Practices.
               for you. We may not be able to agree to your request.              You can also find this Notice on our website at
                  You have the right to ask us to contact you only in writing    www.lacare.org
               or at a different address, post office box, or by telephone. We
               will send you a form to fill out to tell us what you want. Or,
               we can fill out the form for you. We will accept reasonable       How Do You Contact Us to Use Your Rights?
               requests when necessary to protect your safety.                     If you want to use any of the privacy rights explained in
                  You and your personal representative have the right to         this Notice, please call or write us at:
               inspect and get a copy of your health information. We will          L.A. Care Privacy Officer
               send you a form to fill out to tell us what you want copied.
                                                                                   L.A. Care Health Plan
               Or, we can fill out the form for you. You may have to pay for
               the costs of copying and mailing records. (We may keep you          555 West Fifth Street
               from seeing certain parts of your records for reasons allowed       Los Angeles, CA 90013
               by law.)                                                            Toll-free: 1-888-839-9909
                  You have the right to ask that information in your records       California Relay: 1-800-854-7784 or
               be changed if it is not correct or complete. We will send you a     1-866-LACARE1 (1-866-522-2731) TTY line
               form to fill out to tell us what changes you want. Or, we can
LA0541 09/09




                                                                                                                                              53
                    Complaints
                      If you believe that we have not protected your privacy,
                    you have the right to complain. You may file a complaint (or
                    grievance) by contacting us at:
                      L.A. Care Privacy Officer
                      L.A. Care Health Plan
                      555 West Fifth Street
                      Los Angeles, CA 90013
                      Toll-free: 1-888-839-9909



                      OR you may contact the agency below:
                      •	 Secretary	of	the	U.S.	Department	of	Health	and
                         Human Services
                         Office for Civil Rights
                         Attention:	Regional	Manager
                         50 United Nations Plaza, Room 322
                         San Francisco, CA 94102

                      For additional information call 1-800-368-1019.
                      •	 U.S.	Office	for	Civil	Rights	at	1-866-OCR-PRIV
                         (1-866-627-7748) or 1-866-788-4989 TTY


                    Use Your Rights Without Fear
                      L.A. Care cannot take away your health care benefits or do
                    anything to hurt you in any way if you file a complaint or use
                    any of the privacy rights in this Notice.


                    Questions
                      If you have any questions about this Notice and want
                    further information, please contact the L.A. Care Privacy
                    Officer, L.A. Care Health Plan, at the address and phone
                    number	 in	 the	 “How	 Do	 You	 Contact	 Us	 to	 Use	 Your	
                    Rights?” section.
     LA0541 09/09




54
Nurse Advice Line
List of Audio Health Topics
1-800-249-3619                                                                                                        www.lacare.org




Aging                                         Allergies                                   Bipolar Disorder
A Healthy Lifestyle for Older Adults   3000   Allergies                            3100     (Manic-Depressive Illness)           3314
                                              Allergies: National Support Services 3101   Bulimia Nervosa                        3315
Abuse of Older Adults                  3001
                                              Allergies: Controlling Your                 Bullying: How to Help the Victim       3370
Adult Day Care Programs                3002
                                                Environment                        3102   Bullying: When Your Child is
Advance Directives                     3003
                                              Allergy Tests                        3103     a Bully                              3369
Alcohol and Aging                      3004                                               Child Abuse and Neglect                3300
Alzheimer’s Disease                    3005   Contact Dermatitis                   3106
                                              Drug Allergy                         3107   Choosing a Mental Health
Constipation                           3007                                                 Therapist for Your Child             3371
                                              Eczema                               3108
Dementia                               3008                                               Cocaine Use                            3317
                                              Food Allergy                         3109
Dental Care for Older Adults           3009                                               Cognitive-Behavioral Therapy           3373
                                              Hay Fever (Seasonal Allergic
Depression in Older Adults             3010                                               Compulsive Gambling                    3318
                                                Rhinitis)                          3110
Erectile Dysfunction (Impotence)       3012   Hives                                3111   Conflict Management                    3372
Exercise for Older Adults              3013   Insect Bites and Stings              3105   Confusion                              3319
Fluid Needs of Older Adults            3014   Poison Ivy, Sumac, and Oak           3112   Delirium                               3320
Health Changes with Aging              3016   Severe Allergic Reaction                    Depression                             3321
Home Healthcare                        3017     (Anaphylaxis)                      3113   Designer Drugs                         3316
How to Choose a Nursing Home           3019                                               Drug Abuse Resources                   3324
Hypothermia in Older Adults            3020   Behavioral Health                           Emotional Abuse:
Insomnia in Older Adults               3021   Abuse and Domestic Violence –                 Effects on Children                  3326
Loneliness in Older Adults             3022     Adults                           3301     Exhibitionism                          3327
Medicine: Related Problems                    Aggressive Behavior in Children    3302     Fetishism                              3328
   for Older Adults                    3026   Agoraphobia                        3303     Gender Identity Disorder               3329
Medicines: Using Them Safely           3031   Alcohol Dependence (Alcoholism)    3304     Grief and Loss                         3330
Nutrition for the Later Years          3027   Alcoholism: Information and                 Hallucinations                         3331
Personal Emergency Response                     Resources                        3305     Hazards of Smoking                     3332
   Systems                             3040   Amnesia                            3306     Hypnotherapy                           3333
Pets and Older Adults                  3028   Anger Management                   3307     Hypochondria
Preventing a Broken Hip                3030   Anorexia Nervosa                   3308       (Hypochondriasis Disorder)           3334
                                              Antisocial Personality Disorder    3309     Incest                                 3335
Safe Driving for Older Adults          3041
                                              Anxiety                            3310     Kleptomania                            3336
Self-Esteem in Older Adults            3032
                                              Attention-Deficit/Hyperactivity             Letting Go of Resentment               3337
Senior Centers                         3033
                                                Disorder (ADHD)                   3312    Living with a Mentally Ill Person      3374
Sexuality in the Later Years           3034
                                              Attention-Deficit/Hyperactivity             Marijuana                              3375
Skin Care and Protection               3035     Disorder (ADHD) in Adults         3311    Masochism                              3339
Stroke                                 3038   Autistic Spectrum Disorder          3377    Multiple Personality
Talking with Your Healthcare                  Binge Eating Disorder                         (Dissociative Identity Disorder)     3341
   Provider                            3039     (Compulsive Overeating)           3313    Narcissism (Narcissistic Personality
                                                                                            Disorder)                            3342

                                                                                                                                        55
     Nicotine Withdrawal                3376   Bone Chips in Knee                           Low Back Exercises                   3204
     Nightmares                         3344      (Osteochondritis Dissecans)      3268     Low Back Pain                        3205
     Obsessive-Compulsive Disorder             Bone Infection (Osteomyelitis)      3162     Lumbar Stenosis                      3206
       (OCD)                            3345   Bowlegs and Knock-Knees             3163     Lupus                                3207
     Panic Attacks (Panic Disorder)     3346   Broken Ankle                        3164     Mallet Finger (Baseball Finger)      3208
     Paranoid Personality Disorder      3347   Broken Arm (Forearm)                3260     Medial Collateral Ligament Sprain 3266
     Pedophilia                         3348   Broken Collarbone                   3257     Muscle Cramps and Spasms             3209
     Phobias                            3349   Broken Elbow                        3165     Muscle Strain                        3210
     Post-Traumatic Stress Disorder     3350   Broken Finger                       3166     Neck Exercises                       3211
     Prescription Drug Abuse            3351   Broken Toe                          3258     Neck Injuries                        3212
     Psychosis                          3352   Broken Wrist                        3167     Neck Spasms                          3213
     Psychosomatic Illness                     Bruised Hip (Hip Pointer)           3262     Neck Strain                          3214
       (Somatization Disorder)          3353   Bunion                              3168     Nose Injury                          3270
     Pyromania                          3354   Bursitis                            3169     Osgood-Schlatter Disease             3216
     Recognizing Drug Abuse in Kids 3323       Calcific Tendonitis                 3170     Osteoarthritis                       3217
     Sadism                             3355   Carpal Tunnel Syndrome              3171     Osteogenesis Imperfecta              3218
     Schizophrenia                      3356   Cast Care                           3172     Osteoporosis                         3219
     Seasonal Affective Disorder (SAD) 3357    Choosing Shoes that Fit             3180     Over-Pronation                       3220
     Self-Esteem                        3358   Coping with Arthritis               3259     Paget’s Disease of Bone              3221
     Sex Therapy                        3359   Corns and Calluses                  3174     Physical Therapy                     3222
     Sexual Abuse and Children          3360   Costochondritis                     3173     Pigeon Toe                           3223
     Sexual Problems                    3378   Dislocated Elbow                    3176     Plantar Fasciitis                    3224
     Smokeless Tobacco                  3361   Dupuytren’s Contracture             3256     Polymyalgia Rheumatica               3225
     Smoking: Ways to Quit              3362   Fibromyalgia                        3177     Polymyositis and Dermatomyositis 3226
     Social Phobia                      3379   Finger Dislocation                  3178     Pulled Elbow in Children             3227
     Suicide                            3363   Finger Sprain                       3179     Rheumatoid Arthritis                 3228
     Teenage Drinking                   3364   Flat Feet                           3181     Rotator Cuff Injury                  3229
     Transvestism                       3365   Foot Care                           3182     Runner’s Knee
     Treating Teens for Substance Abuse 3322   Fracture Treatment                  3185        (Patellofemoral Pain Syndrome) 3230
     Twelve Step Programs               3366   Frozen Shoulder                     3187     Scleroderma                          3231
     Types of Therapy for Mental Health 3367   Ganglion Cyst                       3188     Scoliosis                            3232
     Voyeurism                          3368   Golfer’s Elbow                      3261     Septic Arthritis                     3233
                                               Gout                                3189     Setting a Broken Bone Without
     Bones, Joints and Muscles                 Hammertoe                           3190        Surgery (Closed Reduction)        3234
     Achilles Tendon Injury             3150   Heel Pain                           3191     Shoulder Bursitis                    3235
     Amputation                         3151   Hip Dislocation in Childhood        3192     Shoulder Dislocation                 3236
     Ankle Sprain                       3152   Hip Fracture                        3193     Shoulder Injuries                    3237
     Anterior Cruciate Ligament (ACL)          Hip Replacement Surgery             3195     Shoulder Replacement Surgery         3238
       Injury                           3153   Ingrown Toenail                     3196     Shoulder Separation                  3239
     Arthritis                          3154   Jumper’s Knee (Patellar Tendonitis) 3197     Slipped Capital Femoral Epiphysis 3240
     Arthritis: Chores Made Easier      3155   Juvenile Rheumatoid Arthritis       3198     Slipped Disk (Herniated Disk)        3241
     Arthroscopic Meniscal Surgery      3156   Knee Arthroscopy                    3199     Spinal Fusion                        3242
     Arthroscopy                        3157   Knee Cartilage Tear (Meniscal Tear) 3200     Spinal Instrumentation               3243
     Aspirin and Arthritis              3159   Knee Pain                           3263     Spondylolysis and Spondylolisthesis 3244
     Athlete’s Foot                     3160   Knee Replacement Surgery            3201     Sprains                              3245
     Back Pain Prevention: Body                Knee Sprain                         3202     Stress Fractures                     3246
       Mechanics                        3161   Lateral Collateral Ligament Sprain 3264      Surgery to Set a Broken Bone         3247
     Baker’s Cyst                       3269   Legg-Calve-Perthes Disease          3203     Tennis Elbow (Lateral Epicondylitis) 3248
     Bone Chips in Elbow                       Little Leaguer’s Elbow                       Thumb Sprain                         3249
       (Osteochondritis Dissecans)      3267      (Medial Apophysitis)             3265     Torticollis                          3250


                  You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
56                                         You can call this number for free anytime, day or night.
Trigger Finger                       3251       Child and Teen Health                       Normal Development:
Ultrasound Treatment                 3252       Anger Management: Teaching                     15 to 18 Months Old                3743
Using Crutches Safely                3253         Children                         3788     Normal Development:
                                                                                               18 to 24 Months Old                3744
Wrist Sprain                         3255       Asthma in Children                 3701
                                                                                            Normal Development:
                                                Attention-Deficit/Hyperactivity
                                                                                               2 to 4 Months Old                  3745
Brain and Nervous System                          Disorder (ADHD)                  3702
                                                                                            Normal Development: 2 Years Old 3747
AIDS: Nervous System                            Attitude – Make It Positive!       3703
                                                                                            Normal Development: 3 Years Old 3748
   Complications                     3400       Autism                             3704
                                                                                            Normal Development:
Alzheimer’s Disease                  3401       Bacterial Meningitis in Children   3705        4 to 6 Months Old                  3749
Bacterial Meningitis in Adults       3402       Bedwetting (Enuresis)              3706     Normal Development: 4 Years Old 3750
Bell’s Palsy                         3403       Breast-Feeding                     3707     Normal Development: 5 Years Old 3751
                                                Breast-Feeding Positions           3790     Normal Development:
Caring for People with
   Progressive Dementia              3431       Breast-Feeding: Advantages over                6 to 9 Months Old                  3752
                                                  Formula Feeding                  3708     Normal Development:
Caring for Someone with
   Alzheimer’s Disease               3404       Childhood Cancers                  3711        2 Weeks to 2 Months Old            3746
                                                Circumcision                       3712     Normal Development:
Cluster Headaches                    3405
                                                Croup                              3714        9 to 12 Months Old                 3753
Concussion                           3406
                                                Crying Baby                        3715     Pregnancy Prevention for
Confusion                            3407                                                      Young Men and Women                3755
                                                Dental Care for Children           3717
Delirium                             3408                                                   Preparing for the First Day of School 3795
                                                Depression in Children and Teens 3772
Dementia                             3409                                                   Prevention of Sexually Transmitted
                                                Diaper Rash                        3718
Epilepsy                             3410                                                      Diseases                           3756
                                                Dyslexia                           3720
Facial Tics                          3411                                                   Puberty for Boys                      3757
                                                Earache                            3721
Guillain-Barre Syndrome              3412                                                   Puberty for Girls                     3758
                                                Exercise for Kids                  3732
Head Trauma                          3413                                                   Rashes in Infants                     3759
                                                Exercise for Teens                 3792
Huntington’s Disease                 3414                                                   Reye’s Syndrome                       3760
                                                Fetal Alcohol Syndrome             3724
Hydrocephalus                        3415                                                   Rheumatic Fever                       3761
                                                Finding and Choosing Child Care 3791
Lou Gehrig’s Disease                                                                        RSV (Respiratory Syncytial Virus) 3794
                                                Formula Feeding                    3725
   (Amyotrophic Lateral Sclerosis)   3416                                                   Self Esteem for Teens                 3763
                                                Head Lice                          3726
Lumbar Puncture                      3417                                                   Sleep Apnea in Babies                 3789
                                                Healthy Love Relationships
Migraine Headache                    3418                                                   Sleep Disorders in Children           3766
                                                  and Teens                        3773
                                                                                            Sleep Patterns in Babies              3765
Multiple Sclerosis (MS)              3435       Healthy Meal Planning for Children 3754
                                                                                            Sleep Patterns in Children            3764
Myasthenia Gravis                    3419       Hearing Loss in Children           3727
                                                                                            Speech and Language Problems          3767
Myelography                          3420       Hernias                            3728
                                                                                            Speech Development in Newborns
Narcolepsy                           3421       Homosexuality and Teens            3730        to 5 Year Olds                     3769
Neuralgias (Neuropathic Pain)        3422       Jaundice                           3731     Spitting Up                           3770
Parkinson’s Disease                  3423       Lead Poisoning: Prevention         3800     Sudden Infant Death Syndrome
Peripheral Neuropathy                3424       Living with an Alcoholic Parent    3700        (Sids)                             3771
Sciatica                             3425       Masturbation                       3733     Teething                              3774
Seizures                             3426       Measles                            3734     Temper Tantrums                       3775
Sinus Headache                       3427       Medicines Can Be Poisonous         3735     Thumbsucking                          3777
                                                Mumps                              3737     Tic Disorders                         3778
Slipped Disk (Herniated Disk)        3428
                                                Muscular Dystrophy                 3738     Tobacco and Smoking in
Spinal Cord Injury                   3429
                                                New Baby Creates Jealousy          3739        Children and Teens                 3796
Stroke                               3430
                                                New Father                         3722     Toddler Discipline                    3779
Tension Headache                     3432
                                                New Mother                         3736     Toilet Training                       3780
Trigeminal Neuralgia                 3433                                                   Tourette’s Syndrome                   3781
                                                Newborn Screening Tests            3740
Viral Meningitis in Adults           3434                                                   Type 1 Diabetes in Children           3782
                                                Normal Development:
                                                  12 to 15 Months Old              3742     Undescended Testicle                  3783



               You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
                                            You can call this number for free anytime, day or night.                                     57
     Very Small Premature Baby          3784    Skin Cancer (Nonmelanoma)           3541     Pacemakers                        3642
     Viral Infections                   3713    Stomach Cancer                      3543     Paroxysmal Supraventricular
     Viral Meningitis in Children       3785    Testicular Cancer                   3544        Tachycardia (PSVT)             3643
     Weaning from Bottle to Cup         3797    Thyroid Cancer                      3546     Pericarditis                      3644
     Weaning from Breast to Bottle      3798                                                 Peripheral Artery Disease         3645
     Weaning from Breast to Cup         3799    Cardiovascular Health                        Stroke                            3646
     Whooping Cough (Pertussis)         3787    Aneurysm                            3600     Stroke Rehabilitation             3647
                                                Angina                              3601     Superficial Thrombophlebitis      3648
     Cancer                                     Angioplasty                         3602     Tests to Diagnose Heart Disease   3652
     Biological Therapy                  3525   Aortic Valve Regurgitation          3603     Triglycerides                     3649
     Bladder Cancer                      3501   Aortic Valve Stenosis               3604     Varicose Veins                    3650
     Bone Cancer                         3502   Atherosclerosis                     3605     Ventricular Tachycardia           3651
     Bone Marrow or Stem Cell                   Atrial Fibrillation                 3606
       Transplant                        3503   Blood Clots                         3607     Dental Health
     Brain Tumors                        3504   Blood Pressure                      3608     Bad Breath (Halitosis)            3850
     Brain Tumors in Children            3505   Cardiac Arrest                      3609     Choosing a Dentist                3851
     Breast Cancer in Men                3507   Cardiac Rehabilitation              3610     Dental Care for Children          3852
     Breast Cancer in Women              3506   Cardiomyopathy                      3611     Denture Care                      3854
     Cancer Information Resources        3509   Chest Pain (Noncardiac)             3612     Gingivitis                        3855
     Cancer of the Esophagus             3523   Congenital Heart Disease            3614     How to Take Care of Your Teeth    3856
     Cancer of the Ovary                        Controlling Cholesterol             3615     Periodontal Disease               3857
       Ovarian Cancer)                   3533   Coronary Angiogram                  3616     Thrush                            3858
     Cancer of the Pancreas              3535   Coronary Artery Bypass Surgery      3617     Toothache                         3859
     Cancer of the Throat                3545   Coronary Artery Disease             3618     Tooth Grinding (Bruxism)          3860
     Cancer of the Uterus                       Deep Vein Thrombosis                3621
       (Endometrial Cancer)              3547                                                Diabetes and Other
                                                Dietary Approaches to Stop
     Cancer Prevention and Diet          3510     Hypertension (The DASH Diet)      3654     Hormonal Disorders
     Cancer Screening                    3511   Exercise Test                       3623     Diabetes and Exercise:
     Cancer Treatment Team               3513   Heart Attack: Early Warning Signs   3624       Preventing Low Blood Sugar     3923
     Cancer: Clinical Trials             3515   Heart Attack                                 Diabetes and Heart Disease       3921
     Cancer: Seven Warning Signs         3517     (Myocardial Infarction)           3640     Diabetes and Illness             3900
     Cervical Cancer                     3518   Heart Catheterization               3625     Diabetes: Food Management        3902
     Chemotherapy                               Heart Disease and Women             3653     Diabetes: Foot Care              3901
       (Drug Therapy for Cancer)         3519   Heart Disease: Prevention           3626     Diabetes: Nerve Damage
     Childhood Leukemia                  3500   Heart Failure                       3627       (Neuropathy)                   3922
     Chronic Lymphocytic Leukemia        3520   Heart Murmur                        3628     Diabetes: Self Blood Glucose
     Colon and Rectal Cancer             3521   Heart Palpitations                  3629       Monitoring                     3903
     Hodgkin’s Lymphoma                  3524   Heart Transplant                    3630     Diabetes: Importance of Exercise 3904
     Kidney Cancer                       3526   High Blood Pressure                 3631     Diabetes: Type 1                 3905
     Liver Cancer                        3527   High Cholesterol                             Diabetes: Type 2                 3906
     Lung Cancer                         3528     (Hypercholesterolemia)            3632     Diabetic Eye Problems            3907
     Melanoma                            3529   Implantable Cardioverter                     Diabetic Ketoacidosis            3908
     Multiple Myeloma                    3531     Defibrillator (ICD)               3633     Diabetic Retinopathy             3909
     Non-Hodgkin’s Lymphoma              3532   Infective Endocarditis              3634     Early Puberty in Boys            3919
     Patient-Controlled Analgesia System        Low Blood Pressure                  3635     Early Puberty in Girls           3920
       (PCA)                             3536   Low Sodium Diet                     3636     Growth Delay or Disorder         3911
     Prostate Cancer                     3537   Mitral Valve Prolapse               3637     Hemoglobin a1C Test              3924
     Prostate Specific Antigen (PSA)     3538   Mitral Valve Regurgitation          3638     High Blood Sugar (Hyperglycemia) 3912
     Protecting Yourself from Cancer     3539   Mitral Valve Stenosis               3639     Hyperosmolar Hyperglycemic State 3913
     Radiation Therapy                   3540   Myocarditis                         3641     Hyperthyroidism                  3914


                   You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
58                                          You can call this number for free anytime, day or night.
Hypoglycemia                       3915       Ear, Nose and Throat                         Running Shoes:
Hypothyroidism                     3916       Ear Infection: Middle Ear                       Finding the Right Fit                4147
Metabolic Syndrome                 3917          (Otitis Media)                    3950    Safe Exercise for People with
Pituitary Tumors                   3918       Ear Infection: Outer Ear                        Heart Disease                        4164
                                                 (Otitis Externa)                  3951    Shin Pain (Shin Splints)                4148
Digestive System                              Earwax                               3953    Shoulder Injuries                       4149
Acute Pancreatitis                  4000      Hearing Loss in Adults               3954    Sports Drinks                           4150
Anal Fissure                        4001      Laryngitis                           3955    Strength Training                       4153
Anal Fistula                        4002      Meniere’s Disease                    3962    Stretching                              4154
                                              Nosebleed (Epistaxis)                3956    Swimming and Water Exercise             4155
Antibiotic-Associated Diarrhea      4041
                                              Ruptured Eardrum                     3957    Tendonitis                              4157
Appendicitis                        4003
                                              Sinusitis                            3958    Tennis Elbow (Lateral Epicondylitis)    4158
Cholecystostomy                     4004
                                              Sore Throat                          3959    Training Heart Rates                    4159
Chronic Pancreatitis                4005
                                              Strep Throat                         3960    Wrist Sprain                            4163
Cirrhosis                           4006
                                              Tonsil and Adenoid Removal           3961
Colostomy and Ileostomy             4028
Constipation                        4008
                                                                                           Eyes and Vision
                                              Exercise and Fitness                         Astigmatism                             4224
Crohn’s Disease                     4009
                                              Achilles Tendon Injury               4100    Cataract                                4200
Diarrhea                            4010
                                              Altitude Sickness                    4102    Cataract Extraction Surgery             4201
Diverticulitis                      4011
                                              Anabolic Steroids                    4103    Color Blindness                         4202
Diverticulosis                      4012
                                              Ankle Sprain                         4104    Common Vision Problems                  4203
Duodenal Ulcer                      4013
                                              Athletic Amenorrhea                  4105    Contact Lens Care:
Gallbladder Disease/Gallstones      4014
                                              Athletic Shoes                       4106      Gas Permeable Lenses                  4204
Gallbladder Removal
                                              Caffeine and Athletic Performance    4107    Contact Lens Care:
   (Cholecystectomy)                4015
                                              Circuit Training                     4108      Soft Contact Lenses                   4205
Gastric Ulcer                       4016
                                              Cross-Training                       4109    Corneal Abrasions                       4206
Gastritis                           4017
                                              Deep Heat Treatment                  4113    Crossed or Misaligned Eyes
Gastrostomy Feeding Tube Placement4018                                                       (Strabismus)                          4207
                                              Electrical Nerve Stimulation         4116
Groin (Inguinal) Hernia             4019                                                   Eye Allergy (Allergic Conjunctivitis)   4209
                                              Exercise and Weight Control          4117
Groin (Inguinal) Hernia Repair      4020                                                   Eye Care                                4210
                                              Exercise for Kids                    4129
Heartburn                           4021                                                   Eye Exam                                4211
                                              Exercise to Stay Healthy             4118
Helicobacter Pylori                 4042                                                   Eye Symptoms Demanding
                                              Finger Sprain                        4120
Hemorrhoidectomy                    4022                                                     Immediate Attention                   4212
                                              Fluid Replacement                    4122
Hemorrhoids                         4023                                                   Eyeglass Care                           4225
                                              Groin Strain                         4123
Hepatitis A                         4024                                                   Eyelid Cyst (Chalazion)                 4213
                                              Hamstring Strain                     4125
Hepatitis B                         4025                                                   Eyestrain                               4214
                                              Home Exercise Equipment              4126
Hepatitis C                         4026                                                   Flashes and Floaters                    4215
                                              Ice Therapy                          4127
Hiatal Hernia                       4027                                                   Glaucoma                                4216
                                              Mallet Finger (Baseball Finger)      4131
Indigestion                         4029      Measuring Body Fat                   4132    LASIK                                   4227
Intestinal Gas (Flatulence)         4030      Morton’s Neuroma                     4133    Lazy Eye (Amblyopia)                    4217
Irritable Bowel Syndrome                      Muscle Cramps and Spasms             4134    Macular Degeneration                    4228
   (Spastic Colon)                  4031                                                   Pinkeye (Viral or Bacterial
                                              Neck Injuries                        4135
Laparoscopic Cholecystectomy        4032                                                     Conjunctivitis)                       4218
                                              Neck Stinger                         4136
Laxatives                           4033                                                   Presbyopia                              4229
                                              Overuse Injuries                     4139
Pilonidal Disease                   4034                                                   Retinal Detachment                      4219
                                              Personal Fitness Plan                4112
Polyps in the Colon and Rectum 4007                                                        Safety Eyewear                          4226
                                              Rice: Rest, Ice, Compression,
Rectal Bleeding                     4035         Elevation for Injuries            4142    Something in Your Eyes                  4220
Stomach Flu (Viral Gastroenteritis) 4037      Runner’s Knee (Patellofemoral Pain           Stye                                    4221
Traveler’s Diarrhea                 4038         Syndrome)                         4144    Sunglasses                              4222
Ulcerative Colitis                  4039      Running or Jogging                   4146    Types of Contact Lenses                 4223


              You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
                                           You can call this number for free anytime, day or night.                                       59
     Family Health                                Anemia                             4402      Common Cold                         4506
     Adoption                              4300   Blood Donation                     4403      Dengue Fever and
     Anger Management for Parents          4301   Blood Transfusion                  4404         Dengue Hemorrhagic Fever         4507
     Birth Control                         4302   Botox Treatment of Wrinkles        4439      Ehrlichiosis                        4546
     Birth Control Patch                   4303   Chronic Fatigue Syndrome           4406      Fifth Disease                       4508
     Birth Control Pills                   4304   Chronic Pain                       4440      Flu (Influenza)                     4522
     Cerebral Palsy                        4305   Communication in Intimate                    Genital Herpes                      4510
                                                     Relationships                   4407      Genital Warts                       4511
     Cervical Cap                          4306
                                                  Excessive Hair Growth (Hirsutism) 4410       Giardiasis                          4547
     Child Spacing                         4307
                                                  Flu Shots                          4441      Gonorrhea                           4512
     Communicating with Your Teen          4309
                                                  Hearing Aids                        4414     Group A Strep Invasive Diseases     4513
     Cystic Fibrosis                       4310
                                                  Hearing Impaired: Assistive Devices 4415     Hand-Foot-And-Mouth Disease         4514
     Depo-Provera                          4311
                                                  Hiccups                             4416     Herpes Encephalitis                 4515
     Diaphragm                             4312
                                                  Home Healthcare                     4417     HIV Infection and AIDS              4516
     Discipline Your Children              4313
                                                  Hospice                             4418     HIV Infection from Blood
     Down Syndrome                         4314
                                                  How to Choose a Primary Care                    Transfusions                     4517
     Emergency Birth Control
                                                     Provider                        4405      HIV/AIDS: Risk Factors and
        (Morning-After Pill)               4315
                                                  Jet Lag                            4442         Prevention of Transmission       4500
     Female Condom                         4317
                                                  Occupational Therapy                4419     HIV-1 Antibody Test
     Fertility Drugs                       4319
                                                  Physical Therapy                   4420         (Elisa and Western Blot)         4519
     Finding and Choosing Child Care 4320
                                                  Restless Legs Syndrome             4421      Human Papillomavirus (HPV)          4520
     Healthy Families                      4316
                                                  Secondhand Smoke                   4423      Infectious Mononucleosis            4521
     Hemophilia                            4321
                                                  Sensual Touch                      4434      Legionnaires’ Disease               4523
     In Vitro Fertilization                4322
                                                  Shots for Travel                   4443      Lice                                4524
     Infertility                           4323
                                                  Speech Therapy for Children        4424      Listeriosis                         4548
     Intrauterine Device (IUD)             4324
                                                  Stress                             4425      Lyme Disease                        4525
     Male Condom                           4325
                                                  Stress Management                  4426      Pinworms                            4526
     Natural Family Planning               4326
                                                  Stress Management:                           Rabies                              4549
     Preventing Separation Anxiety         4329      Deep Breathing                  4427      Rheumatic Fever                     4527
     Sexual Abstinence                     4332   Stress Management:                           Ringworm                            4528
     Sibling Relationships                 4333      Mental Imaging                  4428
                                                                                               Roseola                             4529
     Sickle Cell Anemia                    4334   Stress Management:
                                                                                               Rubella (German Measles)            4530
     Single Parenting                      4335      Progressive Muscle Relaxation 4429
                                                                                               Salmonellosis                       4509
     Spermicides                           4336   Talking with Your Healthcare
                                                     Provider                        4430      Scabies                             4531
     Spina Bifida                          4337
                                                  Telephone Assistive Devices         4431     Severe Acute Respiratory Syndrome
     Talking with Your Child
                                                  Temporomandibular Joint Syndrome                (SARS)                           4532
        About Drinking and Drugs           4338
                                                     (TMJ)                           4432      Sexually Transmitted Diseases       4533
     Talking with Your Child
        About HIV                          4339   The Stresses of Chronic Illness    4433      Shingles (Herpes Zoster)            4534
     Talking with Your Teen About Sex 4340        Vasectomy Reversal                  4331     Skin or Soft Tissue Abscess         4536
     Teen Pregnancy                        4341   Vital Signs                        4436      Syphilis                            4537
     Tubal Ligation (Female Sterilization) 4318   Water: Essential for Good Health 4437        Tetanus                             4538
     Tubal Sterilization Reversal          4330                                                Trichomoniasis                      4539
     Vaginal Contraceptive Ring            4342   Infectious Diseases                          Tuberculosis (TB)                   4540
     Vasectomy                             4343   Bird Flu (Avian Influenza A H5N1)   4543     West Nile Virus                     4542
     Your Child’s Self-Esteem              4344   Cat Scratch Disease                 4544
     General Health                               Cellulitis                          4502     Medications
     Alcohol and Health                   4400    Chickenpox                          4545     ACE Inhibitors                      4250
     Alternative or Complementary                 Chlamydial Infection in Men         4503     Antacids                            4251
        Ways to Control Pain               4438   Chlamydial Infection in Women       4504     Antibiotics                         4252
     Altitude Sickness                     4401   Cold Sores (Fever Blisters)         4505     Anticoagulants                      4277


                   You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
60                                            You can call this number for free anytime, day or night.
Antidepressant Medicines           4253      Fast Food                             4735   Respiratory Health
Antidiarrheal Medicines            4254      Fat in the Diet: Good and Bad         4709   Acute Bronchitis                     4800
Anti-Inflammatory Medicines        4255      Fiber in Your Diet                    4711   Asthma                               4801
Ask About Your Medicines           4256      Food and Feelings                     4703   Breathing Exercises                  4802
Beta Blockers                      4257      Grains in the Diet                    4712   Bronchoscopy                         4804
Calcium Channel Blockers           4258      Healthy Diet                          4728   Chronic Bronchitis                   4805
Corticosteroids                    4259      Healthy Snacks for Children           4737   Chronic Obstructive Pulmonary
Cortisone Injection                4278      Healthy Weight Gain                   4713      Disease (COPD)                    4806
Cough Medicine, Nonprescription    4260      Keeping a Food Diary                  4730   Collapsed Lung: Injury-Related       4807
Decongestants and Antihistamines   4261      Lactose Intolerance                   4736   Collapsed Lung:
Diuretics                          4262      Losing Weight                         4714      Non-Injury-Related                4808
Drug Interactions                  4263      Nutrition for Diabetics:                     Cough                                4809
Generic and Brand-Name Drugs       4264        Dining Out                          4715   Emphysema                            4810
High Blood Pressure Medicines      4266      Nutrition for People with Diabetes:          Peak Flow Meter                      4821
Laxatives                          4267        Use of Alcohol                      4718   Pleurisy                             4820
Medicines to Keep on Hand          4273      Obesity                               4719   Pneumonia                            4811
Medicines: Using Them Safely       4268      Overweight Children                   4721   Pulmonary Embolism                   4812
Nitroglycerin and Other Nitrates   4269      Reading Food Labels                   4724   Pulmonary Function Tests             4813
Nonprescription Medicines          4270      Salt in the Diet                      4725   Sleep Apnea                          4815
Sedatives (Tranquilizers)          4275      Sugar Substitutes                     4727   Snoring                              4817
Sleeping Pills                     4271      Vegetarian Diet                       4731   Thoracentesis                        4818
Statins                            4279      Vitamins                              4732   Using Oxygen at Home                 4819
Tetanus Vaccine                    4274      Weight Loss Diets                     4733
Vasodilators                       4276                                                   Safety and Emergency
                                             Preventive Health                            Preparedness
Men’s Health                                 Back Pain Prevention: Body                   Animal and Human Bites                4900
Enlarged Prostate                              Mechanics                           4650   Anthrax                                4901
  (Benign Prostatic Hyperplasia)   4600      Bathroom Safety                       4651   Biological Terrorism Agents            4903
Erectile Dysfunction (Impotence)   4601      Cancer Prevention and Diet            4652   Blisters                              4904
Hair Loss                          4602      Childproofing Your Home               4653   Botulism                               4919
Infertility                        4603      Controlling Cholesterol               4654   Bruise                                 4905
Male Condom                        4604      Drowning Prevention                   4656   Carbon Monoxide Poisoning             4944
Premature Ejaculation              4606      Exercise to Stay Healthy              4657   Cardiopulmonary Resuscitation
Prostate Problems                  4607      Exercises for the Workplace           4658      (CPR)                              4906
Routine Healthcare for Men         4609      Heart Disease: Prevention             4660   Chemical Terrorism Agents              4907
Sexual Response in Men             4610      Immunization Schedule:                       Choking                                4909
Testicular Self-Examination        4611        Children                            4663   Cuts, Scrapes, and Scratches           4934
Transurethral Resection of                   Immunizations: Adults                 4664   Dehydration                            4910
  the Prostate                     4608      Management of                                E. Coli Infection                      4920
Vasectomy                          4612        Your Personal Health                4659   Electrical Shock                       4912
                                             Medicines: Using Them Safely          4666   Electric Shock: Prevention of Injuries 4913
Nutrition and Weight Control                 Noise and Hearing Loss                4662   Eye Symptoms Demanding
Caffeine in Your Diet              4700      Obesity                               4667      Immediate Attention                 4914
Calcium                            4701      Preventing Burns and Scalds           4669   First Aid for First-Degree Burns       4915
Carbohydrates                      4702      Preventing Falls                      4670   First Aid for Second-Degree Burns 4916
Celiac Disease and                           Protecting Yourself from Cancer       4671   First Aid for Third-Degree Burns       4917
  Gluten-free Diet                 4734      Routine Healthcare for Men            4672   Food Poisoning                         4918
Diabetes: Food Management          4704      Routine Healthcare for Women          4673   Frostbite                              4922
Eating Healthy Snacks              4707      Safety Seats for Children             4674   Heart Attack: Early Warning Signs 4923
Exercise to Stay Healthy           4708      Water: Essential for Good Health      4676   Heat Illness                           4924


              You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
                                          You can call this number for free anytime, day or night.                                      61
     Home First Aid Supplies            4925   Surgery                                      Bone Scan                          5108
     Hypothermia                        4927   Anesthesia                          5000     Bronchoscopy                       5109
     Insect Repellent Use               4945   Breast Enlargement                           Cholesterol: Lipid Panel Test       5110
     Puncture Wound                     4929     (Augmentation Mammoplasty)        5002     Colonoscopy                         5111
     Rape                               4930   Breast Reconstruction               5003     Colorectal Cancer Screening         5112
     Rice: Rest, Ice, Compression,             Breast Reduction (Reduction                  Colposcopy of the Vagina and Cervix 5113
       Elevation for Injuries           4932     Mammoplasty)                      5004     Complete Blood Count Test (CBC) 5114
     Safety Eyewear                     4933   Eyelid Surgery (Blepharoplasty)     5005     Coronary Angiogram                  5115
     Salmonellosis                      4921   Facelifts                           5006     CT Scanning                         5116
     Smallpox Vaccine                   4935   Liposuction                         5008     Cystoscopy                          5117
     Snakebite                          4936   Lumpectomy and Removal of                    Diagnostic Laparoscopy              5118
     Something in Your Eyes             4937     Lymph Nodes                       5013     Echocardiogram                      5119
     Sore Throat                        4938   Nose Reconstruction (Rhinoplasty)   5009     Electrocardiogram (ECG or EKG) 5120
     Spider Bites and Scorpion Stings   4939   Outpatient Cryosurgery              5012     Electroencephalogram (EEG)          5121
     Splinter                           4940   Skin Resurfacing                    5010     Electromyogram (EMG)               5122
     Sunburn                            4941   Tracheotomy                         5014     Endoscopic Retrograde Cholangio-
     Tetanus Vaccine                    4942   Tummy Tuck                          5011        pancreatography (ERCP)          5123
     Tick Bite                          4943   Wound Closure and Wound Care        5015     Heart Catheterization               5125
                                                                                            Holter Monitors                    5126
     Skin Health                               Symptoms                                     IVP (Intravenous Pyelogram)         5141
     Acne                               4850   Abdominal Pain                      5050     Liver Panel Test                    5140
     Blisters                           4851   Constipation                        5051     Magnetic Resonance Imaging (MRI) 5127
     Boils and Carbuncles               4852   Cough                               5052     Mammogram                          5128
     Canker Sore                        4853   Dehydration                         5053     Pap Test (Cervical Smear)          5129
     Cellulitis                         4854   Dizziness and Vertigo               5054     Percutaneous Transhepatic
     Cold Sores (Fever Blisters)        4855   Earache                             5055        Cholangiography (PTHC)          5130
     Contact Dermatitis                 4856   Fatigue                             5056     Sigmoidoscopy                       5131
     Dandruff                           4857   Fever                               5057     Strep Test                          5142
     Eczema                             4858   Heart Palpitations                  5058     Thyroid Scan                        5132
     Hives                              4859   Heartburn                           5059     Thyroid-Stimulating Hormone
     Impetigo                           4860   Insomnia                            5060        (TSH) Test                       5133
     Itching                            4861   Lymph Nodes: Enlarged               5063     Thyroxine (T4) Test                5134
     Jock Itch                          4875   Nausea and Vomiting                 5065     Ultrasound Scanning                 5135
     Moles                              4862   Rectal Bleeding                     5068     Urine Culture                      5136
     Nail Infection                     4876   Swallowing Difficulty (Dysphagia)   5071     Urine Tests                        5137
     Plantar Warts                      4863   Tinnitus                            5072     X-Rays                             5138
     Pressure Ulcers                    4874   Urinary Incontinence                5073
     Psoriasis                          4864   Urination Problems                  5074     Urinary and Genital Systems
     Rosacea                            4865                                                Acute Kidney Failure (Acute Renal
                                               Test and Examinations                          Insufficiency)                    5350
     Seborrhea                          4866
                                                                                            Bladder Infection (Cystitis)        5351
     Sjogren’s Syndrome                 4867   Angiograms                          5100
                                                                                            Blood in Urine (Hematuria)          5352
     Skin Exam                          4869   Arterial Blood Gases                5101
                                                                                            Chronic Kidney Failure
     Skin Infection Around Fingernail          Barium Enema                        5102
                                                                                              (Chronic Renal Insufficiency)     5353
        or Toenail                      4877   Barium X-Ray Exam:
                                                                                            Functional Urinary Incontinence     5354
     Skin or Soft Tissue Abscess        4870     Esophagus and Stomach             5103
                                                                                            Indwelling Catheter Care            5355
     Sunburn                            4871   Biopsy                              5104
                                                                                            Kegel Exercises                     5356
     Tanning Beds                       4872   Blood (Serum) Glucose Test          5105
                                                                                            Kidney Dialysis                     5367
     Warts                              4873   Blood: Iron Test                    5106
                                                                                            Kidney Infection (Pyelonephritis)   5357
                                               Bone Marrow Biopsy                  5107
                                                                                            Kidney Stones                       5358
                                               Bone Mineral Density Testing        5139


                   You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
62                                         You can call this number for free anytime, day or night.
Lithotripsy for Kidney Stones      5359        Episiotomy                          5232    Prenatal Care                         5274
Overflow Incontinence              5360        Estimating Gestational Age          5299    Prenatal Tests                        5275
Urge Incontinence                  5361        Exercise After Delivery             5233    Preterm Labor                         5309
Urinary Catheterization            5362        Exercise During Pregnancy           5234    Rh Incompatibility                    5311
Urinary Incontinence               5363        Female Condom                       5235    Routine Healthcare for Women          5276
Urinary Obstruction                5364        Feminine Hygiene                    5237    Ruptured Membranes                    5277
Urinary Tract Infection in Men     5365        Fetal Alcohol Syndrome              5238    Sex During Pregnancy                  5278
Urinary Tract Infection in Women   5366        Fibrocystic Breast Changes          5239    Sexual Abstinence                     5279
                                               Genetic Screening Before or                 Sexual Response in Women              5280
Women’s Health                                   During Pregnancy                  5240    Skin Changes During Pregnancy 5281
Abdominal Hysterectomy              5200       Getting Ready for Pregnancy         5241    Smoking During Pregnancy              5282
Abuse and Domestic Violence –                  Hair Loss in Women                  5242    Sore Nipples                          5304
  Adults                            5201       Heart Disease and Women             5313    Spermicides                           5283
Amniocentesis                       5202       Hot Flashes                         5243    Stress Incontinence in Women          5284
Atrophic Vaginitis                  5203       Hysteroscopy                        5244    Tipped Uterus                         5285
Bartholin’s Gland Cyst              5204       Induction of Labor                  5302    Travel When You Are Pregnant          5287
Benign Ovarian Tumor                5205       Infertility                         5245    Triple or Quad Test for
Beta Strep Infection During                    Intrauterine Device (IUD)           5246       Birth Defects                      5308
  Pregnancy                         5301       Labor and Delivery                  5247    Tubal Ligation (Female Sterilization) 5236
Birth Control                       5206       Mammogram                           5248    Uterine Fibroids                      5288
Birth Control Patch                 5207       Menopausal Hormone Therapy          5249    Vaginal Contraceptive Ring            5289
Birth Control Pills                 5208       Menopause                           5250    Vaginal Hysterectomy                  5291
Bleeding Between Menstrual Periods             Menorrhagia (Heavy or Extended              Vaginal Hysterectomy with
  (Metrorrhagia)                    5209         Menstrual Bleeding)               5303       Laparoscopy                        5292
Breast Infection (Mastitis)         5210       Menstrual Cramps                    5251    Vaginitis                             5293
Breast Self-Exam                    5211       Miscarriage                         5252    Vulvar Dystrophy                      5294
Cervical Cap                        5212       Missed Menstrual Periods                    Vulvitis                              5295
Cervical Intraepithelial Neoplasia               (Amenorrhea)                      5253    Working During Pregnancy              5296
  (CIN)                             5213       Morning Sickness                    5254    X-Rays During Pregnancy               5310
Cervical Polyps                     5214       Natural Family Planning             5255    Yeast Infection (Candidiasis)         5297
Cervicitis                          5215       Nipple Discharge (Galactorrhea)     5256
Cesarean Section                    5216       Nonreassuring Fetal Status
Choosing a Healthcare Provider                   (Fetal Distress)                  5300
  for Your Pregnancy                5217       Nonstress Test                      5305
Chorionic Villus Sampling (CVS) 5218           Normal Growth of a Baby During
Conization of the Cervix with Laser 5298         Pregnancy                         5257
Contraction Stress Test             5312       Ovarian Cysts                       5259
D&C (Dilation and Curettage)        5220       Pain Relief in Labor and Delivery   5306
Danger Signs in Pregnancy           5221       Painful Intercourse                 5262
Depo-Provera                        5222       Pelvic Exam                         5263
Diabetes in Pregnancy               5223       Pelvic Inflammatory Disease         5264
Diaphragm                           5224       Pelvic Support Problems             5265
Diet During Pregnancy               5225       Polycystic Ovary Syndrome           5307
Diethylstilbestrol (DES)            5226       Postmenopausal Bleeding             5266
Drug, Alcohol, and Tobacco                     Postpartum Care                     5267
  Use During Pregnancy              5227       Postpartum Depression               5269
Ectopic Pregnancy                   5228       Preeclampsia                        5270
Emergency Birth Control                        Pregnancy Tests                     5271
  (Morning-After Pill)              5229       Premenstrual Dysphoric Disorder
Endometrial Biopsy                  5230         (PMDD)                            5272
Endometriosis                       5231       Premenstrual Syndrome (PMS)         5273


              You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
                                           You can call this number for free anytime, day or night.                                     63
      555 West Fifth Street
Los Angeles, CA 90013-3036

           www.lacare.org

  Toll Free: 1-888-839-9909




                  LA0265 11/09

				
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