A Helpful Guide to Your Health Care Benefits
Una guía útil para sus beneficios de atención de la salud
Ձեր առողջապահական խնամքի նպաստների օգտակար ուղեցույց
건강보험 혜택에 관한 안내서
Moät höôùng daãn höõu ích veà caùc lôïi ích y teá cuûa quyù vò
ភៅម ុ ជ ពោ ក រ ់ ក ្ច ស ភា រ លោ អ
សៀវ គ្គទ្ទេសក៍ ំនួយចំ ះ មេ ៉ាបរង ិចថេទាំ ុខ ពបស់ ក ្នក
Полезное руководство к Вашим пособиям
по медицинскому страхованию
(Makatutulong na) Patnubay sa Iyong mga Benepisyo
sa Pangangalagang Pangkalusugan
A Helpful Guide to Your Health Care Bene ts
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.
is Member Handbook you are reading contains the Evidence of Coverage and Disclosure Form (EOC). It
has the terms and conditions of your health care bene ts, summarizes the L.A. Care Health Plan (L.A. Care)
policies and rules, and tells you how to get health care. e Member Handbook is broken down into the
• Combined Evidence of Coverage and Disclosure Form ......................................................... 1
• Preventive Health Guidelines – How to Stay Healthy ..........................................................59
• Preventive Health Guidelines – How to Keep Your Child or Teen Healthy .......................63
• Notice of Privacy Practices ........................................................................................................67
• Nurse Advice Line – List of Audio Health Topics ...................................................................71
e information listed below can be found in this Member Handbook:
• What bene ts and services are covered
• What bene ts and services are not covered
• How your health plan makes decisions about when new treatments will become bene ts
• What care you can and cannot get when you are out of Los Angeles County or the L.A. Care network
• 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 for special care or to go to the hospital
• What to do when you need care right away or when the o ce is closed
• What to do if you have an emergency
• How to get prescriptions lled and other pharmacy program information
• Co-payments and other charges
• What to do if you get a bill
• Programs to improve care and services for our members
• Programs for people with a disease, like diabetes or asthma
How Decisions Are Made About Your Care
• How our doctors and sta make decisions about your care based only on need and bene ts. We do not
encourage doctors to provide less care than you need and doctors are not paid to deny 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
• 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
• How to get help if you speak a di erent language
You may view this Member Handbook before enrollment in the Medi-Cal 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.
2010–2011 Medi-Cal Member Handbook
… a helpful guide to getting services
(Combined Evidence of Coverage and Disclosure Form)
Benefit Year 2010–2011
L.A. Care Health Plan
555 West Fifth Street
Los Angeles, CA 90013
TTY/TDD: 1-866-LACARE1 (1-866-522-2731)
Oﬃce Hours: Monday through Friday, 8 a.m. to 5 p.m.
Web site address: www.lacare.org
2010–2011 Medi-Cal Member Handbook
As an L.A. Care member, you have the right to receive emergency treatment whenever and
the right to… wherever you need it.
Respectful and courteous treatment. You have the Service and information in your language. You have
right to be treated with respect, dignity and courtesy from the right to request an interpreter at no charge instead of
your health plan’s providers and sta . You have the right to using a family member or friend to interpret for you. You
be free from retaliation or force of any kind when making should not use children to interpret for you. You have the
decisions about your care. right to get the Member Handbook and other information
in another language or format (such as audio, large print
Privacy and con dentiality. You have the right to have or Braille).
a private relationship with your provider and to have your
medical record kept con dential. You also have the right Know your rights. You have the right to receive
to receive a copy of, amend, and request corrections to information about your rights and responsibilities. You
your medical record. If you are a minor, you have the right have the right to make recommendations about these
to certain services that do not need your parents' okay. rights and responsibilities.
Choice and involvement in your care. You have the
right to receive information about your health plan, its As an L.A. Care member, you have a
services, its doctors and other providers. You have the right responsibility to…
to choose your primary care provider (PCP doctor) from Act courteously and respectfully. You are responsible
the doctors and clinics listed in your health plan’s provider for treating your doctor and all providers and sta with
directory. You also have the right to get appointments courtesy and respect. You are responsible for being on time
within a reasonable amount of time. You have the right to for your visits or calling your doctor’s o ce at least 24
talk with your doctor about any care your doctor provides hours before your visit to cancel or reschedule.
or recommends, discuss all treatment options, and
participate in making decisions about your care. You have Give up-to-date, accurate and complete information.
the right to a second opinion. You have the right to talk You are responsible for giving correct information and as
candidly to your doctor about appropriate or medically much information as you can to all of your providers, to
necessary treatment options for your condition, regardless L.A. Care. You are responsible for getting regular checkups
of the cost or what your bene ts are. You have the right to and telling your doctor about health problems before they
information about treatment regardless of the cost or what become serious.
your bene ts are. You have the right to decline treatment. Follow your doctor’s advice and take part in your
You have a right to decide in advance how you want to be care. You are responsible for talking over your health care
cared for in case you get a life-threatening illness or injury. needs with your doctor, developing and agreeing on goals,
doing your best to understand your health problems, and
Voice your concerns. You have the right to complain
following the treatment plans and instructions you both
about L.A. Care, the health plans and providers we work
with, or the care you get without fear of losing your
bene ts. L.A. Care will help you with the process. If you Use the Emergency Room only in an emergency. You
don’t agree with a decision, you have the right to appeal, are responsible for using the emergency room in cases of an
which is to ask for a review of the decision. You have the emergency or as directed by your doctor.
right to disenroll from your health plan whenever you
Report wrong-doing. You are responsible for reporting
want. As a Medi-Cal member, you have the right to
health care fraud or wrongdoing to L.A. Care. You can do
request a State Fair Hearing.
this without giving your name by calling the L.A. Care
Service outside of your health plan’s provider network. Compliance Helpline toll-free at 1-800-400-4889 or
You have the right to receive emergency or urgent services you could call the Department of Health Care Services
as well as family planning and sexually transmitted disease (DHCS) Medi-Cal Fraud and Abuse Hotline toll-free at
services outside of your health plan’s network. You have 1-800-822-6222.
Table of contents
Welcome: ank you for choosing
L.A. Care Health Plan! 6 How to keep seeing your doctor if your doctor
When your care starts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 leaves your health plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Your health plan choices with L.A. Care . . . . . . . . . . . . . . . . . 6 How to keep seeing your doctor if you
are a new member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
How to change health plans . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Care outside of L.A. Care’s network . . . . . . . . . . . . . . . . . . . . 18
How to change your Health Maintenance
Organization (HMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What is covered: What kinds of
is Member Handbook: health care can I get from L.A. Care? 19
Why is it important to you? 8 Covered benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Need this handbook in another language? . . . . . . . . . . . . . . 8
Whom do I call and when? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Helpful information on the Internet at www.lacare.org . . 9 What other services can I get? 26
California Children’s Services (CCS) . . . . . . . . . . . . . . . . . . . . . 26
Let’s get started: Child Health and Disability Prevention (CHDP) . . . . . . . . . 26
How do I get health care? 10 Women, Infants and Children (WIC) Program. . . . . . . . . . . 26
Your PCP doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Special services for American Indians . . . . . . . . . . . . . . . . . . 26
Start getting your care now! Call your PCP doctor Medi-Cal benefit changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
for a checkup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Services you can get outside of your health plan . . . . . . . 27
How to see your PCP doctor . . . . . . . . . . . . . . . . . . . . . . . . . . 10
How to get care when your PCP doctor’s Non-covered services:
oﬃce is closed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 What does Medi-Cal not cover? 29
If you get a bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
What is a second opinion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Pharmacy beneﬁts:
How to get a second opinion. . . . . . . . . . . . . . . . . . . . . . . . . . 12 How do I get prescription drugs? 30
Are you pregnant? Call L.A. Care at 1-888-839-9909 . . . . 12 What is a pharmacy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
How to get health care that your PCP doctor can’t give you . . .12 How to get a prescription filled . . . . . . . . . . . . . . . . . . . . . . . .30
How to get a standing referral with a specialist. . . . . . . . . 12 Prescription refills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
What is a formulary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
ID cards: How do I use them? 14 Drugs not on the formulary . . . . . . . . . . . . . . . . . . . . . . . . . . .30
What to do with your L.A. Care ID card . . . . . . . . . . . . . . . . . 14 What drugs are covered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
What to do with your Medi-Cal card What drugs are not covered? . . . . . . . . . . . . . . . . . . . . . . . . . . 31
(also known as BIC card) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Emergency contraception (“Plan B”) . . . . . . . . . . . . . . . . . . . 31
Prescription authorization process for emergencies or
Our provider network: urgent circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Who gives me health care? 15 Medicare Part D: Prescription drug coverage for
Your PCP doctor gives you most of your care . . . . . . . . . . 15 beneficiaries who get both Medicare and Medi-Cal . . . 32
How to change your PCP doctor. . . . . . . . . . . . . . . . . . . . . . . 15
Kinds of PCP doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Emergency care: How do I get care in
Choosing a Federally Qualified Health Center (FQHC) an emergency? 33
as your PCP doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 How to get urgent care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
How to get care from a specialist . . . . . . . . . . . . . . . . . . . . . . 16 What is emergency care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Our doctors' professional qualifications . . . . . . . . . . . . . . . . 16 What to do in an emergency . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Certified Nurse Midwives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Outside of Los Angeles County . . . . . . . . . . . . . . . . . . . . . . . .34
Certified Nurse Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 What to do after an emergency . . . . . . . . . . . . . . . . . . . . . . .34
What care can you get from a provider who is not How to get emergency transportation . . . . . . . . . . . . . . . . .34
your PCP doctor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Not sure you have an emergency? . . . . . . . . . . . . . . . . . . . . .34
iv Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Help in another language and for people Mandatory Medi-Cal Managed Care members . . . . . . . . . 45
with disabilities: How can I get help? 35 Voluntary Medi-Cal Managed Care members . . . . . . . . . .46
Information in other languages . . . . . . . . . . . . . . . . . . . . . . . . 35 Voluntary disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Interpreters for members who don’t speak English Involuntary disenrollments . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
or are hearing or speech impaired. . . . . . . . . . . . . . . . . . . 35 Expedited disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
If you need interpreting services . . . . . . . . . . . . . . . . . . . . . . . 35 Transitional Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Protection for people with disabilities. . . . . . . . . . . . . . . . . . 35
Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Getting involved: How do I participate? 48
L.A. Care Public Policy Committee . . . . . . . . . . . . . . . . . . . . .48
Complaints: What should I do if I am L.A. Care Regional Community Advisory
Committees (RCAC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
unhappy? 37 Board of Governors meetings . . . . . . . . . . . . . . . . . . . . . . . . .48
What is a grievance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Communicating policy changes . . . . . . . . . . . . . . . . . . . . . . .48
How to file a grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
If you don’t agree with the outcome of your grievance .38 More important information:
How to file a grievance for urgent cases . . . . . . . . . . . . . . .38 What else do I need to know? 49
If you don’t agree with the outcome of your
grievance for urgent cases . . . . . . . . . . . . . . . . . . . . . . . . . .38 If you travel outside of Los Angeles County . . . . . . . . . . . . 49
Independent Medical Review. . . . . . . . . . . . . . . . . . . . . . . . . . 39 How a provider gets paid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
IMRs for Experimental and Investigational If you have other insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Therapies (IMR-EIT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Contacting the California Department of Third party liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Managed Health Care (DMHC) . . . . . . . . . . . . . . . . . . . . . .40 Medi-Cal Estate Recovery Program . . . . . . . . . . . . . . . . . . . . 49
State Fair Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Disruption in services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Expedited State Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Organ donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Ombudsman Oﬃce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 What is an advance directive? . . . . . . . . . . . . . . . . . . . . . . . . .50
Arbitration: Solving problems without going to court.. . 41 New technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Voluntary mediation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Glossary of Terms 51
Conﬁdentiality: What are my privacy Important Phone Numbers 57
Health information privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Protect yourself from identity theft . . . . . . . . . . . . . . . . . . . . 43
Fraud, waste & abuse: How to identify
and report it 44
Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Waste. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
How to report fraud, waste and abuse. . . . . . . . . . . . . . . . . .44
Why should you care about fraud, waste and abuse? . . .44
Preventing health care fraud. . . . . . . . . . . . . . . . . . . . . . . . . . .44
Medi-Cal: How can I make sure
I don’t lose my coverage? 45
Keeping your Medi-Cal eligibility . . . . . . . . . . . . . . . . . . . . . . 45
If you move you must tell us! . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Two types of Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). v
Welcome: ank you for
choosing L.A. Care Health Plan!
L.A. Care is a government agency that was created Your health plan choices with L.A. Care
over 10 years ago to help Los Angeles County Medi-Cal
L.A. Care works with ve (5) Health Plan Partners
members get quality health care. L.A. Care is also called
to provide health care services for members.
the Local Initiative Health Authority for Los Angeles
County. But you can call us “L.A. Care.” L.A. Care and the Health Plan Partners have
contracts with many doctors, hospitals, pharmacies
With the help of the health plans we work with,
and other health care providers to serve you. When a
L.A. Care serves nearly 800,000 members in Los Angeles
Medi-Cal member joins L.A. Care, the member can
County. We only serve people who live in Los Angeles
choose to receive services through:
County (called our “service area”). L.A. Care Health
Plan is the largest public health plan in the nation. We • Anthem Blue Cross
are growing because we are a trusted source for health • Care1st Health Plan
care and we respect our members. • Community Health Plan
• Kaiser Permanente
When your care starts • L.A. Care Health Plan
To enroll in the Medi-Cal program, call or visit the L.A. Care and the Health Plan Partners are pre-paid
Los Angeles County Department of Public Social Services health coverage programs called “health maintenance
o ce (DPSS) near you. Once DPSS nds you eligible, organizations,” or HMOs. L.A. Care and the Health
you can enroll in a health plan of your choice. Enrollment Plan Partners are licensed with the State of California.
in a health plan can take between 15 to 45 days. e State of California has given L.A. Care and the
While your enrollment in a health plan is processed, Health Plan Partners permission to serve you. e State
you can access your Medi-Cal bene ts using the Bene ts of California pays for your health care. ere is no cost
Identi cation Card (BIC) sent to you by the California to you when you get services covered by Medi-Cal.
Department of Health Care Services. e bene ts you When you chose L.A. Care for your Medi-Cal,
access during this time are covered by Medi-Cal. you also chose L.A. Care as your health plan. (If you
Your care through L.A. Care starts when your did not choose a health plan, we chose one for you).
enrollment in a health plan is complete. You can start L.A. Care is responsible for almost all of your health
using your Medi-Cal bene ts through L.A. Care on your care services. Some bene ts, like dental and vision, are
e ective date of coverage. Your e ective date of coverage not provided by your health plan. You can learn more
is the 1st day of the month following completion of about this in the “More bene ts: What other services
enrollment in a health plan. Check the L.A. Care member can I get?” section of this handbook.
ID card mailed to you for the e ective date of coverage.
6 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
How to change health plans How to change your Health
We believe you will like L.A. Care. But you can Maintenance Organization (HMO)
change your health plan for any reason. Call L.A. Care You can also leave L.A. Care to enroll with another
at 1-888-839-9909 to change your health plan. If you health maintenance organization (HMO) at any time
call L.A. Care before the 20th of the month, the change and for any reason. To change your HMO, call Health
will be e ective on the 1st of the next month. If you call Care Options (HCO). You can nd HCO’s phone
L.A. Care on or after the 20th of the month, the change number in the “Important Phone Numbers” section of
will start on the 1st of the month following the next this handbook. When you change your HMO, you will
month. For example, if you call on June 15th to change get a new ID card and Member Handbook from your
health plans, the change will become e ective on July new HMO. Be sure to tear up your old ID card.
1st. If you call after June 20th to change health plans,
the change will become e ective August 1st. When you
change health plans, you will get an ID card from your
new health plan. Be sure to tear up your old health plan
Some plans do not serve all of Los Angeles County.
Call the health plan to ask about their service area and
to make sure it can serve you before you change. You
can't get routine care like checkups outside of your
health plan’s service area. But don’t worry: No matter
which health plan you choose, you can get urgent or
emergency care anywhere when you need it – even
outside of Los Angeles County. For more information,
see the “Emergency care: How do I get care in an
emergency?” section of this handbook.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 7
is Member Handbook:
Why is it important to you?
is Member Handbook has important information.
Keep this handbook where you can nd it easily. is
handbook contains information on:
• How and from whom to get care sUmTUrs&BæeTA L.A. Care ebIG~kcg'Vn esovePA
t¨maenH CaPasaExµr . (Khmer)
• What types of care are and are not covered
L.A. Care 에게 전화를 하시면 이 핸드북을 다른
• Who to contact if you have problems 언어로 받아보실 수 있습니다. (Korean)
• Your rights regarding Medi-Cal and how you are
treated Tumawag sa L.A. Care kung kailangan mo ang
handbook sa lengguwaheng ito. (Tagalog)
In this handbook, we use “you” and “your” to
mean “the Medi-Cal member.” Only the member Позвоните в офис L.A. Care, если Вам необходим
can get the bene ts talked about in this handbook. данный справочник на следующем языке
Your Member Handbook is also called the
Combined Evidence of Coverage and Disclosure Xin goïi L.A. Care neáu quyù vò muoán coù cuoán caåm
Form. It gives only a summary of L.A. Care Health nang baèng ngoân ngöõ naøy. (Vietnamese)
Plan policies and rules. You must look at the contract
between L.A. Care and the California Department Call L.A. Care’s Member Services
of Health Care Services (DHCS) to learn the exact
terms and conditions of coverage. Call L.A. Care if
if you would like this handbook or
you would like a copy of the contract. other materials that you may receive
from L.A. Care in large print, Braille,
audio or an alternative format.
Need this handbook in another language?
Call L.A. Care if you would like your handbook in
this language. (English)
Whom do I call and when?
You can call your Primary Care Provider (PCP) –
Llame a L.A. Care si desea una copia del manual en your doctor – when you:
este idioma. (Spanish)
• Need an appointment
Ð»é³Ó³ÛÝ»ù L.A. Care »Ã» ó³ÝÏ³ÝáõÙ »ù • Need a checkup
ëáõÛÝ ï»Õ»Ï³·ÇñÝ áõÝ»Ý³É Ñ»ï»õÛ³É É»½íáí` • Are sick
• Need urgent care services in Los Angeles County
如果您想取得後述語言的手冊，請致電 • Have a health question
L.A. Care。(高棉文) (Chinese)
Your doctor’s name and telephone number are on your
8 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
You can call L.A. Care when you: plan. Since this information is private, you will need to
• Need a new ID card log in. Go to www.lacare.org to nd out what to do.
• Want to change your PCP doctor Be sure to have your ID card ready because we will ask
• Have questions about services and how to get them for your member ID number.
• Want to know what’s covered or what is not covered
• Need help getting the care you need
• Get a bill from a doctor
• Are pregnant
• Have a problem you can’t solve
• Want to change health plans from L.A. Care to a
di erent health plan
• Are unsure who to call
L.A. Care’s toll-free number is 1-888-839-9909.
Helpful information on the Internet at
Do you use the Internet? Our Web site, www.lacare.org,
is a great resource. You can:
• Find a doctor
• Learn about the nurse advice line and how and when
to use it
• Learn about your bene ts
• Learn more about privacy rights
• Learn about health education services
• Find out about your rights and responsibilities
• File a complaint (called a “grievance”)
• Learn about fraud, waste and abuse and how to
report suspected fraud, waste and abuse
You can also check your eligibility for medical
coverage. You can even request to change your health
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 9
Let’s get started:
How do I get health care?
In this handbook, we will call your primary care provider When you need a checkup or if you get sick, you need
(PCP) “your PCP doctor.” Your PCP doctor is responsible to go to your PCP doctor. Call your PCP doctor. e
for making sure you get the medical care you need and are phone number is on your ID card.
You were asked to choose a PCP doctor and a health
plan when you lled out the Medi-Cal enrollment form. Start getting care now! Call your
Sometimes we can't give you the PCP doctor you choose. PCP doctor for a checkup.
Some of the reasons are: It is important for new members to get a checkup even
• e doctor is not taking new patients. if they are not sick. Be sure to schedule a checkup soon af-
ter becoming an L.A. Care member. Call your PCP doc-
• e doctor does not work with the health plan you tor today to make an appointment for a “new member
chose. checkup.” is visit is also called a “well visit” or “initial
• e doctor only sees patients of a certain age or only health assessment.” Your PCP doctor’s telephone number is
women (Ob/Gyns). on your L.A. Care ID card.
• e doctor does not work with L.A. Care. is rst visit is important. Your PCP doctor looks at your
If you did not get the PCP doctor or health plan you chose, medical history, nds out what your health status is today,
call L.A. Care at 1-888-839-9909 to see if that PCP doctor and can begin any new treatment you might need. You and
or health plan is available. your PCP doctor will also talk about preventive care. is
is care that helps “prevent” you from getting sick or keeps
Each member has a PCP doctor. A PCP doctor can even certain conditions from getting worse. Remember, children
be a clinic. You can choose one PCP doctor for all members need to get a checkup every year, even when they are not
of your family in Medi-Cal. Or you can choose a di erent sick, to make sure they are healthy and growing properly.
PCP doctor for each member of your family in Medi-Cal.
Women can choose an Ob/Gyn or family planning clinic as
their PCP doctor. How to see your PCP doctor
1. Call your PCP doctor’s o ce to schedule an
Your PCP doctor appointment. You should get an appointment to see
Your PCP doctor gives you “primary” (or basic) medical your PCP doctor within 10 business days from the
care. Health care services you can get from your PCP doctor date of your call. Your PCP doctor’s phone number is
include: on your L.A. Care ID card.
• Routine care 2. Be on time for your appointment. If you need
directions, call the PCP doctor’s o ce.
• Checkups (also called “well visits”). is is when you go
to your PCP doctor when you are not sick, like when 3. If you can’t go to your appointment, call the
you need immunization shots. It is important to see PCP doctor’s o ce right away. By canceling your
your PCP doctor even when you are not sick! appointment, you allow someone else to be seen by
• Sick care. ese visits are when you see your PCP doctor
because you are not feeling well. 4. If you miss your appointment, call right away to make
5. Show the PCP doctor’s o ce your ID card when you
10 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
You should not be billed for emergency care, urgent
Important! You can still get services without care, the care required to stabilize an emergency
your ID card. If you need to see your PCP doctor, condition, family planning services, or for sexually
transmitted disease testing at a clinic. If you receive a
your PCP doctor (or hospital or pharmacy) can call
bill, do not pay it. Call L.A. Care right away to take care
L.A. Care so you can get care. of the bill for you.
Do not pay medical bills you get from a collection
How to get care when your company. If you get a bill for covered services and need
PCP doctor’s o ce is closed help or if you want to le a complaint, call Member
If you need care when your PCP doctor’s o ce is closed Services at L.A. Care Health Plan. When your doctor
(such as after normal business hours, on the weekends or receives proof that you had Medi-Cal at the time of your
holidays), call your PCP doctor’s o ce. Ask to speak to visit, your doctor must let the collection company know
your PCP doctor or to the doctor on call. A doctor will you had Medi-Cal at that time. If you had Medi-Cal
call you back. at the time of your doctor visit, you can't be charged
for covered medical services. Your doctor must tell the
You can also call the nurse advice line number that collection company to stop trying to make you pay
is on your ID card. is number is available to you 24 the bill. e doctor may have to pay up to three (3)
hours a day, seven (7) days a week, to help answer your times what is owed if he/she does not tell the collection
health care questions and have your health concerns and company to stop trying to make you pay the bill. If you
symptoms reviewed by a registered nurse. is service get a bad credit report because of an unpaid medical bill
is free of charge and available to you in your language. for covered services, the doctor has up to 30 days from
For urgent care (this is when a condition, illness or the time they found out about your Medi-Cal to correct
injury is not life-threatening, but needs medical care it or have it deleted.
right away), call or go to your nearest urgent care center.
Many of L.A. Care’s doctors have urgent care hours in
What is a second opinion?
the evening, on weekends or during holidays.
You have the right to ask for and get a second opinion
at no cost to you. You also have the right to ask for a
If you get a bill timely response to your request for a second opinion. A
L.A. Care pays for all covered medical costs approved second opinion is a visit with another doctor when:
by your PCP doctor or for an emergency. You should not • You question a diagnosis for a chronic condition or
get a bill for any services covered by L.A. Care. Please for a condition that endangers your life or body. (A
call L.A. Care right away if you receive a medical bill. diagnosis is when a doctor identi es a condition,
L.A. Care will make sure the doctor stops sending you illness or disease.)
• You do not agree with your PCP doctor or specialist’s
You may get a medical bill if you go to a doctor that treatment plan. (A treatment plan is what the
does not work with L.A. Care or is located outside of doctor says is best for you, based upon the doctor’s
L.A. County. If this happens, then you may be billed diagnosis.)
by the doctor and you may have to pay for services
that are not covered by L.A. Care. If you pay the bill, • You would like to make sure your treatment plan is
keep a copy or record of your payment. Send a copy right for you.
of your payment to L.A. Care for review. If the bill is e second opinion must be from a quali ed health care
for covered or authorized services, you may receive a professional in the L.A. Care network. (A quali ed health
refund from L.A. Care. care professional is a person who has the training and
expertise to treat or review a speci c medical condition.)
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 11
If there is no quali ed health care professional within How to get health care that your
L.A. Care’s network, then L.A. Care will authorize PCP doctor can’t give you
(or okay) a second opinion by a quali ed health care
Sometimes you need care your PCP doctor can’t give
professional outside L.A. Care’s network.
you. You may need care from a specialist or a hospital. To
see a specialist or for treatment at a hospital, your PCP
How to get a second opinion doctor must authorize (or okay) the care, and give you a
To get a second opinion: “referral.” A referral is a request from your PCP doctor to
another doctor or to the hospital for health care services
1. Talk to your PCP doctor, specialist or L.A. Care and or treatment you may need. Your PCP doctor will start
let them know you would like to see another doctor the referral process. You MUST get a referral BEFORE
and the reason why. you get specialized health care services or treatment at a
2. Your PCP doctor, specialist or L.A. Care will refer hospital (except for emergency care, urgent care, or if you
you to a quali ed health care professional. If you are need to see an Ob/Gyn).
requesting a second opinion about a diagnosis that Routine referrals take up to ve (5) business days to
your PCP doctor made, the second opinion shall process (business days are Monday through Friday), but
be from a PCP doctor of your choice from the same may take up to 10 business days if more information is
physician organization as your PCP doctor’s. If you needed from your PCP doctor. In some cases, your PCP
are requesting a second opinion about a diagnosis doctor may ask to “rush” your referral. Expedited (rush)
that your specialist made, a second opinion must referrals may not take more than three (3) calendar days.
come from any independent physician association Please call L.A. Care if you do not get a response by
(IPA) or medical group within the network for these times.
the same specialty. If there is no quali ed health If a referral is not approved, your PCP doctor or
care professional within your plan’s network, L.A. Care will tell you why. You will receive a letter
L.A. Care will authorize (or okay) a second opinion explaining why the referral was not authorized or
by a quali ed provider outside the network. denied. If you do not agree with the explanation given,
3. Call the second opinion doctor to make an you may le a complaint. For information on how to le
appointment. a complaint, turn to the “Complaints: What should I do
if I am unhappy?” section of this handbook.
4. Show the doctor’s o ce your ID card.
Emergency services anywhere or urgently needed
You may complain if your health plan denies your services when outside of Los Angeles County do not
request for a second opinion or if you do not agree with need a referral.
the second opinion. is is also called “ ling a grievance.”
You can learn more about this in the “Complaints: What
should I do if I am unhappy?” section of this handbook. How to get a standing referral with a specialist
You may need to see a specialist (or other quali ed health
Are you pregnant? Call L.A. Care at care professional) for a long time if you have a condition
1-888-839-9909 or disease that is chronic (such as diabetes or asthma),
life-threatening (such as HIV/AIDS) or disabling.
Call your health plan right away if you are pregnant
or become pregnant. is is because we want you and is is called a “standing referral.” A standing
your baby to be healthy. en, call your PCP doctor or referral is made to a specialist who is in L.A. Care’s
Ob/Gyn to make an appointment. You should get an network or who is with a contracted specialty care
appointment to see your PCP doctor or Ob/Gyn within center. If L.A. Care does not have a quali ed specialist,
14 calendar days from the date of your call. When you L.A. Care will send you to a specialist outside their network.
are pregnant, it is important to get care right away, A standing referral needs an approval by L.A. Care.
throughout your pregnancy and after you give birth. You can ask your PCP doctor for a standing referral. Or,
12 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
your doctor can ask L.A. Care for a standing referral.
L.A. Care must decide on your request for a standing
referral within three (3) business days. Once you have a
standing referral, you will not need permission for each
visit with the specialist.
Your specialist will develop a treatment plan for you.
e treatment plan will show how often you need to go
to the doctor. Once the treatment plan is approved, the
specialist will coordinate the care you get. is specialist
will be authorized to provide health care services the
same way your PCP doctor would, based on his or her
skill, training and the treatment plan.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 13
How do I use them?
What to do with your L.A. Care ID card What to do with your Medi-Cal
Along with this handbook you received an L.A. Care card (also known as BIC card)
ID card for every family member covered by Medi-Cal. e State of California sent you another ID card, your
If you did not receive an ID card for a family member Medi-Cal Bene ts Identi cation Card (also called a BIC
who is covered by Medi-Cal, call L.A. Care right away. card). You need to show your Medi-Cal card whenever
Your L.A. Care ID card has important information on you get services you don’t get from L.A. Care. You can
it, including: learn more about these services in the “More bene ts:
What other services can I get?” section of this hand-
• Your PCP doctor’s name (or the name of your clinic book. Call the California Department of Public Social
or medical group) Services (DPSS), toll-free at 1-877-481-1044 if you need
• Your PCP doctor’s phone number a new Medi-Cal card.
• e 24-hour nurse advice line and member services
Never let anyone use your health plan ID card
or Medi-Cal card. This is called fraud. You can lose
Here’s what to do with your ID card:
your Medi-Cal bene ts if someone else uses your ID
• Check to make sure the information on your ID
card is correct. Is your name spelled right? Is your cards to get care. If you lose your Medi-Cal bene ts,
birth date right? If anything on your ID card is L.A. Care will not be able to give you care.
wrong, call L.A. Care at 1-888-839-9909 right
away. L.A. Care will connect you to the California
Department of Public Social Services (DPSS), toll-
free at 1-877-481-1044, to get it xed.
• Keep your ID card in a safe place. If you lose
or damage your ID card, call L.A. Care at
• Show your ID card whenever you:
º Have a doctor’s appointment
º Go to the hospital
º Need emergency services
º Pick up a prescription
14 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
Our provider network:
Who gives me health care?
Please read the following information so you will shown in the provider directory mailed to you with
know from whom or what group of providers you can this handbook. Call L.A. Care for another copy of the
get health care. provider directory or to help you choose another
L.A. Care works with a large group of doctors, PCP doctor.
specialists, pharmacies, hospitals and other health care You can change your PCP doctor for any reason if
providers. is group is called a “network.” You can get you are not happy. To change your PCP doctor, call
a copy of L.A. Care’s network by calling 1-888-839- L.A. Care. You may choose a PCP doctor within the
9909 and asking for a provider directory. rst 30 calendar days of enrollment and change at
In most cases, you need to get care within least monthly after that.
L.A. Care’s network. at is not the case if you need
emergence care or need urgent care outside of Los ings to remember if you choose a new PCP doctor:
Angeles County. You can learn more about this in the • Some doctors work within a group of doctors with
“Emergency care: How do I get care in an emergency?” certain specialists, hospitals and other health care
section of this handbook. providers. If you need a specialist, your PCP doctor
may send you to these providers. If you are going to
a specialist already or want to use a speci c hospital,
Your PCP doctor gives you most of your care talk with the PCP doctor you are choosing.
Your PCP doctor is responsible for making sure you • A PCP is a doctor or even a clinic. You can pick
get the health care bene ts you need and should receive one PCP doctor for all members of your family in
from Medi-Cal. Medi-Cal or you can pick a di erent PCP doctor
for each member of your family in Medi-Cal.
Women may choose an Ob/Gyn or family
How to change your PCP doctor planning clinic as their PCP doctor.
If you didn’t choose a PCP doctor when you enrolled • Ask about o ce access if you or a family member
in Medi-Cal, a PCP doctor was chosen for you has a disability.
by L.A. Care. Your PCP doctor was chosen for you
based on: e PCP doctor you choose may not agree to treat
• e language you speak you and may ask L.A. Care to make a change. is can
• Your age
• You are disruptive or disrespectful to your doctor or
• How close you live to the PCP doctor’s o ce your doctor’s o ce sta .
It is best to stay with the same PCP doctor. Your PCP • You do not follow your doctor’s treatment plan.
doctor gets to know your health history and health • e service or care you need are not within the
needs. If you can't stay with the same PCP doctor, you doctor’s scope of care (like a high-risk pregnancy).
can choose a new one from the L.A. Care network
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 15
Kinds of PCP doctors Choosing a Federally Quali ed Health
You can choose your PCP doctor from the L.A. Care Center (FQHC) as your PCP doctor
provider directory that came with this handbook. e A Federally Quali ed Health Center (FQHC) is a
kinds of physicians that can be PCP doctors are: clinic and can be your PCP doctor. FQHCs get money
• Family Practice from the federal government because they are located
in areas without a lot of health care services. Call
• General Practice L.A. Care for the names and addresses of the FQHCs
• Internal Medicine that work with L.A. Care or look in the provider
• Pediatricians directory mailed to you with this handbook.
• Ob/Gyns (for female members only)
Some hospitals and other providers may have a moral How to get care from a specialist
objection to providing some services. To ensure you Your PCP doctor is the doctor who makes sure you
can get the health care services you need, get more get the care you need when you need it. Sometimes your
information about the hospital or provider before you PCP doctor will send you to a specialist. A “specialist”
choose them. Also, some hospitals and other providers is a doctor who is an expert in a certain kind of health
do not provide one or more of the following services that care. ese specialists are within your PCP doctor and
may be covered under your plan contract and that you L.A. Care’s network. If you need care from a specialist,
or your family may need: your PCP doctor must approve these services before you
• Family planning receive them. Routine referrals to a specialist take up
to ve (5) business days and rush referrals (for when
• Contraceptive services, including emergency
you need medical care right away or have an urgent
condition) can't take more than three (3) calendar days.
• Sterilization, including tubal ligation at the time of
Female members who need Ob/Gyn care don’t need
labor and delivery
their PCP doctor’s okay to go to an Ob/Gyn or family
• Infertility treatments planning doctor with L.A. Care.
If a hospital or other provider tells you that it has a Our doctors’ professional quali cations
moral objection to providing you with these services,
We are proud of our doctors and their professional
you should call L.A. Care’s Member Services to ensure
training. If you have questions about the professional
you can get the health care services you need.
quali cations of network doctors and specialists, call
L.A. Care. L.A. Care can tell you about their medical
training or quali cations.
16 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Certi ed Nurse Midwives How to keep seeing your doctor if
Certi ed Nurse Midwife services are available outside your doctor leaves your health plan
of L.A. Care’s network. Members may see a Certi ed Sometimes L.A. Care stops working with a doctor or
Nurse Midwife without a PCP doctor’s okay. To nd hospital. If this happens, we will let you know as soon as
out more, ask your PCP doctor or call L.A. Care. we can. You can ask to keep seeing your doctor (including
specialists and hospitals) if that doctor agrees and has
been treating you for any of the following conditions:
Certi ed Nurse Practitioners • An acute condition (a serious and sudden condition
Some PCP doctors who work with L.A. Care have that lasts a short time like a heart attack, pneumonia
Certi ed Nurse Practitioners on sta to see patients. or appendicitis) – for the time the condition lasts.
Members may see a Certi ed Nurse Practitioner. To see
• A serious chronic (long-term) condition – for a period
a Certi ed Nurse Practitioner, or for more information,
of time necessary to complete a course of treatment
ask your PCP doctor or call L.A. Care.
and arrange for a safe transfer to another provider.
• A pregnancy – during the pregnancy and immediate
What care can you get from a provider postpartum care (6 weeks after giving birth).
who is not your PCP doctor? • A terminal illness/condition – for the length of the
ere are some kinds of care that you can get from illness/condition.
someone other than your PCP doctor: • Children from 0 to 36 months – for up to 12 months.
• Emergency care. In an emergency, dial 911. • A surgery or other procedure authorized by
Emergency services do not require a referral or an L.A. Care as part of a documented course of
okay from your PCP doctor or L.A. Care before you treatment. is treatment was set to occur within
get them. 180 calendar days of the time the doctor or hospital
• Urgent care when you are not in Los Angeles County stops working with L.A. Care or within 180 calendar
and can’t come back to Los Angeles County to get days of the time you began coverage with L.A. Care.
care. Call your PCP doctor if you are not sure how
to get urgent care when you are not in Los Angeles
County. Your PCP doctor or your doctor’s o ce will How to keep seeing your doctor
help you. if you are a new member
• Family planning services and sexually transmitted Members who have just joined L.A. Care may ask to
disease testing. You may get these services from keep seeing their doctor or hospital if they are in the
any health care provider licensed to provide these middle of treatment or have scheduled treatments or
services. You do not need your PCP doctor’s okay to procedures. is is called a “continuity of care” bene t.
get these services. You will not be eligible for the continuity of care
• Specialist care. A “specialist” is a type of doctor who bene t if EITHER:
is an expert in a certain kind of health care. Your • You are a new enrollee with L.A. Care and were
PCP doctor will send you to a specialist if you need o ered an opportunity from your previous health
one. In most cases, you can't see a specialist without plan to continue receiving care from an out-of-
your PCP doctor’s okay. network provider; or
• Members may see an in-network Ob/Gyn for Ob/ • You had the option to continue care from your previous
Gyn services without the PCP doctor’s okay. provider but still chose to change health plans.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 17
Doctors not contracted with L.A. Care may be
required to agree to the same terms and conditions
as contracted providers. If the doctor does not agree,
L.A. Care is not required to provide the services
through that doctor.
You can get a copy of L.A. Care’s continuity of care
policy by calling 1-888-839-9909. Please call L.A. Care
and ask how to request “continuity of care.”
Care outside of L.A. Care’s network
As a member of L.A. Care your service area is
Los Angeles County. For routine (regular) care, all
health care services are provided in Los Angeles County.
Routine care outside of L.A. County is not covered.
In most cases, you need to get care within L.A. Care’s
network and within Los Angeles County. However, you
can always get emergency care or urgent care anywhere.
If you get care from a non-contracted provider (a
doctor or other provider that is not a part of L.A. Care’s
network) or outside of Los Angeles County, you may be
billed by the provider and you may have to pay, except
for emergency care, urgent care, family planning and
for sexually transmitted disease (STD) testing services.
You can learn more about this in the “Emergency care:
How do I get care in an emergency?” section of this
18 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
What is covered: What kinds of
health care can I get from L.A. Care?
In order for you to get any health care service through Call L.A. Care at 1-888-839-9909 if you have
L.A. Care, the service must be both: questions about:
• A covered bene t in Medi-Cal and • Your bene ts
• Medically necessary. • How or where to get bene ts
A “covered bene t” means that you can get this • What is covered or not covered.
service through Medi-Cal and L.A. Care. “Medically All covered bene ts are free.
necessary” means you need the service to get healthy
or stay healthy.
All health care services are reviewed, modi ed Covered bene ts:
(changed), approved or denied according to medical
necessity. If you would like a copy of the policies and Alcohol/Drug Abuse
procedures L.A. Care uses to decide if a service is • Crisis intervention
medically necessary, call L.A. Care. No doctor has to
• Health education services
give you services that he/she doesn’t believe you need.
Services are subject to all terms, conditions, limits and
exclusions. You can learn more about this in the “Non- Asthma Services
covered services: What does Medi-Cal not cover?” • Nebulizers (including face mask and tubing), inhaler
section of this handbook. spacers and peak ow meters for management and
All services require prior authorization unless treatment of asthma
the bene t says that it does not require prior • Member education on proper use of nebulizers,
authorization. “Prior authorization” means that your inhaler spacers and peak ow meters for asthma
PCP doctor and L.A. Care agree that services and care
are necessary. You must have a prior authorization before
you get services or care, such as services from a specialist.
• All generally medically accepted cancer screening
Services that do not require prior authorization are:
tests, including coverage for screening and diagnosis
• PCP doctor visits of prostate cancer
• Emergency services • Mammography for breast cancer screening
• Urgently needed services when outside of • Cervical cancer screening test, including:
Los Angeles County
º Human Papilloma Virus (HPV) screening
• Family planning services
• Preventive services º HPV vaccinations including, but not limited
to, Gardasil® for girls and young women ages 9
• Sexually transmitted disease (STD) services
• HIV testing
• Basic prenatal care from a doctor who works with
• In-network Certi ed Nurse Midwife/Ob-Gyn
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 19
• Cancer clinical trials. If you have cancer, you may º Insulin syringes
be able to be part of a cancer clinical trial. A cancer º Visual aids, excluding eyewear, to assist the
clinical trial is a research study with cancer patients to visually impaired with proper dosing of insulin
nd out if a new cancer treatment or drug is safe and
treats a member’s type of cancer. e cancer clinical • Training and health education for self-management
trial must meet certain requirements, when referred • Family education for self-management
by your L.A. Care doctor or treating provider. It
must have a meaningful potential to bene t you Doctor’s O ce Visits
and must be approved by one of the following: the
• All routine visits, exams, treatments, required
National Institute of Health (NIH), the Food and
immunization shots and Child Health Disability
Drug Administration (FDA), the U.S. Department
Prevention Program (CHDP) visits are provided by
of Defense or the U.S. Veteran’s Administration.
If you are part of an approved cancer clinical trial,
L.A. Care will provide coverage for all routine • Services received from a specialist
patient care cost related to the clinical trial. • Any CHDP services from school-based programs or the
Los Angeles County Department of Health Services.
If you have a life-threatening or weakened condition,
ere is more information about CHDP under the
or were eligible but denied coverage for a cancer clinical
“More bene ts: What other services can I get?”
trial, you have the right to request an Independent
section of this handbook. You can also call CHDP at
Medical Review (IMR) on the denial. You can learn
more about this in the “Complaints: What should I do
if I am unhappy?” section of this handbook.
Diabetic Services • Prescription drugs and over-the-counter drugs on
the L.A. Care formulary are covered. You can learn
ese services are covered for diabetics when medically
more about this in the “Pharmacy bene ts: How do
I get prescription drugs?” section of this handbook.
• Medical equipment
• Prescription drugs Durable Medical Equipment (DME)
• Diabetes-related supplies: DME is medical equipment used repeatedly (over and
º Blood glucose monitors and testing strips over again) by a person who is ill or injured. ese items
º Blood glucose monitors designed to assist the are ordered by your doctor. Examples include:
visually impaired for insulin dependent, non- • Apnea monitors
insulin dependent and gestational diabetes • Blood glucose monitors, including monitors for the
º Insulin pumps and all related necessary supplies visually impaired for insulin dependent, non-insulin
º Ketone urine testing strips dependent and gestational diabetes
º Lancets and lancet puncture devices • Insulin pumps and all related supplies
º Pen delivery systems for the administration • Nebulizer machines
of insulin • Orthotics (shoe inserts)
º Podiatric devices of the feet (such as special • Ostomy bags
footwear or shoe inserts) to prevent or treat • Oxygen and oxygen equipment
20 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
• Pulmo-Aides and related supplies Family planning services also include counseling
• Spacer devices for metered-dose inhalers and surgical procedures for the termination of
pregnancy (called an abortion). Please call L.A. Care
• Tubing and related supplies to find out more.
• Urinary catheters and related supplies Many of our doctors who provide family planning
services are also Ob/Gyn specialists. Women may pick a
Emergency Services PCP doctor from a list of family planning clinics located
Emergency services are covered 24 hours a day, seven near them. Call L.A. Care for a copy of this list.
(7) days a week, anywhere. Emergency care is a service Women have the right to family planning services given
that a member reasonably believes is necessary to stop by a family planning provider who is not in L.A. Care’s
or relieve: network. You do not need an okay from your PCP doctor
• Sudden serious illnesses or symptoms to do this. L.A. Care will pay that doctor or clinic for the
family planning services you get.
• Injury or conditions requiring immediate diagnosis
and treatment e California Department of Health Care Services
(DHCS), O ce of Family Planning, can also answer
Emergency services and care include ambulances, questions or give you a referral for family planning
medical screening, examination, and evaluation by a services. You can reach them at 1-800-942-1054.
doctor or appropriate personnel. Emergency services
include both physical and psychiatric emergency
Health Education Services
conditions, and active labor. You can learn more about
these in the “Emergency care: How do I get care in an L.A. Care has health education materials, programs
emergency?” section of this handbook. and services to help you stay healthy and take care of
yourself. ese programs are free. Health education
services can help members by:
• Promoting health: Learn to develop life-long
Family planning services are provided to members of
child-bearing age to help them choose the number and
spacing of children. ese services include all methods • Preventing diseases: Learn how to prevent and care
of birth control approved by the Food and Drug for life-threatening illnesses.
Administration (FDA). You may receive family planning • Helping you manage chronic diseases.
services and FDA-approved contraceptives from any Learn more about these topics by talking to your
health care provider licensed to provide these services. doctor or through health education services:
Examples of family planning providers include: • Asthma
• Your PCP doctor • Dental Health
• Clinics • Diabetes
• Certi ed Nurse Midwives and Certi ed Nurse • Drug and Alcohol Programs
• Ob/Gyn specialists (doctors who specialize in
female reproductive health care) • Family Planning/Birth Control
• Planned Parenthood clinics • HIV
• Healthy Foods
• High Blood Pressure
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 21
• Immunization (Shots) Home Health
• Parenting/Child Health ese services are provided in the home by health care
• Prenatal Health personnel for all of the following:
• Safety Tips • Short-term physical, occupational, and speech
• Sexually Transmitted Diseases (STDs)
• Respiratory therapy when prescribed by a licensed
• Tobacco Use (how to quit or prevent smoking) practitioner acting within the scope of his or her license
• Weight Problems
Home health services ordered by your doctor are
• Violence/Abuse provided by home health personnel such as:
• Registered Nurses (RNs)
Health education services include:
• Licensed Vocational Nurses (LVNs)
• Written materials (booklets)
• Home Health Aides
• Tapes, DVDs, CDs or videos
• Medical Social Services
• Referrals to health education classes or programs
• Counseling (one-on-one teaching, phone or group) If a service can be provided in more than one location,
L.A. Care will work with the provider to choose the
• Support groups location.
• Online community resource and health education
information Hospice Care
For health education services information, visit Care is limited to terminally ill members expected to
L.A. Care online at www.lacare.org. live 12 months or less. If you decide to receive hospice
Ask your doctor for health education materials and bene ts, you are waiving all rights to all other bene ts
classes. You can also call L.A. Care. for the terminal illness for the duration of the hospice
election. e hospice election may be made of up to two
(2) periods of 90 days each, one subsequent period of 30
days, and one 180-day extension of the 30-day period.
Hearing aids are covered when ordered by your doctor. Hospice services are not covered for more than 390 days.
HIV Testing Hospital Care
You can get con dential HIV testing from any health Includes, but is not limited to:
care provider licensed to provide these services. You do • Inpatient services
not need a referral or okay from your PCP doctor or
• Intensive care
health plan for con dential HIV testing. Examples of
where you can get con dential HIV testing include: • Outpatient services
• Your PCP doctor
Incontinent Creams and Washes
• Los Angeles County Department of Health Services
These are provided at no cost when there is a
• Family planning services providers
• Prenatal clinics
Please call L.A. Care to request a list of testing sites.
22 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Lab Services If you are pregnant, call L.A. Care at 1-888-839-
• Blood work 9909 right away. We want to make sure you get the
care you need. L.A. Care will help you choose your
• Urine tests maternity care doctor from a doctor in your network.
• roat cultures Ask your doctor to nd out more.
Services must be provided at a network: After giving birth, you will receive breastfeeding
education and special equipment if needed. Ask your
• Doctor’s o ce
doctor, or call L.A. Care if you have any questions.
Go to “Women, Infants and Children (WIC)
• Laboratory Program” under the “More bene ts: What other services
can I get?” section of this handbook for information
Mastectomy about nutrition and food stamps.
Mastectomy is a surgery to remove a breast, due
to cancer. Minor Consent Services
• Prosthesis (replacing a missing body part with an There are some services adolescent members (12
arti cial one) to 21 years of age) can get without a parent’s okay.
Minors can decide to get these services through their
• Reconstructive surgery (see “Reconstructive Surgery”
PCP doctor or from other qualified providers not
in this section for more information)
with L.A. Care’s network.
You and your doctor decide how long you need to stay in
e following services are covered:
the hospital after the surgery based on medical necessity.
• Counseling and surgical procedures to end pregnancy
• Drug and alcohol abuse services for members 12
Maternity care includes:
years of age or older
• Regular doctor visits during your pregnancy (called
• Family planning
• Pregnancy related services
• Diagnostic and genetic testing
• Sexual assault treatment (including rape)
• Nutrition counseling
• Sexually transmitted disease (STD) services for
• Labor and delivery care
members 12 years of age or older
• Health care six (6) weeks after delivery (called
• Outpatient mental health treatment and counseling
for minors (12 to 21 years of age) who are mature
• Inpatient hospital care for at least 48 hours after enough to participate, and where either:
normal vaginal deliveries or for at least 96 hours after
º ere is danger of serious physical or mental harm
a Cesarean section. Coverage for inpatient hospital
to themselves or to others; or
care may be less than 48 hours or 96 hours if:
º ey are a victim of incest or child abuse.
º e decision is made by the mother and treating
º A post-discharge follow-up visit for the mother and
newborn is made within 48 hours of discharge
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 23
Newborn Care Obstetrical/Gynecological (Ob/Gyn)
Your newborn baby will be covered by L.A. Care for Pregnant members do not need a referral or okay from
the month of birth and the following month. their PCP doctor or L.A. Care to see an Ob/Gyn who
When you have a baby, it is important to do three works in their network. Please call L.A. Care if you have
(3) things: any questions.
1. Please call L.A. Care at 1-888-839-9909. We want
to make sure you and your baby get the care you Podiatry (services for the feet)
need right away. Podiatry services are limited and require prior authorization
2. Contact your eligibility worker at DPSS toll- except when received on an emergency basis.
free at 1-877-481-1044 to enroll your baby in
Medi-Cal. is is important so that your baby Prenatal Care
can continue to get Medi-Cal bene ts! • Regular doctor visits during your pregnancy (called
3. Take your baby to the doctor within three (3) prenatal visits)
days of getting home from the hospital after • Prenatal supplements
delivery. A L.A. Care doctor in your network
should see your newborn baby within a few • Diagnostic and genetic testing
days of the birth. Call L.A. Care for more
information on getting an appointment. Reconstructive Surgery
Newborn baby screenings for certain treatable genetic Reconstructive surgery to repair abnormal body parts,
disorders are covered. ese genetic disorders include: improve body function, or bring back a normal look.
• Phenylketonuria (PKU)
Sexually Transmitted Disease (STD) Services
STD services include:
• Preventive care
• Sickle cell disease
• Amino acid disorders
• Organic acid oxidation disorders
• Fatty acid oxidation disorders
• Congenital adrenal hyperplasia (CAH)
• Related blood disorders You can get con dential STD services from any
doctor or clinic. You do not need a referral or okay from
Babies with these conditions will be referred to your doctor.
California Children’s Services (CCS) for treatment or to
L.A. Care if the treatment is not covered by CCS. Skilled Nursing Facility Services
Treatment of PKU includes medically prescribed A facility licensed to provide medical services for non-
formulas and special food products. PKU cases are acute conditions.
followed by a health care professional who consults
with a doctor specializing in PKU-related diseases. You If you need long-term skilled nursing facility services,
can learn about this in the “More bene ts: What other you may be disenrolled from L.A. Care and provided these
services can I get?” section of this handbook. services through Medi-Cal or another state program.
24 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Temporomandibular Joint (TMJ) Disease hospital to another hospital or facility, or facility to
• A disease of the temporomandibular joint (TMJ) home when the transportation is:
that connects the lower jaw to the skull. º Medically necessary, and
TMJ disease is covered only for medically necessary º Requested by the PCP doctor, and
surgery or treatment to realign the jaw, and not for a º Authorized in advance by L.A. Care.
dental disorder. Non-emergency medical transportation is available
if the member is recovering from serious injury or
erapy – Occupational, Physical and Speech medical procedure that prevents them from driving
• Occupational therapy is used to improve and to a medical appointment, they have no other
maintain a patient’s daily living skills because of a form of transportation available, and the attending
disability or injury. physician (PCP doctor or specialist appointment is
scheduled with) asserts that the member requires
• Physical therapy uses exercise to improve and non-emergency medical transportation to and from
maintain a patient’s ability to function after an appointment on a speci ed date. If you need non-
illness or injury. emergency medical transportation, please call your
• Speech therapy is used to treat speech problems. PCP doctor or L.A. Care to see if you qualify for
these services. You must have approval to get these
Topical Fluoride Varnish services before the services are given.
Topical Fluoride varnish helps prevent and control Exclusion: Coverage for public transportation includ-
tooth decay. Topical application of uoride is a Medi- ing transportation by airplane, passenger car, taxi, or
Cal bene t for children younger than 6 years of age, up other forms of public conveyance.
to three times in a 12-month period.
Transportation Eye exams are covered by L.A. Care for all members
• Emergency transportation for a member that under 21 years of age. You are limited to one pair of
believes it is necessary to stop or relieve sudden eyeglasses every two (2) years unless your prescription
serious illnesses or symptoms, or injury or changes. is includes lenses and covered frames for
conditions requiring immediate diagnosis and eyeglasses when authorized. Diabetic members age 21
treatment. Emergency transportation (ambulance) and older are covered for eye exams only.
or ambulance transport services provided through To nd out more about eye exams or vision care
the "911" emergency response system will be covered coverage call L.A. Care.
in a medical emergency when medically necessary.
• Non-emergency medical transportation to medical X-ray Services
facilities is covered when your medical and physical ese services will be provided when ordered by your
condition does not allow you to take regular means doctor from a network:
of public or private transportation (car, bus, etc.) and
you have a written prescription from your doctor. • Doctor’s o ce
Examples of non-emergency medical transportation • Hospital
include, but are not limited to, litter vans and • Laboratory
wheelchair vans. Also includes non-emergency
transportation for the transfer of a member from a
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 25
What other services can I get?
Medi-Cal members are entitled to other health care Women, Infants and Children (WIC) Program
bene ts and services that are not provided by L.A. Care.
The Women, Infants and Children (WIC)
Supplemental Nutrition Program gives pregnant women
and new mothers nutrition information and coupons to
California Children’s Services (CCS)
buy healthy foods. Ask your doctor or maternity nurse
CCS is for people under the age of 21 with a disability. to nd out more about WIC. You may call WIC directly
If your child has a chronic (long-term) medical illness, at 1-888-942-9675.
your child may be eligible for services under CCS.
L.A. Care will identify children with CCS eligible
conditions, arrange for a referral to the local CCS Special services for American Indians
o ce, and continue to provide case management until American Indians have the right to get health
eligibility is established with the CCS program. Primary care services at Indian Health Centers and Native
care services will continue to be provided by L.A. Care. American Health Clinics. American Indians may stay
Please call L.A. Care if your child is getting CCS with or disenroll from L.A. Care while getting health
services. L.A. Care can arrange for those services to care services from an Indian Health Center or Native
continue. Your child can continue getting services as American Health Clinic. American Indians have a right
a member of L.A. Care. You can call the Los Angeles to not enroll in a Medi-Cal managed care plan or may
County CCS o ce toll-free at 1-800-288-4584 to nd leave their health plans and return to regular (fee-for-
out more. service) Medi-Cal at any time and for any reason. Please
call Indian Health Services at 1-916-930-3927 to nd
out more. You may visit the Indian Health Services Web
Child Health and Disability site at www.ihs.gov to nd out more.
Your child may get preventive services through his
Medi-Cal bene t changes
or her local school. CHDP services help keep children
from getting sick and include regular checkups, e state cut a few bene ts from the Medi-Cal
immunizations (shots), education and counseling, and program. ese changes only a ect some adults age 21
vision and hearing tests. and older who are on Medi-Cal.
You may call CHDP at 1-800-993-CHDP (1-800- ese changes do not a ect members under 21 years
993-2437) if you have any questions. of age. Medi-Cal bene ts for members under 21 remain
ese bene ts will NOT change for Medi-Cal
members who are:
• Under the age of 21
• Living in a skilled nursing facility (Level A or B. is
includes subacute care facilities.)
26 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
• Pregnant (If you are pregnant, you can continue to • Childhood lead poisoning (through the Los Angeles
receive pregnancy-related bene ts and services. You County Department of Health Services)
can also receive other bene ts and services listed
above to treat conditions that, if left untreated, might • Chiropractic services (Limited – please see the
cause di culties for the pregnancy. is includes “Medi-Cal benefit changes” section of this
dental exams, cleanings and gum treatment. Dental handbook)
and other bene ts and services may also be available • Direct Observed erapy for the treatment of
up to 60 days after the baby is born.) tuberculosis (through the Los Angeles County
• Receiving bene ts through the California Children’s Department of Health Services)
Services (CCS) program
• Dental Services (Limited – please see the “Medi-
• Receiving bene ts through a Program of All- Cal bene t changes” section of this handbook)
Inclusive Care for the Elderly that are normally done by a dentist, orthodontist or
However, L.A. Care feels that ve (5) bene ts the state oral surgeon, and dental appliances. You must get
cut are important to our members and will still provide Dental Services through Denti-Cal. Call toll-free
these bene ts when there is a medical need. at 1-800-322-6384 to learn more. L.A. Care covers
As an L.A. Care Medi-Cal member, you will dental screenings under the rst health checkup and
keep getting: will refer members to Medi-Cal dental providers.
L.A. Care covers the following when medically
• Speech therapy services necessary: prescription drugs, lab services, outpatient
• Podiatry (foot) services surgical services, and inpatient services. General
• Audiology (hearing) services anesthesia for dental work is covered for members
under seven (7) years of age, the developmentally
• Incontinence creams and washes disabled or when medically necessary.
• Annual optometry (eye) exam for diabetic members
• Early Start/Early Intervention. Early Start/Early
Intervention is for children ages 0 to 3. If your
Services you can get outside PCP doctor tells you that your child is at risk for
of your health plan developmental delays, your child may be eligible
Some services are not covered by L.A. Care but are for the Early Start program. Developmental delays
still bene ts. ey are available through Medi-Cal or include di culties in communicating, adjusting to
another state program. Please call L.A. Care if you have di erent situations, following directions or relating
any questions about the services below. to others. For more information about Early Start/
• Acupuncture (Limited – please see the “Medi-Cal Early Intervention or a referral to the Regional
bene t changes” section of this handbook) Center for Early Start/Early Intervention, talk to
your doctor or to L.A. Care.
• Adult day health care
• Local Education Agency (LEA) assessment services
• Alcohol and drug treatment services (outpatient) are provided to students who qualify through the
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 27
• Major organ transplants, except for renal or • Prayer or spiritual healing
• State laboratory services under the state Serum
• Members with developmental disabilities. Alpha-fetoprotein Testing Program
Developmental disabilities include di culty learning
and di culty with motor skills. If your PCP doctor • Home and Community Based Services Waiver
tells you that you have a developmental disability, Program provides services beyond those that
you may be eligible for services from the Regional are covered by Medi-Cal. ese services allow
Centers. For more information about or for a referral individuals to remain in a community setting rather
to a Regional Center, talk to your PCP doctor or call than be admitted to a long-term care facility.
• Mental health services. Mental health services may
include treatment for anxiety, behavioral health
problems or depression. Your PCP doctor will provide
you with some outpatient mental health services
within the scope of their training and practice. Call
your PCP doctor for more information about mental
health services available through your PCP doctor.
Specialized mental health services may be
needed for services beyond your PCP doctor’s
training and practice. These services are
provided through the Los Angeles County
Department of Mental Health (LACDMH).
You can receive services from LACDMH with or
without a referral from your doctor. LACDMH
can be reached toll-free at 1-800-854-7771.
L.A. Care will coordinate and cover laboratory,
radiological and radioisotope services needed for
the diagnosis, treatment and monitoring of a mental
health condition. L.A. Care or regular (fee-for-
service) Medi-Cal cover mental health drugs listed
on the formulary and prescribed by your PCP doctor
or by a licensed mental health provider authorized to
prescribe drugs. If medically necessary, you can also
get a mental health drug not listed on the formulary.
Go to a network pharmacy to ll your prescription.
You can learn more about this in the “Pharmacy
bene ts: How do I get prescription drugs?” section
of this handbook.
28 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
What does Medi-Cal not cover?
The following is a list of services not covered e following is a list of services not covered for
by L.A. Care or by the regular (fee-for-service) some L.A. Care Medi-Cal members over the age of 21
Medi-Cal program: (please see the “Medi-Cal bene t changes” section of
• All services excluded from Medi-Cal under state this handbook):
and/or federal law • Dental
• Routine circumcision, unless medically necessary • Chiropractic
• Cosmetic surgery (surgery performed to alter or • Acupuncture
reshape normal structures of the body in order to
improve your appearance) • Psychiatry Services
• Custodial care. Some custodial care may be covered If you have questions about what is covered or not
under regular (fee-for-service) Medi-Cal. For covered, please call L.A. Care.
more information about custodial care covered
under regular Medi-Cal, call DPSS. You can nd
DPSS’ phone number under the “Important Phone
Numbers” section of this handbook.
• Experimental and investigational services. You can
learn more about this in “IMRs for Experimental
and Investigational erapies (IMR-EIT)” under the
“Complaints: What should I do if I am unhappy?”
section of this handbook.
• Immunizations (shots) for sports, work or travel
• Personal comfort items such as a phone, television or
guest tray when in the hospital
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 29
How do I get prescription drugs?
What is a pharmacy? What is a formulary?
A pharmacy is a place to get your prescriptions lled. L.A. Care uses a list of approved drugs called a
L.A. Care works with pharmacies in many neighbor- “formulary.” A committee of L.A. Care doctors and
hoods. You must get your prescribed medications (drugs) pharmacists reviews drugs to add or remove from the
from a pharmacy in L.A. Care’s network. A “network” formulary every three (3) months.
is all of the pharmacies that work with L.A. Care. A Drugs can be added to the formulary when they are
pharmacy list is in the provider directory provided to all of the following:
you with this handbook. Or you can call L.A. Care at
1-888-839-9909 for pharmacies in your neighborhood. • Approved by the Food and Drug Administration
• Generally accepted to be safe and e ective
How to get a prescription lled
1. Choose a pharmacy that works with L.A. Care. • Cost e ective
2. Bring your prescription to the pharmacy. Your doctor usually prescribes drugs from the for-
mulary. Your doctor will only prescribe a drug based
3. Show the pharmacy your L.A. Care ID card. on your health status. Just because a drug is on the
formulary does not mean a doctor will prescribe to
4. Make sure your pharmacy knows about all you. Your doctor may not believe you need it.
medications you are taking and/or any allergies
you have to any medicine. You may call L.A. Care to ask for a copy of the
formulary in your language, large print, Braille, audio,
You should not be asked to pay for covered or alternate format. You may also call L.A. Care for a list
prescription drugs. Call L.A. Care if a pharmacy that compares all health plan partner formularies.
asks you to pay.
Drugs not on the formulary
Prescription re lls Sometimes, your doctor may need to prescribe a drug
If you are re lling a prescription you already have, go that is not on the formulary. Your doctor must call to get
to a pharmacy listed in L.A. Care’s provider directory. an okay from L.A. Care.
Also, you may be able to receive a 90-day supply of To decide if this drug will be covered, L.A. Care may
maintenance medications at most local pharmacies. ask your PCP doctor or the pharmacist (or both) for
Maintenance medications are drugs that you need more information. Within 24 hours after getting this
to take for a long time, such as pills for high blood information, L.A. Care will tell your PCP doctor or the
pressure or diabetes. Please ask your doctor to write a pharmacist if the drug will be covered. Your PCP doctor
30-day prescription supply, as well as a 90-day supply or the pharmacist will then tell you.
for prescription re lls to take to your local network
pharmacy for your maintenance medication(s). If the drug is approved, you can get the drug at a
pharmacy that works with L.A. Care. If the drug is not
approved, you have the right to appeal the decision. An
30 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
“appeal” is when you want a decision to be reviewed. investigational drug, you have the right to request an
You can learn about this in the “Complaints: What Independent Medical Review (IMR). You can learn
should I do if I am unhappy?” section of this handbook. more about this in the “Complaints: What should I
do if I am unhappy?” section of this handbook.
• Cosmetic drugs, except as prescribed for medically
What drugs are covered? necessary conditions
You can get the following drugs and other items when • Dietary or nutritional products, except when medically
they are prescribed by your doctor and are medically necessary or for the treatment of Phenylketonuria
• Any injectable drug that is not medically necessary
• Prescription drugs listed on the L.A. Care formulary and not prescribed by a doctor
• Prescription drugs you get from a pharmacy not in • Appetite suppressants, except as medically necessary
L.A. Care’s network when you have an emergency for morbid obesity
• Non-prescription drugs or over-the-counter drugs • Compounded medications with formulary alternatives
(such as cough syrups, cough drops or aspirin) listed or those with no FDA-approved indications
on the L.A. Care formulary
• Replacement of lost or destroyed drugs no more
• Diabetic supplies: insulin, insulin syringes, glucose than two (2) times each calendar year (from January
test strips, lancets and lancet puncture devices, pen
delivery systems, blood glucose monitors (including
monitors for the visually impaired) and ketone urine
testing strips Emergency contraception ("Plan B")
• FDA-approved birth control devices, birth control You may get emergency contraceptive drugs from:
pills, diaphragms, condoms and contraceptive jellies
on the L.A. Care formulary • Your doctor
• Emergency contraception • A pharmacy with a prescription from your doctor, if
• EpiPens, ana-kits, peak ow meters and spacers you are younger than 17 years of age
• A pharmacy without a prescription if you are 17
years of age or older
What drugs are not covered?
• Drugs from a non-network pharmacy, except drugs • A pharmacy not in your health plan’s network. If this
needed because of an emergency or out-of-area care is the case, you may be asked to pay for the service.
Your health plan will reimburse you for this cost.
• Non-formulary drugs, except with an okay from
L.A. Care • A local family planning clinic
• Drugs that are experimental or investigational in Call L.A. Care for a list of pharmacies that provide
nature, except in certain cases of terminal illness. emergency contraceptive drugs.
If you have been denied an experimental or
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 31
Prescription authorization process for
emergencies or urgent circumstances
Your pharmacist is authorized to dispense a 72-hour
supply of medication to you if you are out of medication
after an emergency room visit that did not result in
hospitalization and you need to ll an emergency
prescription. Your pharmacist is also authorized to
dispense a 72-hour supply of medication to you if you
need the medication to avoid interruption of your current
or prescribed drug therapy in an emergency situation.
Medicare Part D: Prescription drug
coverage for bene ciaries who get
both Medicare and Medi-Cal
Medicare administers a federal prescription drug
program called Medicare Part D. If you are a Medi-
Cal bene ciary with Medicare, you will get most of
your prescription drugs from Medicare. ere are some
prescription drugs that are not covered by Medicare but
that you can get through Medi-Cal. However, if you have
Medicare Part D coverage with another health plan, your
pharmacy will not be able to ll your Medicare Part D
prescriptions with your L.A. Care Medi-Cal. Please contact
your Medicare Part D Plan.
Please call L.A. Care for more information. To nd out
more about Medicare Part D and to choose a Medicare
Prescription Drug Plan, call Medicare at 1-800-633-4227
or go to www.medicare.gov on the Internet.
32 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
How do I get care in an emergency?
ere is a di erence between needing care urgently and Emergency services and care include ambulance,
an emergency. Urgent care is when a condition, illness medical screening, examination and evaluation by a
or injury is not life-threatening, but needs medical care doctor or other medical personnel. Emergency services
right away. Many of L.A. Care’s doctors have urgent include both physical and psychiatric emergency
care hours in the evening and on weekends. conditions, as well as active labor.
Examples of emergencies include but are not limited to:
How to get urgent care • Having trouble breathing
1. Call your PCP doctor. You may speak to an • Seizures (convulsions)
operator who answers calls for your PCP doctor’s • Lots of bleeding
o ce when closed. • Unconsciousness/blackouts (when you can’t wake up)
2. Ask to speak to your PCP doctor or the doctor on • Lots of pain (including chest pain)
call. Another doctor may answer your call if your • Swallowing of poison or medicine overdose
PCP doctor is not available. A doctor is available
by phone 24 hours a day, seven (7) days a week, • Active labor
and also on weekends and holidays. • Broken bones
3. Tell them about your condition and follow their • Head injury
instructions. • Eye injury
You may receive same-day urgent care services. It Examples of psychiatric emergency medical conditions
should not take longer than 48 hours from the time you include but are not limited to:
call to request an appointment to get urgent care services • oughts or actions about hurting yourself or
from your PCP doctor. If you are outside of Los Angeles someone else
County, you do not need to call your PCP doctor or get
prior authorization before getting urgent care services. • Unable to care for yourself, such as being unable
Be sure to let your PCP doctor know about this care. You to feed, shelter or dress yourself due to a mental
may need follow-up care from your PCP doctor. disorder
If you think you have a health emergency, call 911.
What is emergency care? You are not required to call your doctor before you
go to the emergency room. Do not use the emergency
Emergency services are covered anywhere–24 hours a room for routine (regular) health care.
day, seven (7) days a week. Emergency care is a service a
member reasonably believes is necessary to stop or relieve:
• Serious illnesses or symptoms What to do in an emergency
Call 911 or go to the nearest emergency room if
• Injuries or conditions requiring immediate diagnosis
you have an emergency. Emergency care is covered at
all times and in all places.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 33
Outside of Los Angeles County? How to get emergency transportation
If you have an emergency when you are not in Call 911 if you have an emergency. Ambulances for
Los Angeles County, you can get emergency services at emergencies are paid for by L.A. Care as long as you had
the nearest emergency facility. Emergency services do a reasonable belief that an emergency condition existed
not require a referral or okay from your PCP doctor. at the time of the service.
If you are admitted to a hospital not in L.A. Care’s
network or to a hospital your PCP doctor or other provider
does not work at, L.A. Care has the right to move you to Not sure you have an emergency?
a network hospital as soon as it is medically safe. If you are not sure, call your PCP doctor. Do what your
You may need hospital care after an emergency PCP doctor tells you to do. Non-emergency problems
to stabilize your condition. is is called post- may include, but are not be limited to, the following:
stabilization care. If you do, the hospital will call earaches, colds, the u and sore throats. Do not call 911
L.A. Care to ask for an okay. e hospital may ask for non-emergency problems. Call your PCP doctor.
you for your health plan's name and phone number.
Show the hospital your L.A. Care ID card. If you don’t
have your ID card, tell them to call L.A. Care.
Your PCP doctor must provide follow-up care when
you leave the hospital.
What to do after an emergency
1. Call L.A. Care within 24 hours of receiving
emergency care or as soon as you can.
2. Follow the instructions of the emergency room
3. Call you PCP doctor to make an appointment for
34 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
Help in another language
and for people with disabilities:
How can I get help?
Information in other languages You should not use children or family members as
interpreters. Call L.A. Care or your doctor if you need
You have the right to receive all member materials
interpreting services. We will work with you and your
in any of the following languages: Spanish, Armenian,
PCP doctor to make sure you can have services in a
Chinese, Farsi, Khmer, Korean, Tagalog, Russian,
language you understand.
Vietnamese and English.
California Relay Service. e California Relay
Service (CRS) helps a person using a TTY to
Interpreters for members who don’t speak communicate by phone with a person who does not
English or are hearing or speech impaired use a TTY. CRS can also help a non-TTY user call a
We know doctors and other providers must understand TTY user. Trained operators take phone calls and help
you so that you can get the health care services you hearing people and non-hearing people communicate.
need. Laws such as the Civil Rights Act of 1964 and the Statewide access for voice or TTY/TDD is 1-888-
Americans with Disabilities Act (ADA) of 1990 protect 877-5379 voice (SPRINT) or 1-800-735-2922 voice
you if you do not speak English or have a disability and (MCI). Members and providers can also dial 711 on
need help communicating with your doctor. their phones to call the California Relay Service directly.
Your doctor’s o ce, clinic or hospital can’t deny
services to you because you do not speak English or
have a disability. You have the right to free interpreting
Protection for people with disabilities
services including American Sign Language interpreters e Americans with Disabilities Act (ADA) of
when getting health care service or other services that 1990 is a law that protects people with disabilities
are paid for by your health plan, including after-hours from being treated unfairly. A disability is a physical
interpreting services. or mental condition that totally or seriously limits a
person’s ability in at least one major life activity. is
An interpreter is a person who helps you understand
law protects people who:
what is being said by the person who is giving you care.
An interpreter also tells the other person what you said, • Are any age, including seniors (65 years of age or
but in the language that person understands. is allows older), who have disabilities
people who speak di erent languages to talk with and
• Have disabilities such as hearing, speech or vision
understand each other. is is also more private because
loss, developmental disabilities and other types of
you are not telling your child, family member or friend
to interpret for you.
• May not look like they have a disability or had a
disability in the past
If you need interpreting services
Interpreting services in your language, including
American Sign Language, are free–24 hours a day, seven
(7) days a week.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 35
e ADA law makes sure there are equal chances for
people with disabilities in employment and in state and
local government services, including health care.
A doctor’s o ce, clinic or hospital can’t deny you
services because you are hearing impaired or have other
disabilities. Call your health plan right away if you don’t
get the services you need or if services are hard to get.
Here are some telephone numbers that can help you
if you have a disability or want more information about
the Americans with Disabilities Act (ADA):
ADA Information Line:
Remember: Tell your doctor’s o ce if you need an
interpreter, require extra time during your visit, or
need help because of a disability.
You can also le a complaint if:
• You can’t get an interpreter
• You couldn’t get information in your language
• You feel that you were denied services because of a
You can learn more about this in the “Complaints:
What should I do if I am unhappy?” section of this
36 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
What should I do if I am unhappy?
If you are not happy, are having problems, or have How to le a grievance
questions about the service or care given to you, you have
You have many ways to le a grievance. You can do
the option of letting your PCP doctor know. Your PCP
any of the following:
doctor will be able to help you or answer your questions.
• Fill out a grievance form at your doctor’s o ce.
At any time, you or your Member Representative may
Your PCP doctor will have grievance forms
le a grievance (or complaint) with L.A. Care. A Member
available in his or her o ce.
Representative is a person or persons appointed by the
member, via written statement, to represent them in the • Write, visit or call L.A. Care.
State of California as a health care proxy, trustee named L.A. Care Health Plan
in a durable power of attorney or court appointed Member Services Department
guardian. Also known as a Personal Representative(s), a 555 West Fifth Street
Member Representative can be a spouse, relative, friend, Los Angeles, CA 90013
advocate, doctor, practitioner or someone designated as 1-888-839-9909
a representative by the member under Durable Power of 1-213-438-5748 (fax)
Attorney, or as an Executor/Administrator of Estate or as
a legal/court-appointed guardian. • You may also le a grievance online through
L.A. Care’s Web site at www.lacare.org. Call
L.A. Care can’t take away your health care bene ts or L.A. Care to get a grievance form in another
do anything to hurt you in any way if you le a grievance language or format (Braille, large print or other
or use any of your privacy rights in this handbook. alternative formats).
If you receive a Notice of Action from L.A. Care, you
What is a grievance? have three (3) options on how to le a grievance:
A grievance is a complaint that is recorded and tracked. • You have 90 calendar days from the date on the
You have the right to le a grievance. You have two (2) Notice of Action to le a grievance with L.A. Care.
time limits to le a grievance:
• You may request a State Hearing regarding your
• If you receive a Notice of Action from L.A. Care, Notice of Action from the Department of Social
then you have 90 calendar days from the date on Services (DSS) within 90 calendar days.
the notice to le a grievance with L.A. Care. A
Notice of Action is a formal letter telling you that a • You may request an Independent Medical Review
medical service has been denied, deferred, modi ed (IMR) regarding your Notice of Action from the
or terminated. If you receive a Notice of Action it Department of Managed Health Care (DMHC).
will tell you in the section about “Your Rights” that
º Youcan also ask for a State Fair Hearing at the
you have 90 calendar days to le a grievance.
same time you are ling your grievance to a
• You can also le a grievance that is not about a Notice of Action.
Notice of Action. You must le your grievance
within 180 calendar days from the day you became L.A. Care can help you ll out the grievance form over
unhappy with the service or care given to you by the phone or in person. Or we can send you a grievance
either your PCP doctor, specialist, medical group, form to ll out and send back to us.
hospital, pharmacy or L.A. Care.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 37
Within ve (5) calendar days of getting your How to le a grievance for urgent cases
grievance, L.A. Care will send you a letter to let you
Examples of urgent cases include:
know that we have your grievance and are working
on it. en, within 30 calendar days of getting your • Severe pain
grievance, L.A. Care will send you a letter explaining • Potential loss of life, limb or major bodily function
how the grievance was resolved. • Immediate and serious decline of your health
Filing a grievance or requesting a State Fair Hearing
does not a ect your medical bene ts. If you le a In urgent cases, you can request an expedited (or
grievance or request a State Fair Hearing, you may be quick) review of your grievance. You may present
able to continue a medical service while the grievance evidence to support your grievance; however, the time
is being resolved. To nd out more about continuing a available to present this evidence is limited. A decision
medical service, call L.A. Care. will be made by L.A. Care within three calendar days
(or 72 hours) from the day your grievance was received.
Grievances for Medi-Cal eligibility are not
processed by L.A. Care. To le a grievance about You have the right to request an expedited State
Medi-Cal eligibility, call DPSS. You can nd Fair Hearing. You can request an expedited State Fair
DPSS' phone number under the “Important Phone Hearing and le a grievance with L.A. Care. For more
Numbers” section of this handbook. information about State Fair Hearings, go to the “State
Fair Hearing” section of this handbook.
You have the right to le an urgent grievance with
If you don’t agree with the outcome DMHC without ling a grievance with L.A. Care. For
of your grievance information on how to le a grievance with DMHC,
If you don’t agree with the decision made on your go to the “Contacting to the Department of Managed
grievance, you may request a State Fair Hearing and Health Care (DMHC)” section of this handbook.
le a grievance with the Department of Managed
Health Care (DMHC). You can also le a grievance
with the DMHC if you do not hear from L.A. Care If you don’t agree with the outcome
within 30 calendar days. You may also request an of your grievance for urgent cases
Independent Medical Review (IMR) with DMHC. If you don’t agree with the decision made on your
For more information about State Fair Hearings, go grievance, you may request a State Fair Hearing and le
to the “State Fair Hearing” section of this handbook. a grievance with the Department of Managed Health
For information on how to le a grievance with Care (DMHC). You can also le a grievance with
DMHC, go to the “Contacting the Department of DMHC if you do not hear from L.A. Care within 30
Managed Health Care (DMHC)” section of this calendar days. You may also request an Independent
handbook. For information on how to request an Medical Review (IMR) with DMHC. For more
IMR, go to the “Independent Medical Review” information about State Fair Hearings, go to the “State
section of this handbook. Fair Hearing” section of this handbook. For information
on how to le a grievance with DMHC, go to the
“Contacting the Department of Managed Health Care
(DMHC)” section of this handbook. For information
on how to request an IMR, go to the “Independent
Medical Review” section of this handbook.
38 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Independent Medical Review You must rst go through the L.A. Care grievance
process, before applying for an IMR. In special
You may request an Independent Medical Review
cases, the DMHC can not require you to follow the
(IMR) from DMHC. You have up to six (6) months
L.A. Care grievance process before ling an IMR. In
from the date you get a Notice of Action from L.A. Care
urgent circumstances or cases of emergency, you are
to le an IMR. A Notice of Action lets you know about
not required to participate in the L.A. Care expedited
an action by L.A. Care to delay, deny, modify or
grievance process for more than three (3) days before
terminate a health care service or bene t. You will
ling an IMR.
receive information on how to le an IMR with your
notice. You may reach DMHC toll-free at 1-888-HMO- e dispute will be submitted to a DMHC medical
2219 or 1-888-466-2219. specialist if it is eligible for an IMR. e specialist will
make an independent decision on whether or not the
You can still request a State Fair Hearing if you request
care is medically necessary. You will receive a copy of
an IMR. However, you will not be able to use the IMR
the IMR decision from DMHC. If it is decided that the
process if you have requested a State Fair Hearing. Go
service is medically necessary, L.A. Care will provide
to the “State Fair Hearing” section of this handbook to
the health care service.
nd out how to le a grievance.
ere are no fees for an IMR. You have the right
to provide information to support your request for For non-urgent cases, the IMR decision must be made
an IMR. After the IMR application is submitted, a within 30 calendar days. e 30 calendar day period
decision not to take part in the IMR process can cause starts when your application and all documents are
you to lose certain legal rights to pursue legal action received by DMHC.
against the plan.
When to le an Independent Medical Review (IMR) If your grievance is urgent and requires fast review,
You may le an IMR if you meet the following you can bring it to DMHC’s attention right away. You
requirements: will not be required to participate in the health plan
• Your doctor says you need a health care service
because it is medically necessary, but it was denied, For urgent cases, the IMR decision must be made
or within three (3) calendar days from the time your
information is received.
• You received urgent or emergency services
determined to be necessary, but they were denied; or Examples of urgent cases include:
• You have seen a network doctor for the diagnosis • Severe pain
or treatment of the medical condition, even if the • Potential loss of life, limb or major bodily function
health care services were not recommended.
• Immediate and serious decline of your health
• e disputed health care service is denied, changed
or delayed by L.A. Care based in whole or in part
on a decision that the health care service is not IMRs for Experimental and
medically necessary; and Investigational Therapies (IMR-EIT)
• You have led a grievance with L.A. Care and the You can request an IMR-EIT through the DMHC
health care service is still denied, changed, delayed when a medical service, drug or equipment is denied
or the grievance remains unresolved after 30 because it is experimental or investigational in nature.
calendar days. L.A. Care will notify you in writing that you can request
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 39
an IMR-EIT within ve (5) days of the decision to deny Contacting the California Department
coverage. You have up to six (6) months from the date of of Managed Health Care (DMHC)
denial to le an IMR-EIT. You can give information to
e California Department of Managed Health
the IMR-EIT panel. e IMR-EIT panel will give you
Care (DMHC) is responsible for regulating health
a written decision within 30 calendar days from when
care service plans. If you have a grievance against your
your request was received. If your doctor thinks that
health plan, you should rst telephone your health plan
the proposed therapy will be less e ective if delayed, the
at 1-888-839-9909 and use your health plan’s grievance
decision will be made within seven (7) days of the request
process before contacting the department. Utilizing this
for an expedited (or quick) review. In urgent cases the
grievance procedure does not prohibit any potential
IMR-EIT panel will give you a decision within three (3)
legal rights or remedies that may be available to you.
business days from the time your information is received.
If you need help with a grievance involving an
You can le an IMR-EIT if you meet the following
emergency, a grievance that has not been satisfactorily
resolved by your health plan, or a grievance that has
• You have a very serious condition that is life- remained unresolved for more than 30 days, you may
threatening or debilitating (for example, terminal call the department for assistance. You may also be
cancer). eligible for an Independent Medical Review (IMR).
• Your doctor must certify that: If you are eligible for an IMR, the IMR process will
provide an impartial review of medical decisions made
º e standard treatments were not or will not be
by a health plan related to the medical necessity of a
e ective, or
proposed service or treatment, coverage decisions for
º e standard treatments were not medically treatments that are experimental or investigational in
appropriate, or nature, and payment disputes for emergency or urgent
º e proposed treatment will be the most e ective. medical services.
• Your doctor certi es in writing that: e department also has a toll-free telephone number
º A drug, device, procedure or other therapy is likely
(1-888-HMO-2219) and a TDD line (1-877-688-9891)
to work better than the standard treatment. for the hearing and speech impaired. e department’s
Web site, (www.hmohelp.ca.gov) has complaint forms,
º Based on two (2) medical and scienti c documents, IMR application forms and instructions online.
the recommended treatment is likely to work
better than the standard treatment.
• You have been denied a drug, equipment, procedure State Fair Hearing
or other therapy recommended or requested by your A State Fair Hearing is another way you can le a
doctor. grievance. You can present your case directly to the State
• e treatment would normally be covered as a of California. All L.A. Care members have the right to
bene t, but L.A. Care has determined that it is ask for a State Fair Hearing at any time within 90 days
experimental or investigational in nature. of the incident. You can still request a State Fair Hearing
To nd out more, get help with the IMR or IMR- if you request an Independent Medical Review (IMR).
EIT process, or ask for an application form, please However, you will not be able to use the IMR process
call L.A. Care. if you have requested a State Fair Hearing. Go to the
“IMR” section to nd out more.
You do not need to participate in L.A. Care’s grievance
process before asking for an IMR of a decision to deny You may ask for a State Fair Hearing by calling
coverage on the basis that the treatment is experimental toll-free 1-800-952-5253 (English and Spanish), or by
or investigational in nature. writing to:
40 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
California Department of Social Services Arbitration: Solving problems
State Hearings Division without going to court
P.O. Box 944243, MS 19-37
L.A. Care knows that some members wish to get health
Sacramento, CA 94244-2430
care services from a health plan that uses arbitration.
When you choose arbitration, you give up the right to
Expedited State Hearing have your problem settled by a judge or jury. Many view
arbitration as cheaper, quicker and better than the courts.
In cases of health services denials, you or your provider
can ask for a faster decision through an Expedited State During arbitration, a neutral (fair and unbiased)
Hearing if your life, health or ability to attain, maintain arbitrator will listen to everyone and make a decision.
or regain maximum function could be in serious danger You and your doctor or health plan must follow
by going through a standard State Fair Hearing. An that decision. at is why the process is often called
emancipated minor, a parent on behalf of his/her minor “binding” arbitration.
child, and a duly-appointed guardian or conservator of e party that does not win will pay for the costs
a member can also request an Expedited State Hearing. unless the arbitrator decides otherwise. at being said,
Requests for Expedited State Hearings should be the winning party will never be responsible for more than
directed to: legal fees and costs or more than one-half of the costs.
Expedited Hearings Unit L.A. Care can pay some or all of the fees and expenses of
California Department of Social Services the arbitrator in cases of great nancial hardship. Please
State Hearings Division contact L.A. Care for information and an application.
744 P Street, MS 19-65 Arbitration does not apply to claims or disputes about
Sacramento, CA 95814 alleged medical malpractice.
You can also call the DPSS Los Angeles County o ce
You can ask for mediation to resolve a grievance. An
toll-free at 1-877-481-1044. If you do not speak English,
independent third person will resolve your grievance. is
please stay on the line and ask for the language you
person is not related to L.A. Care. You and L.A. Care
speak. DPSS has sta members who speak Armenian,
must agree to use the mediation process. You may ask
Chinese, Russian, Spanish, Tagalog and Vietnamese.
for mediation, but L.A. Care can decline your request.
You can also write to:
You can still le a grievance with DMHC even if you use
Department of Public Social Services (DPSS) mediation. You do not need to participate in L.A. Care’s
State Fair Hearings Section mediation process for any longer than 30 days prior to
P.O. Box 10280 submitting a grievance to DMHC. To request mediation,
Glendale, CA 91209 call L.A. Care.
Ombudsman O ce
You can call the Ombudsman O ce of the California
Department of Health Care Services (DHCS) for help
with grievances. e Ombudsman O ce was created
to help Medi-Cal bene ciaries fully use their rights and
responsibilities as members of a managed care plan. To
nd out more, call toll-free 1-888-452-8609.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 41
What are my privacy rights?
You have the right to keep your medical records of password protection and software technology.
con dential. at means that only people who need L.A. Care’s does not give out health information to
to see your records in order for you to get good health anyone or any group that does not have a right to the
care will see them. You can request a copy of our Notice information by law.
of Privacy Practices (NOPP). Just call L.A. Care. An L.A. Care need information about you so that we
NOPP is provided to you in this handbook. If you would can give you good health care services. e routine
like another copy of this information, call L.A. Care. collection, use and disclosure of your protected health
e NOPP is also available on L.A. Care’s Web site at information and other kinds of private information
Health information privacy • Gender
We want you to know the things that L.A. Care does • Date of birth
to keep health information about you and your family • Language you speak
private. To keep health information about you and your
family private, we: • Home address
• Handle health information the same way, every time • Home or work telephone number
• Employer and occupation
• Review the way health information is handled
• Whether you are married or single
• Follow all laws about the privacy and con dentiality • Health history
of health information
L.A. Care does not have complete copies of your
All L.A. Care sta with access to your health medical records. We may get this information from you
information are trained on privacy and information or any of these other sources:
security laws. ey also follow L.A. Care rules on
how to take care of your health information so it stays • A parent, guardian or conservator
private. ey follow L.A. Care policies and procedures • Another health plan
to protect conversations about you as well as written • Your doctor
and electronic documents that contain protected health
information about you. Employees even sign a note • Your application for the health care program
that promises they will keep all health information • Your health records
private. For example, employees are not allowed to • e California Department of Health Care
speak about your information in elevators or hallways. Services
Employees must also protect any written or electronic
documents containing your health information across Before L.A. Care gives your health information to
the organization. Employees have access only to someone else or another group, we need your approval in
the amount of information needed to do their job. writing. However, there are times when we don’t have to
L.A. Care’s computer systems protect your electronic get your approval in writing. is may happen when:
health information at all times by using various levels
42 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
• A court, arbitrator or similar agency needs your You can also get more information about privacy,
health information. information security and con dentiality of your health
• A subpoena or search warrant is requested. information, or how to access your health information,
by visiting L.A. Care online at www.lacare.org.
• A coroner needs your health information.
If you believe that your privacy has not been protected,
• Your health information is needed by law. you have the right to complain. You can le a grievance
• Your health information is needed for treatment, (complaint) by contacting L.A. Care Member Services
payment or for health care operations. and asking to speak with the Privacy & Information
We may give your health information to another Security O cer at 1-888-839-9909, or you can contact
health plan to: the Department of Health Care Services (DHCS) at
1-916-255-5259, TTY at 1-877-735-2929, or the U.S.
• Make a diagnosis or give treatment
O ce of Civil Rights 1-866-627-7748, TTY 1-866-
• Make a payment for your health care 788-4989. ese phone numbers are available to you
• Review the quality of your health care 24 hours a day, seven (7) days a week. All calls are
con dential. All calls are free except for 1-916-255-5259.
Sometimes, we may also give your health information
• Groups who license health care providers Protect yourself from identity theft
• Public agencies Here are some steps you can take to help prevent your
• Investigators personal information from being stolen, also known as
• Probate courts
• Protect your member ID card like you protect your
• Organ donation groups
bank or credit cards.
• Federal or state agencies as required by law
• Take your ID card to your doctor’s appointment.
• Disease management programs Avoid speaking about your membership information,
• Other health plans or providers involved in your personal facts or saying your social security number
care out loud or to other people.
Please note that we won’t tell anyone the results from • Don’t give out your personal information unless it
any genetic testing. is asked for by your doctor, clinic, hospital, other
medical sta or health plan.
If you have any questions, would like a printed copy of
the NOPP mailed to you, would like to pick up a paper
copy of the NOPP, or would like to know more about
the privacy, information security and con dentiality of
your health information, please call L.A. Care’s Member
Services to reach the Privacy & Information Security
O cer at 1-888-839-9909.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 43
Fraud, waste & abuse:
How to identify and report it
Fraud Services Fraud & Abuse Hotline at 1-800-822-6222
or the Department of Justice O ce of the Attorney
Fraud includes, but is not limited to, using someone
General Bureau of Medi-Cal Fraud & Elder Abuse at
else’s medical bene ts for your health care services,
1-800-722-0432. Your call is free and con dential.
using someone else’s social security number to qualify
for government assistance or billing from the doctor for
services that did not occur. If you commit fraud you Why should you care about
may lose your Medi-Cal coverage. fraud, waste and abuse?
Health care fraud, waste and abuse are serious issues.
Waste Fraudulently received bene ts or services impact the
Waste is the planned use, throwing away or spending cost of your health care services. e cost of health care
of health care or government resources in an unwise and impacts the bene ts available to you.
wrong manner. Examples of waste include:
• Prescribing more medication than is medically Preventing health care fraud
necessary Here are a few helpful tips on how you can help
• Providing more health care services than is prevent health care fraud:
medically necessary • Do not give your ID card or ID card number to
anyone except your doctor, clinic, hospital, health
care provider or health plan.
• Do not let anyone borrow your ID card.
Abuse is the planned misuse of health care or
government resources. Examples of abuse include: • Never loan your social security card to anyone.
• Requesting and obtaining medications or medical • Never sign a blank insurance claim form.
equipment you do not need to use for your bene t
• Beware of anyone who o ers you free medical
• Billing from the doctor for services that did not services in exchange for your ID card. You should
occur never give away your ID card to anyone in exchange
for free medical services.
How to report fraud, waste and abuse • If it sounds too good to be true, it probably is.
If you suspect someone of using your information or Be careful about accepting medical services in
committing fraud, waste or abuse, please call L.A. Care’s addition to Medi-Cal when you are told they will
Compliance Helpline at 1-800-400-4889. is number be free of charge.
is available 24 hours a day, seven (7) days a week.
You can also call L.A. Care’s Member Services and
ask to speak with the Compliance O cer at 1-888-839-
9909, or you could call the Department of Health Care
44 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
Medi-Cal: How can I make
sure I don’t lose my coverage?
Keeping your Medi-Cal eligibility Two types of Medi-Cal
To stay in Medi-Cal, you must be eligible for it. ere are two types of Medi-Cal in Los Angeles
“Eligible” means that a person meets certain requirements County: “fee-for-service” and “managed care.” In
to receive bene ts from programs like Medi-Cal. Los Angeles County, most Medi-Cal members are in
managed care. L.A. Care is a managed care health plan.
If you lose Medi-Cal eligibility, you will not be able “Managed care” is when your health care is managed
to keep your Medi-Cal bene ts with L.A. Care. and coordinated by a health plan and a PCP doctor.
is makes it easier for you to get the care you need.
Be sure to ll out and return any information requested It is L.A. Care’s job to make sure you get the care you
before the due date on the letter or form. If you have need. For example, if you need to see a specialist, it is
any questions about your Medi-Cal eligibility, call your your PCP doctor’s and our job to nd a specialist who
eligibility worker or the Department of Public and will see you.
Social Services (DPSS) toll-free at 1-877-481-1044. In “fee-for-service” Medi-Cal, you are not in a health
plan and must nd doctors and other providers who
will accept payment from Medi-Cal. No one manages
If you move, you must tell us! or coordinates your care for you. No one helps you nd
Don’t lose your Medi-Cal coverage if you move! DPSS doctors and providers who will accept payment from
must have your address so they can send you mail to Medi-Cal.
renew and stay eligible. is section explains why you are in managed care
If you move but still live in Los Angeles County, and the reasons why you can or can’t be enrolled in
please: or disenrolled from a managed care health plan. To
“enroll” means you become a member of a health plan.
1. Call your eligibility worker at DPSS right away at
To “disenroll” means you leave a health plan and are no
longer a member.
2. Call L.A. Care. We need to know your new address
and phone number.
Mandatory Medi-Cal managed care members
If you move outside of Los Angeles County but still
e California Department of Health Care Services
live in California, call your eligibility worker at DPSS
(DHCS) is in charge of Medi-Cal. DHCS says that in
right away toll-free at 1-877-481-1044. Your eligibility
Los Angeles County, most Medi-Cal members must
worker can help you nd out what Medi-Cal services are
enroll in a health plan and be in managed care. Members
available in your new community.
who must enroll in a health plan are called “mandatory
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 45
A mandatory member may disenroll from Medi-Cal Voluntary disenrollment
managed care only if the member:
To “disenroll” means you leave a health plan and are
• Has a complex medical condition (such as HIV/ no longer a member. To disenroll from L.A. Care, call
AIDS or cancer), and Health Care Options at 1-800-430-4263. Health Care
Options enrolls or disenrolls Medi-Cal bene ciaries in or
• Has been in Medi-Cal managed care fewer than 90
out of a Medi-Cal managed care health plan. ey will
send you a disenrollment form. Your membership will
• Is being treated by a doctor who does not work with end on the last day of the month in which Health Care
any Medi-Cal managed care health plan. Options approves your request. Disenrollment takes 15
to 45 days. You must continue to receive services through
Otherwise, the member must choose a health plan like L.A. Care until you are disenrolled from L.A. Care.
L.A. Care. For help with fee-for-service bene ts outside
If you leave L.A. Care, you can’t stay enrolled with
of managed care, call L.A. Care.
L.A. Care for your Medi-Cal coverage.
Voluntary Medi-Cal managed care members
In Los Angeles County, some people with Medi-Cal
You will lose managed care coverage with L.A. Care,
can choose to enroll in a health plan. Members who
but not necessarily your Medi-Cal bene ts, if any of the
choose to enroll in a health plan are called “voluntary
members.” A voluntary member can choose to leave
his or her health plan and return to fee-for-service • You move out of Los Angeles County permanently.
Medi-Cal at any time. Voluntary members include: • You are in a long-term care or intermediate care
• e disabled or elderly receiving Supplemental facility beyond the month of admission and the
Security Income (SSI) following month.
• ose 65 years or older • You require medical health care services not
provided by L.A. Care (for example, some major
• American Indians and their household, and others
organ transplants, and chronic kidney dialysis).
who are eligible to get services from an Indian
Health Center or Native American Health Clinic • You have other non-government or government-
sponsored health coverage.
• Children in foster care or the Adoption Assistance
Program • You are in prison or jail.
• Members with HIV/AIDS diagnosis If you are a mandatory or voluntary member, you can
also be disenrolled from L.A. Care, even if you don’t
want to leave, if:
• You take part in any fraud having to do with services,
bene ts or facilities of the plan.
• You show an ongoing signi cant disruptive behavior
toward other members, providers, provider sta or
• L.A. Care is not able, in good cause, to give health
care services to you. L.A. Care will use their best
e orts to provide the needed services.
46 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
If you are disenrolled from L.A. Care, we will send you Transitional Medi-Cal
a letter that says when your coverage will end and why.
Transitional Medi-Cal is also called “Medi-Cal for
You may le an appeal with the California Department
working people.” You may be able to get transitional
of Managed Health Care (DMHC) if you think that
Medi-Cal if you stop getting Medi-Cal because:
your cancellation is because of your health status or
need for services. is means you can ask DMHC to • You started earning more money; OR
make sure we are allowed to disenroll you. You may • Your family started receiving more child or spousal
also ask for a review from the California Department support.
of Health Care Services (DHCS). You can learn more For example, if you are the person in your household
about this in the “Complaints: What should I do if I am who earns the most money, you might get transitional
unhappy?” section of this handbook. You can also call Medi-Cal. Even if you are a caretaker relative, you
L.A. Care to nd out more. might get transitional Medi-Cal if you started earning
more money or you are receiving more child or spousal
Parents and caretaker relatives who get transitional
L.A. Care will process an Expedited Disenrollment
Medi-Cal can get free Medi-Cal coverage for six (6) to
if we are not able to provide you with medical services
24 months. If you stopped getting Medi-Cal, you should
due to your condition or situation which is indicated
ask your eligibility worker if you qualify for transitional
in L.A. Care’s contract with the California Department
Medi-Cal. Call your eligibility worker at DPSS toll-free
of Health Care Services (DHCS). is may include a
at 1-877-481-1044. You can stay with L.A. Care if you
major organ transplant, long-term care service, Foster
are eligible for transitional Medi-Cal.
Care or Adoption Assistance Programs, or if you move
out of Los Angeles County. We will submit a disen-
rollment request to DHCS, which will make a decision
within 72 hours. When we receive the decision, we will
notify you and your PCP doctor of the e ective date of
disenrollment. Your health care for the condition will be
covered by regular Medi-Cal.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 47
How do I participate?
Many L .A. Care policies are decided by Board of Governors meetings
California Department of Health Services. Other
e Board of Governors decides policies for L.A. Care.
policies are set by L.A. Care and members like you.
Anyone can attend these meetings. e Board of Gov-
ernors meets on the rst ursday of each month from
2 p.m. to 4 p.m. To nd out more call the L.A. Care
L.A. Care Public Policy Committee
Meeting Information Line at 213-438-5408.
L.A. Care has a public policy committee you may
join. is committee discusses member and health plan
issues. To nd out more, please call L.A. Care. Communicating policy changes
As an L.A. Care member, you will get information
on all policy changes that a ect your health care. All
L.A. Care Regional Community
important information will be included in your member
Advisory Committees (RCAC) newsletter or special mailings.
ere are 11 L.A. Care Regional Community Advisory
Committees (RCAC) in Los Angeles County. (RCAC
is pronounced “rack.”) eir purpose is to give input
to L.A. Care that might a ect policies, procedures,
programs and practices.
• Talk about member issues
• Advise the L.A. Care Board of Governors
• Educate and empower the community on health
RCACs meet once a month. RCACs include
L.A. Care members, member advocates (supporters) and
health care providers. To nd out more about RCACs,
call the L.A. Care Community Outreach and Educa-
tion Department toll-free at 1-888-LA-CARE2 (1-888-
48 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
More important information:
What else do I need to know?
If you travel outside of Los Angeles County Third party liability
As a member of L.A. Care, your service area is L.A. Care will provide covered services when an injury
Los Angeles County. All locations outside of Los Angeles or illness is caused by a third party. L.A. Care may request
County are out of your service area. the legal right to keep any payment or right to payment
Routine care is not covered out of the service area. you may have received as a result of a third party injury
Emergency and urgent care services are covered outside or illness. Under California State Law, this is called
of Los Angeles County. “asserting a lien.” e amount of this lien may include:
• Reasonable and true costs paid for health care
services given to you
How a provider gets paid • An additional amount as provided under California
Health care providers can be paid in several ways by State Law
the health plan or medical group which they may have a As a member, you also agree to help L.A. Care in
contract with. Providers may receive: recovering payments for services provided. is may
• A fee for each service provided require you to sign or provide documents needed to
• Capitation (a at rate paid each month permember) protect the rights of L.A. Care.
• Provider incentives or bonuses
Please call L.A. Care if you would like to know Medi-Cal Estate Recovery Program
more about how your doctor is paid or about nancial e Medi-Cal program pays for medical care for
incentives or bonuses. some people whose savings and income are too low for
them to be able to pay for their own care. e cost
of a member’s medical care may have to be paid back
If you have other insurance to the Medi-Cal program after the member’s death.
Please call L.A. Care at 1-888-839-9909 to tell is is called the Medi-Cal Estate Recovery Program.
us about any health insurance you have other than After getting notice of the death of a member, the
L.A. Care so that we can send all bills to the correct Department of Health Care Services (DHCS) will
place for payment. decide if the cost of the member’s medical care must
be paid back. DHCS will never ask for more to be paid
back than the value of the assets owned by the member
Workers’ Compensation at the time of his or her death.
L.A. Care will not pay for work-related injuries To learn more about the Medi-Cal Estate Recovery
covered by Workers’ Compensation. L.A. Care will Program, write or call DHCS.
provide health care services you need while there are
Department of Health Care Services
questions about an injury being work-related. Before
Estate Recovery Section, MS 4720
L.A. Care will do this, you must agree to give L.A. Care
P.O. Box 997425
all information and documents needed to recover costs
Sacramento, CA 95899-7425
for any services provided.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 49
Disruption in services What is an advance directive?
L.A. Care will use its best e orts to provide services An advance directive is a signed legal document. It
in the event of a war, riot or other unusual event. If allows you to select a person to make your health care
L.A. Care is not able to provide health services, we will choices at a time when you can’t make them yourself
send members to the nearest hospital for emergency (for example if you are in a coma). An advance directive
services and pay for these services. must be signed when you are able to make your own
decisions. L.A. Care will tell you about any changes to
state law about advance directives. We will send you
Organ donation this information as soon as possible but no later than
ere is a need for organ donors in the United States. 90 days after the date of change. Ask your doctor or call
You can agree to donate your organs in the event of your L.A. Care to nd out more about advance directives.
death. e California Department of Motor Vehicles
(DMV) will give you a donor card if you wish to become
an organ or tissue donor. e DMV will also give you a New technology
donor sticker to place on your driver’s license or ID card. L.A. Care follow changes and advances in health care.
To nd out more, call 1-800-777-0133 (voice) or 1-800- We study new treatments, medicines, procedures and
368-4327 (TTY). devices. We call all of this “new technology.” We review
scienti c reports and information from the government
and medical specialists. en we decide whether to
cover the new technology. Members and providers may
ask L.A. Care to review new technology.
50 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
Glossary of Terms
is glossary will help you understand words used in California Department of Health Care Services
this Member Handbook. (CDHCS) is the state agency that is responsible for the
Acute is a word used for a serious and sudden condition
that lasts a short time and is not chronic. Examples California Department of Managed Health Care
include a heart attack, pneumonia or appendicitis. (DMHC) is the state agency responsible for regulating
health care service plans.
Advance Directive is a signed legal document that
allows you to select a person to make your health care Cancer Clinical Trial is a research study with cancer
choices at a time when you can’t make them yourself. It patients to nd out if a new cancer treatment or drug is
expresses your decision about your end-of-life care ahead safe and treats a member’s type of cancer.
Case Management refers to doctors and nurses who
Americans with Disabilities Act (ADA) is a law that make sure that you are getting the right health care
protects people with disabilities from not being treated services when you need them. is includes checkups,
fairly. e ADA law makes sure there are equal chances plans to make you better, getting you the right doctors,
for people with disabilities in employment and state and and coordinating care to meet your health care needs.
local government services, including health care.
Certified Nurse Midwife (CNM) is a registered nurse
Arbitration is the process by which parties to a dispute who has experience in labor and delivery, and at least
submit their di erences to the judgment of an impartial one year of hands-on training in midwifery. A CNM has
(fair and unbiased) person or group appointed by mutual completed an advanced course of study and is certi ed
consent or statutory provision. by the American College of Nurse-Midwives.
Authorize/Authorization is when a health plan Certified Nurse Practitioner is a registered nurse
approves treatment for covered health care services. who has completed an advanced training program in a
Members may have to pay for non-approved treatment. medical specialty.
Note: Emergency service and out-of-area urgent care
services do not require prior authorization. Child Health and Disability Prevention (CHDP)
is for people under the age of 21 with a disability.
Benefits are the health care services, supplies, drugs CHDP is a preventive program that delivers periodic
and equipment that are medically necessary and covered health assessment and services. CHDP provides care
by Medi-Cal. coordination to assist families with medical appointment
scheduling, transportation, and access to diagnostic and
California Children’s Services Program (CCS) is treatment services.
the public health program that assures the delivery of
specialized diagnostic, treatment and therapy services to Chronic is a word used for a condition that is long-
nancially and medically eligible children under the age term and ongoing, and is not acute. Examples include
of 21 who have CCS eligible conditions. diabetes, asthma, allergies and hypertension.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 51
Clinic is a facility that members can select as a Primary Evidence of Coverage and Disclosure Form
Care Provider (PCP). It can be either a Federally (EOC) is the L.A. Care Member Handbook which
Quali ed Health Center (FQHC), Los Angeles County has information about bene ts, services and terms for
clinic, community clinic, rural health clinic, Native members.
American Health Clinic, or other primary care facility.
Exclusions are any medical, surgical, hospital or other
Complain/Complaint is an oral or written expression treatments for which the program o ers no coverage.
of dissatisfaction, including any complaint dispute
request for reconsideration or appeal. A complaint is also Expedited Review is a complaint that must be
known as a grievance. resolved as quickly as possible if it involves an imminent
or serious threat, including but not limited to, severe
Diagnostic/Diagnosis is when a doctor identi es a pain or the potential loss of life, limb or major bodily
condition, illness or disease. function. With an expedited review, the health plan will
resolve the complaint as quickly as the medical condi-
Disability is a physical or mental condition that tion requires and no later than within 72 hours.
substantially limits a person’s ability in at least one major
life activity. Experimental or investigational in nature refers
to new medical treatment that is still being tested but
Disenroll/Disenrollment is when a member leaves a has not been proven to treat a condition.
Family planning services help people learn about
Disputed health care service is a health care service and plan the number and spacing of children they want
eligible for coverage and payment under a plan that has through the use of birth control.
been denied, modi ed or delayed based on the plan’s
decision that the service was not medically necessary. Fee-For-Service Medi-Cal, also known as regular
Medi-Cal, is the component of the Medi-Cal Program
Durable Medical Equipment is medical equipment that is paid directly by the state for services.
used in the course of treatment or home care, including
items such as crutches, knee-braces or wheelchairs. Federally Qualified Health Center (FQHC) is a
community-based health organization that provides
Eligible/Eligibility means that a person meets certain comprehensive primary health, oral health, mental
requirements to receive bene ts from programs such as health, and substance abuse services.
Medi-Cal, California Children’s Services (CCS) and
Child Health Disability Program (CHDP). Food and Drug Administration (FDA) is the
U.S. government agency that enforces the laws on the
Enroll/Enrollment is when a member joins a health manufacturing, testing, and use of drugs and medical
Emergency Services are covered anywhere–24 hours Formulary is a list of approved drugs that is generally
a day, seven (7) days a week. Emergency care is a service accepted in the medical community as safe and e ective.
a member reasonably believes is necessary to stop or
relieve serious illness or symptoms, injury or conditions Grievance is sometimes called a complaint. A grievance
requiring immediate diagnosis and treatment, including is the process used when a member is not happy with his
physical and psychiatric emergency conditions and or her health care. Grievances are about services of care
active labor. received or not received.
52 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Health care services prevent and treat disease, and Independent Physician Association (IPA) is a
keep people healthy. Examples include some of the company that organizes a group of doctors, specialists
following: and other providers of health services to see members.
• Doctor services (includes one-on-one visits with a
doctor and referrals) Infertility is when a person is not able to conceive
and produce children after having unprotected sex on a
• Emergency services (includes ambulance and out-of- regular basis for more than 12 months.
• Home health services Inpatient is when a person receives medical treatment
in a hospital or other health care facility with an over-
• Hospital inpatient and outpatient services night stay.
• Laboratory services
Involuntary/Involuntarily is when something is
• Pharmacy services
done without choice.
• Preventive health services
• Radiology services Liable/Liability is the responsibility of a party or
person according to law.
Health Maintenance Organization (HMO) is
an organization that, through a coordinated system of Life-threatening is a disease, illness or condition that
health care, provides or assures the delivery of an agreed may put a person’s life in danger if it is not treated.
upon set of comprehensive health maintenance and treat-
ment services for an enrolled group of persons through a Local Education Agency is the school district or
predetermined, periodic xed prepayment. county o ce of education that will receive and disburse
Health Plan means an individual or group plan that
arranges for the provision, or pays the cost of, medical Managed care is a health care system in which the
care. health care provider, in return for a xed fee per year from
a health plan, manages the care of the individual, includ-
Hospice is the care and services provided to people who ing decisions about whether a specialist is required.
have received a diagnosis for a terminal illness. ese
services are given in a home or facility to relieve pain Medi-Cal is a California health coverage program for
and provide support. low-income families. is program is funded by state
and federal dollars.
Hospital provides inpatient and outpatient care from
doctors or nurses. Medi-Cal card, also known as the Bene ciary Identi -
cation Card (BIC), is the plastic card issued by the state
Human Immunodeficiency Virus (HIV) is the virus to Medi-Cal recipients. e BIC is used by providers to
that a ects the immune system and causes the disease verify Medi-Cal eligibility.
known as AIDS (acquired immunode ciency disorder).
Mediation is a process by which a neutral person tries
Independent Medical Review for Experimen- to help individuals resolve a dispute. e results of the
tal and Investigational Therapies (IMR-EIT ) mediation are not binding.
is a process by which expert independent medical
professionals are selected to review a denial by the health Medical group is a group of PCPs, specialists, and
plan for a medical service, drug or equipment because it other health care providers who work together.
is experimental or investigational in nature.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 53
Medically necessary/Medical necessity refers to Notice of Privacy Practice (NOPP) informs the
all covered services that are reasonable and necessary member how medical information may be used and
to protect life, prevent signi cant illness or signi cant distributed by the health plans.
disability, or to ease severe pain through the diagnosis
or treatment of disease, illness or injury. Occupational therapy is used to improve and main-
tain a patient’s daily living skills when the patient has a
Member is a person who has joined a health plan. disability or injury.
Member Handbook, also called a Combined Orthotic is used to support, align, correct or improve
Evidence of Coverage/Disclosure Form, is what you are the function of movable body parts.
reading right now. It has information about the bene ts,
services and terms o ered by the health plan. Outpatient is when a person receives medical treat-
ment in a hospital or other health care facility without
Member Representative is a person or persons an overnight stay.
appointed by the member, via written statement, to
represent them in the State of California as a health care Out-of-area services are emergency care or urgent
proxy, trustee named in a durable power of attorney care services provided outside of the health plan’s service
or court appointed guardian. Also known as Personal area that could not be delayed until the member returned
Representative(s), a Member Representative may be to the service area.
a spouse, relative, friend, advocate, your doctor, a
practitioner or someone designated as a representative Out-of-network providers are doctors and providers
by the member under Durable Power of Attorney, or as not under contract, either directly or indirectly, with the
an Executor/Administrator of Estate or as a legal/court health plan.
Pharmacy is a place to get prescribed drugs.
Member Services Department is the health plan’s
department that helps members with questions and Phenylketonuria (PKU) is a rare disease. PKU
concerns. can cause mental retardation and other neurological
problems if treatment is not started within the rst few
Mental or behavioral health services are given weeks of life.
for the diagnosis or treatment of a mental or emotional
illness. Physical therapy uses exercise to improve and
maintain a patient’s ability to function after an illness
Network is a team of health care providers contracted or injury.
with a health plan to provide services. e health care
providers may be contracted directly with the health Physician is a licensed medical doctor.
plan or through a medical group.
Prescription is a written order given by a licensed
Non-contracted provider is a doctor or provider provider for drugs and equipment.
who is not under contract with the health plan to provide
services to members. Preventive health care consists of health checkups
or services given at certain times due to a person’s age,
Non-formulary drug is a drug that is not listed on the sex and medical history in order to keep that person
health plan’s formulary and requires an authorization well.
from the health plan in order to be covered.
54 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
2010–2011 Medi-Cal Member Handbook
Primary care is a basic level of health care usually Referrals are when a doctor sends a member to another
provided in ambulatory settings by general practitioners, doctor, such as a specialist or providers of services
family practitioners, internists, obstetricians, including lab, X-ray, physical therapy and others.
pediatricians and mid-level practitioners. is type of
care emphasizes caring for the member’s general health Service area means the zip codes in Los Angeles
needs as opposed to specialists focusing on speci c needs. County that the health plan, to which a member is
Primary care provider (PCP doctor) is a doctor or
clinic that takes care of a member’s health care needs and Skilled nursing facility (SNF) is a facility licensed to
works with the member to keep them healthy. e PCP provide medical services for non-acute conditions.
doctor will also make specialty referrals when medically
necessary. Specialist is a physician or other health professional
who has advanced education and training in a clinical
Prior authorization is a formal process requiring area of practice and is accredited, certi ed, or recognized
a health care provider to obtain advanced approval by a board of physicians or peer group, or an organization
to provide speci c services or procedures. Prior o ering qualifying examinations (board certi ed) as
authorization is required for most services or care. having special expertise in that clinical area of practice.
However, for emergency or out-of-area urgent care
services, prior authorization is not required. Specialty mental health services are rehabilitative
services that include mental health services, medication
Prosthesis is used to replace a missing part of the body. support services, day treatment intensives, day
rehabilitation, crisis intervention, crisis stabilization,
Providers are contracted with a health plan to provide adult residential treatment services, crisis residential
covered health care services. Examples include: services, and psychiatric health facility services such as:
• Doctors • Psychiatric inpatient hospital services
• Clinics • Targeted case management
• Hospitals • Psychiatric services
• Skilled nursing facilities • Psychologist services
• Home health agencies • Early, Periodic, Screening, Diagnosis and Treat-
ment (EPSDT) supplemental specialty mental health
• X-ray facilities Speech therapy is used to treat speech problems.
• Durable medical equipment suppliers Standing referral is a referral by a doctor for more
than one visit by a specialist.
Provider directory is a list of providers contracted
with a health plan. TTY/TDD is a telecommunications device for the deaf.
Provider network is a group of doctors, specialists, Urgent care is any service required to prevent serious
pharmacies, hospitals and other health care providers deterioration of health following the onset of an
that are contracted by and work with the health plan. unforeseen condition or injury.
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 55
Women, Infant and Children Program (WIC) is a
state nutrition program that helps pregnant women, new
mothers and young children eat well and stay healthy.
56 Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731).
Important phone numbers
L.A. Care Health Plan 1-888-839-9909
L.A. Care’s 24-Hour Nurse Advice Line 1-800-249-3619
L.A. Care Compliance Helpline 1-800-400-4889
California Relay Service (CRS) — TTY/TDD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .711
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sprint 1-888-877-5379 (Voice)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MCI 1-800-735-2922 (Voice)
Americans with Disabilities Act (ADA) Information . 1-800-514-0301 (Voice) – 1-800-514-0383 (TDD)
California Children’s Services (CCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-288-4584
Child Health and Disability Prevention (CHDP) . . . . . . . . . . . . . .1-800-993-2437 (1-800-993-CHDP)
California State Services
California State Department of Health Services (CDHS) . . . . . . . . . . . . . . . . . . . . . . . . 1-916-445-4171
CDHS Ombudsman O ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-452-8609
Denti-Cal Bene ciary Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-322-6384
Department of Social Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-952-5253
Department of Managed Health Care (DMHC) . . . . . . . . . . . 1-888-466-2219 (1-888-HMO-2219)
Health Care Options:
Armenian . . . . . . . . . . . . . . . . 1-800-840-5032 Lao . . . . . . . . . . . . . . . . . . . . . 1-800-430-4091
Cambodian/Khmer . . . . . . . . 1-800-430-5005 Russian . . . . . . . . . . . . . . . . . 1-800-430-7007
Cantonese . . . . . . . . . . . . . . . 1-800-430-6006 Spanish . . . . . . . . . . . . . . . . . 1-800-430-3003
English . . . . . . . . . . . . . . . . . . 1-800-430-4263 Tagalog . . . . . . . . . . . . . . . . . 1-800-576-6890
Farsi . . . . . . . . . . . . . . . . . . . . 1-800-840-5034 Vietnamese. . . . . . . . . . . . . . . 1-800-430-8008
Hmong . . . . . . . . . . . . . . . . . 1-800-430-2022
U.S. O ce for Civil Rights . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-627-7748 – 1-866-788-4989 (TTY)
Social Security Administration
Supplemental Social Income (SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-772-1213
Los Angeles County Services
Department of Public Social Services (DPSS)
Central Help Line (includes language services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-877-481-1044
Customer Service Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-613-3777
DPSS Public Charge Information Lines:
Los Angeles County Department of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-213-250-8055
Los Angeles County Department of Mental Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-854-7771
Women, Infant and Children (WIC) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-942-9675
Questions? Call L.A. Care Member Services at 1-888-839-9909 (TTY 1-866-522-2731). 57
Preventive Health Guidelines
How to Stay Healthy
How to Stay Healthy
Going to your doctor for regular checkups helps you If you are a new member, see your doctor right away
stay healthy. This guide tells you when to go and what for your first checkup. Remember to go for a checkup
needs to be done at these checkups. every year. Regular checkups help you stay healthy!
Your doctor is always a good resource for you and your
family. You can ask questions and get advice about
important health topics.
Well Care Guidelines for Adults*
Tests/Exams 19 to 39 Years 40 to 64 Years 65+ Years
Checkup: medical history, physical
exam, height, weight, and BMI (a test for Every 1 to 3 years Every 2 years Every year
Blood Pressure Every 1 to 2 years
Age 50 to 75:
Your doctor will talk to you about having one or more of these tests:
Colon and Rectal Cancer • Fecal Occult blood test: every year [a test to see if there is blood in your stool (bowel movement)]
• Flexible sigmoidoscopy: every 5 years (a test of the lower part of your colon for cancer)
• Colonoscopy: every 10 years (a test of a larger part of your colon)
Hearing and Vision As recommended
Recommended for all adults as part of their initial checkup.
Tuberculosis (TB) Test and Risk Screening
Doctors will also screen those at a higher risk for TB.
Immunizations/Shots for Adults*
Immunizations (Shots) 19 to 39 Years 40 to 64 Years 65+ Years
Tetanus-Diphtheria (Td) Tetanus
Every 10 years
(Lockjaw-tightening of the jaw muscle)
— — One dose
(Bacteria-can cause lung or blood infection)
In uenza (Flu shot) Every year
Human Papilloma Virus (HPV) For women up to age 26 (3 doses),
(Virus-can cause cervical cancer) if not immunized before
Shingles (Herpes Zoster)
(Virus-can cause painful skin rash — One dose, starting at age 60
* Your doctor may recommend other screenings or immunizations (shots) such as Hepatitis, if you are at high risk.
60 LA0220 08/10
How to Stay Healthy
Well Care Guidelines for Men
Tests/Exams 20 to 39 Years 40 to 64 Years 65+ Years
Screening for Prostate Cancer —
Not recommended after age 75
Cholesterol Screening Ages 20 - 35 only if at high risk 35 and older as recommended
Well Care Guidelines for Women
Tests/Exams 19 to 39 Years 40 to 64 Years 65+ Years
— First mammogram by age 50, then every 1 to 2 years after 50
(an X-ray of the breasts)
Pelvic Exam (Pap Smear) Pelvic exam and cervical cancer screening (Pap Smear) by age 21, then every 1 to 3 years as doctor recommends
To be done regularly for women 16 to 25 years (up to their 26th birthday) and
[a test for a sexually
only for women who are at high risk over 25
transmitted disease (STD)]
Screening for 65+ or younger as recommended
(thinning of the bone)
Ages 20 to 45 only if at high risk
After age 45 as recommended
How to Stay Healthy When You Are Pregnant
Care Before Pregnancy:
Before you are pregnant, your doctor will talk to you about a vitamin (folic acid) that helps prevent birth
defects. As soon as you think or you know you are pregnant, SEE YOUR DOCTOR RIGHT AWAY!
Care During Pregnancy (Prenatal):
Checkups: How Often?
First 28 Weeks Every 4 weeks
29-36 Weeks Every 2-3 weeks
36 weeks and beyond Weekly
Each checkup is important to help keep you and your baby healthy
• Certain tests may be done during your checkups
• Your doctor may want to see you more often
Care After Pregnancy (Postpartum):
• After you have your baby, it is important you get a checkup (postpartum check)
• Postpartum checkup should be done 21 to 56 days after you have your baby
• If you have a surgical delivery (C-section), you will need 2 checkups
How to Stay Healthy
You may also talk to your doctor about:
Drug and Alcohol Problems
Family Planning/Birth Control
How to Quit Smoking
STDs and HIV
Violence and Abuse
You may also call the
Nurse Advice Line 24/7
for health questions.
Sources for all information in this document: 2009 update from U.S.
Preventive Services Task Force, Centers for Disease Control and Prevention
(CDC) and The American College of Obstetricians and Gynecologists
Guideline for Perinatal Care (2007 edition).
Preventive Health Guidelines
How to Keep Your Child
or Teen Healthy
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
checkups to help them stay healthy. This guide tells you to the doctor right away for their first checkup.
when to take them and what needs to be done at these Remember, regular checkups help them stay healthy!
Your doctor is always a good resource for you and your
family. You can ask questions and get advice about
important health topics.
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, Every year
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 Every 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 checkup
by a dentist or dental hygienist by May 31 of their rst school
year (public school kindergarten or rst grade level).
64 LA0221 08/10
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, development, and risky Every year
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)
Every 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 (Pap Smear) by
Pelvic Exam (Pap Smear)
age 21 for all females; more often if doctor recommends
Sexually Transmitted Disease (STD) Screening
Every year for all sexually active patients
(including Chlamydia, HPV)
Ask your doctor if your child is at high risk
Tuberculosis (TB) Test and Risk Screening
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:
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
Advisory Committee on Immunization Practices, Department of Health
and Human Services, Centers for Disease Control and Prevention.
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. ese shots protect your child from serious diseases.
Use the guide below to find out about the shots needed. Your doctor can help you understand what each shot does.
Diseases Prevented by
Age Your child should get these shots
the Vaccine (shot)
Birth Hepatitis B ** (Some infants may get their rst shot at birth) Hepatitis B - a bad disease that hurts the liver
2 Months Hepatitis B *** Polio (#1)
Diphtheria – causes a thick covering in the back of the throat
DTaP (#1) Diphtheria, Tetanus, and Pertussis
Hib (#1) Haemophilus in uenzae type b Tetanus – (Lockjaw) causes tightening of the jaw muscle
PCV (#1) Pneumococcal disease Rotavirus (#1)
Pertussis - (Whooping Cough) causes bad coughing spells
4 Months Hepatitis B *** Rotavirus (#2)
DTaP (#2) Hib (#2) Hib Meningitis – an infection of the brain
PCV (#2) Polio (#2) and spinal cord
6 Months Hepatitis B *** Rotavirus (#3)
PCV Pneumococcal disease – causes blood infection,
DTaP (#3) Hib (#3)
pneumonia, and infection of the brain
PCV (#3) Polio (#3)
12 Months* Hib (#4) PCV (#4) Polio – can cause paralysis (can’t move arms or legs)
MMR (#1) Measles, Mumps, and Rubella Hepatitis A (#1)
Rotavirus – causes bad diarrhea
15 Months* DTaP (#4) (can be given as early as 12 months) Measles – causes rash, cough, runny nose, eye irritation, and
* Hepatitis A (#2) fever
Age 4 to 6 DTaP (#5) Polio (#4) Mumps – causes fever, headache, and swollen glands
(Before MMR (#2) Varicella-Chickenpox (#2)
Kindergarten) Get these shots if they were missed before: Rubella – (German Measles) causes rash, mild fever
Hep B Series – Hep A Series – Hib Varicella-(Chickenpox) rash, skin blisters, itching, and fever
Age 11 to 12 MCV4 Meningococcal (Meningitis)
(Before 7th Grade) Tdap (Tetanus, Diphtheria, Pertussis) Hepatitis A – causes a bad liver disease
HPV (3 doses) Human Papilloma Virus
MCV4 Meningococcal (Meningitis) – an infection of the
Get these shots if they were missed before:
Hep B series – Hep A series – Polio series brain and spinal cord
MMR (#2) – Pneumococcal series – Varicella HPV (Human Papilloma Virus) – can cause cervical cancer
Age 13 to 18 If shots not received at ages 11 to 12: and genital warts
MCV4 (at age 15)
HPV (3 doses)
* 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).
Notice of Privacy Practices
A Message for Medi-Cal Members
Please review it carefully. www.lacare.org
This notice describes how medical information about you Employees must ensure member PHI is picked up from fax
may be used and disclosed and how you can get access to machines, printers and copiers and only is received by those who
have access. Portable media devices with PHI are encrypted and
must have password protections applied. Computer screens and
work stations must have privacy screen lters and workstations,
L.A. Care Health Plan provides health care to you for the
drawers and cabinets have secure locks placed on them.
Medi-Cal program. We are required by state and federal law
to protect your health information. We also must give you this
Notice. is Notice tells you how we may use and share your
Your Information is Personal and Private
information. It also tells you what your rights are. We get information about you from Medi-Cal after you join
our health plan. We also get medical information from your
What is “Protected Health Information?” doctors, clinics, labs and hospital so we can approve and pay
for your health care.
Your Protected Health Information (“PHI”) is health
information that contains identi ers, such as your name,
Changes to Notice of Privacy Practices
Social Security number, or other information that reveals who
you are. For example, your medical record is PHI because it L.A. Care must obey the Notice that we are using now. We
includes your name and other identi ers. have the right to change these privacy practices. Any changes
Your con dentiality is important to us. We are required by in our practices will apply to all of your medical information.
state and federal law to protect your health information. Our E ective April 14, 2003, whenever there is an important change
sta follows policies and procedures at L.A. Care Health Plan in our practices, we will change this Notice and notify you.
which protects your health information given to us in oral,
written or electronic ways. How We May Use and Share Information About You
Our sta goes through training which covers the internal L.A. Care may use or share your information only for a
ways members’ oral, written and electronic PHI may be used reason directly connected to the Medi-Cal program. Some of
or disclosed across the organization. All L.A. Care sta with the information we use and share is:
access to your health information is trained on privacy and • Your name,
information security laws. Sta has access only to the amount • Address,
of information they need to do their job. • Personal facts,
Our computer systems protect your electronic PHI at • Medical care given to you,
all times by using various levels of password protection and • e cost of your medical care, and
• Your medical history.
Our L.A. Care employees follow internal practices, policies
and procedures to protect any conversations about your health Some actions we take when we act as a Medi-Cal health plan
information. For example, employees are not allowed to speak include:
about your information in elevators or hallways. Employees must • Checking whether you are covered by Medi-Cal,
also protect any written or electronic documents containing • Checking the amount of medical aid you can get from
your health information across the organization. Medi-Cal,
Fax machines, printers, copiers, computer screens, work • Approving, giving, and paying for Medi-Cal services,
stations, portable media disks containing your information • Investigating or taking legal action in Medi-Cal cases (like
are carefully guarded from others who should not have access. fraud),
LA0260 08/10 67
Notice of Privacy Practices, cont’d
• Checking the quality of care you receive, What Are Your Privacy Rights?
• Making sure you get all the care you need. You have the right to ask us not to use or share your personal
health care information. We will send you a form to ll out to
ese are some examples of how we may use and share tell us what you want. Or, we can ll out the form for you. We
information about you: may not be able to agree to your request.
• For treatment: You may need medical treatment that needs You have the right to ask us to contact you only in writing
to be approved ahead of time. We will share information or at a di erent address, post o ce box, or by telephone. We
with doctors, hospitals and others in order to get you the will send you a form to ll out to tell us what you want. Or, we
care you need. can ll out the form for you. We will accept reasonable requests
• For payment: We share your information with other when necessary to protect your safety.
health plans or providers that are responsible to pay for You and your personal representative have the right to get a
your care. We may also forward bills to other health plans copy of your health information. We will send you a form to
or providers for payment. ll out to tell us what you want copied. Or, we can ll out the
• For health care operations: We may use information form for you. You may have to pay for the costs of copying and
in your health record to check the quality of the health mailing records. (We may keep you from seeing certain parts of
care you receive. We may also use this information in your records for reasons allowed by law.)
audits, programs to stop fraud, planning, and general You have the right to ask that information in your records
administration. be changed if it is not correct or complete. We will send you a
form to ll out to tell us what changes you want. Or, we can ll
Other Uses for Your Health Information out the form for you. We may refuse your request if
Sometimes a court will order us to give out your health infor- • e information is not created or kept by L.A. Care, or
mation. We will also give information to a court, investigator, • e information is not part of a standard set of information
or lawyer if it is about the operation of Medi-Cal. is may in- kept by us, or
volve fraud or actions to get money from others when Medi-Cal • e information has been gathered for a court case or other
has paid your medical claims. legal action, or
You or your doctor, hospital, and other health care providers • We believe it is correct and complete.
may not agree if we decide not to pay for your Medi-Cal care.
We may use your health information to review these decisions. We will let you know if we agree to make the changes you
want. If we don’t agree to make the changes you want, we
We may share your health information with groups that
will send you a letter telling you why. You may ask that we
check how our health plan is providing services.
review our decision if you disagree with it. You may also send
We may share your information with persons involved in a statement saying why you disagree with our records. We will
your health care, or with your personal representative. keep your statement with your records.
We must share your health information with the federal
government when it is checking on how we are meeting pri-
vacy rules. Important
We may also share your information when the law says we L.A. Care does not have complete copies of your medical
can or must share it, such as for national security purposes. But records. If you want to look at, get a copy of, or change your
we will not share your information if the Medi-Cal program medical records, please contact your doctor or clinic.
would not allow it.
L.A. Care sta is trained to protect information given to
plan sponsors or employers. L.A. Care requires plan sponsors E ective April 14, 2003, whenever we share your health
or employers to have the same protections as L.A. Care has in information, you have the right to request a list of:
place. Plan sponsors or employers must agree to protect your • Whom we shared the information with,
medical information. • When we shared it,
• For what reasons, and
When Written Permission is Needed • What information was shared.
If we want to use your information for any purpose not listed
is list will not include when we share information with
above, we must get your written permission. If you give us your
you, with your permission, or for treatment, payment, or health
permission, you may take it back in writing at any time.
Notice of Privacy Practices, cont’d
You have a right to request a printed paper copy of this Notice Use Your Rights Without Fear
of Privacy Practices. You may get a paper or printed copy of this L.A. Care cannot take away your health care bene ts or do
communication by calling the Privacy O cer. You can also anything to hurt you in any way if you le a complaint or use
nd this Notice on our website at www.lacare.org. any of the privacy rights in this Notice.
How Do You Contact Us to Use Your Privacy Rights? Questions
If you want to use any of the privacy rights explained in this If you have any questions about this Notice and want further
Notice, please call or write us at: information, please contact the L.A. Care Privacy O cer,
L.A. Care Privacy O cer L.A. Care Health Plan, at the address and phone number in
L.A. Care Health Plan the “How Do You Contact Us to Use Your Rights?” section.
555 West Fifth Street To get a copy of this notice in other languages, Braille,
Los Angeles, CA 90013 large print, on audiocassette or CD-ROM, please call or
Toll-free: 1-888-839-9909 write the L.A. Care Privacy O cer at the number or address
California Relay: 1-800-854-7784 or listed above.
1-866-LA-CARE1 (1-866-522-2731) TTY
If you believe that we have not protected your privacy,
you have the right to complain. You may le a complaint (or
grievance) by contacting us at:
L.A. Care Privacy O cer
L.A. Care Health Plan
555 West Fifth Street
Los Angeles, CA 90013
OR you may contact the agencies below:
• Privacy O cer
c/o O ce of Legal Services
CA Department of Health Care Services
1501 Capitol Avenue
P.O. Box 997413, MS0010
Sacramento, CA 95899-7413
1-916-445-4646 or 1-877-735-2929 TTY/TDD
E-mail address: privacyo firstname.lastname@example.org
• Secretary of the U.S. Department of Health and
O ce 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. O ce for Civil Rights at 1-866-OCR-PRIV
(1-866-627-7748) or 1-866-788-4989 TTY
Nurse Advice Line
List of Audio Health Topics
Allergies and Immune System Agoraphobia 3303 Gender Identity Disorder 3329
Allergies 3100 Alcohol and Aging 3004 Grief and Loss 3330
Allergy Tests 3103 Alcohol and Health 4400 Hallucinations 3331
Controlling Your Environment Alcohol Dependence 3304 Healthy Love Relationships and Teens 3773
When You HaveAllergies 3102 Amnesia 3306 Hypnotherapy 3333
Drug Allergy 3107 Anger and Teaching Children Hypochondria or
Enlarged Lymph Nodes in Children 3811 to Manage It 3788 Hypochondriasis Disorder 3334
Flu Shots for Seasonal Flu 4441 Anger Management 3307 Incest 3335
Food Allergy 3109 Anger Management for Parents 4301 Kleptomania 3336
Food Allergy in Children 3814 Anorexia 3308 Letting Go of Resentment 3337
Guillain-Barré Syndrome 3412 Antisocial Personality Disorder 3309 Living with a Mentally Ill Person 3374
Hay Fever 3110 Anxiety 3310 Living with an Alcoholic Parent 3700
Hay Fever in Children 3817 Autism 3704 Loneliness in Older Adults 3022
Hives 3111 Autistic Spectrum Disorders 3377 Marijuana 3375
Immunization Schedule for Children 4663 Binge Eating Disorder or Masochism 3339
Immunizations for Adults 4664 Compulsive Overeating 3313
Lupus 3207 Bipolar Disorder 3314
Multiple Personality or
Lymph Nodes, Enlarged 5063 Bulimia 3315 Dissociative Identity Disorder 3341
Myasthenia Gravis 3419 Bullying and How to Help the Victim 3370 Narcissism or Narcissistic
National Support Services for Child Abuse and Neglect 3300 Personality Disorder 3342
People Who Have Allergies 3101 Choosing a Mental Health New Baby Creates Jealousy 3739
Poison Ivy, Sumac, and Oak 3112 erapist for Your Child 3371 OCD or Obsessive-Compulsive
Scleroderma 3231 Cocaine Use 3317 Disorder 3345
Severe Allergic Reaction 3113 Cognitive-Behavioral erapy 3373 Panic Attacks or Panic Disorder 3346
Shots for Travel 4443 Compulsive Gambling 3318 Paranoid Personality Disorder 3347
Sjogren’s Syndrome 4867 Depression in Children and Teens 3772 Pedophilia 3348
Tetanus Shot 4942 Depression in Older Adults 3010 Phobias 3349
Depression Overview 3321 Positive Attitude 3703
Behavioral Health Designer Drugs 3316 Postpartum Depression 5269
Abuse and Domestic Violence Disciplining Your Child 4313 Post-Traumatic Stress Disorder 3350
in Adults 3301
Dyslexia 3720 Prescription Drug Abuse 3351
Abuse of Older Adults 3001
Emotional Abuse: E ects on Children 3326 Psychosis 3352
ADHD or Attention De cit
Hyperactivity Disorder in Adults 3311 Exhibitionism 3327 Psychosomatic Illness 3353
ADHD or Attention De cit Fetal Alcohol Syndrome 3724 Pyromania 3354
Hyperactivity Disorder in Children 3312 Fetishism 3328 Recognizing Drug Abuse in Kids 3323
Aggressive Behavior in Children 3302 Food and Feelings 4703 Ritalin 4280
LA0281 08/10 71
SAD or Seasonal A ective Disorder 3357 Bones, Muscles and Joints Trigger Finger 3251
Sadism 3355 Amputation 3151
Schizophrenia 3356 Arthritis 3154 Brain and Nervous System
Self-Esteem 3358 Arthroscopy 3157 AIDS - Nervous System Complications 3400
Aspirin and Arthritis 3159 Alzheimer’s Disease 3401
Self-Esteem for Teens 3763
Back Pain Prevention at Work 4650
Self-Esteem in Older Adults 3032 Bell’s Palsy 3403
Baker’s Cyst 3269
Separation Anxiety Prevention 4329 Bone Chips in the Elbow 3267 Brain Tumors in Children 3505
Sexual Abuse and Children 3360 Bone Chips in the Knee 3268 Cerebral Palsy 4305
Sexual Behaviors in Children 3801 Bowlegs and Knock-Knees 3163 Chronic Fatigue Syndrome 4406
Social Anxiety Disorder 3379 Brittle Bones in Children 3218 Cluster Headaches 3405
Stress 4425 Bursitis 3169
Calci c Tendonitis 3170
Stress Management 4426 Delirium 3408
Carpal Tunnel Syndrome 3171
Stress Management with Dementia 3409
Cast Care 3172
Deep Breathing 4427
Chores Made Easier Dizziness and Vertigo 5054
Stress Management with When You Have Arthritis 3155
Mental Imaging 4428 Coping with Arthritis 3259
Facial Tics 3411
Stress Management with Costochondritis 3173
Progressive Muscle Relaxation 4429 Curved Spine or Scoliosis 3232 Fatigue 5056
Suicide 3363 Dupuytren’s Contracture 3256 Fibromyalgia 3177
Talking with Your Child Frozen Shoulder or Adhesive Capsulitis 3187 Fluid on the Brain or Hydrocephalus 3415
about Drinking and Drugs 4338 Ganglion Cyst 3188
Huntington’s Disease 3414
Teenage Drinking 3364 Gout 3189
Lou Gehrig’s Disease 3416
Hip Dislocation in Childhood 3192
e Stresses of Chronic Illness 4433
Juvenile Rheumatoid Arthritis 3198 Lumbar Stenosis 3206
Knee Arthroscopy 3199 Migraine Headache 3418
Treating Teens for Substance Abuse 3322 Low Back Pain 3205 Migraine Headaches in Children 3436
Twelve Step Programs 3366 Muscle Cramps and Spasms 3209 Multiple Sclerosis 3435
Types of erapy for Mental Health 3367 Muscular Dystrophy 3738
Parkinson’s Disease 3423
Voyeurism 3368 Neck Spasms 3213
Osgood-Schlatter Disease 3216 Peripheral Neuropathy 3424
When Your Child Is a Bully 3369
Osteoarthritis 3217 Restless Legs Syndrome 4421
Your Child’s Self-Esteem 4344
Osteoporosis 3219 Sciatica 3425
Paget’s Disease of Bone 3221 Seizures 3426
Blood and Cancer
Pigeon Toe 3223
Anemia 4402 Seizures in Children 3820
Polymyalgia Rheumatica 3225
Blood Clots 3607 Spina Bi da 4337
Rheumatoid Arthritis 3228
Blood Donation 4403 Septic Arthritis 3233 Stroke 3430
Blood Transfusion 4404 Shoulder Bursitis 3235 Stroke Rehabilitation 3647
Bone Marrow or Stem Cell Transplant 3503 Slipped Disk or Herniated Disk 3241 Tension Headache 3432
Spondylolysis and Spondylolisthesis 3244
Childhood Leukemia 3500 Tic Disorders 3778
e Hip Problem of
Hemophilia 4321 Legg-Calve-Perthes Disease 3203 Tourette’s Syndrome 3781
Sickle Cell Anemia 4334 Torticollis 3250 Trigeminal Neuralgia 3433
You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
72 You can call this number for free anytime, day or night.
Cancer Breast-Feeding and How to Very Small Premature Baby 3784
Increase Your Milk Supply 4740 Weaning from Bottle to Cup 3797
Biological erapy 3525
Breast-Feeding Bene ts 3708 Weaning from Breast to Bottle 3798
Bladder Cancer 3501
Breast-Feeding Positions 3790 Weaning from Breast to Cup 3799
Bone Cancer 3502
Brain Cancer 3504
Croup 3714 Diabetes
Breast Cancer in Men 3507
Crying Baby 3715 Diabetes: A1C Test 3924
Breast Cancer in Women 3506
Formula Feeding 3725 Diabetes: Type 1 3905
Cancer and Ways to
Protect Yourself Against It 4671 Growth Delay or Disorder 3911 Diabetes: Type 2 3906
Jaundice in Newborns 3731 Diabetes and Alcohol 4718
Cancer Clinical Trials 3515
Lead Poisoning Prevention in Children 3800 Diabetes and Eating Out 4715
Cancer Prevention and Diet 4652
Medical Reasons Not to Breast-Feed 5336 Diabetes and Food Management 3902
Cancer Screening 3511
Normal Development Diabetes and Heart Disease 3921
Cancer Treatment Team 3513
12 to 15 Months Old 3742 Diabetes and Illness 3900
Cancer Warning Signs 3517
Normal Development Diabetes and Nerve Damage 3922
Cervical Cancer 3518 15 to 18 Months Old 3743
Diabetes and Preventing Low
Chemotherapy 3519 Normal Development Blood Sugar during Exercise 3923
Childhood Cancers 3711 2 to 4 Months Old 3745
Diabetes and the Importance
Chronic Lymphocytic Leukemia 3520 Normal Development of Exercise 3904
2 Weeks to 2 Months Old 3746
Colon and Rectal Cancer 3521 Diabetes Foot Care 3901
Normal Development 2 Years Old 3747
Endometrial Cancer 3547 Diabetes Self Blood
Normal Development 3 Years Old 3748 Glucose Monitoring 3903
Esophageal Cancer 3523
Normal Development Diabetic Eye Problems 3907
Hodgkin Lymphoma 3524 4 to 6 Months Old 3749
Kidney Cancer 3526 Diabetic Ketoacidosis 3908
Normal Development 4 Years Old 3750
Liver Cancer 3527 Diabetic Retinopathy 3909
Normal Development 5 Years Old 3751
Lung Cancer 3528 High Blood Sugar 3912
6 to 9 Months Old 3752 Hyperosmolar Hyperglycemic
Nonketotic State 3913
Multiple Myeloma 3531 Normal Development
9 to 12 Months Old 3753 Low Blood Sugar 3915
Non-Hodgkin Lymphoma 3532
Overweight Children 4721 Metabolic Syndrome 3917
Ovarian Cancer 3533 Type 1 Diabetes in Children 3782
Reye’s Syndrome 3760
Pancreatic Cancer 3535
Sleep Apnea in Babies 3789
Prostate Cancer 3537 Diagnostic Tests and Procedures
Sleep Patterns in Babies 3765
Radiation erapy 3540 Angiograms 5100
Sleep Patterns in Children 3764
Skin Cancer 3541 Arterial Blood Gases 5101
Speech Development in
Stomach Cancer 3543 Newborns to 5 Year Olds 3769 Barium Enema 5102
Testicular Cancer 3544 Spitting Up in Infants 3770 Barium X-Ray Exam of the
roat Cancer 3545 Esophagus and Stomach 5103
Sudden Infant Death Syndrome
yroid Cancer 3546 or SIDS 3771 Biopsy 5104
Temper Tantrums 3775 Blood Glucose Test 5105
Children umbsucking 3777 Blood Pressure 3608
Baby Walkers 4946 Tobacco and Smoking in Blood Test for Iron 5106
Bedwetting in Children 3706 Children and Teens 3796 Bone Density Testing 5139
Breast-Feeding Advice 4738 Toddler Discipline 3779 Bone Marrow Biopsy 5107
Breast-Feeding and Giving Toilet Training 3780 Bone Scan 5108
Your Baby Enough Milk 4739 Undescended Testicle 3783 Bronchoscopy 4804
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. 73
Colonoscopy 5111 Diet and Exercise Sugar Substitutes 4727
Colorectal Cancer Screening 5112 Ca eine and Athletic Performance 4107 Swimming and Water Exercise 4155
Colposcopy of the Vagina and Cervix 5113 Ca eine in Your Diet 4700 Training Heart Rates 4159
Complete Blood Count Test 5114 Calcium 4701 Vegetarian Diet 4731
Carbohydrates 4702 Vitamins 4732
Coronary Angiogram 3616
Circuit Training 4108 Vitamins and Minerals for Children 4742
CT Scan 5116
Controlling Cholesterol 3615 Weight Loss Diets 4733
Cross Training 4109
Diagnostic Laparoscopy 5118
DASH Diet for Hypertension 3654 Digestive System
Echocardiogram 5119 Eating Healthy Snacks 4707 Abdominal Pain 5050
Electrocardiogram or ECG or EKG 5120 Exercise and Weight Control 4117 Acute Pancreatitis 4000
Electroencephalogram 5121 Exercise for Kids 4129 Anal Fissure 4001
Electromyogram 5122 Exercise for Older Adults 3013 Anal Fistula 4002
Exercise for Teens 3792 Antibiotic-Associated Diarrhea 4041
Endometrial Biopsy 5230
Exercise to Stay Healthy 4118 Botulism 4919
Fast Food 4735 Celiac Disease 4734
Fiber in Your Diet 4711 Chronic Pancreatitis 4005
HIV Tests 4519
Fluid Needs for Good Health 4743 Cirrhosis 4006
Fluid Needs of Older Adults 3014 Constipation 4008
Intravenous Pyelogram 5141 Crohn’s Disease 4009
Fluid Replacement 4122
Lipid Panel Test 5110 Diarrhea 4010
Good and Bad Fats in Your Diet 4709
Liver Panel Test 5140 Grains in Your Diet 4712 Diarrhea in Children 3809
Lumbar Puncture 3417 Healthy Diet 4728 Diverticulitis 4011
Mammogram 5248 Healthy Meal Planning for Children 3754 Diverticulosis 4012
MRI or Magnetic Resonance Imaging 5127 Healthy Snacks for Children 4737 Duodenal Ulcer 4013
Healthy Weight Gain 4713 Food Poisoning 4918
Home Exercise Equipment 4126 Food Poisoning in Children 3815
Newborn Screening Tests 3740
Iron in Your Diet 4741 Gallstones 4014
Pap Test 5129
Keeping a Food Diary 4730 Gastritis 4017
Pelvic Exam 5263 Groin Hernia 4019
Lactose Intolerance 4736
Percutaneous Transhepatic Heartburn 4021
Losing Weight 4714
Low Sodium Diet 3636 Hemorrhoidectomy 4022
Prostate Speci c Antigen Screening 3538 Hemorrhoids 4023
Measuring Body Fat 4132
Sigmoidoscopy 5131 Hernias in Children 3728
Neck Exercises 3211
Strep Test 5142 Nutrition for Healthy Aging 3027 Hiatal Hernia 4027
T4 Test 5134 Obesity 4719 Indigestion 4029
Tests to Diagnose Heart Disease 3652 Personal Fitness Plan 4112 Intestinal Gas 4030
yroid Scan 5132 Reading Food Labels 4724 Irritable Bowel Syndrome 4031
Running or Jogging 4146 Nausea and Vomiting 5065
TSH Test 5133
Safe Exercise for People Nausea and Vomiting in Children 3819
Ultrasound Scanning 5135
with Heart Disease 4164 Polyps in the Colon and Rectum 4007
Urine Culture 5136 Salt in Your Diet 4725 Rectal Bleeding 4035
Urine Tests 5137 Sports Drinks 4150 Stomach Flu 4037
Vital Signs 4436 Strength Training 4153 Stomach Ulcer 4016
X-Rays 5138 Stretching 4154 Swallowing Di culty or Dysphagia 5071
You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
74 You can call this number for free anytime, day or night.
Traveler’s Diarrhea 4038 Contact Lens Care for Fever in Children 3812
Ulcerative Colitis 4039 Gas Permeable Lenses 4204 Hiccups 4416
Contact Lens Care for
Soft Contact Lenses 4205
Ear, Nose and Throat Genes and Heredity
Crossed or Misaligned Down Syndrome 4314
Assistive Listening Devices for Eyes or Strabismus 4207
the Hearing Impaired 4415 Tay Sachs Disease 3802
Eye Allergy or Allergic Conjunctivitis 4209
Eye Care 4210
Earache in Children 3810 Health Promotion
Eye Exam 4211
Earwax 3953 A Healthy Lifestyle for Older Adults 3000
Eye Symptoms Demanding
Hearing Aids 4414 Immediate Attention 4212 Bathroom Safety 4651
Hearing Loss in Adults 3954 Eyeglass Care 4225 Childproo ng Your Home 4653
Hearing Loss in Children 3727 Eyelid Cyst or Chalazion 4213 Drowning Prevention in Children 4656
Laryngitis 3955 Eyestrain 4214 Falls Prevention and Home Safety 4670
Ménière’s Disease 3962 Flashes and Floaters 4215 Hazards of Smoking 3332
Middle Ear Infection 3950 Glaucoma 4216 Health Changes with Aging 3016
Noise and Hearing Loss 4662 Lazy Eye or Amblyopia 4217 Home Healthcare 3017
Nosebleed 3956 Macular Degeneration 4228 How to Choose a
Primary Care Provider 4405
Outer Ear Infection 3951 Pinkeye or Conjunctivitis 4218
Insect Repellent Use 4945
Ruptured Eardrum 3957 Presbyopia 4229
Management of Your Personal Health 4659
Sinus Headache 3427 Retinal Detachment 4219
Nicotine Withdrawal 3376
Sinus Headache in Children 3821 Scratch on the Surface of
the Eye or Corneal Abrasion 4206 Personal Emergency Response Systems 3040
Something in Your Eyes 4220 Routine Healthcare for Men 4672
Stye 4221 Routine Healthcare for Women 4673
Sore roat 3959 Safe Driving for Older Adults 3041
Sore roat in Children 3822 Safety Eyewear 4226
Types of Contact Lenses 4223
Speech and Language Problems 3767 Safety Seats for Children 4674
Speech erapy for Children 4424 Feet Secondhand Smoke 4423
Telephone Assistive Devices 4431 Athletic Shoes 4106 Smokeless Tobacco 3361
Tinnitus 5072 Bunion 3168 Talking with Your Healthcare Provider 4430
Choosing Shoes at Fit 3180 Ways to Quit Smoking 3362
Emergency Medicine Flat Feet in Children 3181
Appendicitis 4003 Foot Care 3182 Heart and Blood Vessels
Biological Terrorism Agents 4903 Hammertoe 3190 Aneurysm 3600
Carbon Monoxide Poisoning 4944 Heel Pain 3191 Angina 3601
Chemical Terrorism Agents 4907 Ingrown Toenail 3196 Angioplasty 3602
Choking 4909 Morton’s Neuroma 4133 Aortic Valve Regurgitation 3603
Electric Shock 4912 Over-Pronation 3220 Aortic Valve Stenosis 3604
Heat Illness 4924 Plantar Fasciitis 3224 Atherosclerosis 3605
Plantar Warts 4863 Atrial Fibrillation 3606
Eyes Running Shoes 4147 Cardiac Arrest 3609
Astigmatism 4224 Cardiac Rehabilitation 3610
Cataracts 4200 General Health Cardiomyopathy 3611
Color Blindness 4202 Dehydration 4910 Congenital Heart Disease 3614
Common Vision Problems 4203 Fever 5057 Coronary Artery Disease 3618
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. 75
Deep Vein rombosis 3621 Chickenpox in Children 3805 Strep roat 3960
Early Warning Signs of a Heart Attack 3624 Chlamydial Infection in Men 4503 Syphilis 4537
Exercise Test 3623 Chlamydial Infection in Women 4504 Tetanus 4538
Heart Attack or Myocardial Infarction 3640 Cytomegalovirus 5316 Trichomoniasis 4539
Heart Catheterization 3625 Dengue Fever and Tuberculosis 4540
Heart Conditions in Pregnancy 5324 Dengue Hemorrhagic Fever 4507 Viral Infections in Children 3713
Heart Disease and Women 3653 E. Coli Infection 4920 Viral Meningitis in Adults 3434
Heart Disease Prevention 4660 Ehrlichiosis 4546 Viral Meningitis in Children 3785
Heart Failure 3627 Fifth Disease 4508 West Nile Virus 4542
Heart Murmur 3628 Flu or In uenza in Children 3813 Whooping Cough 3787
Heart Palpitations 3629 Genital Herpes 4510 Yeast Infection 5297
High Blood Pressure 3631 Genital Warts 4511
High Cholesterol 3632 Giardiasis 4547 Injuries
Holter Monitors 5126 Gonorrhea 4512 Achilles Tendon Injury 3150
Infective Endocarditis 3634 Group A Strep Disease 4513 ACL or Anterior Cruciate
H1N1 or Swine Flu 4560 Ligament Injury 3153
Low Blood Pressure 3635
H1N1 or Swine Flu in Children 3816 Animal and Human Bites 4900
Mitral Valve Prolapse 3637
Hand-Foot-and-Mouth Disease 4514 Ankle Sprain 3152
Mitral Valve Regurgitation 3638
Helicobacter Pylori 4042 Baseball Finger or Mallet Finger 3208
Mitral Valve Stenosis 3639
Hepatitis A 4024 Broken Ankle 3164
Hepatitis B 4025 Broken Arm or Forearm Fracture 3260
Hepatitis C 4026 Broken Collarbone 3257
Tachycardia or PSVT 3643 Herpes Encephalitis 4515 Broken Elbow 3165
Pericarditis 3644 HIV and AIDS Risk Factors Broken Finger 3166
Peripheral Artery Disease 3645 and Prevention 4500 Broken Toe 3258
Pulmonary Embolism 4812 HIV Infection and AIDS 4516 Broken Wrist 3167
Super cial rombophlebitis 3648 HIV Infection from Blood Transfusions 4517 Bruise 4905
Triglycerides 3649 Human Papillomavirus 4520 Bruised Hip or Hip Pointer 3262
Varicose Veins 3650 Infectious Mononucleosis 4521 Burn and Scald Prevention 4669
Ventricular Tachycardia 3651 Legionnaires’ Disease 4523 Burns 4915
Lice 4524 Collapsed Lung Caused by Injury 4807
Hormones Listeriosis 4548 Concussion 3406
Hyperthyroidism 3914 Lyme Disease 4525 Cuts, Scrapes, and Scratches 4934
Hypothyroidism 3916 Measles 4550 Dislocated Elbow 3176
Pituitary Tumors 3918 Mumps 4551 Electric Shock Prevention 4913
Pelvic In ammatory Disease 5264 Finger Dislocation 3178
Infectious Disease Pinworms 4526 Finger Sprain 3179
Anthrax 4901 Rabies 4549 Fracture Treatment 3185
Antibiotic-Resistant Infections 4552 Rheumatic Fever 4527 Frostbite 4922
Bacterial Meningitis in Adults 3402 Roseola in Children 4529 Golfer’s Elbow 3261
Bacterial Meningitis in Children 3705 Rubella 4530 Groin Strain 4123
Bird Flu 4543 Salmonellosis 4509 Hamstring Strain 4125
Bone Infection 3162 Seasonal Flu 4522 Head Injury 3413
Cat Scratch Disease 4544 Sexually Transmitted Diseases 4533 Hip Fracture 3193
Chickenpox 4545 Shingles 4534 Hip Fracture Prevention 3030
You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
76 You can call this number for free anytime, day or night.
Hypothermia 4927 Chronic Bronchitis 4805 Nitroglycerin and Other Nitrates 4269
Hypothermia in Older Adults 3020 Chronic Obstructive Nonprescription Medicines 4270
Insect Bites and Stings 3105 Pulmonary Disease 4806
Jumper’s Knee 3197 Collapsed Lung Not Related to Injury 4808
Sleeping Pills 4271
Knee Cartilage Tear or Meniscal Tear 3200 Common Cold 4506
Knee Sprain 3202 Common Cold in Children 3806
Talking with Your Provider
Lateral Collateral Ligament Sprain 3264 Cough 4809 about Your Medicines 4256
Little Leaguer’s Elbow 3265 Cough in Children 3807
Using Medicines Safely 4268
Medial Collateral Ligament Sprain 3266 Cystic Fibrosis 4310
Muscle Strain 3210 Emphysema 4810
Neck Injuries 3212 Peak Flow Meter 4821 Men’s Health
Neck Stinger 4136 Pleurisy 4820
Enlarged Prostate 4600
Neck Strain 3214 Pneumonia 4811
Prostate Problems 4607
Nose Injury 3270 Pulmonary Function Tests 4813
Testicular Self-Exam 4611
Overuse Injuries 4139 Respiratory Syncytial Virus or RSV 3794
Pulled Elbow in Children 3227 Sleep Apnea 4815
Vasectomy Reversal 4331
Puncture Wound 4929 oracentesis 4818
Rotator Cu Injury 3229 Using Oxygen at Home 4819
Mouth and Teeth
Runner’s Knee 3230
Medications Bad Breath 3850
Shin Pain or Shin Splints 4148
ACE Inhibitors 4250 Canker Sore 4853
Shoulder Dislocation 3236
Shoulder Injuries 3237 Anabolic Steroids 4103 Canker Sores in Children 3804
Shoulder Separation 3239 Antacids 4251 Choosing a Dentist 3851
Snakebite 4936 Antibiotics 4252 Cold Sores or Fever Blisters 4505
Spider Bites and Scorpion Stings 4939 Anticoagulants and Antiplatelets 4277 Dental Care for Adults 3856
Spinal Cord Injury 3429 Antidepressant Medicines 4253 Dental Care for Children 3852
Splinter 4940 Antidiarrheal Medicines 4254 Dental Care for Older Adults 3009
Sprains 3245 Anti-In ammatory Medicines 4255 Denture Care 3854
Stress Fractures 3246 Beta Blockers 4257 Gingivitis 3855
Tendonitis 4157 Calcium Channel Blockers 4258 Periodontal Disease 3857
Tennis Elbow 3248 Corticosteroids 4259 Teeth Grinding in Children 3860
umb Sprain 3249 Cortisone Injection 4278 Teething 3774
Tick Bite 4943 Cough Medicine, Nonprescription 4260 Temporomandibular Joint Disorder 4432
Using Crutches Safely 3253 Cough Medicines and Children 3808
Wound Closure and Wound Care 5015 Decongestants and Antihistamines 4261
Wrist Sprain 3255 Diuretics 4262
Drug Interactions 4263
Lungs Fertility Drugs 4319
Alternative Ways to Control Pain 4438
Acute Bronchitis 4800 Generic and Brand-Name Drugs 4264
Altitude Sickness 4401 Anesthesia 5000
High Blood Pressure Medicines 4266
Asthma 4801 Chronic Pain 4440
Asthma and How to Use Inhalers 4822 Knee Pain 3263
Medicine Safety in Children 3735
Asthma in Children 3701 Neuralgias or Neuropathic Pain 3422
Asthma Inhalers for Children 3803 for Older Adults 3026 Noncardiac Chest Pain 3612
Breathing Exercises 4802 Medicines to Keep on Hand 4273 Patient-Controlled Analgesia 3536
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. 77
Physical and Sports Medicine Induction of Labor 5302 Sexual and Reproductive Health
Deep Heat Treatment 4113 Injury during Pregnancy 5344 Birth Control Methods 4302
Electrical Nerve Stimulation 4116 Labor and Delivery 5247 Birth Control Patch 4303
Ice erapy 4127 Later Childbearing 5328 Birth Control Pills 4304
Low Back Exercises 3204 Leg Cramps during Pregnancy 5329 Cervical Cap 4306
Occupational erapy 4419 Leg Numbness during Pregnancy 5330 Depo-Provera 4311
Physical erapy 3222 Low Back Pain during Pregnancy 5331 Diaphragm 4312
RICE or Rest, Ice, Compression, Mental Illness during Pregnancy 5332 Early Puberty in Boys 3919
and Elevation for Injuries 3271 Miscarriage 5252 Early Puberty in Girls 3920
Ultrasound Treatment 3252 Morning Sickness 5254 Erectile Dysfunction 4601
Natural Family Planning 4326 Female Condom 4317
Pregnancy Nonreassuring Fetal Status 5300 Tubal Ligation 4318
Amniocentesis 5202 Nonstress Test 5305 Homosexuality and Teens 3730
Beta Strep during Pregnancy 5301 Normal Growth of a In Vitro Fertilization 4322
Blood Tests for Birth Defects 5308 Baby during Pregnancy 5257
Breast Care If You Choose Pain in the Vagina during Pregnancy 5339
Not to Breast-Feed 5313 IUD 4324
Pain Relief in Labor and Delivery 5306
Cesarean Section 5216 Male Condom 4325
Physical Abuse During Pregnancy 5334
Chickenpox during Pregnancy 5315 Morning-After Pill or
Postpartum Care 5267 Emergency Birth Control 4315
Child Spacing 4307
Pregnancy and Weight Control 5335 Painful Intercourse 5262
Choosing a Healthcare
Provider for Your Pregnancy 5217 Pregnancy Tests 5271 Pregnancy Prevention for
Chorionic Villus Sampling 5218 Prenatal Care 5274 Young Men and Women 3755
Contraction Stress Test 5312 Prenatal Tests 5275 Premature Ejaculation 4606
Counseling during Pregnancy 5319 Preterm Labor 5309 Puberty for Boys 3757
Danger Signs in Pregnancy 5221 Rh Incompatibility 5311 Puberty for Girls 3758
Diabetes in Pregnancy 5223 Round Ligament Pain in Pregnancy 5338 Rape 4930
Diet during Pregnancy 5225 Ruptured Membranes 5277 Sensual Touch 4434
Drinking Fluids during Pregnancy 5323 Sex during Pregnancy 5278 Sex erapy 3359
Drug, Alcohol, and Tobacco Use Skin Changes during Pregnancy 5281 Sexual Abstinence 4332
During Pregnancy 5227 Slowed Growth of Baby Sexual Problems 3378
Ectopic Pregnancy 5228 during Pregnancy 5340 Sexual Response in Men 4610
Emotional Stress or Smoking during Pregnancy 5282 Sexual Response in Women 5280
Depression during Pregnancy 5321 Surgery to Close the Cervix 5341 Sexuality in the Later Years 3034
Episiotomy 5232 Swelling in the Hands Sexually Transmitted
Estimating Gestational Age 5299 and Feet during Pregnancy 5342 Disease Prevention 3756
Exercise after Delivery 5233 Teen Pregnancy 4341 Spermicides 4336
Exercise during Pregnancy 5234 Toxoplasmosis during Pregnancy 5343 Talking with Your Child about HIV 4339
Genetic Screening Before Travel When You Are Pregnant 5287 Talking with Your Teen about Sex 4340
or During Pregnancy 5240
Trouble Breathing during Pregnancy 5322 Tubal Sterilization Reversal 4330
Getting Ready for Pregnancy 5241
Trouble Sleeping during Pregnancy 5345 Vaginal Contraceptive Ring 4342
Heartburn during Pregnancy 5325
Types of Baby Movements 5346
High Blood Pressure during Pregnancy 5270
Urinary Frequency during Pregnancy 5347 Skin
Household or Chemical
Exposure during Pregnancy 5326 Vision Changes during Pregnancy 5349 Acne 4850
How Long Should I Stay Working during Pregnancy 5296 Athlete’s Foot 3160
in the Hospital after Delivery? 5327 X-Rays during Pregnancy 5310 Blisters 4851
You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
78 You can call this number for free anytime, day or night.
Boils and Carbuncles 4852 Social and Family Hip Replacement Surgery 3195
Botox Treatment of Wrinkles 4439 Adoption 4300 Implantable Cardioverter
Cellulitis 4854 De brillator or ICD 3633
Adult Day Care Programs 3002
Contact Dermatitis 3106 Knee Replacement Surgery 3201
Advance Directives 3003
Corns and Calluses 3174 Laparoscopic Cholecystectomy 4032
Caring for People with
Dandru 4857 Progressive Dementia 3431 LASIK 4227
Diaper Rash 3718 Caring for Someone with Liposuction 5008
Eczema 3108 Alzheimer’s Disease 3404 Lumpectomy and Removal
Common Problems of New Mothers 5317 of Lymph Nodes 5013
Excessive Hair Growth 4410
Communicating with Your Teen 4309 Nose Reconstruction 5009
Communication in Setting a Broken Bone Without Surgery 3234
Fungal Infection of a Nail 4876
Intimate Relationships 4407 Shoulder Replacement Surgery 3238
Hair Loss in Men 4602
Con ict Management 3372 Spinal Fusion 3242
Hair Loss in Women 5242
Finding and Choosing Child Care 3791 Spinal Instrumentation 3243
Healthy Families 4316 Surgery to Set a Broken Bone 3247
Hospice 4418 Tonsil and Adenoid Removal 3961
Itching in Children 3818
How to Choose a Nursing Facility 3019 Tonsil and Adenoid
Jock Itch 4875
Informed Consent 4308 Removal in Children 3824
New Father 3722 Tracheotomy 5014
Pilonidal Disease 4878
New Mother 3736 Transurethral Resection of the Prostate 4608
Pressure Ulcers 4874
Normal Development Tummy Tuck 5011
18 to 24 Months Old 3744 Vaginal Hysterectomy 5291
Rashes in Infants 3759
Pets and Older Adults 3028
Preparing for the First Day of School 3795 Urinary System
Senior Centers 3033 Acute Kidney Failure 5350
Sibling Relationships 4333 Bladder Infection 5351
Single Parenting 4335 Blood in Urine 5352
Skin Care for Older Adults 3035
Chronic Kidney Failure 5353
Skin Exam 4869
Surgery Cystocele 5320
Skin Infection Around
a Fingernail or Toenail 4877 Abdominal Hysterectomy 5200 Functional Urinary Incontinence 5354
Skin or Soft Tissue Abscess 4870 Arthroscopic Meniscal Surgery 3156 Indwelling Catheter Care 5355
Skin Resurfacing 5010 Breast Enlargement Surgery 5002 Kegel Exercises 5356
Sunburn 4871 Breast Reconstruction Surgery 5003 Kidney Dialysis 5367
Sunburn in Children 3823 Breast Reduction Surgery 5004 Kidney Infection 5357
Tanning Beds 4872 Cataract Surgery 4201 Kidney Stones 5358
Warts 4873 Cholecystostomy 4004 Lithotripsy for Kidney Stones 5359
Warts in Children 3825 Colostomy and Ileostomy 4028 Over ow Incontinence 5360
Cone Biopsy of the Cervix with a Laser 5298 Stress Incontinence in Women 5284
Sleep Disorders Coronary Artery Bypass Surgery 3617 Urge Incontinence 5361
Insomnia 5060 Cryosurgery 5012 Urinary Catheterization 5362
Insomnia in Older Adults 3021 D&C 5220 Urinary Incontinence 5363
Jet Lag 4442 Eyelid Surgery or Blepharoplasty 5005 Urinary Obstruction 5364
Narcolepsy 3421 Gallbladder Removal 4015 Urinary Tract Infection in Men 5365
Nightmares and Night Terrors 3344 Gastrostomy Feeding Tube Placement 4018 Urinary Tract Infection in Women 5366
Sleep Disorders in Children 3766 Heart Transplant 3630 Urination Problems 5074
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. 79
Atrophic Vaginitis 5203
Bartholin’s Gland Cyst 5204
Benign Ovarian Tumor 5205
Bleeding Between Menstrual Periods 5209
Breast Infection 5210
Breast Self-Exam 5211
Breast Tenderness 5314
Cervical Intraepithelial Neoplasia 5213
Cervical Polyp 5214
Feminine Hygiene 5237
Fibrocystic Breast Changes 5239
Heavy or Extended Menstrual Bleeding 5303
Hot Flashes 5243
Menopausal Hormone erapy 5249
Menstrual Cramps 5251
Midcycle Pain 5333
Missed Menstrual Periods 5253
Missed Menstrual Periods
or Amenorrhea due to Exercise 4105
Ovarian Cysts 5259
Pelvic Support Problems 5265
PMS or Premenstrual Syndrome 5273
Polycystic Ovary Syndrome 5307
Postmenopausal Bleeding 5266
Premenstrual Dysphoric Disorder 5272
Sore Nipples 5304
Tipped Uterus 5285
Uterine Fibroids 5288
Uterine Prolapse 5348
Vulvar Dystrophy 5294
You can call L.A. Care’s 24-hour nurse advice line at 1-800-249-3619.
80 You can call this number for free anytime, day or night.
555 West Fifth Street
Los Angeles, CA 90013-3036
Toll Free: 1-888-839-9909