About Your Health Plan

Heart Health

L.A. Care identifies members at risk for heart disease monthly based on blood pressure and cholesterol medications, lab results and doctor visits, hospital and emergency room visits and automatically enrolls members into a free disease management program called L.A. Cares About Your Heart®. The program includes:

• Heart Health materials
• Classes for you and your family to maintain a healthy life
• Nurses to: 
  • Coach you on reducing your risk of heart disease
  • Review your medicines
  • Guide you on healthy eating
  • Give tips for talking with your doctor about your heart health

The program gives your doctor resources on the best care plan for you by giving them health guides to follow and educational materials.

Each year, L.A. Care surveys members on their satisfaction with the program and tracks the number of members with high cholesterol results, high blood pressure and weight management. Based on this feedback the program improves each year.

If you are identified at risk for heart disease, to help you stay heart healthy:  

• Make sure to visit your doctor to get your preventive tests.
• Make sure you write down how much of each medicine you take and how often you take it.  Keep your list in your purse or wallet at all times and take your medicines as your doctor says.

If you would like to sign up for the program or speak with a Care Manager about heart health, call us Monday to Friday (excluding holidays) from 8am - 5pm at 1-855-707-7852 (TTY/TTD: 711).

Outside of our normal operating hours, you can call the Nurse Advice Line 24-hours a day (including holidays) at 1-800-249-3619 (TTY/TTD: 711).

How to contact health plan staff if you have questions about Utilization Management issues

When L.A. Care makes a decision to approve or deny your care, this is called Utilization Management (UM). If you have questions about UM or our UM Process, you can call L.A. Care during business hours:

Monday through Friday, 8 a.m. to 5 p.m.

• The number to call is 1-888-839-9909. This call is free.

To learn more about how decisions about your care are made and services that need an OK, see your Member Handbook (also called "A Helpful Guide to Your Health Care Benefits").

L.A. Care Health Plan provides access to staff for members and practitioners seeking information regarding the Utilization Management process and the authorization of care.

UM staff is available during normal business hours Monday through Friday, 8:00 a.m. - 5:00 p.m. After hours staff is available for urgent requests and assistance to members and practitioners.

• Members and practitioners may use the toll-free number to communicate with UM staff. The toll free number is (877) 431-2273.
• Collect calls regarding UM issues are accepted.
• Members who need language assistance to discuss UM issues may contact L.A. Care at (888) 839-9909 or TDD/TTY 711.

Additional instructions on how to obtain authorizations and communicate with UM staff are listed in your Member Handbook or L.A. Care Provider Manual.

Our policy about financial incentives for providers and staff

When L.A. Care makes a decision to approve or deny your care, this is called Utilization Management (UM). L.A. Care Health Plan wants you to know that decisions about your health care are based on two things:

If the care and/or service is right for your condition and

• If your benefits cover the care and/or service.

L.A. Care doctors and other health care staff do not get money or other rewards when making decisions about your care. L.A. Care does not reward staff to make decisions that result in less care than what is requested.

There is no cost to you when you get services covered by Medi-Cal.

How to get care from your primary care physician (PCP) doctor

You were asked to choose a primary care physician (PCP) doctor and a health plan when you filled out the Medi-Cal enrollment form. Sometimes we cannot give you the PCP doctor you choose. Some of the reasons are:

• the doctor is not taking new patients;
• the doctor does not work with the health plan you chose;
• the doctor only sees patients of a certain age or only women (Ob/Gyns);
• the doctor does not work with L.A. Care.

If you did not get the PCP doctor or health plan you chose, call L.A. Care at 1-888-839-9909 to see if that PCP doctor or health plan is available.

Each member has a PCP doctor. A PCP doctor can even be a clinic. You can pick one PCP doctor for all members of your family in Medi-Cal. Or, you can pick a different PCP doctor for each member of your family in Medi-Cal. Women can choose an Ob/Gyn or family planning clinic as their PCP doctor.

Your PCP doctor

Your PCP doctor gives you "primary" or basic medical care. Health care services you can get from your PCP doctor include:

Routine care

• Checkups (also called "well visits"). This is when you see your PCP doctor when you are not sick, like when you need shots. It is important to see your PCP doctor even when you are not sick!
• Sick care. These visits are when you see your PCP doctor when you are not feeling well.

When you need a checkup or if you get sick, you need to go to your PCP doctor. Call your PCP doctor. The phone number is on your ID card.

Start getting your care now! Call your PCP doctor for a checkup.

It is important for a new member to get a checkup even if you are not sick. Be sure to schedule this checkup soon after becoming an L.A. Care member. Call your PCP doctor today to make an appointment for a "new member checkup."

How to change your primary care physician (PCP) doctor

If you didn't choose a PCP doctor when you enrolled in Medi-Cal, a PCP doctor was chosen for you by L.A. Care. Your PCP doctor was chosen for you based on:

• the language you speak
• your age
• how close you live to the PCP doctor's office

It is best to keep the same PCP doctor. Your PCP doctor gets to know your health history and health needs. But sometimes you cannot stay with your PCP doctor. You can choose a PCP doctor from the L.A. Care network shown in the provider directory mailed to you with this handbook. Call L.A. Care for another copy of the provider directory or to help you choose another PCP doctor.

You can change your PCP doctor for any reason if you are not happy. To change your PCP doctor, call L.A. Care. You may choose a PCP doctor within the first 30 calendar days of enrollment and change at least monthly after that.

Things to remember if you choose a new PCP doctor:

• Some doctors work within a group of doctors with certain specialists, hospitals and other health care providers. If you need a specialist, your PCP doctor may send you to these providers. If you are going to a specialist already or want to use a specific hospital, talk with the PCP doctor you are choosing.
• A PCP is a doctor or even a clinic. You can pick one PCP doctor for all members of your family in Medi-Cal. Or, you can pick a different PCP doctor for each member of your family in Medi-Cal. Women may choose an Ob/Gyn or family planning clinic as their PCP doctor.
• Ask about office access if you or a family member has a disability.

The PCP doctor you choose may not agree to treat you and may ask L.A. Care to make a change. This can happen if:

• you are disruptive or disrespectful to your doctor or your doctor's office staff; or
• you do not follow your doctor's treatment plan; or
• the service or care you need are not within the doctor's scope of care (like a high-risk pregnancy)

What services you can and cannot get outside of Los Angeles County.

If you travel outside of Los Angeles County

As a member of L.A. Care, your service area is Los Angeles County. All locations outside of Los Angeles County are out of your service area.

Routine care is not covered out of service area. Emergency and urgent care services are covered outside of Los Angeles County.

Outside of Los Angeles County?

If you have an emergency when you are not in Los Angeles County, you can get emergency services at the nearest emergency facility (doctor's office, clinic or hospital). Emergency services do not require a referral or an okay from your PCP doctor.

If you are admitted to a hospital not in L.A. Care's network or to a hospital your PCP doctor or other provider does not work at, L.A. Care has the right to move you to a network hospital as soon as medically safe.

Your PCP doctor must provide follow-up care when you leave the hospital.

What to do if you get a bill

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Learn about your rights here: For Members on L.A. Care Covered Health Plans.

You may get a bill if you go to a doctor that does not work with L.A. Care or is located outside of L.A. County. If this happens, then you may be billed by the doctor.  If you pay the bill, keep a copy or record of your payment. Send a copy of your payment to L.A Care for review.  If the bill is for covered or authorized services, you may receive a reimbursement from L.A. Care.  If the bill is for covered or authorized services, you may receive a reimbursement from L.A. Care. Please contact LA. Care’s Members Services Department at 1-855-270-2327 (711 TTY/TDD: 711) for assistance.  

How to get information about doctors and specialists who work with your health plan

We are proud of our doctors and their professional training. If you have questions about the professional qualifications of network doctors and specialists, call L.A. Care. L.A. Care can tell you about the medical school they attended, their residency or board certification.

How to get specialty care when you need it, like services that require a referral, behavioral health services and hospital services.

Referrals to Specialty Physicians

Specialists are doctors with training, knowledge, and practice in one area of medicine.  For example, a cardiologist is a heart specialist and who has years of special training to deal with heart problems.
 
Your PCP will ask for prior authorization if he or she thinks you should see a specialist.

Referral to Non-physician Providers

You may get services from non-physician providers who work in your PCP's office.  Non-physician providers may include, but are not limited to, clinical social workers, family therapists, nurse practitioners, and physician assistants.

Standing Referrals

You may have a chronic, life-threatening or disabling condition or disease such as HIV/AIDS.  If so, you may need to see a specialist or qualified health care professional for a long length of time.  Your PCP may suggest, or you may ask for, what is called a standing referral.
 
A standing referral to a specialist or qualified health care professional needs prior authorization.  With a standing referral, you will not need authorization to visit the specialist or qualified health care professional.  You may ask for a standing referral to a specialist that works with your PCP or with a contracted specialty care center.
 
The specialist or qualified health care professional will develop a treatment plan for you.  The treatment plan will show how often you need to be seen.  Once the treatment plan is approved, the specialist or qualified health care professional will be authorized to provide health services.  The specialist will provide health services in his or her area of expertise and training and based on the treatment plan.

Behavioral Health Care

Mental health services may include treatment for anxiety, behavior health problems or depression. Your PCP will provide you with some outpatient mental health services, within the scope of their training and practice. Specialized mental health services may be needed for services beyond your PCP doctor's training and practice and may require a referral to a provider that specializes in behavioral health treatment.

Hospital Services

Hospital services customarily furnished by a hospital will be covered when medically necessary and authorized. Your PCP or specialist caring for you will request authorization when you need hospital care. For a list of these hospital services, please refer to Your Benefits for Inpatient Hospital Services and Outpatient Hospital Services.

How to get care when the office is closed, like weekends, holidays and evenings

If you need care when your PCP doctor's office is closed (like after normal business hours, on the weekends or holidays), call your PCP doctor's office. Ask to speak to your PCP doctor or to the doctor on call. A doctor will call you back.

For urgent care (this is when a condition, illness or injury is not life-threatening, but needs medical care right away), call or go to your nearest urgent care center. Many of L.A. Care's doctors have urgent care hours in the evening, on weekends or during holidays.

How to get emergency care, like when to go to the emergency room or call 911.

Emergency services

Emergency services are covered 24-hours a day, seven days a week, anywhere. Emergency care is a service that a member reasonably believes is necessary to stop or relieve:

• Sudden serious illnesses or symptoms
• Injury or conditions requiring immediate diagnosis and treatment

Emergency services and care include ambulance, medical screening, exam and evaluation by a doctor or appropriate personnel. Emergency services include both physical and psychiatric emergency conditions.

Examples of emergencies include but are not limited to:

• Having trouble breathing
• Seizures (convulsions)
• Lots of bleeding
• Unconsciousness/blackouts (will not wake up)
• In a lot of pain (including chest pain)
• Swallowing of poison or medicine overdose
• Broken bones
• Head injury
• Eye injury
• Thoughts or actions about hurting yourself or someone else

If you think you have a health emergency, call 911. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine health care.

What to do in an emergency

Call 911 or go to the nearest emergency room if you have an emergency. Emergency care is covered at all times and in all places.

How to complain when you are unhappy about care or service you get.

Complaints: What should I do if I am unhappy?

If you are not happy, are having problems or have questions about the service or care given to you, let your PCP doctor know. Your PCP doctor may be able to help you or answer your questions. If you are still not happy, you may file a grievance with L.A. Care.

What is a grievance?

A grievance is a complaint. This complaint is written down and tracked. You might be unhappy with the health care services you get or how long it took to get a service, and have the right to complain.

Some examples are complaints about:

• The service or care your PCP doctor or other providers give you
• The service or care your PCP doctor's medical group gives you
• The service or care your pharmacy gives you
• The service or care your hospital gives you
• The service or care L.A. Care gives you

How to file a grievance

You have many ways to file a grievance. You can do any of the following:

• Write, visit or call L.A. Care. You may also file a grievance online through L.A. Care's Web site at www.lacare.org
  L.A. Care Health Plan
  Member Services Department
  1200 West 7th Street
  Los Angeles, CA 90017
  1-888-839-9909
  213-438-5748 (fax)
• Fill out a grievance form at your doctor's office.
• You can ask for a State Fair Hearing:
  • You can ask for a State Fair Hearing before, during or after filing a grievance with your health plan
  • You can file a grievance with your health plan and ask for a State Fair Hearing at the same time

L.A. Care can help you fill out the grievance form. Or, we can send you a form for you to fill out and send back to us. Within five calendar days of receiving your grievance, you will get a letter from L.A. Care saying we have your grievance and are working on it. Then, within 30 calendar days of receiving your grievance, L.A. Care will send you a letter explaining how the grievance was resolved.

Filing a grievance or requesting a State Fair Hearing does not affect your medical benefits. If you file a grievance or request a Fair Hearing, you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call L.A. Care.

Grievances for Medi-Cal eligibility are not processed by L.A. Care. To file a grievance about Medi-Cal eligibility, call DPSS.

How to appeal a decision or ask for an independent review if you are denied services, coverage or benefits; or if you are disenrolled from your health.

If you don't agree with the outcome of your grievance

If you do not hear from L.A. Care within 30 calendar days, or you do not agree with the decision about your grievance, you may request a State Fair Hearing and you may file a grievance with the Department of Managed Health Care (DMHC). For more information about State Fair Hearing, go to the "State Fair Hearing" section below. For information on how to file a grievance with DMHC, go to "Contacting the Department of Managed Health Care (DMHC)" section below.

How to file a grievance for health care services denied or delayed as not medically necessary

If you believe a health care service has been wrongly denied, changed, or delayed by L.A. Care because it was found not medically necessary, you may file a grievance. This is known as a disputed health care service.

Within five calendar days of receiving your grievance, you will get a letter from L.A. Care saying we have received your grievance and that we are working on it. The letter will also let you know the name of the person working on your grievance. Then, within 30 calendar days you will receive a letter explaining how the grievance was resolved.

Filing a grievance or requesting a State Fair Hearing does not affect your medical benefits. If you file a grievance or a request for a State Fair Hearing, you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call L.A. Care.

If you don't agree with the outcome of your grievance for health care services denied or delayed as not medically necessary.

If you do not hear from L.A. Care within 30 calendar days, or you do not agree with the decision about your grievance, you may request a State Fair Hearing and you may file a grievance with DMHC. For more information about State Fair Hearing, go to the "State Fair Hearing" section below. For information on how to file a grievance with DMHC, go to "Contacting the Department of Managed Health Care (DMHC)" section below.

How to file a grievance for urgent cases

Examples of urgent cases include:

• Severe pain
• Potential loss of life, limb or major bodily function
• Immediate and serious deterioration of your health

In urgent cases, you can request an "expedited review" of your grievance. You will receive a call and/or a letter about your grievance within 24 hours. A decision will be made by L.A. Care within three calendar days (or 72 hours) from the day your grievance was received.

You have the right to request an expedited "State Fair Hearing." You can request an expedited "State Fair Hearing" and file a grievance with or L.A. Care. For more information about State Fair Hearing, go to the "State Fair Hearing" section below.

You have the right to file an urgent grievance with DMHC without filing a grievance with L.A. Care. For information on how to file a grievance with DMHC, go to "Contacting the Department of Managed Health Care (DMHC)" section below.

If you don't agree with the outcome of your grievance for urgent cases

If you do not hear from L.A. Care within 30 calendar days, or you do not agree with the decision about your grievance, you may request a State Fair Hearing and you may file a grievance with the Department of Managed Health Care (DMHC). For more information about State Fair Hearing, go to the "State Fair Hearing" section below. For information on how to file a grievance with DMHC, go to "Contacting the Department of Managed Health Care (DMHC)" section below.

Independent Medical Review

You may request an Independent Medical Review (IMR) from DMHC. You have up to six months from the date of denial to file an IMR. You will receive information on how to file an IMR with your denial letter. You may reach DMHC toll-free at 1-888-466-2219.

You may still request a State Fair Hearing if you request an IMR. However, you will not be able to use the IMR process if you have requested a State Fair Hearing. Go to the "State Fair Hearing" below to find out how to file a complaint.

There are no fees for an IMR. You have the right to provide information to support your request for an IMR. After the IMR application is submitted, a decision not to take part in the IMR process may cause you to lose certain legal rights to pursue legal action against the plan.

When to File an Independent Medical Review (IMR)

You may file an IMR if you meet the following requirements:

• Your doctor says you need a health care service because it is medically necessary and it is denied; or
• You received urgent or emergency services determined to be necessary and they were denied; or
• You have seen a network doctor for the diagnosis or treatment of the medical condition, even if the health care services were not recommended.
• The 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 medically necessary, and
• You have filed a grievance with L.A. Care and the health care service is still denied, changed, delayed or the grievance remains unresolved after 30 days.

You must first go through the L.A. Care grievance process, before applying for an IMR. In special cases, the DMHC may not require you to follow the L.A. Care grievance process before filing an IMR. The dispute will be submitted to a DMHC medical specialist if it is eligible for an IMR. The specialist will make an independent decision on whether or not the care is medically necessary. You will receive a copy of the IMR decision from DMHC. If it is decided that the service is medically necessary, L.A. Care will provide the health care service.

Non-urgent cases

For non-urgent cases, the IMR decision must be made within 30 days. The 30-day period starts when your application and all documents are received by DMHC.

Urgent cases

If your grievance is urgent and requires fast review, you may bring it to DMHC's attention right away. You will not be required to participate in the health plan grievance process.

For urgent cases the IMR decision must be made within three calendar days from the time your information is received.

Examples of urgent cases include:

• Severe pain
• Potential loss of life, limb or major bodily function
• Immediate and serious deterioration of your health

IMRs for Experimental and Investigational Therapies (IMR-EIT)

You can request an IMR-EIT through the DMHC when a medical service, drug or equipment is denied because it is experimental or investigational in nature. L.A. Care will notify you in writing that you may request an IMR-EIT within five days of the decision to deny coverage. You have up to six months from the date of denial to file an IMR-EIT. You may give information to the IMR-EIT panel. The IMR-EIT panel will give you a written decision within 30 days from when your request was received. If your doctor thinks that the proposed therapy will be less effective if delayed, the decision will be made within seven days of the request for an expedited review. In urgent cases the IMR-EIT panel will give you a decision within three business days from the time your information is received.

You may file an IMR-EIT if you meet the following requirements:

1. You have a very serious condition that is "life threatening" or "debilitating" (for example, terminal cancer).

2. Your doctor must certify that:

• The standard treatments were not or will not be effective, or
• The standard treatments were not medically appropriate, or
• The proposed treatment will be the most effective.

3. Your doctor certifies in writing that:

• A drug, device, procedure or other therapy is likely to work better than the standard treatment
• Based on two medical and scientific documents, the recommended treatment is likely to work better than the standard treatment.

4. You have been denied a drug, equipment, procedure or other therapy recommended or requested by your doctor.

5. The treatment would normally be covered as a benefit, but L.A. Care has determined that it is experimental or investigational in nature.

To find out more, get help with the IMR or IMREIT process, or ask for an application form, please call L.A. Care.

You do not need to participate in L.A. Care's grievance process before asking for an IMR of a decision to deny coverage on the basis that the treatment is experimental or investigational in nature.

Contacting the California Department of Managed Health Care (DMHC)

The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-839-9909 and use your health plan's grievance process before contacting the DMHC. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the DMHC for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

The DMHC also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The DMHC's internet website, http://www.dmhc.ca.gov, has complaint forms, IMR application forms and instructions online.

State Fair Hearing

A State Fair Hearing is another way you can file a grievance. You can present your case directly to the State of California. All L.A. Care members have the right to ask for a State Fair Hearing at any time within 90 days of the incident. You may still request a State Fair Hearing if you request an IMR. However, you will not be able to use the IMR process if you have requested a State Fair Hearing. Go to the "IMR" section to find out more.

You may ask for a State Fair Hearing by calling toll-free 1-800-952-5253 (English and Spanish), or by writing to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 19-37
Sacramento, CA 94244-2430

Expedited State Hearing

In cases of health services denials, you or your provider may ask for a faster decision through an Expedited State Hearing if your life, or health, or ability to attain, maintain or regain maximum function could be seriously risked by going through a standard State Fair Hearing. An emancipated minor, a parent on behalf of his/her minor child, and a duly-appointed guardian or conservator of a member may also request an Expedited State Hearing. Requests for Expedited State Hearings should be directed to:

Expedited Hearings Unit
California Department of Social Services
State Hearings Division
744 P Street, MS 19-65
Sacramento, CA 95814
Fax: 916-229-4267

You can also call the DPSS Los Angeles County office toll-free at 1-877-481-1044. If you do not speak English, please stay on the line and ask for the language you speak. DPSS has staff who speaks Armenian, Chinese, Russian, Spanish, Tagalog and Vietnamese. You may also write to:

Department of Public Social Services (DPSS)
State Fair Hearings Section
P.O. Box 10280
Glendale, CA 91209

Ombudsman Office

You may call the Ombudsman Office of the California Department of Health Services (CDHS) for help with grievances. The Ombudsman Office was created to help Medi-Cal beneficiaries to fully use their rights and responsibilities as a member of a managed care plan. To find out more, call toll-free 1-888-452-8609.

Arbitration: Solving problems without going to court

L.A. Care knows that some members wish to get health care services from a health plan that uses arbitration. When you choose arbitration, you give up the right to have your problem settled by a judge or jury. Many view arbitration as cheaper, quicker and better than the courts.

During arbitration, a neutral (unbiased) arbitrator will listen to everyone and make a decision. You and your doctor or health plan must follow that decision. That is why the process is often called "binding" arbitration.

The party that does not win will pay for the costs unless the arbitrator decides otherwise. That being said, the winning party will never be responsible for more than legal fees and costs or more than one-half of the costs.

L.A. Care may pay some or all of the fees and expenses of the arbitrator in cases of great financial hardship. Please contact L.A. Care for information and an application. Arbitration does not apply to claims or disputes about alleged medical malpractice.

Voluntary mediation

You may ask for mediation to resolve a grievance. An independent third person will resolve your grievance. This person is not related to L.A. Care. You and L.A. Care must agree to use the mediation process. You may ask for mediation, but L.A. Care may decline your request. You may still file a grievance with the DMHC even if you use mediation. You do not need to participate in L.A. Care's mediation process for any longer than 30 days prior to submitting a grievance to the DMHC. To request mediation, call L.A. Care.

How your health plan evaluates new technology to decide if it should be a covered benefit

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