Member Handbook - Los Angeles County Department of Health ...

Member Handbook07/06Community Health Plan is an affiliate of L.A. Care Health Plan in providingMedi-Cal Managed Care coverage in Los Angeles County.English/Tagalog

Medi-Cal Member Handbook / Benefit Year 2006-2007As a Member of L.A. Care Health Plan,you have a right to…Respectful and courteous treatment. You have theright to be treated with respect, dignity and courtesyfrom your health plan’s providers and staff. You havethe right to be free from retaliation or force of any kindwhen making decisions about your care.Privacy and confidentiality. You have a right to havea private relationship with your provider and to haveyour medical record kept confidential. You also have aright to receive a copy of and request corrections toyour medical record. If you are a minor, you have aright to certain services that do not need your parent’sokay.Choice and involvement in your care. You have theright to receive information about your health plan andits services. You have the right to choose your PrimaryCare Physician (doctor) from the doctors and clinicslisted in your health plan’s provider directory. Youalso have the right to get appointments within areasonable amount of time. You have a right to talkwith your doctor about any care your doctor providesor recommends. You have the right to a secondopinion. You have a right to information abouttreatment regardless of the cost or what your benefitsare. You have the right to say “no” to treatment. Youhave a right to decide in advance how you want to becared for in case you have a life-threatening illness orinjury.Voice your concerns. You have the right to complainabout L.A. Care, the health plans we work with, or ourproviders without fear of losing your benefits. L.A.Care will help you with the process. If you don’t agreewith a decision, you have a right to ask for a review.You have a right to disenroll from your health planwhenever you want. As a Medi-Cal member, youhave a right to request a State Fair Hearing.Service outside of your health plan’s providernetwork. You have a right to receive emergency orurgent services as well as family planning and sexuallytransmitted disease services outside of your healthplan’s network. You have the right to receive emergencytreatment whenever and wherever you need it.Service and information in your language. You havea right to request an interpreter at no charge and notuse a family member or a friend to translate for you.You have the right to get the Member Handbook andother information in another language or format.Know your rights. You have the right to receiveinformation about your rights and responsibilities. Youcan make recommendations about these rights andresponsibilities.As a Member of L.A. Care Health Plan,you have a responsibility to…Act courteously and respectfully. You are responsiblefor treating your doctor and all providers and staffwith courtesy and respect. You are responsible forbeing on time for your visits or calling your doctor’soffice at least 24 hours before the visit to cancel orreschedule.Give up-to-date, accurate and complete information.You are responsible for giving correctinformation to all of your providers. You are responsiblefor getting regular check-ups and telling yourdoctor about health problems before they becomeserious.Follow your doctor’s advice and take part in yourcare. You are responsible for talking over your healthcare needs with your doctor and following the treatmentyou both agree on.Use the Emergency Room only in an emergency.You are responsible for using the emergency room incases of an emergency or as directed by your doctor.Report wrong doing. You are responsible for reportinghealth care fraud or wrong doing to L.A. Care. Youcan do this without giving your name by calling theL.A. Care Fraud and Abuse Hotline toll-free at 1-800-400-4889.Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Benefit Year 2006-2007Medi-Cal Member Handbook…a helpful guide to getting services(Combined Evidence of Coverage & Disclosure Form)L.A. Care Health Plan555 West Fifth StreetLos Angeles, CA 90013Toll-free: 1-888-452-2273 (1-888-4LA-Care)TTY/TDD: 1-866-LACARE1 (1-866-522-2731)Fax: 213-623-8097Office Hours: Monday thru Friday, 8 a.m. to 5 p.m.Website address: www.lacare.orgCommunity Health Plan1000 South Fremont AvenueBuilding A-9 East, 2 nd Floor, Unit #4Alhambra, CA 91803-8859Toll-free: 1-800-475-5550TDD: 1-800-353-7988Fax: 1-626-299-7258 or1-626-299-7259Office Hours: Monday thru Friday, 8 a.m. to 5 p.m.Website address: www.ladhs.org/chp

Medi-Cal Member Handbook / Benefit Year 2006-2007Table of ContentsThis Member Handbook: Why is it important to you? .................................................................1Whom do I call and when?...................................................................................................................................... 1Helpful information at www.lacare.org on the Internet............................................................................................. 2WELCOME: Now that you are with L.A. Care Health Plan!.........................................................3Your Health Plan Choices with L.A. Care................................................................................................................ 3How to Change Health Plans .................................................................................................................................. 3ID Cards: How do I use them?......................................................................................................4What to do with your L.A. Care/Community Health Plan ID card ............................................................................ 4What to do with your Medi-Cal card (also known as BIC card) ............................................................................... 4Let’s get started: How do I get health care?................................................................................5Your PCP doctor ..................................................................................................................................................... 5Start getting your care now! Call your PCP doctor for a check-up. ........................................................................ 5How to see your PCP doctor................................................................................................................................... 6If you get a bill......................................................................................................................................................... 6What is a second opinion? ...................................................................................................................................... 6How to get a second opinion................................................................................................................................... 6Are you pregnant? Call Community Health Plan at 1-800-475-5550...................................................................... 7How to get health care that your PCP doctor can’t give you ................................................................................... 7How to get a standing referral with a specialist ....................................................................................................... 7Our Provider Network: Who gives me health care?....................................................................8Your PCP doctor gives you most of your care......................................................................................................... 8How to change your PCP doctor............................................................................................................................. 8Kinds of PCP doctors .............................................................................................................................................. 9Picking a Federally Qualified Health Center (FQHC) as your PCP doctor .............................................................. 9How to get care from a specialist ............................................................................................................................ 9Our doctor’s professional qualifications................................................................................................................... 9Certified Nurse Midwives......................................................................................................................................... 9What care can you get from a provider who is not your PCP doctor? ................................................................... 10How to keep seeing your doctor if your doctor leaves your health plan................................................................. 10How to keep seeing your doctor if you are a new member.................................................................................... 10What is Covered: What kinds of health care can I get from Community Health Plan? ...........12iCommunity Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007These benefits are covered................................................................................................................................... 12More Benefits: What other services can I get? .........................................................................19California Children’s Services (CCS)..................................................................................................................... 19Child Health and Disability Prevention (CHDP)..................................................................................................... 19Women, Infants and Children (WIC) Program....................................................................................................... 19Special services for Native American Indians ....................................................................................................... 19Services you can get outside of your health plan.................................................................................................. 19Non-Covered Services: What does Medi-Cal not cover? .........................................................21Pharmacy Benefits: How do I get prescription drugs? .............................................................22What is a pharmacy? ............................................................................................................................................ 22How to get a prescription filled .............................................................................................................................. 22What is a formulary? ............................................................................................................................................. 22Drugs not on the formulary.................................................................................................................................... 22What drugs are covered?...................................................................................................................................... 23What drugs are not covered?................................................................................................................................ 23Emergency contraception...................................................................................................................................... 23Medicare Part D: Prescription drug coverage for beneficiaries who get both Medicare and Medi-Cal ................. 24Emergency Care: How do I get care in an emergency? ............................................................25How to get urgent care.......................................................................................................................................... 25What is emergency care?...................................................................................................................................... 25What to do in an emergency ................................................................................................................................. 25Outside of Los Angeles County?........................................................................................................................... 26What to do after an emergency............................................................................................................................. 26How to get emergency transportation ................................................................................................................... 26Not sure you have an emergency? ....................................................................................................................... 26Help in Another Language and for the Disabled: How can I get help? ................................................................. 27Information in other languages.............................................................................................................................. 27Interpreters for members who don’t speak English or are hearing or speech impaired......................................... 27If you need interpreter services............................................................................................................................. 27Protection for the disabled..................................................................................................................................... 27Complaints ............................................................................................................................................................ 28Complaints: What should I do if I am unhappy?........................................................................29What is a grievance?............................................................................................................................................. 29How to file a grievance.......................................................................................................................................... 29iiCommunity Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007If you don’t agree with the decision....................................................................................................................... 30How to appeal urgent complaints.......................................................................................................................... 30Voluntary mediation .............................................................................................................................................. 30Contacting the California Department of Managed Health Care (DMHC) ............................................................. 30How to appeal health care services denied or delayed as not medically necessary ............................................. 31IMRs for Experimental and Investigational Therapies (IMR-EIT) ......................................................................... 32State Fair Hearing................................................................................................................................................. 33Expedited State Hearing ....................................................................................................................................... 33Ombudsman Office ............................................................................................................................................... 33Arbitration: Solving problems without going to court.............................................................................................. 33Confidentiality: What are my privacy rights?............................................................................35Health information privacy..................................................................................................................................... 35Medi-Cal: How can I make sure I don’t lose my coverage?......................................................37Keeping your Medi-Cal Eligibility........................................................................................................................... 37If you move you must tell us!................................................................................................................................. 37Two types of Medi-Cal .......................................................................................................................................... 37Mandatory Medi-Cal Managed Care members ..................................................................................................... 37Voluntary Medi-Cal Managed Care members ....................................................................................................... 38Voluntary disenrollment......................................................................................................................................... 38Involuntary disenrollments..................................................................................................................................... 38Expedited disenrollment........................................................................................................................................ 39Transitional Medi-Cal ............................................................................................................................................ 39Getting involved: How do I participate? ....................................................................................40Community Health Plan Public Policy Committee................................................................................................. 40L.A. Care Regional Community Advisory Committees (RCAC)............................................................................. 40Board of Governors meetings ............................................................................................................................... 40Communicating policy changes............................................................................................................................. 40More important information: What else do I need to know?....................................................41If you travel outside of Los Angeles County .......................................................................................................... 41How a provider gets paid....................................................................................................................................... 41If you have other insurance................................................................................................................................... 41Workers' Compensation........................................................................................................................................ 41Third party liability ................................................................................................................................................. 41Disruption in services ............................................................................................................................................ 41iiiCommunity Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Organ donation ..................................................................................................................................................... 41What is an advance directive? .............................................................................................................................. 42New technology..................................................................................................................................................... 42Important Phone Numbers...........................................................................................................43Disability Services................................................................................................................................................. 43Children Services.................................................................................................................................................. 43California State Services....................................................................................................................................... 43Health Care Options.............................................................................................................................................. 43Los Angeles County Services ............................................................................................................................... 43DPSS Public Charge Information Lines................................................................................................................. 43ivCommunity Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007This Member Handbook:Why is it important to you?This Member Handbook has important information.Keep this handbook where you can find iteasily. This handbook contains information on:• How and from whom to get care• What types of care are and are not covered• Whom to contact if you have problems• Your rights regarding Medi-Cal and how youare treated.In this handbook, we use “you” and “your” tomean “the Medi-Cal member.” Only themember can get the benefits talked about inthis handbook.Your Member Handbook is also called theCombined Evidence of Coverage and DisclosureForm. It gives only a summary ofL.A. Care Health Plan policies and rules. Youmust look at the contract between L.A. Careand the California Department of HealthServices to learn the exact terms and conditionsof coverage. Call L.A. Care if you wouldlike a copy of the contract.Need this handbook in another language?Call Community Health Plan if you would likeyour handbook in this language. (English)Llame a Community Health Plan si desea unacopia del manual en este idioma. (Spanish)лé³Ó³ÛÝ»ù Community Health Plan, »Ã»ó³ÝϳÝáõÙ »ù ëáõÛÝ ï»Õ»Ï³·ÇñÝ áõݻݳÉÑ»ï»õÛ³É É»½íáí` (Armenian)如 果 您 想 取 得 後 述 語 言 的 手 冊 , 請 致 電Community Health Plan。( 高 棉 文 ) (Chinese)اگر این دفترچه را به این زبان می خواهید ‏(فارسی)‏ بهCommunity Health Plan زنگ بزنید.‏sUmTUrs&BæeTA Community Health Plan ebIG~kcg'VnesovePA t¨maenH CaPasaExµr . (Khmer)Community Health Plan에게 전화를 하시면 이핸드북을 다른 언어로 받아보실 수 있습니다.(Korean)Tumawag sa Community Health Plan kungkailangan mo ang handbook sa lengguwaheng ito.(Tagalog)Позвоните в офис Community Health Plan, еслиВам необходим данный справочник наследующем языке. (Russian)Xin goïi Community Health Plan neáu quyù vòmuoán coù cuoán caåm nang baèng ngoân ngöõ naøy.(Vietnamese)Call Community Health Plan ifyou would like this book in largeprint or alternate format.Whom do I call and when?You can call your Primary Care Physician(PCP)—your doctor —when you:• need an appointment• need a check up• are sick• need urgent care services in Los AngelesCounty• have a health question1Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Your doctor’s name and telephone number are onyour ID card.You can call Community Health Plan whenyou:• need a new ID card• want to change PCP doctor• have questions about services and how to getthem• want to know what’s covered or what is notcovered• need help getting the care you need• get a bill from a doctor• are pregnant• have a problem you cannot solveCommunity Health Plan’s toll-free number is1-800-475-5550.Helpful information at www.lacare.org onthe InternetDo you use the Internet? Our website,www.lacare.org, is a great resource. You can:• Find a doctor• Learn about your benefits• Learn more about privacy rights• Find out about your rights and responsibilities• File a complaint (called a “grievance”)You can also check your eligibility for medicalcoverage. You can even request to change yourhealth plan. Since this information is private, youwill need to log in. Go to www.lacare.org to findout what to do. (Be sure to have your ID cardready as we ask for your Member ID number.)You can call L.A. Care Health Plan when you:• have a problem you cannot resolve• get a bill from a doctor• want to change health plans from CommunityHealth Plan to a different health plan• are unsure whom to callL.A. Care’s toll-free number is 1-888-4LA-Careor 1-888-452-2273.2Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007WELCOME: Now that you arewith L.A. Care Health Plan!Thank you for choosing L.A. Care Health Plan.L.A. Care is a government agency created tenyears ago to help Los Angeles County Medi-Calmembers get quality health care. L.A. Care is alsocalled the Local Initiative Health Authority forLos Angeles County. But you can call us“L.A. Care.”With the help of the health plans we work with,L.A Care serves nearly 800,000 members in LosAngeles County. We only serve people who livein Los Angeles County (called our “servicearea”). L.A. Care Health Plan is the largest publichealth plan in the nation. We are growing becausewe are a trusted source for health care and werespect our members.L.A. Care is a pre-paid health coverage program,called a “health maintenance organization” orHMO. The State of California has givenL.A. Care permission to serve you. The State ofCalifornia pays for your health care. There is nocost to you when you get services covered byMedi-Cal.Your Health Plan Choices with L.A. CareL.A. Care works with five other health plans toprovide health care services for members. L.A.Care and these health plans are licensed with theState of California. L.A. Care and our health planpartners have contracts with many doctors,hospitals, pharmacies and other health careproviders to serve you.When a Medi-Cal member joins L.A. Care, themember can choose to receive services throughone of five health plans:• Blue Cross of California• Care1st Health Plan• Community Health Plan• Kaiser Permanente• UHP HealthcareWhen you picked L.A. Care for your Medi-Cal,you also picked Community Health Plan as yourhealth plan. (If you didn’t pick a health plan, wepicked one for you.) Community Health Plan isresponsible for almost all of your health careservices. Some benefits like dental and vision arenot provided by your health plan. This is talkedabout in the section “More benefits: What otherservices can I get?” in this handbook.How to Change Health PlansWe believe you will like Community Health Plan.But you can change your health plan for anyreason. Call L.A. Care at 1-888-4LA-CARE (1-888-452-2273) to change your health plan. Ifyou call L.A. Care before the 20 th of the month,the change will be effective on the 1 st of the nextmonth. If you call L.A. Care on or after the 20 thof the month, the change will start on the 1 st ofthe month following the next month. When youchange health plans, you will get an ID card fromyour new health plan. Be sure to tear-up your oldhealth plan ID card.Some plans do not serve all of Los AngelesCounty. Call the health plan to ask about theirservice area and to make sure it can serve youbefore you change. You cannot get routine carelike check ups outside of your health plan’sservice area. But don’t worry: No matter whichhealth plan you choose, you can get urgent oremergency care anywhere when you need it –even outside of Los Angeles County.3Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007ID Cards: How do I use them?What to do with your L.A. Care/CommunityHealth Plan ID cardAlong with this handbook you received an L.A.Care/Community Health Plan ID card for everyfamily member covered by Medi-Cal. If you didnot receive an ID card for a family member whois covered by Medi-Cal, call Community HealthPlan right away.Your L.A. Care/Community Health Plan ID cardhas important information on it, including:• Your PCP doctor’s name (or the name of yourclinic or medical group)• Your PCP doctor’s phone numberHere’s what to do with your ID card:What to do with your Medi-Cal card(also known as BIC card)The State of California sent you another ID card,your Medi-Cal Benefits Identification Card (alsocalled a BIC card). You need to show your Medi-Cal card whenever you get services you don’t getfrom L.A. Care/Community Health Plan. Theseservices are talked about in the section, “ Morebenefits: What other services can I get?” in thishandbook. Call the California Department ofPublic Social Services (DPSS), toll-free at 1-877-481-1044 if you need a new Medi-Cal card.Never let anyone use your health plan ID cardor Medi-Cal card. This is called fraud. Youcan lose your Medi-Cal benefits if someone elseuses your ID cards to get care. If you lose yourMedi-Cal benefits, L.A. Care/CommunityHealth Plan will not be able to give you care.• Check to make sure the information on yourID card is correct. Is your name spelled right?Is your birth date right? If anything on yourID card is wrong, call Community Health Planat 1-800-475-5550 right away. CommunityHealth Plan will connect you to the CaliforniaDepartment of Public Social Services (DPSS),toll-free at 1-877-481-1044, to get it fixed.• Keep your ID card in a safe place. If you loseor damage your ID card, call CommunityHealth Plan at 1-800-475-5550.• Show your ID card whenever you:ooooHave a doctor’s appointmentGo to the hospitalNeed emergency servicesPick up a prescription4Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Let’s get started:How do I get health care?In this handbook, we will call your primary carephysician “your PCP doctor.” Your PCP doctor isresponsible for making sure you get the medicalcare you need and are entitled to.You were asked to choose a primary care physician(PCP) doctor and a health plan when youfilled out the Medi-Cal enrollment form. Sometimeswe cannot give you the PCP doctor youchoose. Some of the reasons are:• the doctor is not taking new patients;• the doctor does not work with the health planyou chose;• the doctor only sees patients of a certain ageor only women (Ob/Gyns);• the doctor does not work with L.A. Care.If you did not get the PCP doctor or health planyou chose, call L.A. Care at 1-888-452-2273 tosee if that PCP doctor or health plan is available.Each member has a PCP doctor. A PCP doctorcan even be a clinic. You can pick one PCPdoctor for all members of your family in Medi-Cal. Or, you can pick a different PCP doctor foreach member of your family in Medi-Cal.Women can choose an Ob/Gyn or family planningclinic as their PCP doctor.Your PCP doctorYour PCP doctor gives you “primary” – or basicmedical care. Health care services you can getfrom your PCP doctor include:not sick, like when you need shots. It is importantto see your PCP doctor even when youare not sick!• Sick care. These visits are when you see yourPCP doctor when you are not feeling well.When you need a check-up or if you get sick,you need to go to your PCP doctor. Call yourPCP doctor. The phone number is on your IDcard.Start getting your care now! Call yourPCP doctor for a check-up.It is important for a new member to get a checkupeven if you are not sick. Be sure to schedulethis check-up soon after becoming a L.A.Care/Community Health Plan member. Call yourPCP doctor today to make an appointment fora “new member check-up.” This visit is alsocalled a “well visit” or “initial health assessment.”Your PCP doctor’s telephone number ison your L.A. Care/Community Health Plan IDcard.This first visit is important. Your PCP doctorlooks at your medical history, finds out what yourhealth is today, and can begin any new treatmentyou might need. You and your PCP doctor willalso talk about preventive care. This is care thathelps “prevent” you from getting sick or diseases.And, remember, children need to get a check-upevery year, even when they are not sick to makesure they are healthy and growing properly.L.A. Care gives rewards to babies and teens whoget check-ups! Call L.A. Care for more information.• Routine care.• Check-ups (also called “well-visits”). This iswhen you see your PCP doctor when you are5Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007How to see your PCP doctor1. Call your PCP doctor’s office to schedule anappointment. Your PCP doctor’s phone numberis on your L.A. Care/Community HealthPlan ID card.2. Be on time for your appointment. If you needdirections, ask the PCP doctor’s office.3. If you cannot go to your appointment, call thePCP doctor’s office right away. By cancelingyour appointment, you allow someone else tobe seen by the doctor.4. If you miss your appointment, call right awayto make another appointment.5. Show the PCP doctor’s office your ID cardwhen you are there.Important! You can still get services withoutyour ID card. If you need to see your PCPdoctor, your PCP doctor (or hospital orpharmacy) can call L.A. Care or CommunityHealth Plan so you can get care.If you get a billCommunity Health Plan pays for all coveredmedical costs approved by your PCP doctor or foran emergency. You should not get a bill for anyservices covered by Community Health Plan.Please call Community Health Plan or L.A. Careright away if you receive a bill for medicalservices. Community Health Plan or L.A. Carewill make sure the doctor stops sending you abill. If you get care from a non-contracted provider(a doctor or other provider that doesn't workwith L.A. Care) for any services except emergency,urgent care when you're outside L.A.County, family planning or sexually transmitteddisease testing, then you may be billed by theprovider and may have to pay.What is a second opinion?You have the right to ask for and get a secondopinion. You also have the right to ask fortimelines for making routine and urgent opinionsavailable. A second opinion is a visit with anotherdoctor when:• You question a diagnosis for a chronic conditionor for a condition that endangers your lifeor body. (A diagnosis is when a doctor identifiesa condition, illness or disease.)• You do not agree with your PCP doctor’streatment plan. (A treatment plan is what thedoctor says is best for you, based upon thedoctor’s diagnosis.)• You would like to make sure your treatmentplan is right for you.The second opinion must be from an appropriatelyqualified health care professional in theCommunity Health Plan’s network. (An “appropriatelyqualified health care professional” is anindividual who has the training and expertise totreat or review a specific medical condition.)How to get a second opinionTo get a second opinion:1. Talk to your PCP doctor or CommunityHealth Plan and let them know you wouldlike to see another doctor and the reasonwhy.2. Your PCP doctor or Community HealthPlan will refer you to an appropriatelyqualified health care professional. If thereis no “appropriately qualified health careprofessional” within your plan’s network,Community Health Plan may authorize6Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007(okay) a second opinion by a qualifiedprovider outside the network.3. Call the second opinion doctor to make anappointment.4. Show the doctor’s office your ID card.You may complain if your health plan deniesyour request for a second opinion or you do notagree with the second opinion. This is also called“filing a grievance.” This is talked about in“Complaints: What do I do if I am unhappy?” inthis handbook.Are you pregnant? Call CommunityHealth Plan at 1-800-475-5550Call your health plan right away if you arepregnant or become pregnant. This is because wewant you and your baby to be healthy. When youare pregnant, it is important to get care right awayand throughout your pregnancy.How to get health care that your PCPdoctor can’t give youSometimes you need care your PCP doctor can’tgive you. If you need care from a specialist, yourPCP doctor must okay (authorize) these servicesbefore you receive them. This is called a “referral.”A referral is when you request health careservices your PCP doctor does not normallyprovide.Routine referrals take up to five working days(“working days” are Monday through Friday).Expedited (rush) referrals may not take more thanthree working days. Please call CommunityHealth Plan if you do not get a response by thesetimes.Emergency services anywhere or urgently neededservices when outside of Los Angeles County donot need a referral.How to get a standing referral with aspecialistYou may need to see a specialist (or other appropriatelyqualified health care professional) for along time if you have a chronic (a long-termcondition like diabetes or asthma), lifethreatening(such as HIV/AIDS) or disablingcondition or disease.This is called a “standing referral.” A standingreferral is made to a specialist who is inCommunity Health Plan’s network or who is witha contracted specialty care center. If CommunityHealth Plan does not have a qualified specialist,Community Health Plan will send you to aspecialist outside their network. Once you have astanding referral, you will not need permissionfor each visit with the specialist.A standing referral needs an approval byCommunity Health Plan. You can ask your PCPdoctor for a standing referral. Or, your doctor canask Community Health Plan for a standingreferral. Community Health Plan must decide onyour request for a standing referral within threebusiness days.Your specialist will develop a treatment plan foryou if needed. The treatment plan will show howoften you need to go to the doctor. Once thetreatment plan is approved, the specialist willcoordinate the care you get. This specialist will beauthorized to provide health care services thesame way your PCP doctor would, based onexpertise, training and the treatment plan.7Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Our Provider Network:Who gives me health care?Please read the following information so you willknow from whom or what group of providers youcan get health care.Community Health Plan works with a large groupof doctors, specialists, pharmacies, hospitals andother health care providers. This group is called a“network.” You can get a copy of CommunityHealth Plan’s network by calling CommunityHealth Plan and asking for a provider directory.In most cases, you need to get care withinCommunity Health Plan’s network. That is notthe case if you need emergency care or needurgent care outside of Los Angeles County. Thisis talked about more in the section “EmergencyCare: How Do I Get Care in an Emergency?” inthis handbook.Your PCP doctor gives you most of your careYour PCP doctor is responsible for making sureyou get the health care benefits you need and areentitled to from Medi-Cal.How to change your PCP doctorIf you didn’t choose a PCP doctor when youenrolled in Medi-Cal, a PCP doctor was chosenfor you by L.A. Care. Your PCP doctor waschosen for you based on:• the language you speak• your age• how close you live to the PCP doctor’s officeIt is best to keep the same PCP doctor. Your PCPdoctor gets to know your health history andhealth needs. But sometimes you cannot stay withyour PCP doctor. You can choose a PCP doctorfrom the Community Health Plan network shownin the provider directory mailed to you with thishandbook. Call Community Health Plan foranother copy of the provider directory or to helpyou choose another PCP doctor.You can change your PCP doctor for anyreason if you are not happy. To change yourPCP doctor, call Community Health Plan. Youmay choose a PCP doctor within the first 30calendar days of enrollment and change atleast monthly after that.Things to remember if you choose a new PCPdoctor:• Some doctors work within a group of doctorswith certain specialists, hospitals and otherhealth care providers. If you need a specialist,your PCP doctor may send you to these providers.If you are going to a specialist alreadyor want to use a specific hospital, talk with thePCP doctor you are choosing.• A PCP is a doctor or even a clinic. You canpick one PCP doctor for all members of yourfamily in Medi-Cal. Or, you can pick a differentPCP doctor for each member of yourfamily in Medi-Cal. Women may choose anOb/Gyn or family planning clinic as their PCPdoctor.• Ask about office access if you or a familymember has a disability.The PCP doctor you choose may not agree totreat you and may ask L.A. Care to make achange. This can happen if:• you are disruptive or disrespectful to yourdoctor or your doctor’s office staff; or• you do not follow your doctor’s treatmentplan; or• the service or care you need are not within thedoctor’s scope of care (like a high-risk pregnancy)8Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Kinds of PCP doctorsYou can pick your PCP doctor from theCommunity Health Plan provider directory thatcame with this handbook. The kinds of physiciansthat can be PCP doctors are:• Family Practice• General Practice• Internal Medicine• Pediatricians• Ob/Gyns (for female members only)Some hospitals and other providers do notprovide one or more of the following services thatmay be covered under your plan contract and thatyou or your family member might need:• Family planning• Contraceptive services, including emergencycontraception• Sterilization, including tubal ligation at thetime of labor and delivery• Infertility treatments• AbortionYou should get more information before youchoose. Call your prospective doctor, medicalgroup, independent practice association, or clinicor call Community Health Plan to ensure you canget the health care services you need.Picking a Federally Qualified HealthCenter (FQHC) as your PCP doctorAn FQHC is a clinic and can be your PCP doctor.FQHCs are health centers that get money fromthe federal government because they are locatedin areas without a lot of health care services. CallCommunity Health Plan for the names andaddresses of the FQHCs that work withCommunity Health Plan or look in their providerdirectory.How to get care from a specialistYour PCP doctor is the doctor who makes sureyou get the care you need when you need it.Sometimes your PCP doctor will send you to aspecialist. A “specialist” is a type of doctor whois an expert in some kind of health care. Thesespecialists are within your PCP doctor andCommunity Health Plan’s network. If you needcare from a specialist, your PCP doctor mustapprove these services before you receive them.Routine referrals to a specialist take up to fivework days and rush referrals cannot take morethan three working days (for example, when youneed medical care right away or it’s urgent).Female members who need Ob/Gyn care don’tneed their PCP doctor’s okay to go to an Ob/Gynor family planning doctor with CommunityHealth Plan.Our doctor’s professional qualificationsWe’re proud of our doctors and their professionaltraining. If you have questions about the professionalqualifications of network doctors andspecialists, call Community Health Plan.Community Health Plan can tell you about themedical school they attended, their residency orboard certification.Certified Nurse MidwivesCertified Nurse Midwife (CNM) services areavailable outside of Community Health Plan’snetwork. Pregnant members may see a CNMwithout her PCP doctor’s okay. To find out more,ask your PCP doctor or call Community HealthPlan.9Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007What care can you get from a providerwho is not your PCP doctor?There are some kinds of care that you can getfrom someone other than your PCP doctor:• Emergency care. In an emergency, dial 911.Emergency services do not need a referral oran okay from your PCP doctor or CommunityHealth Plan before you get them.• Urgent care when you are not in Los AngelesCounty and can’t come back to Los AngelesCounty to get care. Call your PCP doctor ifyou are not sure how to get urgent care whenyou are not in Los Angeles County. Your PCPdoctor or your doctor’s office will help you.• Ob/Gyn family planning services and sexuallytransmitted disease testing. You may get theseservices from any health care provider licensedto provide these services. You do notneed to get your PCP doctor’s approval to getthese services.• Specialist care. A “specialist” is a type ofdoctor who is an expert in some kind of healthcare. Your PCP doctor will send you to a specialistif you need one. In most cases, youcannot see a specialist without your PCP doctor’sokay. Pregnant members may see an innetwork Ob/Gyn for Ob/Gyn services withouther PCP doctor’s okay.How to keep seeing your doctor if yourdoctor leaves your health planSometimes Community Health Plan stops workingwith a doctor or hospital. If this happens, wewill let you know as soon as we can. You can askto keep seeing your doctor (including specialistsand hospitals) if that doctor agrees and has beentreating you for any of the following conditions:• Acute condition (a serious and sudden conditionthat lasts a short time like a heart attack,pneumonia or appendicitis) – For the time thecondition lasts.• Serious chronic (long-term) condition – For aperiod of time necessary to complete a courseof treatment and arrange for a safe transfer toanother provider.• Pregnancy – During the pregnancy and immediatepostpartum care (six weeks after givingbirth)• Terminal illnesses/conditions – For the lengthof the illness.• Children ages birth to 36 months – For up to12 months.• You have surgery or other procedure authorizedby Community Health Plan as part of adocumented course of treatment. This treatmentwas set to occur – within 180 days of thetime the doctor or hospital stops working withCommunity Health Plan or – within 180 daysof the time you began coverage withCommunity Health Plan.How to keep seeing your doctor if youare a new memberMembers who have just joined L.A. Care andCommunity Health Plan may ask to keep seeingtheir doctor or hospital if they are in the middle oftreatment or have scheduled treatments or procedures.This is called a “continuity of care”benefit.You will not be eligible for the continuity of carebenefit if EITHER:• you are a new enrollee with CommunityHealth Plan and were offered an opportunityfrom your previous health plan to continuereceiving care from an out-of-network provider;OR• you had the option to continue care from yourprevious provider but chose to change healthplans.10Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Doctors not contracted with Community HealthPlan may be required to agree to the same termsand conditions as contracted providers. If thedoctor does not agree, Community Health Plan isnot required to provide the services through thatdoctor.You can get a copy of Community Health Plan’scontinuity of care policy by calling 1-800-475-5550. Please call Community Health Plan and askhow to request “continuity of care.”11Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007What is Covered: What kindsof health care can I get fromCommunity Health Plan?In order for you to get any health care servicethrough Community Health Plan, the service mustbe both:• A covered benefit in Medi-Cal and• Medically necessaryA “covered benefit” means that you can get thisservice through Medi-Cal and Community HealthPlan. “Medically necessary” means that you needthe service so you can get healthy or stay healthy.• Family planning services• Preventive service• Basic prenatal care• Sexually transmitted disease services• HIV testingCall Community Health Plan at 1-800-475-5550 if you have questions about:• Your benefits• How or where to get benefits• What is covered or not covered.All health care services are reviewed, modified(changed), approved or denied according tomedical necessity. If you would like a copy of thepolicies and procedures Community Health Planuses to decide if a service is medically necessary,call Community Health Plan. No doctor has togive you services that the doctor doesn’t believeyou need. Services are subject to all terms,conditions, limits and exclusions. These aretalked about in the section, “Non-CoveredServices: What does Medi-Cal not cover?” inthis handbook.All services require prior authorization unlessthe benefit says that it does not require priorauthorization. “Prior authorization” means thatyour PCP doctor and Community Health Planagree that services and care are necessary. Priorauthorization must happen before you get theservices or care.Services that do not require prior authorizationare:• Emergency services• Urgently needed services when outside of LosAngeles CountyAll covered benefits are free.These benefits are coveredAlcohol/Drug Abuse• Crisis intervention• Health education servicesAsthma Services• Nebulizers (including face mask and tubing),inhaler spacers and peak flow meters for managementand treatment asthma• Member education on proper use of nebulizers,inhaler spacers and peak flow meters forasthmaCancer Screening• All generally medically accepted cancerscreening tests, including coverage for screeningand diagnosis of prostate cancer• Mammography for breast cancer screening12Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007• Cervical cancer screening test.• Cancer clinical trials. If you have cancer, youmay be able to be part of a cancer clinicaltrial. A cancer clinical trial is a research studywith cancer patients to find out if a new cancertreatment or drug is safe and treats amember’s type of cancer. The cancer clinicaltrial must meet certain requirements, whenreferred by your Community Health Plan doctoror treating provider. The cancer clinicaltrial must have a meaningful potential to benefityou and must be approved by one of thefollowing: the National Institute of Health(NIH), FDA, U.S. Department of Defense orthe U.S. Veteran’s Administration. If you arepart of an approved cancer clinical trial,Community Health Plan will provide coveragefor all routine patient care cost related to thecancer clinical trial.If you have a life threatening or debilitatingcondition or were eligible but denied coveragefor a cancer clinical trial, you have the right torequest an Independent Medical Review(IMR) on the denial. This is talked about inthe section, “Complaints: What should I do ifI am unhappy?” in this handbook.Diabetic Services• Medical equipment• Prescription drugs• Diabetes-related supplies:o Blood glucose monitors and blood glucosetesting stripso Blood glucose monitors designed to assistthe visually impaired for insulin dependent,non-insulin dependent and gestational diabeteso Insulin pumps and all related necessary supplieso Ketone urine testing stripso Lancets and lancet puncture deviceso Pen delivery systems for the administrationof insulino Podiatric devices to prevent or treat diabetes-relatedcomplicationso Insulin syringeso Visual aids, excluding eyewear, to assist thevisually impaired with proper dosing of insulin• Training and health education for selfmanagement• Family education for self-managementDoctor Office Visits• All routine visits, exams, treatments, shots andCHDP visits are provided by your doctor.• Services received from specialist visits.• Any CHDP services from school-based programsor the Los Angeles County Departmentof Health Services. There is more informationabout the Child Health Disability PreventionProgram (CHDP) under “More benefits: Whatother services can I get?” in this handbook.You can also call CHDP at 1-800-993-2437.Drugs/Medications• Prescription drugs and over-the-counter drugson the Community Health Plan formulary arecovered. This is talked about in the section,“Pharmacy Benefits: How do I get prescriptiondrugs?” in this handbook.Durable Medical Equipment (DME)DME is medical equipment used repeatedly (overand over again) by a person who is ill or injured.These items are ordered by your doctor.• Apnea monitors• Blood glucose monitors, including monitorsfor the visually impaired for insulin depend-13Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007ent, non-insulin dependent and gestationaldiabetes• Insulin pumps and all related supplies• Nebulizer machines• Orthotics• Ostomy bags• Oxygen and oxygen equipment• Prosthesis• Pulmo-Aides and related supplies• Spacer devices for metered dose inhalers• Tubing and related supplies• Urinary catheters and related suppliesEmergency ServicesEmergency services are covered 24 hours a day,seven days a week, anywhere. Emergency care isa service that a “prudent layperson” believes isnecessary to stop or relieve sudden seriousillnesses or symptoms, or injury or conditionsrequiring immediate diagnosis and treatment.A “prudent layperson” is a non-medical personwith an average knowledge of health and medicinebut has awareness or information to make agood decision.Emergency services and care include ambulance,medical screening, exam and evaluation by adoctor or appropriate personnel. Emergencyservices cover physical and psychiatric emergencyconditions. Emergency services also coveractive labor or emergency labor and delivery.These are talked about in “Emergency Care:How do I get care in an emergency?” in thishandbook.Family PlanningFamily planning services are provided to membersof child bearing age to help them choose thenumber and spacing of children. These servicesinclude all methods of birth control approved bythe Food and Drug Administration (FDA). Youmay receive family planning services and FDAapprovedcontraceptives from any health careprovider licensed to provide these services.Examples of family planning providers include:• Your PCP doctor• Clinics• Certified Nurse Midwives and Certified NursePractitioners• Ob/Gyn specialists (Ob/Gyns are doctors whospecialize in female reproductive health care.)• Planned Parenthood clinicsFamily planning services also include counselingand surgical procedures for the termination ofpregnancy (called an abortion). Please callCommunity Health Plan to find out more.Many of our doctors who provide family planningservices are also Ob/Gyn specialists. Women maypick a PCP doctor from a list of family planningclinics located near them. Call Community HealthPlan for a copy of this list.Women also have the right to family planningservices given by an Ob/Gyn specialist who is notin Community Health Plan’s network. You do notneed an okay from your PCP doctor to do this.Community Health Plan will pay that doctor orclinic for the family planning services you get.The California Department of Health Services(CDHS), Office of Family Planning, can alsoanswer questions or give you a referral for familyplanning services. You may reach them at 1-800-942-1054.Health Education ServicesCommunity Health Plan has programs to help youstay healthy and take care of yourself. These14Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007programs are free. Health education services helpmembers by:• Promoting health• Preventing diseases• Helping manage chronic diseases (such asasthma, heart disease and diabetes)• Providing information on tobacco, alcohol anddrug abuseHealth education services are delivered through:• Literature (booklets)• Tapes• Classes• Counseling (one-to-one learning or counseling)• Support groups• Diabetic self-management education programsthat include nutrition and counseling.Ask your doctor for health education materialsand classes. You can also call Community HealthPlan.Hearing Aids• Hearing aids are covered when ordered byyour doctor.HIV TestingYou can get confidential HIV testing from anyhealth care provider licensed to provide theseservices. You do not need a referral or okay fromyour PCP doctor or health plan for confidentialHIV testing. Examples of where you can getconfidential HIV testing include:• Your PCP doctor• Los Angeles County Department of HealthServices• Family planning services providers• Prenatal clinicsPlease call Community Health Plan to request alist of testing sites.Home HealthThese services are provided in the home by healthcare personnel for all of the following:• Short-term physical, occupational and speechtherapy• Respiratory therapy when prescribed by alicensed practitioner acting within the scope ofhis or her licensure.Home health services ordered by your doctor areprovided by home health personnel such as:• Registered Nurses (RNs)• Licensed Vocational Nurses (LVNs)• Home Health Aides• Medical Social ServicesIf a service can be provided in more than onelocation, Community Health Plan will work withthe provider to choose the location.Hospice CareCare is limited to terminally ill members expectedto live 12 months or less. If you decide to receivehospice benefits, you are waiving all rights to allother benefits for the terminal illness for theduration of the hospice election.Hospital CareIncludes, but is not limited to:• Inpatient services• Intensive care• Outpatient services15Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Lab Services• Blood work• Urine tests• Throat culturesServices must be provided at a network:• Doctor’s office• Hospital• LaboratoryMastectomy• Mastectomy is a surgery to remove a breast,due to cancer.• Mastectomy• Prosthesis• Reconstructive surgery. See the “ReconstructiveSurgery” in this section for more.You and your doctor decide how long you need tostay in the hospital after the surgery based onmedical necessity.Maternity CareMaternity care includes:• Regular doctor visits during your pregnancy(called “prenatal” visits)• Diagnostic and genetic testing• Nutrition counseling• Labor and delivery care• Health care six weeks after delivery (called“postpartum” care)• Inpatient hospital care for at least 48 hoursafter a normal vaginal deliveries, or for atleast 96 hours after a cesarean section.Coverage for inpatient hospital care may beless than 48 hours or 96 hours if:o The decision is made by the mother andtreating physician, ando A post-discharge follow up visit for themother and newborn is made within 48hours of discharge.If you are pregnant, call Community HealthPlan at 1-800-475-5550 right away. We want tomake sure you get the care you need.Community Health Plan will help you chooseyour maternity care doctor from a doctor in yournetwork. Ask your doctor to find out more.After giving birth, you will receive breastfeedingeducation and special equipment if needed. Askyour doctor, or call Community Health Plan ifyou have any questions.Go to “Women, Infants and Children (WIC)Program” under “More Benefits: What otherservices can I get?” for information about nutritionand food stamps.Minor Consent ServicesThere are some services adolescent members(children ages 12 to 18) can get without a parent’sokay. Minors may choose to get these servicesthrough their PCP doctor or from other qualifiedproviders not with Community Health Plan’snetwork.The following services are covered:• Counseling and surgical procedures to endpregnancy (abortion)• Drug and alcohol abuse services• Family planning services• Outpatient mental health treatment and counseling• Pregnancy related services• Sexual assault services• Sexually transmitted disease (STD) services16Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Newborn CareYour newborn baby will be covered byCommunity Health Plan for the month of birthand the following month.When you have a baby, it is important to dothree things:1. Please call L.A. Care at 1-888-452-2273.We want to make sure you and yourbaby get the care you need right away.2. Contact your eligibility worker at DPSStoll-free at 1-877-481-1044 to enrollyour baby in Medi-Cal. This is importantso that your baby can continue toreceive Medi-Cal benefits!3. Take your baby to the doctor withinthree days after you go home from thehospital. A Community Health Plandoctor in your network should see yournewborn baby within a few days afterbirth. Call Community Health Plan.Newborn baby screenings for certain treatablegenetic disorders are covered. These geneticdisorders include:• Phenylketonuria (PKU)• Galactosemia• Hypothyroidism• Sickle cell disease• Related blood disordersBabies with these conditions will be referred toCalifornia Children’s Services (CCS) for treatmentor to Community Health Plan if thetreatment is not covered by CCS. Treatment ofPKU includes medically prescribed formulas andspecial food products. PKU cases are followed bya health care professional who consults with adoctor specializing in PKU-related diseases. Thisis talked about in the section, “More benefits:What other services can I get? in this handbook.Obstetrical/Gynecological (Ob/Gyn)Pregnant members do not need a referral or okayfrom their PCP doctor or Community Health Planto see an Ob/Gyn who works in their network.Please call Community Health Plan if you haveany questions.Podiatry (services for the feet)• Podiatry services are limited and require priorauthorization except when received on anemergency basis.Prenatal Care• Regular doctor visits during your pregnancy(called “prenatal” visits)• Diagnostic and genetic testingReconstructive Surgery• Reconstructive surgery repairs abnormal bodyparts, improves body function or brings back anormal look.Sexually Transmitted Disease (STD)ServicesSTD services include:• Preventive care• Screening• Testing• Diagnosis• Counseling• Treatment• Follow-upYou can get confidential STD services from anydoctor or clinic. You do not need a referral orokay from your doctor.17Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Skilled Nursing Facility Services• A facility licensed to provide medical servicesfor non-acute conditionsIf you need long-term skilled nursing facilityservices, you may be disenrolled from L.A. Careand provided these services through Medi-Cal oranother State program.Therapy – Occupational, Physical andSpeech• Occupational therapy is used to improve andmaintain a patient’s daily living skills becauseof a disability or injury.• Physical therapy uses exercise to improve andmaintain a patient’s ability to function after anillness or injury.• Speech therapy is used to treat speech problems.Vision CareEye exams are covered by Community HealthPlan. You are limited to one pair of eyeglassesevery two years unless your prescription changes.This includes lenses and covered frames foreyeglasses when authorized.To find out more about eye exams or vision carecoverage call Community Health Plan.X-ray ServicesThese services will be provided when ordered byyour doctor from a network:• Doctor’s office• Hospital• LaboratoryTransportationIncludes non-emergency transportation for thetransfer of a member from a hospital to anotherhospital or facility, or facility to home when thetransportation is• Medically necessary, and• Requested by the PCP doctor, and• Authorized in advance by Community HealthPlan.Exclusion: Coverage for public transportationincluding transportation by airplane, passengercar, taxi, or other forms of public conveyance.18Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007More Benefits:What other services can I get?Medi-Cal members are entitled to other healthcare benefits and services that are not provided byL.A. Care/Community Health Plan.California Children’s Services (CCS)CCS is for people under the age of 21 with adisability. If your child has a chronic (long-term)medical illness, your child may be eligible forservices under CCS.L.A. Care and/or Community Health Plan willidentify children with CCS eligible conditions,arrange for a referral to the local CCS office andcontinue to provide case management untileligibility is established with the CCS program.Primary care services will continue to be providedby L.A. Care/Community Health Plan.Please call Community Health Plan if your childis receiving CCS services. Community HealthPlan can arrange for those services to continue.Your child can continue getting services as amember of L.A. Care/Community Health Plan.You can call the Los Angeles County CCS officetoll-freeat1-800-288-4584 to find out more.Child Health and Disability Prevention(CHDP)Your child may receive preventive servicesthrough your child’s local school. CHDP serviceshelp keep children from getting sick and includeregular checkups, immunizations (shots), educationand counseling, and vision and hearing tests.You may call CHDP at 1-800-993-2437 (1-800-993-CHDP), if you have any questions.Women, Infants and Children (WIC)ProgramThe Women, Infants and Children (WIC) SupplementalNutrition Program gives pregnantwomen and new mothers nutrition informationand coupons to buy healthy foods. Ask yourdoctor or maternity nurse to find out more aboutWIC. You may call WIC directly at 1-888-942-2229 or 1-888-WIC-baby.Special services for Native AmericanIndiansNative American Indians have the right to gethealth care services at Indian Health Centers andNative American Health Clinics. Native AmericanIndians may stay with or disenroll fromL.A. Care/Community Health Plan while gettinghealth care services from an Indian Health Centeror Native American Health Clinic. Native AmericanIndians have a right not to enroll in a Medi-Cal managed care plan or may leave their healthplans and return to regular (fee-for-service) Medi-Cal at any time and for any reason. Please callIndian Health Services at 1-916-930-3927 to findout more. You may visit the Indian HealthServices website at www.ihs.gov to find outmore.Services you can get outside of yourhealth planSome services are not covered by L.A. Care orCommunity Health Plan but are still benefits.They are available through Medi-Cal or anotherState program.• Acupuncture• Adult day health care• Alcohol and drug treatment services (outpatient)19Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007• Childhood lead poisoning (through the LosAngeles County Department of Health Services)• Chiropractic services• Direct Observed Therapy for the treatment oftuberculosis (through the Los Angeles CountyDepartment of Health Services)• Dental services. Community Health Plancovers dental screenings under the first healthcheck-up and will refer members to Medi-Caldental providers. Community Health Plancovers the following when medically necessary:prescription drugs, lab services,outpatient surgical services and inpatient services.General anesthesia for dental work iscovered for members under seven years of ageor the developmentally disabled, or whenmedically necessary.• Local Education Agency (LEA) assessmentservices.• Major organ transplants.• Mental health services. Specialized mentalhealth services are provided through the LosAngeles County Department of Mental Health(LACDMH). You may receive services fromLACDMH with or without a referral fromyour doctor. LACDMH may be reached tollfreeat 1-800-854-7771.Your PCP doctor will treat mental health conditionswithin the scope of their training andpractice. Mental health drugs listed on theformulary and prescribed by a licensed mentalhealth provider are covered by CommunityHealth Plan, or regular (fee-for-service) Medi-Cal. For mental health services provided byCommunity Health Plan, if medically necessary,you may also get a mental health drugnot on the formulary. Go to a network pharmacyto fill your prescription. This is talkedabout in the section, “Pharmacy Benefits:How do I get Prescription Drugs?” in thishandbook.• Prayer or spiritual healing.• State laboratory services under the StateSerum Alpha-fetoprotein Testing Program.Please call L.A. Care or Community Health Planif you have any questions.20Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Non-Covered Services:What does Medi-Cal notcover?The following is a list of services not covered byL.A. Care/Community Health Plan or by theregular Medi-Cal program:• All services excluded from Medi-Cal understate and/or federal law• Routine circumcision, unless medically necessary• Cosmetic surgery (surgery performed to alteror reshape normal structures of the body inorder to improve your appearance)• Custodial care• Experimental and investigational services.This is talked about in “IMRs for Experimentaland Investigational Therapies (IMR-EIT)”under “Complaints: What should I do if I amunhappy?” in this handbook• Infertility• Immunizations (shots) for work or travel• Personal comfort items, (such as phones,television and guest tray) when in the hospital• Temporal Mandibular Joint (TMJ) diseaseunless medically necessary after examinationIf you have questions about what is covered ornot covered, please call Community HealthPlan.21Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Pharmacy Benefits:How do I get prescriptiondrugs?What is a pharmacy?A pharmacy is a place to get your prescriptionsfilled. Community Health Plan works withpharmacies in many neighborhoods. You mustget your prescribed medications (drugs) from apharmacy in Community Health Plan’s network.A “network” is all of the pharmacies that workwith Community Health Plan. A pharmacy list isin the provider directory with this handbook. Or,you can call Community Health Plan at 1-800-475-5550 for pharmacies in your neighborhood.How to get a prescription filled1. Choose a pharmacy that works withCommunity Health Plan.2. Bring your prescription to the pharmacy.3. Show the pharmacy your L.A.Care/Community Health Plan ID card.You should not be asked to pay for coveredprescription drugs. Call Community HealthPlan if a pharmacy asks you to pay.What is a formulary?Community Health Plan uses a list of approveddrugs called a “formulary.” A committee ofCommunity Health Plan physicians and pharmacistsreviews drugs to add or remove from theformulary every three months.• Approved by the Food and Drug Administration(FDA)• Generally accepted to be safe and effective• Cost effectiveYour doctor usually prescribes drugs from theformulary. Your doctor will only prescribe a drugbased on your health status. Just because a drug ison the formulary does not mean a doctor willprescribe it. You doctor may not believe you needit.You may call Community Health Plan to ask for acopy of the formulary. You may also callL.A. Care for a list that compares all health planpartner formularies.Drugs not on the formularySometimes, your doctor may need to prescribe adrug not on the formulary. Your doctor must callto get an okay from Community Health Plan.To decide if this drug will be covered,Community Health Plan may ask your PCPdoctor or the pharmacist (or both) to find outmore. Within 24 hours after getting this information,Community Health Plan will tell your PCPdoctor or the pharmacist if the drug will becovered. Your PCP doctor or the pharmacist willtell you.If the drug is approved, you can get the drug at apharmacy that works with Community HealthPlan. If the drug is not approved, you have theright to appeal the decision. An “appeal” is whenyou want a decision to be reviewed. This is talkedabout in “Complaints: What should I do if I amunhappy?” in this handbook.Drugs can be added to the formulary when theyare all of the following:22Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007What drugs are covered?You can get the following drugs and other itemswhen they are prescribed by your doctor and aremedically necessary:• Prescription drugs listed on the CommunityHealth Plan formulary• Prescription drugs you get from a pharmacynot in Community Health Plan’s networkwhen you have an emergency.• Non-prescription drugs or “over-the-counter”drugs (such as cough syrups, cough drops oraspirin) listed on the formulary• Diabetic supplies: insulin, insulin syringes,glucose test strips, lancets and lancet puncturedevices, pen delivery systems, blood glucosemonitors including monitors for the visuallyimpaired, ketone urine testing strips• FDA-approved birth control and birth controldevices, birth control pill, diaphragms, condomsand contraceptive jellies on theCommunity Health Plan formulary• Emergency contraception• EpiPens, Anakits and inhaler extender devicesWhat drugs are not covered?• Drugs from a non-network pharmacy, exceptdrugs needed because of an emergency or outof area care.• Non-formulary drugs, except with an okayfrom Community Health Plan.• Drugs that are experimental or investigationalin nature, except in certain cases of terminalillness. If you have been denied an experimentalor investigational drug, you have the rightto request an Independent Medical Review(IMR). This is talked about in “Complaints:What should I do if I am unhappy?” in thishandbook.• Cosmetic drugs, except as prescribed formedically necessary conditions.• Dietary or nutritional products, except whenmedically necessary or for the treatment ofPhenylketonuria.• Any injectable drug that is not medicallynecessary and not prescribed by a doctor.• Appetite suppressants, except as medicallynecessary for morbid obesity.• Compounded medications with formularyalternatives or those with no FDA-approvedindications.• Replacement of lost or destroyed drugs morethan two times each calendar year (from Januaryto December).Emergency contraceptionYou may get emergency contraceptive drugsfrom:• your doctor• a pharmacy with a prescription from yourdoctor• a pharmacy without a prescription if theyparticipate in the Pharmacy Access Programin your health plan’s network• a pharmacy not in your health plan’s networkif they participate in the Pharmacy AccessProgram. If this is the case, you will be askedto pay for the service. Your health plan willreimburse you for this cost.Call L.A. Care or Community Health Plan for alist of pharmacies that participate in the PharmacyAccess Program. You may also call your pharmacyand ask if they participate in the PharmacyAccess Program.23Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Medicare Part D: Prescription drugcoverage for beneficiaries who get bothMedicare and Medi-CalMedicare administers a federal prescription drugprogram called Medicare Part D. If you are aMedi-Cal beneficiary with Medicare, you mustget your prescription drugs from Medicare andnot Medi-Cal. You choose a Medicare PrescriptionDrug Plan working with Medicare Part D.To find out more about this program, call Medicare1-800-633-4227 or go to www.medicare.govon the Internet.24Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Emergency Care: How do I getcare in an emergency?There is a difference between needing careurgently and an emergency. Urgent care is when acondition, illness or injury is not life-threatening,but needs medical care right away. Many ofCommunity Health Plan’s doctors have urgentcare hours in the evening and on weekends.How to get urgent care1. Call your PCP doctor. You may speak toan operator who answers calls for yourPCP doctor’s office when closed.2. Ask to speak to your PCP doctor or thedoctor on-call. Another doctor may answeryour call if your PCP doctor is notavailable. A doctor is available by phone24 hours a day, seven days a week.3. Tell them about your condition and followtheir instructions.If you are outside of Los Angeles County, you donot need to call your PCP doctor or get priorauthorization before getting urgent care services.Be sure to let your PCP doctor know about thiscare. You may need follow-up care from yourPCP doctor.What is emergency care?Emergency services are covered anywhere 24hours a day, seven days a week. Emergency careis a service a “prudent layperson” believes isnecessary to stop or relieve:• Serious illnesses or symptoms• Injury or conditions requiring immediatediagnosis and treatmentA “prudent layperson” is a non-medical personwith an average knowledge of health and medicinebut has awareness or information to make agood decision.Emergency services and care include ambulance,medical screening, exam and evaluation by adoctor or appropriate personnel. Emergencyservices include both physical and psychiatricemergency conditions.Examples of emergencies include but are notlimited to:• Having trouble breathing• Seizures (convulsions)• Lots of bleeding• Unconsciousness/blackouts (will not wake up)• Trouble breathing• 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 orsomeone elseIf you think you have a health emergency, call911. You are not required to call your doctorbefore you go to the emergency room. Do notuse the emergency room for routine healthcare.What to do in an emergencyCall 911 or go to the nearest emergency roomif you have an emergency. Emergency care iscovered at all times and in all places.25Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Outside of Los Angeles County?If you have an emergency when you are not inLos Angeles County, you can get emergencyservices at the nearest emergency facility (doctor’soffice, clinic or hospital). Emergencyservices do not require a referral or an okay fromyour PCP doctor.limited to, the following: earaches, colds, flu andsore throats. Do not call 911 for non-emergencyproblems. Call your PCP doctor.If you are admitted to a hospital not inCommunity Health Plan’s network or to a hospitalyour PCP doctor or other provider does notwork at, Community Health Plan has the right tomove you to a network hospital as soon asmedically safe.Your PCP doctor must provide follow-up carewhen you leave the hospital.What to do after an emergency1. Call Community Health Plan within 24hours of receiving emergency care or assoon as you can.2. Follow the instructions of the emergencyroom doctor.3. Call your PCP doctor to make an appointmentfor follow-up care.How to get emergency transportationCall 911 if you have an emergency. Ambulancesfor emergencies are paid for by CommunityHealth Plan. Community Health Plan may refuseto pay if you use an ambulance when you do nothave a reasonable belief that you have an emergency.Not sure you have an emergency?If you are not sure, call your PCP doctor. Dowhat your PCP doctor tells you to do. Nonemergencyproblems may include, but not be26Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Help in Another Language andfor the Disabled:How can I get help?Information in other languagesYou have the right to receive all member materialsin any of the following languages: Spanish,Armenian, Chinese, Farsi, Khmer, Korean,Tagalog, Russian, Vietnamese, and English.Interpreters for members who don’tspeak English or are hearing or speechimpaired.We know doctors and other providers mustunderstand you so that you can get the health careservices you need. Laws like the Civil Rights Actof 1964 and the ADA Laws protect you if you donot speak English or have a disability and needhelp in communicating with your doctor.Your doctor’s office, clinic or hospital cannotdeny services because you do not speak Englishor have a disability. You have the right to freeinterpreter services when getting health careservice or other services that are paid for by yourhealth plan, including after hours interpreterservices. An “interpreter” is a person who helpsyou understand what is being said by the personwho is giving you care. An interpreter also tellsthe other person what you said, but in the languagethat person understands. This allowspeople who speak different languages to talk witheach other and to understand. This is also moreprivate because you are not telling your child,family member or friend to interpret for you.If you need interpreter servicesInterpreter services in your language are free, 24hours a day, seven days a week.You should not use children or family membersas interpreters. Call Community Health Plan,your doctor or L.A. Care if you need interpreterservices. We will work with you and your PCPdoctor to make sure that you can have servicesthat you understand.California Relay Service. The California RelayService (CRS) helps a person using a TTY tocommunicate by phone with a person who doesnot use a TTY. This service also works anotherway. CRS helps a non-TTY user call a TTY user.Trained operators take phone calls and helphearing people and non-hearing people communicate.Statewide access for voice or TTY/TDD is 1-888-877-5379 voice (SPRINT) or 1-800-735-2922voice (MCI). Members and providers can alsodial 711 on their phones to directly call theCalifornia Relay Service.Protection for the disabledThe Americans with Disabilities Act (ADA) of1990 is a law that protects people with disabilitiesfrom not being treated fairly. A disability is aphysical or mental condition that totally orseriously limits a person’s ability in at least onemajor life activity. This law protects people who:• Have hearing loss who may be deaf, hard ofhearing or hearing impaired• Are seniors (65 years of age or older) andpeople with disabilities such as blindnessThe ADA law makes sure there are equal chancesfor people with disabilities in employment, stateand local government services.27Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007The doctor’s office, clinic or hospital cannot denyservices because you are hearing impaired, orhave other disabilities. Call your health plan rightaway if you don’t get the services you need orservices are hard to get.Here are some telephone numbers that can helpyou if you are disabled:ADA Information Line:1-800-514-0301 (Voice) or1-800-514-0383 (TDD)Remember: Tell your doctor’s office if youhave a special need, such as an interpreter orhave a special need because of a disability.ComplaintsYou can also file a complaint if:• you can’t get an interpreter• you couldn’t get information in one of thelanguages listed on the previous page• you feel that you were denied services becauseof a disability.This is talked about in the section “Complaints:What should I do if I am unhappy?” in thishandbook.28Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Complaints:What should I do if I amunhappy?Call Community Health Plan if you have aproblem or are unhappy. Community Health Planwill try their best to help you. If you are still nothappy, you may use L.A. Care/CommunityHealth Plan’s grievance process.What is a grievance?A grievance is a complaint. This complaint iswritten down and tracked. You might be unhappywith the health care services you get or how longit took to get a service.Some examples are complaints about:• Your PCP doctor or other providers• Your PCP doctor’s medical group• Your pharmacy• Your hospital• Community Health Plan• L.A. CareHow to file a grievanceYou have many ways to file a grievance. You cando any of the following:• Write, visit, fax or call Community HealthPlan.• Write, visit or call L.A. Care. You may alsofile a grievance online through L.A. Care’swebsite at www.lacare.org.Member Services Department555 West Fifth StreetLos Angeles, CA 900131-888-452-2273213-438-5748 (fax)www.lacare.org• Fill out a grievance form at your doctor’soffice.Community Health Plan or L.A. Care can helpyou fill out the grievance form. Or, we can sendyou a form for you to fill out and send back to us.Within five days of receiving your grievance, youwill get a letter from Community Health Plan orL.A. Care saying we have your grievance and areworking on it. Then, within 30 days of receivingyour grievance, Community Health Plan orL.A. Care will send you a letter explaining howthe grievance was resolved.Filing a grievance or requesting a State FairHearing does not affect your medical benefits. Ifyou file a grievance or request a Fair Hearing,you may be able to continue a medical servicewhile the grievance is being resolved. To find outmore about continuing a medical service, callL.A. Care.Administrative Grievance Coordinator1000 South Fremont AvenueBuilding A-9 East, 2 nd Floor, Unit #4Alhambra, CA 91803-88591(800) 475-5550(626) 299-3349www.ladhs.org/chp29Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007If you don’t agree with the decisionIf you are not happy with the outcome of yourgrievance or you do not hear from CommunityHealth Plan or L.A. Care within 30 days, you canfile a complaint about the decision with theDepartment of Managed Health Care (DMHC).Go to “Contacting the Department of ManagedHealth Care (DMHC)” below to find out how tofile a complaint.How to appeal urgent complaintsIn urgent cases, you can request an expeditedappeal. An “expedited appeal” is an urgentreview of your complaint. You will receive a calland/or a letter about your appeal within 24 hours.A decision will be made by Community HealthPlan or L.A. Care within three days from the dayyour appeal was received.Examples of urgent cases include:• Severe pain• Potential loss of life, limb or major bodilyfunction• Immediate and serious deterioration of yourhealthYou have the right to contact the CaliforniaDepartment of Managed Health Care (DMHC)regarding an urgent review. You can do sowithout filing a grievance with L.A. Care orCommunity Health Plan.Voluntary mediationYou may ask for mediation to resolve a grievance.An independent third person will resolveyour grievance. This person is not related toL.A. Care or Community Health Plan. You andL.A. Care or Community Health Plan must agreeto use the mediation process. You may ask formediation, but L.A. Care or Community HealthPlan may decline your request. You may still filea grievance with the DMHC even if you usemediation. You do not need to participate in L.A.Care/Community Health Plan’s mediationprocess for any longer than 30 days prior tosubmitting a grievance to the DMHC. To requestmediation, call L.A. Care or Community HealthPlan.Contacting the California Department ofManaged Health Care (DMHC)The California Department of Managed HealthCare (DMHC) is responsible for regulating healthcare service plans. If you have a grievance againstyour health plan, you should first telephone yourhealth plan at 1-800-475-5550 and use yourhealth plan’s grievance process before contactingthe DMHC. Utilizing this grievance proceduredoes not prohibit any potential legal rights orremedies that may be available to you.If you need help with a grievance involving anemergency, a grievance that has not been satisfactorilyresolved by your health plan, or a grievancethat has remained unresolved for more than 30days, you may call the DMHC for assistance.You may also be eligible for an IndependentMedical Review (IMR). If you are eligible for anIMR, the IMR process will provide an impartialreview of medical decisions made by a healthplan related to the medical necessity of a proposedservice or treatment, coverage decisions fortreatments that are experimental or investigationalin nature and payment disputes for emergency orurgent medical services.The DMHC also has a toll-free telephone number(1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. TheDMHC’s Internet website, http://www.hmohelp.ca.gov, has complaint forms,IMR application forms and instructions online.30Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007L.A. Care/Community Health Plan does nothandle grievances about your Medi-Caleligibility. For these types of questions, callyour DPSS eligibility worker toll-free at 1-877-481-1044.How to appeal health care servicesdenied or delayed as not medicallynecessaryIf you believe a health care service has beenwrongly denied, changed, or delayed byL.A. Care or Community Health Plan because itwas found not medically necessary, you mayrequest an Independent Medical Review (IMR)from DMHC. This is known as a disputed healthcare service.You have up to six months from the date ofdenial to file an IMR. You will receive informationon how to file an IMR with your denial letter.You may reach DMHC toll-free at 1-888-HMO-2219 or 1-888-466-2219.There are no fees for an IMR. You have the rightto provide information to support your request foran IMR. After the IMR application is submitted, adecision not to take part in the IMR process maycause you to lose certain legal rights to pursuelegal action against the plan.You may still request a State Fair Hearing if yourequest an IMR. However, you will not be able touse the IMR process if you have requested a StateFair Hearing. Go to “State Fair Hearing” below tofind out more.When to File an Independent MedicalReview (IMR)You may file an IMR if you meet the followingrequirements:• Your doctor says you need a health care servicebecause it is medically necessary and it isdenied; or• You received urgent or emergency servicesdetermined to be necessary and they were denied;or• You have seen a network doctor for the diagnosisor 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 Community HealthPlan based in whole or in part on a decisionthat the health care service is not medicallynecessary, and• You have filed a grievance with CommunityHealth Plan and the health care service is stilldenied, changed, delayed or the grievance remainsunresolved after 30 days.You must first go through the Community HealthPlan grievance process, before applying for anIMR. In special cases, the DMHC may notrequire you to follow the Community Health Plangrievance process before filing an IMR.The dispute will be submitted to a DMHCmedical specialist if it is eligible for an IMR. Thespecialist will make an independent decision onwhether or not the care is medically necessary.You will receive a copy of the IMR decision fromDMHC. If it is decided that the service is medicallynecessary, Community Health Plan willprovide the health care service.Non-urgent casesFor non-urgent cases, the IMR decision must bemade within 30 days. The 30-day period startswhen your application and all documents arereceived.31Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Urgent casesIf your grievance is urgent and requires fastreview, you may bring it to DMHC attention rightaway. You will not be required to participate inthe health plan grievance process for more thanthree business days before bringing an urgentIMR.For urgent cases the IMR decision must be madewithin three business days from the time yourinformation is received.Examples of urgent cases include:• Severe pain• Potential loss of life, limb or major bodilyfunction• Immediate and serious deterioration of yourhealthIMRs for Experimental and InvestigationalTherapies (IMR-EIT)You can request an IMR-EIT through the DMHCwhen a medical service, drug or equipment isdenied because it is experimental or investigationalin nature. Community Health Plan willnotify you in writing that you may request anIMR-EIT within five days of the decision to denycoverage. You have up to six months from thedate of denial to file an IMR-EIT. You may giveinformation to the IMR-EIT panel. The IMR-EITpanel will give you a written decision within 30days from when your request was received. Ifyour doctor thinks that the proposed therapy willbe less effective if delayed, the decision will bemade within seven days of the request for anexpedited review. In urgent cases the IMR-EITpanel will give you a decision within threebusiness days from the time your information isreceived.You may file an IMR-EIT if you meet thefollowing 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 willnot be effective, or• The standard treatments were not medicallyappropriate, or• The proposed treatment will be the mosteffective.3. Your doctor certifies in writing that:• A drug, device, procedure or other therapyis likely to work better than thestandard treatment• Based on two medical and scientificdocuments, the recommended treatmentis likely to work better than the standardtreatment.4. You have been denied a drug, equipment,procedure or other therapy recommended orrequested by your doctor.5. The treatment would normally be covered asa benefit, but Community Health Plan has determinedthat it is experimental orinvestigational in nature.To find out more, get help with the IMR or IMR-EIT process, or ask for an application form,please call Community Health Plan.You do not need to participate in L.A. Care’s orCommunity Health Plan’s grievance processbefore asking for an IMR of a decision to denycoverage on the basis that the treatment is experimentalor investigational in nature.32Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007State Fair HearingA State Fair Hearing is another way you can file agrievance. You can present your case directly tothe State of California. All L.A. Care/CommunityHealth Plan members have the right to ask for aState Fair Hearing at any time within 90 days ofthe incident. You may still request a State FairHearing if you request an IMR. However, youwill not be able to use the IMR process if youhave requested a State Fair Hearing. Go to the“IMR” section to find out more.You may ask for a State Fair Hearing by callingtoll-free 1-800-952-5253 (English and Spanish),or by writing to:California Department of Social ServicesState Hearings DivisionP.O. Box 944243, MS 19-37Sacramento, CA 94244-2430Expedited State HearingIn cases of health services denials, you or yourprovider may ask for a faster decision through anExpedited State Hearing if your life, or health, orability to attain, maintain or regain maximumfunction could be seriously risked by goingthrough a standard State Fair Hearing. An emancipatedminor, a parent on behalf of his/her minorchild, and a duly-appointed guardian or conservatorof a member may also request an ExpeditedState Hearing. Requests for Expedited StateHearings should be directed to:Expedited Hearings UnitCalifornia Department of Social ServicesState Hearings Division744 P Street, MS 19-65Sacramento, CA 95814Fax: 916-229-4267You can also call the DPSS Los Angeles Countyoffice toll-free at 1-877-481-1044. If you do notspeak English, please stay on the line and ask forthe language you speak. DPSS has staff whospeaks Armenian, Chinese, Russian, Spanish,Tagalog and Vietnamese. You may also write to:Department of Public Social Services(DPSS)State Fair Hearings SectionP.O. Box 10280Glendale, CA 91209Ombudsman OfficeYou may call the Ombudsman Office of theCalifornia Department of Health Services (CDHS)for help with grievances. The Ombudsman Officewas created to empower Medi-Cal beneficiariesto fully use their rights and responsibilities as amember of a managed care plan. To find outmore, call toll-free 1-888-452-8609.Arbitration:Solving problems without going to court.L.A. Care knows that some members wish to gethealth care services from a health plan that usesarbitration. When you choose arbitration, yougive up the right to have your problem settled bya judge or jury. Many view arbitration as cheaper,quicker and better than the courts.During arbitration, a neutral (unbiased) arbitratorwill listen to everyone and make a decision. Youand your doctor or health plan must follow thatdecision. That is why the process is often called“binding” arbitration.The party that does not win will pay for the costsunless the arbitrator decides otherwise. Thatbeing said, the winning party will never beresponsible for more than legal fees and costs ormore than one-half of the costs.33Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007L.A. Care or Community Health Plan, if theyoffer arbitration, may pay some or all of the feesand expenses of the arbitrator in cases of greatfinancial hardship. Please contact L.A. Care orCommunity Health Plan for information and anapplication. Arbitration does not apply to claims,disputes or controversies about alleged medicalmalpractice.34Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Confidentiality:What are my privacy rights?L.A. Care and Community Health Plan needsome information about you so that we can giveyou good health care services. This informationincludes:You have the right to keep your medical recordsconfidential. That means that only people whoneed to see your records in order for you to getgood health care will see them. You can request acopy of our confidentiality policy. Just callCommunity Health Plan or L.A. Care. You weremailed a Notice of Privacy Practices (NOPP) withthis handbook. If you would like another copy ofthis information, call Community Health Plan orL.A. Care. The NOPP is also available on theL.A. Care website at www.lacare.org.Health information privacyWe want you to know the things that L.A. Careand Community Health Plan do to keep healthinformation about you and your family private.To keep health information about you and yourfamily private, L.A. Care and Community HealthPlan:• Use secure computer systems• Handle health information the same way,every time• Review the way health information is handled• Follow all laws about the privacy of healthinformationAll L.A. Care/Community Health Plan staff withaccess to your health information are trained onprivacy laws. They also follow L.A.Care/Community Health Plan rules on how totake care of your health information so it staysprivate. They even sign a note that promises theywill keep all health information private. L.A.Care/Community Health Plan does not give outhealth information to anyone or any group thatdoes not have a right to the information by law.• Name• Gender• Date of birth• Language you speak• Home address• Home or work telephone number• Employer and occupation• Whether you are married or single• Health historyWe may get this information from you or any ofthese other sources:• A parent, guardian, or conservator• Another health plan• Your doctor• Your application for the health care program• Your health records• The California Department of Health ServicesBefore L.A. Care or Community Health Plangives your health information to someone else oranother group, we need your approval in writing.There are times when we don’t have to get yourapproval in writing. This may happen when:• A court, arbitrator or similar agency needsyour health information• A subpoena or search warrant is requested• A coroner needs your health information• Your health information is needed by law35Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007We may give your health information to anotherhealth plan to:• Make a diagnosis or give treatment• Make a payment for your health care• Review the quality of your health careSometimes, we may also give your health informationto:• groups who license health care providers• public agencies• investigators• probate courts• organ donation groups• federal or state agencies as required by law• disease management programsPlease note that we won’t tell anyone the resultsfrom any genetic testing.If you have any questions, would like a copy ofthe NOPP, or would like to know more aboutyour health information, please call L.A. Care’sPrivacy Officer at 1-888-452-2273.36Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Medi-Cal:How can I make sure I don’tlose my coverage?Keeping your Medi-Cal EligibilityTo stay in Medi-Cal, you must be eligible for it.“Eligible” means that a person meets certainrequirements to receive benefits from programslike Medi-Cal.If you lose Medi-Cal eligibility, you will not beable to keep your Medi-Cal benefits withL.A. Care/Community Health Plan.Be sure to fill out and return any informationrequested before the due date on the letter orform. If you have any questions about yourMedi-Cal eligibility, call your eligibility workeror the Department of Public and Social Services(DPSS) toll-free at 1-877-481-1044.If you move you must tell us!Don’t lose your Medi-Cal coverage if you move!DPSS must have your address so they can sendyou mail to renew and stay eligible.If you move but still live in Los AngelesCounty, please:1. Call your eligibility worker at DPSSright away at 1-877-481-1044; and2. call L.A. Care or Community HealthPlan. We need to know your new addressand phone number.If you move outside of Los Angeles County butstill live in California, call your eligibility workerat DPSS right away toll-free at 1-877-481-1044.Your eligibility worker can help you find outwhat Medi-Cal services are available in your newcommunity.Two types of Medi-CalThere are two types of Medi-Cal in Los AngelesCounty: “Fee-for-service” and managed care. InLos Angeles County, most Medi-Cal membersare in “managed care.” L.A. Care andCommunity Health Plan are managed care healthplans.Managed care is when your health care is managedand coordinated by a health plan and a PCPdoctor. This makes it easier for you to get the careyou need. It is L.A. Care and Community HealthPlan’s job to make sure you get the care youneed. For example, if you need to see a specialist,it is your PCP doctor’s and our job to find aspecialist that will see you.In “fee-for-service” Medi-Cal, you are not in ahealth plan and must find doctors and otherproviders who will accept payment from Medi-Cal. No one manages or coordinates your care foryou. No one helps you find doctors and providerswho will accept payment from Medi-Cal.This section explains why you are in managedcare and the reasons why you can or cannot beenrolled in or disenrolled from a managed carehealth plan. To “enroll” means you become amember of a health plan. To “disenroll” meansyou leave a health plan and are no longer amember.Mandatory Medi-Cal Managed CaremembersThe California Department of Health Services(CDHS) is in charge of Medi-Cal. CDHS saysthat in Los Angeles County, most Medi-Calmembers must enroll in a health plan and be inmanaged care. Members who must enroll in ahealth plan are called “mandatory members.”A mandatory member may disenroll from Medi-Cal managed care only if the member:37Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007• has a complex medical condition (such asHIV/AIDS or cancer), and• has been in Medi-Cal managed care less than90 days, and• is being treated by a doctor who does notwork with any Medi-Cal managed care healthplan.Otherwise, the member must choose a health planlike L.A. Care.Voluntary Medi-Cal Managed CaremembersIn Los Angeles County, some people with Medi-Cal can choose to enroll in a health plan. Memberswho choose to enroll in a health plan arecalled “voluntary members.” A voluntary membercan choose to leave their health plan andreturn to fee-for-service Medi-Cal at any time.Voluntary members include:• Disabled or elderly receiving SupplementalSecurity Income (SSI)• Those 65 years or older• Native American Indians and their household,and others who are eligible to get servicesfrom an Indian Health Center or NativeAmerican Health Clinic• Children in foster care or the Adoption AssistanceProgram• Members with HIV/AIDS diagnosison the last day of the month in which Health CareOptions approves your request. Disenrollmenttakes about 15 to 45 days. You must continue toreceive services through Community Health Planuntil you are disenrolled from L.A.Care/Community Health Plan.If you leave L.A. Care, you cannot stay enrolledwith Community Health Plan for yourMedi-Cal coverage.Involuntary disenrollmentsYou will lose managed care coverage with L.A.Care and Community Health Plan if any of thefollowing happens:• You move out of Los Angeles County permanently.• You are in a long-term care or intermediatecare facility beyond the month of admissionand the following month.• You require medical health care services notprovided by Community Health Plan (for example,some major organ transplants, andchronic kidney dialysis).• You have other non-government or government-sponsoredhealth coverage.• You are in prison or jail.If you are a mandatory or voluntary member youalso can be disenrolled from L.A.Care/Community Health Plan, even if you don’twant to leave, if:Voluntary disenrollmentTo “disenroll” means you leave a health plan andare no longer a member. To disenroll fromL.A. Care, call Health Care Options at 1-800-430-4263. Health Care Options enrolls or disenrollsMedi-Cal beneficiaries in or out of a Medi-Cal managed care health plan. They will send youa disenrollment form. Your membership will end• You take part in any fraud having to do withservices, benefits or facilities of the plan.• You show an ongoing significant disruptivebehavior towards other members, providers,provider staff, or L.A. Care/CommunityHealth Plan.• Community Health Plan is not able, in goodcause, to give health care services to you.38Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Community Health Plan will use their bestefforts to provide the needed services.If you are disenrolled from L.A. Care/CommunityHealth Plan, we will send you a letter that sayswhen your coverage will end and why. You mayfile an appeal with the California Department ofHealth Care (DMHC) if you think that yourcancellation is because of your health status orneed for services. This means you can ask DMHCto make sure we are allowed to disenroll you.You may also ask for a review from CaliforniaDepartment of Health Services. This is talkedabout in the section “Complaints: What should Ido if I am unhappy?” in this handbook. You canalso call L.A. Care to find out more.Expedited disenrollmentL.A. Care will process an Expedited Disenrollmentif we are not able to provide you medicalservices due to your condition or situation whichis indicated in L.A. Care’s contract with theDepartment of Health Services (DHS). This mayinclude a major organ transplant, long-term careservice, Foster Care or Adoption AssistancePrograms, or you move out of Los AngelesCounty. We will submit a disenrollment requestto DHS who will make a decision within 72hours. When we receive the decision, we willnotify you and your PCP doctor of the effectivedate of disenrollment. Your health care for thecondition will be covered by regular Medi-Cal.Transitional Medi-CalTransitional Medi-Cal is also called “Medi-Calfor working people.” You may be able to gettransitional Medi-Cal if you stop getting Medi-Cal because:• You started earning more money; OR• your family started receiving more child orspousal support.For example, if you are the person in yourhousehold who earns the most money, you mightget transitional Medi-Cal. Even if you are acaretaker relative, you might get transitionalMedi-Cal if you started earning more money oryou are receiving more child or spousal support.Parents and caretaker relatives who get transitionalMedi-Cal can get free Medi-Cal coveragefor six to 24 months. If you have stopped gettingMedi-Cal, you should ask your eligibility workerif you qualify for transitional Medi-Cal. Call youreligibility worker at DPSS toll-free at 1-877-481-1044. You can stay with L.A. Care/CommunityHealth Plan if you are eligible for transitionalMedi-Cal.39Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Getting involved:How do I participate?Many of the L.A. Care/Community Health Planpolicies are decided by California Department ofHealth Services. Other policies are set byL.A. Care and/or Community Health Plan andmembers like you.Community Health Plan Public PolicyCommitteeCommunity Health Plan has a public policycommittee you may join. This committee discussesmember and health plan issues. To find outmore, please call Community Health Plan.Board of Governors meetingsThe Board of Governors decides policies forL.A. Care. Anyone can attend these meetings.The Board of Governors meets on the firstThursday of each month from 2 p.m. to 4 p.m. Tofind out more call the L.A. Care Meeting InformationLine at 213-438-5408.Communicating policy changesAs a L.A. Care member, you will get informationon all policy changes that affect your health care.All important information will be included inyour member newsletter or special mailings.L.A. Care Regional Community AdvisoryCommittees (RCAC)There are 11 L.A. Care Regional CommunityAdvisory Committees (RCAC) in Los AngelesCounty. (“RCAC” is pronounced “rack.”) Theirpurpose is to:• Talk about member issues• Advise the L.A. Care Board of Governors• Educate and empower the community onhealth care issuesRCACs meet once a month. RCACs includeL.A. Care members, member advocates (supporters)and health care providers. To find out moreabout RCACs, call the L.A. Care CommunityOutreach and Education Department toll-free at1-888-522-2732.40Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007More important information:What else do I need to know?If you travel outside of Los AngelesCountyAs a member of L.A. Care and CommunityHealth Plan, your service area is Los AngelesCounty. All locations outside of Los AngelesCounty are out of your service area.Routine care is not covered out of service area.Emergency and urgent care services are coveredoutside of Los Angeles County.How a provider gets paidHealth care providers can be paid several ways:• A fee for each service provided• Capitation (a flat rate paid each month permember)• Provider incentives or bonusesPlease call Community Health Plan if you wouldlike to know more about how your doctor is paidor about financial incentives or bonuses.If you have other insurancePlease call Community Health Plan at 1-800-475-5550 to tell us about any health insurance youhave other than L.A. Care/Community HealthPlan. We will send all bills to the correct place forpayment.Workers' CompensationL.A. Care/Community Health Plan will not payfor work related injuries covered by Workers’Compensation. Community Health Plan willprovide health care services you need while thereare questions about an injury being work related.Before Community Health Plan will do this, youmust agree to give Community Health Plan allinformation and documents needed to recovercosts for any services provided.Third party liabilityCommunity Health Plan will provide coveredservices where an injury or illness is caused by athird party. Community Health Plan may requestthe legal right to keep any payment or right topayment you may have received as a result of athird party injury or illness. Under CaliforniaState Law, this is called “asserting a lien.” Theamount of this lien may include:• Reasonable and true costs paid for health careservices given to you• An additional amount as provided underCalifornia State LawAs a member, you also agree to help CommunityHealth Plan in recovering payments for servicesprovided. This may require you to sign or providedocuments needed to protect the rights ofCommunity Health Plan.Disruption in servicesL.A. Care will use its best efforts to provideservices in the event of a war, riot, or otherunusual event. If L.A. Care/Community HealthPlan is not able to provide health services, wewill send members to the nearest hospital foremergency services and pay for these services.Organ donationThere is a need for organ donors in the UnitedStates. You can agree to donate your organs inthe event of your death. The California Departmentof Motor Vehicles (DMV) will give you adonor card if you wish to become an organ or41Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007tissue donor. The DMV will also give you adonor sticker to place on your driver’s license orID card. To find out more, call 1-800-777-0133(Voice) or 1-800-368-4327 (TTY).What is an advance directive?An advance directive is a signed legal document.It allows you to select a person to make yourhealth care choices at a time when you cannotmake them yourself (such as if you are in acoma). An advance directive must be signedwhen you are able to make your own decisions.L.A. Care will tell you about any changes to statelaw about advance directives. We will send youthis information as soon as possible but no laterthan 90 days after the date of change. Ask yourdoctor or call Community Health Plan to find outmore about advance directives.New technologyL.A. Care and Community Health Plan followchanges and advances in health care. We studynew treatments, medicines, procedures, anddevices. We call all of this “new technology.”We review scientific reports and informationfrom the government and medical specialists.Then we decide whether to cover the new technology.Members and providers may askL.A. Care or Community Health Plan to reviewnew technology.42Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273

Medi-Cal Member Handbook / Benefit Year 2006-2007Important Phone NumbersL.A. Care Health Plan 1-888-4LA-CARE (1-888-452-2273)Community Health Plan 1-800-475-5550Disability ServicesCalifornia Relay Service (CRS) – TTY/TDDAmericans Disabilities Act (ADA) Information LineSprint 1-888-877-5379 (Voice)MCI 1-800-735-2922 (Voice)1-800-514-0301 (Voice)1-800-514-0383 (TDD)Children ServicesCalifornia Children’s Services (CCS) 1-800-288-4584Child Health and Disability Prevention (CHDP) 1-800-993-2437(1-800-993-CHDP)California State ServicesCalifornia Department of Health Services (CDHS) 1-916-445-4171CDHS Ombudsman Office 1-888-452-8609Department of Social Services 1-800-952-5253Department of Managed Health Care (DMHC)1-888-466-2219 (1-888-HMO-2219)Health Care OptionsArmenian 1-800-840-5032Cambodian 1-800-430-5005Cantonese 1-800-430-6006English 1-800-430-4263Farsi 1-800-840-5034Hmong 1-800-430-2002Lao 1-800-430-4091Russian 1-800-430-7007Spanish 1-800-430-3003Vietnamese 1-800-430-8008Supplemental Social Income (SSI) 1-800-772-1213Los Angeles County ServicesDepartment of Public Social Services (DPSS)Central Help Desk (includes language services) 1-877-481-1044DPSS Public Charge Information LinesArmenian 1-800-453-6968Cambodian 1-800-632-9690Chinese 1-800-557-3731English 1-800-815-5005Farsi 1-800-807-3938Korean 1-800-557-5351Russian 1-800-808-4044Spanish 1-800-576-1519Tagalog 1-800-810-8985Vietnamese 1-800-578-6762Los Angeles County Department of Health Services 1-213-250-8055Los Angeles County Department of Mental Health 1-800-854-7771Women, Infant and Children (WIC) Program1-888-942-2229 (1-888-WIC-baby)L.A. Care Fraud and Abuse Hotline 1-800-400-488943Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273