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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
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