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

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