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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
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