L.A. Care Covered Member FAQs
If you are an L.A. Care Covered member, you can quickly get answers to common questions below.
All L.A. Care Members must have a Primary Care Physician (PCP). The name and phone number of your PCP is found on your L.A. Care ID card. Except for emergency services, your PCP will arrange all your health care needs, refer you to specialists, and make hospital arrangements.
Each PCP works with a Participating Provider Group (PPG), which is another name for medical group. Each PPG works with certain specialists, hospitals, and other health care providers. The PCP you choose determines which health care providers are available to you.
We are proud of our doctors and their professional training. If you have questions about the professional qualifications of network doctors and specialists, call L.A. Care at 1-855-270-2327. L.A. Care can tell you about the medical school they attended, their residency or board certification.
Call your Primary Care Physician (PCP) and explain why you are calling. Ask for an appointment. Your PCP’s office will tell you when to come in and how much time you will need with your PCP.
Clinic and doctor appointments are generally available Monday through Friday between 8:00 a.m. and 4:30 p.m. Evening and Saturday clinic/doctor office appointments may be available at some L.A. Care Health Plan sites. Please call your PCP office to confirm his/her hours or you may check our online provider directory at the L.A. Care Covered website.
Each member of your household that is enrolled with L.A. Care Covered™ may select a different Primary Care Physician (PCP). If you and your Enrolled Dependent(s) did not select a PCP at the time of enrollment, L.A. Care assigned a PCP to each of you.
If you would like to change your or your Enrolled Dependent’s PCP, please call L.A. Care’s Member Services Department at 1-855-270-2327. You may also make this change by visiting at the L.A. Care Covered website.
Specialists are doctors with training, knowledge, and practice in one area of medicine. For example, a cardiologist is a heart specialist and who has years of special training to deal with heart problems.
Your Primary Care Physician (PCP) will ask for prior authorization if he or she thinks you should see a specialist.
If you need care when your Primary Care Physician’s (PCP) office is closed (such as after normal business hours, on the weekends or holidays), call your PCP’s office. Ask to speak to your PCP or to the doctor on call. A doctor will call you back.
You can also call the nurse advice line number that is on your ID card. This number is available to you 24 hours a day, seven (7) days a week, to help answer your health care questions and have your health concerns and symptoms reviewed by a registered nurse. This service is free of charge and available to you in your language.
The PCP or L.A. Care Health Plan nurse will answer your questions and help you decide if you need to come into the clinic/doctor’s office.
For urgent care (this is when a condition, illness or injury is not-life threatening, but needs medical care right away), call or go to your nearest urgent care center. can learn more about urgent care in our For Members section of this website.
If you think you have a health emergency, call 911 or go to the nearest emergency room. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine health care. Learn more about the difference between emergency care and routine care in our For Members section of this website.
If you are not sure whether you have an emergency or require urgent care, please contact L.A. Care Health Plan Nurse Advice Line at 1-800-249-3619 for help 24 hours per day, 7 days per week.
As a member of L.A. Care Covered, your service area is Los Angeles County (excluding Catalina Island). Routine care is not covered out of service area, but emergency and urgent care services are covered outside of Los Angeles County.
If you have an emergency when you are not in Los Angeles County, you can get emergency services at the nearest emergency facility (doctor’s office, clinic, or hospital). Emergency services do not require a referral or okay from your Primary Care Physician (PCP).
If you are admitted to a hospital that is not in L.A. Care’s network or to a hospital your PCP or other provider does not work at, L.A. Care has the right to move you to a network hospital as soon as it is medically safe. Your PCP must provide follow-up care when you leave the hospital.
Invoices are mailed out on the 5th of every month. It takes approximately five to seven days for mailing.
Premium payments are due on the 26th of every month.
If you receive a bill that is for covered or authorized services, you may receive a reimbursement from L.A. Care. Please contact L.A. Care’s Member Services Department at 1-855-270-2327 (1-866-576-1620 TTY) for help.
Aside from the monthly premium, you may be responsible for paying a charge when you receive a covered service. This charge is called a copayment and is outlined in the Summary of Benefits. If you review your Summary of Benefits, you’ll see that the amount of the copayment depends on the service you receive.
An Enrollee must always be prepared to pay the copayment during a visit to the Enrollee’s PCP, Specialist, or any other provider.
Note: Co-payments are not required for preventive care services, prenatal care or for pre-conception visits.
The cost sharing is the amount you are required to pay for a covered service, such as a deductible, copayment or coinsurance. Your cost sharing for covered services will be the cost sharing in effect on the date you receive the services. For more details and exceptions, please see the “Cost Sharing” section of your Member Handbook.
The annual deductible is the amount that you must pay during the calendar year for certain covered services before L.A. Care will cover those services at the applicable copayment or coinsurance in that calendar year. The deductible is based on L.A. Care’s contracted rates with its participating providers and applies to certain service categories as defined in your Summary of Benefits.
The annual out of-pocket maximum (also called the “out-of-pocket limit”) is the highest amount you or your family (if you have Enrolled Dependent(s) receiving health coverage) are/is required to pay during one benefit year. The benefit year for L.A. Care Covered™ Members starts January 1st and ends December 31st. Please refer to the Summary of Benefits for your “Out-of-Pocket limit on expenses.”