Medi-Cal Member FAQs
If you are an L.A. Care Medi-Cal member, you can quickly get answers to common questions below.
All services require prior authorization unless the specific benefit says that prior authorization is not needed. “Prior authorization” means that your doctor and L.A. Care agree that services and care are medically necessary.
Your Primary Care Physician (PCP) will only prescribe a drug based on your health status, and if a medication is needed to improve your health. You must get your prescription medications from a pharmacy in L.A. Care’s network.
You can use our online Find a Pharmacy tool to search for a L.A. Care network pharmacy.
Durable Medical Equipment (DME) is medical equipment used repeatedly by a person who is ill or injured. These items are ordered by your doctor.
Examples of covered DME include apnea monitors, blood glucose monitors, insulin syringes and nebulizer machines. You can see other examples in your Member Handbook.
To find out what other items are on the approved DME list, please call L.A. Care at 1-888-839-9909. You may get other items not on the list if they are covered and are medically necessary.
If you need non-emergency care when your Primary Care Provider’s (PCP) office is closed (such as after normal business hours, on the weekends or holidays), call your PCP’s office anyway. You will get the office’s answering service. Leave your name and telephone number and a doctor will call you back.
You can also call the Nurse Advice Line number that is on your member ID card. The Nurse Advice Line 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 evaluated by a registered nurse. This service is free of charge and available to you in your language.
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. You can call the Nurse Advice Line at 1-800-249-3619 if you need help locating an urgent care center.
Many of L.A. Care’s doctors have urgent care hours in the evening, on weekends or during holidays. For emergency care, call 911 or go to the nearest emergency room.
A referral for special care is made to a specialist by a Primary Care Physician who is in L.A. Care’s network, if you have a chronic disease, life-threatening condition or a disability.
Behavioral health care includes ways of promoting well-being by preventing or intervening in mental illness such as depression or anxiety. It also has an aim of preventing or intervening in substance abuse or other addictions.
Mental health services may include treatment for anxiety, depression, or behavior health problems. Your doctor can provide you with some outpatient mental health services, within the scope of their training and practice.
Specialized mental health services may be needed for services beyond your doctor's training and practice and may require a referral to a provider that specializes in behavioral health treatment.
As a member of L.A. Care, your service area is Los Angeles County. But if you have an emergency when you are not in Los Angeles County, you can still get emergency services at the nearest emergency facility. 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.
You may need hospital care after an emergency to stabilize your condition. This is called post-stabilization care. If you do, the hospital will call L.A. Care to ask for an okay. The hospital may ask you for your health plan’s name and phone number. Show the hospital your L.A. Care ID card. If you don’t have your ID card, tell them to call L.A. Care. Your PCP must provide follow-up care when you leave the hospital.
Please remember that routine care is not covered out of the service area. All locations outside of Los Angeles County are out of your service area.
If you receive a Notice of Action (NOA – a formal letter telling you that a medical service has been denied) and your case is urgent, you can request an “expedited” (or quick) review of your case. Examples of urgent cases include:
• Severe pain
• Potential loss of life, limb or major bodily function
• Immediate and serious decline of your health
L.A. Care physicians will review the case to determine the urgency of the matter. If the matter is expedited (urgent), then the matter will be resolved within three days.
In urgent cases, you may file your appeal to L.A. Care either orally (via telephone or in person) or in writing. You can present evidence to support your appeal; however, the time available to present this evidence is limited to less than three (3) days. A decision will be made by L.A. Care within three (3) calendar days from the day your appeal was received.
You also have the right to request an expedited State Hearing, along with filing an appeal with L.A. Care. For more information about State Hearings, go to the “State Hearing” section of your Member Handbook.
You have the right to file an expedited grievance with the Department of Managed Health Care (DMHC) without filing an appeal with L.A. Care. For information on how to file an expedited grievance with the DMHC, go to the “Contacting the California Department of Managed Health Care (DMHC)” section of your Member Handbook.
L.A. Care pays for all medical costs covered by Medi-Cal for emergency care. You should not get a bill for any services covered by L.A. Care. Please call L.A. Care right away if you receive a medical bill and we will make sure the doctor stops sending you a bill.
You may get a medical bill if you go to a doctor or hospital that does not work with L.A. Care or is located outside of L.A. County. If this happens, then you may be billed by the doctor or hospital and you may have to pay for services that are not covered by L.A. Care.
If you pay the bill, keep a copy or record of your payment and send a copy of your payment to L.A. Care for review. If the bill is for covered or authorized services, you may receive a refund from L.A. Care.
Do not pay medical bills you get from a collection company. If you get a bill for covered services and need help or if you want to file a complaint, call Member Services at L.A. Care at 1-888-839-9909 (TTY 711).
For more information, please review the “If you get a bill” section of your Member Handbook.