Summary of Benefits
Services described in the Summary of Benefits table below are brief descriptions. For full explanation of your benefits, please see the Plan Benefits pages in your Member Handbook. For all additional questions, please call L.A. Care at 1-844-854-7272.
Your doctor must arrange and approve all your care before you receive services. Exception: Emergency room and out of area urgent care services do not require prior authorization.
The PASC-SEIU health benefit plan in Los Angeles County is considered a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.
Being a grandfathered health plan means that your PASC-SEIU health benefit plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
| Benefits | Covered Services | Member Pays |
|---|---|---|
| Asthma Care | Coverage for medically necessary supplies and equipment relating to the management and treatment of asthma, including inhaler spacers, nebulizers (including face masks and tubing), peak flow meters and education on the proper use of these items. Members identified with asthma are enrolled in the L.A. Cares About Asthma® disease management program that includes educational mailings and phone condition monitoring by a nurse for high-severity members. For inquiries on the program or to opt out of the program, members can contact: 1-888-200-3094 (TTY/TDD) 711 Monday through Friday 8 a.m. to 4 p.m. or email: | No co-payment |
| Blood and Blood Products | Inpatient and outpatient processing, storage, and administration and collection, and storage of autologous blood, when medically necessary. | No co-payment |
| Cancer Clinical Trials | Coverage for a member's participation in a cancer clinical trial, phase I through IV, when the member's physician has recommended participation in the trial and member meets certain requirements | $5 per visit Co-payment for prescriptions as described in the "Prescription Drug Program" |
| Cataract Spectacles and Lenses | Cataract spectacles and lenses, cataract contact lenses or intraocular lenses that replace the natural lens of the eye after cataract surgery | No co-payment |
| Confidential HIV and STD Testing | Testing available from L.A. County Department of Health Services, family planning services providers, your doctor, or prenatal clinics; no prior authorization required | No co-payment |
| Dental Services | Only when medically necessary; no coverage for routine dental services (e.g., cleaning, cosmetic) Routine dental coverage is offered separately and paid through a monthly payroll deductions to SEIU. For information, contact SEIU at 1-877-421-0177. | No co-payment |
| Diabetic Care | Equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes and gestational diabetes as medically necessary, even if the items are available without prescription. Training and health education for diabetes self-management. Family education for self-management. Members identified with diabetes are enrolled in the L.A. Cares About Diabetes® disease management program that includes educational mailings and phone condition monitoring by a nurse for high-severity members. For inquiries on the program or to opt out of the program, members can contact: 1-877-796-5878 (TTY/TDD) 711 Monday through Friday, 8 a.m. to 4 p.m. or email diabetesdm@lacare.org | No co-payment |
| Diagnostic, X-Ray and Laboratory Services | Therapeutic radiological services, ECG, EEG, mammography, other outpatient diagnostic laboratory and radiology tests | No co-payment |
| Durable Medical Equipment | Equipment for home used as medically necessary | No co-payment |
| Emergency Care Services | Health care services which a reasonable person would consider necessary to relieve a serious illness or symptom, injury, severe pain, or condition requiring immediate diagnosis. Offered 24 hours a day, seven days a week. | $35 per visit (waived if admitted to hospital) |
| Emergency Contraception | FDA-approved contraceptive drugs and devices | No co-payment |
| Eye Exam/Vision Services | No coverage for routine vision services (eyeglasses and contact lenses) | |
| Family Planning Services | Voluntary family planning services | No co-payment |
| Health Education Services | Effective health education services and materials. This includes education on personal health behavior and health care, and recommendations regarding the optimal use of health care. | No co-payment |
| Home Health Care Services | Services provided at the home by health care personnel Medically necessary skilled care; does not cover custodial care | No co-payment |
| Hospice | Medically necessary skilled care; counseling; medical supplies; short term inpatient care; pain control and symptom management; bereavement services; physical, speech and occupational therapies; medical social services; and respite care | No co-payment |
| Hospital Services — Inpatient | Room and board, nursing care and all medically necessary ancillary services
| No co-payment |
| Hospital Services — Outpatient | Diagnostic, therapeutic and surgical services performed at a hospital or outpatient facility | No co-payment |
| No co-payment | |
| No co-payment | |
| No co-payment | |
| $5 per visit | |
| $35 per visit | |
| Human Papillomavirus Screening & Vaccine (HPV) | Screening test for cervical cancer available to all female members ages 9 through 26 | No co-payment |
| Medical Nutrition Therapy | Treatment of diagnosed medical conditions (uncontrolled diabetes, obesity, underweight or pre-end-stage renal disease) through dietary interventions. Requires physician order. | No co-payment |
| Medical Transportation | Ambulance transportation in an emergency | No co-payment |
| Mental Health — Inpatient Care | Prior authorization is required for the following inpatient, in-network services:
| No co-payment |
| Mental Health — Outpatient Visits | Services obtained during a provider office visit, outpatient hospital visit, or urgent care visit.
Prior authorization is required for psychological testing. | $5 per visit |
| Mental Health - Outpatient Facility-Based Services | Services outside of an office setting, such as a treatment center or home, that involve daily or weekly treatment delivered over several hours. Prior authorization is required for the following outpatient, in-network services:
Call L.A. Care's toll free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you. | No co-payment |
| Physical, Occupational and Speech Therapy | Outpatient | $5 per visit |
| Inpatient Therapy may be provided in a medical office or other appropriate outpatient setting | No co-payment | |
| Pregnancy and Maternity Care | Prenatal and postpartum care | No co-payment |
| Prescription Drug Program | Drugs prescribed by a licensed practitioner
| $5 per prescription |
| $5 per prescription | |
| No co-payment | |
| No co-payment | |
| No co-payment | |
| No co-payment | |
| Preventive Care Services |
| $5 per visit |
| No co-payment | |
| No co-payment | |
| No co-payment | |
| No co-payment | |
| No co-payment | |
| Professional Services |
| $5 per visit |
| $2 per visit | |
| No co-payment | |
| No co-payment | |
| Prosthetics and Orthotics | Prosthetics and orthotics as prescribed by L.A. Care providers | No co-payment |
| Reconstructive Surgery | Reconstructive surgery repairs abnormal body parts, improves body function, or brings back a normal look. | No co-payment |
| Skilled Nursing Care | Services provided in a licensed skilled nursing facility. Benefit is limited to a maximum of 100 days per benefit year. | No co-payment |
| Substance Use Disorder Treatment Outpatient–Facility-Based Services | Prior authorization is required for the following in-network services:
Call L.A. Care's toll-free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you. | No co-payment |
| Substance Use Disorder Treatment – Inpatient Care | Prior authorization is required for the following inpatient, in-network services:
Call L.A. Care's toll-free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you. | No co-payment |
| Substance Use Disorder Treatment – Outpatient Visits | Services obtained during a provider office visit, outpatient hospital visit, or urgent care visit.
Call L.A. Care's toll-free Behavioral Health Hotline at 1-877-344-2858. We will help you find the kind of help that is right for you. | $5 per visit |
| Transplants | Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ | No co-payment |