o Providers are health care professionals and support providers such as doctors, nurses, pharmacists, therapists, and other people who provide care and services. Services include medical care, long-term services and supports, supplies, prescription drugs, equipment and other services.
o The term providers also includes facilities such as hospitals, clinics, and other places that provide medical services, medical equipment, and long-term services and supports.
o Providers that are a part of our plan's network are called network providers.
o Network providers are the providers that have contracted with us to provide services to members in our plan. The providers in our network generally bill us directly for care they give you. When you see a network provider, you usually pay nothing for covered services. All network providers listed in this directory can provide services to L.A. Care Cal MediConnect Plan members if the provider is accepting new members.
o A Primary Care Provider (PCP) is a family practitioner, general practitioner or internist who gives you routine health care. Your PCP will keep your medical records and get to know your health needs over time. Your PCP will also give you a referral if you need to see a specialist or other provider.
o Specialists are doctors who provide health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
o Oncologists care for patients with cancer.
o Cardiologists care for patients with heart conditions.
o Orthopedists care for patients with certain bone, joint, or muscle conditions.
o A Medical Group is a group of PCPs and specialists created to provide and arrange health care services to you as a L.A. Care Cal MediConnect Plan member.
o A referral means that your network PCP or our plan must give you approval before you can see the other provider. You may need a referral to see a specialist or someone that is not your PCP. If you don't get a referral, L.A. Care Cal MediConnect Plan may not cover the service.
o Referrals from your network PCP or our plan are not needed for:
o Emergency care;
o Urgently needed care;
o Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are outside the plan's service area; or
o Services from a women's health specialist.
o Crisis stabilization, including mental health;
o Preventive health services for all ages, including immunizations;
o Basic prenatal care; or
o Communicable disease services, including STI and HIV testing.
o Additionally, if you are eligible to get services from Indian health providers, you may see these providers without a referral. We must pay the Indian health provider for those services even if they are out of our plan's network.
o More information on referrals is available in Chapter 3 of the Member Handbook.
o You also have access to a care manager and a care team that you help choose.
o A Care Manager helps you manage your medical providers and services.
o Your Care Team may include your doctor, your care manager, and/or other health care professionals that you choose. Everyone on the care team works together to make sure your care is coordinated. This means that they make sure tests and labs are done once and the results are shared with the appropriate providers. It also means that your PCP should know all medicines you take so that he or she can reduce any negative effects. Your PCP will always get your permission before sharing your medical information with other providers.