In order for you to get any health care service through HWLA, the service must be a covered benefit. "Covered benefits" are those services that HWLA is required to make sure you can get.
Covered Benefits Are:
- Medical Equipment and Supplies - Supplies and equipment that are medically necessary for medical or surgical care. These include, but are not limited to, ostomy supplies, disposable diabetic supplies, and some drainage and irrigation supplies.
- Emergency Care Services (Including Transportation) - Emergency services and care include ambulance, medical screening, examination, and evaluation by a doctor or appropriate personnel. Emergency services include treatment for both physical and psychiatric emergency conditions.
- Acute Inpatient Hospital Services - Medically necessary emergent or elective services provided in a hospital. Medically necessary means that they are reasonable and necessary in establishing a diagnosis and providing palliative, curative, or restorative treatment for physical and/or mental health conditions in accordance with generally accepted standards of medical practice. Emergent means they are needed immediately. Elective means they are beneficial to the patient but they are not urgently needed. All elective inpatient services require prior authorization from your doctor.
- Laboratory Services - These include blood work, urine tests and throat cultures and are medically necessary services that must be ordered by your doctor.
- Certain Mental Health Services - These services may include treatment for anxiety, depression, and other emotional or behavioral problems. Your medical home doctor will provide you with some outpatient mental health services within the scope of his or her training and practice. Call your medical home doctor for more information about mental health services available through your medical home. You may also directly call the Department of Mental Health Access Center Line at 1-800-854-7771.
- Outpatient Hospital Services - Services that are provided under the direction of a doctor but do not include an overnight stay. They may include any doctor-ordered necessary diagnostic services or specialty care. Your doctor may need to obtain prior authorization before referring you to these services.
- Physical Therapy - Services include exercises to improve and maintain a patient’s ability to function after an illness or injury. Services must be medically necessary and ordered by a doctor.
- Physician Services (Including Specialty Care) - All primary care and specialty care physician services are a covered benefit. Specialty care services will require a referral by your medical home doctor for prior authorization approval.
- Podiatry - Specialty care for foot problems. Podiatry services are limited and require prior authorization except when received on an emergency basis.
- Radiology - Includes routine x-rays, MRI, CT scans, or other tests that are medically necessary and are ordered by your doctor.
- Urgent Care - Urgent care is when a condition, illness or injury is not life-threatening, but needs medical care right away. It can be provided by your medical home within 48 hours or by an urgent care clinic.
- Women’s Health - Services include preventive screenings, such as mammograms, pap smears, and chlamydia screenings.
- Prescription Drugs and Over-the-Counter Drugs - Medications that are included on the HWLA formulary. A formulary is a list of pre-approved medications that are available to HWLA members when they have a prescription from a HWLA doctor filled at a HWLA pharmacy. You can call Member Services to request a copy of the formulary.
- Transportation in Certain Cases - Two types of transportation are available to members. The first kind is emergency transportation. This is used when you have an emergency and call 911, and an ambulance takes you to the hospital emergency room. The second kind is non-emergency medical transportation to medical appointments. This is transportation for members needing a wheel-chair van or litter van, and must be requested by your medical home and pre-approved by HWLA in advance.
Care for an emergency medical condition is covered 24 hours a day, seven (7) days a week in any hospital emergency department. An emergency medical condition is one where a regular, sensible person would believe needs treatment right away or his or her health will be seriously at risk or will lead to serious harm to a bodily function, organ or part.
Emergency services and care include ambulance, medical screening, examination, and evaluation by a doctor or appropriate personnel. Emergency services include both physical and psychiatric emergency conditions. You can learn more about these in the “Emergency Care: How do I get care in an emergency?” section of this handbook.
Nurse Advice Line
You are able to call the Nurse Advice Line 24 hours a day, seven (7) days a week. You can reach a nurse by calling 1-877-333-4952.
Why should I call?
- The top 4 reasons to call the Nurse Advice Line are:
- You feel sick and you need help, even at night or on weekends.
- You want to talk to a nurse right away.
- You need help with a cough or a cold.
- You have a question about your health.
What happens when I call?
The nurse will ask you some questions. Tell the nurse how you feel, where it hurts, and what it looks like. The nurse will help you decide what to do. They can tell if you need to see a doctor, need to get care right away or if it’s okay to wait, or if you can do something at home to feel better.Make sure you have your ID card with you. The nurse will ask you for your ID number.
Health Education Services
HWLA has health education materials, programs and services to help you stay healthy and take care of yourself. These programs are free. Health education services can help members by:
- Promoting health
- Preventing diseases
- Helping you manage chronic diseases, like diabetes, cholesterol and high blood pressure
Learn more about these topics by talking to your medical home doctor and asking for health education materials and a schedule of classes.
Emergency transportation is for a member that believes it is necessary to stop or relieve serious illnesses or symptoms, including pain or injury, that require immediate diagnosis and treatment. Emergency transportation (ambulance) or ambulance transport services provided through the “911” emergency response system will be covered in a medical emergency when medically necessary. Non-emergency medical transportation to medical facilities is covered when your medical and physical condition does not allow you to take regular means of public or private transportation (car, bus, etc.) and you have a written prescription from your doctor and advance permission from HWLA. Examples of non-emergency medical transportation include, but are not limited to, litter vans and wheelchair vans. This also includes non-emergency transportation for the transfer of a member from a hospital to another hospital or facility, or facility to home when the transportation is:
- Medically necessary, and
- Requested by the medical home doctor, and
- Authorized in advance by HWLA.
Non-emergency medical transportation is available if your physical condition prevents you from driving or taking public transportation to a medical appointment, or you have no other form of transportation available and the physician with whom the appointment is scheduled states that you need non-emergency medical transportation to and from the appointment on a specified date. If you need non-emergency medical transportation, please call your medical home or Member Services to see if you qualify for these services. You must have approval to get these services before the services are given.
Exclusion: HWLA does not cover transportation in regularly available vehicles, such as airplane, passenger car, bus or taxi.
Mental Health Services
For mental health services contact your medical home or the Department of Mental Health Access Center Line at 1-800-854-7771.Covered mental health services may include treatment for anxiety, depression, and other emotional or behavioral problems. Your medical home doctor will provide you with some outpatient mental health services within the scope of his or her training and practice. Call your medical home doctor for more information about mental health services available through your medical home.
Specialized mental health services may be needed if your mental health problem is limiting an important area of life functioning. If this care is beyond your medical home doctor’s training and practice, these services will be provided through the Los Angeles County Department of Mental Health (LACDMH). You can receive services from LACDMH with or without a referral from your doctor. LACDMH can be reached toll-free at 1-800-854-7771.