Benefits Grid

Service Coverage Details and Limitations
Abortion  Covered  
Acupuncture Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Alcohol and Substance Abuse Treatment Services (including drugs used for treatment and outpatient heroin detoxification services) Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Allergy Services (testing and desensitization) Covered Limits applicable when office visits billed in conjunction with allergy services
Ambulance - Emergency Transportation Covered Ground, Rotary Wing, Fixed Wing
Ambulance - Non-Emergency Transportation Covered Ground, Rotary Wing, Fixed Wing
Ambulatory Surgery Center - ASC Covered  
Anesthesia Services Covered  
Artificial Insemination Not Covered  
Audiology Services Covered Members age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Under age 21 refer to California Children's Services (CCS) guidelines here: 
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Bariatric Surgery Covered Only covered in a Centers for Medicare & Medicaid Services Certified Center of Excellence. Other limitations may apply.
Biofeedback Not Covered  
Birthing Centers Covered Limitations may apply
Blood and Blood Derivative Products Covered Designated providers for contrack blood factors. Other limitations may apply.
Blood Pressure Equipment Covered Covered only for documented malignant hypertention or end stage renal disease.
Bone Density Testing Covered One test per year for specified diagnoses. Not covered if for screening purposes only.
Breast Pumps Covered  
California Children's Services (CCS) Program medical services for children with certain special health problems Covered by California Children's Service Program Refer to CCS limits here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Only for members under age 21.
Clinical Trials Covered Member and trial must meet specific medical criteria.
Certified Nurse Midwife Covered  
Chemotherapy Covered Under age 21 refer to CCS guidelines:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Chiropractic Services Covered by Medi-Cal Fee-For-Service Only covered by the Health Plan when services are rendered at an Federally Qualified Health Center (FQHC) and Rural Health Center (RHC).  Please bill the state Medi-Cal program for services rendered at any other place of service. For more information, please use the following link: 
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Child Health and Disability Prevention (CHDP) Services Covered  
Christian Science Practitioners Covered by Medi-Cal Fee-For Service Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Circumcision Routine/Elective: Not Covered
Medically Necessary: Covered
 
Comprehensive Perinatal Services Program Covered Limitations may apply.
Cosmetic Surgery (not medically necessary) Not Covered  
Dental (medical providers/medical services related to dental services) Covered Certain prescription drugs, laboratory services, pre-admission physical examinations, facility fees/anesthesia, both inpatient and outpatient.
Diabetic Services Covered Under age 21 refer to CCS guidelines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Dialysis Covered Under age 21 refer to CCS guidelines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Directly Observed Therapy (DOT) Covered by Medi-Cal fee-for-service and County Health Department DOT is specific TB (tuberculosis) treatment rendered by Local Health Departments. Refer to Medi-Cal for limits here:

http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Durable Medical Equipment Covered  
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Covered Only for members under age 21
Emergency Room Services Covered  
Enteral and Parenteral Nutrition Covered  
Erectile Dysfunction Drugs and Therapies Not Covered  
Experimental Services (other than those provided in covered clinical trials) Not Covered This includes, but is not limited to drugs, equipment, procedures or services that are in a testing phase undergoing laboratory and/or animal studies prior to testing in humans.
Family Planning Services (and supplies) Covered Limitations may apply
FQHC - Federally Qualified Health Center Services Covered  
Fluoride Varnish (non-dental provider) Covered Only for members under age 6. Covered 3 times in a 12 month period. Service is provided by physicians, nurses, and other medical personnel.
Gender Reassignment Surgery Covered Procedures that are not medically necessary are not covered. Members age 18 and over.
Health Education Covered  
Hearing Aids and Repairs Covered Limitations may apply. Under age 21 refer to the CCS guidlines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Hearing Screenings Covered Member age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply. Under age 21 refer to CCS guidelines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
HIV Testing and Counseling Covered  
Home and Community Based Services (HCBS) - Waiver Programs Covered by Medi-Cal Fee-For-Service Rever to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Home Health Care Services Covered Limitations may apply
Hospice Care Covered Limitations may apply
Hospital Services - Inpatient Covered  
Hospital Services - Outpatient Covered  
Hyperbaric Oxygen Therapy - HBO Covered Limitations may apply, depending on diagnosis, requency, and provider type. Under 21 refer to CCS guidelines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Hysterectomy Covered Not covered if performed only to make a member permanently sterile.
Immunizations (adults and children) Covered Vaccines for Children program only for children. Other limitations may apply.
Incontinence Creams and Washes Covered Members age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply.
Indian Health Programs Covered  
Infertility (diagnosis and treatment) Not Covered  
Injectible Medications Covered Limits apply to certain medications.
Interpreter Services Covered  
Investigational Services Covered Including, but not limited to drugs, equipment, procedures or services for which laboratory and animals studies have been completed and for which human studies are in progress but testing is not complete, and the efficacy and safety of such services in human subjects are not yet established, and the service is not in wide usage. Other limitations may apply.
Laboratory and Pathology Services (Inpatient and Outpatient) Covered  
Laboratory Services - State Serum Alphafetoprotein Testing Program Covered by Medi-Cal Fee-For-Service Administered by the Genetic Disease Branch of California Department of Public Health
Local Educational Agency (LEA) Services Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Local Health Department Covered Directly Observed Therapy (DOT) is covered by Medi-Cal Fee-For-Services
Long Term Care (LTC) Covered by Medi-Cal Fee-For-Service Upon acceptance by state for LTC, member is dis-enrolled from California Health & Wellness Plan. Long-term care (LTC) is care in a facility for longer than the month of admission plus one month. These health care facilities include skilled nursing facilities, subacute facilities, pediatric subacute facilities, and intermediate care facilities. Refer to Med-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Please note: Hospice services are not considered LTC.
Mammography (screening) Covered Females only. Unless medically necessary, only covered for those age 40 and older.
Mental Health Services Covered by Medi-Cal Fee-For-Services (with Exceptions *)

Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx

* Exceptions covered by California Health & Wellness include certain lab, radiology, pharmacy, Medicare/Medi-Cal crossover claims, FQHC, RHC, IHS, and out of state providers (not border states). Specific diagnoses applicable to Inpatient Hospital and Home Health.

Non-Emergency Medical Transportation (NEMT) - other than ambulance Covered Benefit managed by LogistiCare:
http://www.logisticare.com
Limitations may apply.
Non-Medical Equipment Not Covered  
Obstetrical/Gynecological Services Covered  
Ostomy Supplies Covered  
Oxygen and Respiratory (services, supplies, equipment) Covered  
Pain Management Covered Limits include, but are not restricted to, specific diagnoses
Pap Smears (routine/preventative) Covered Age 21 & older
Pediatric Day Health Care Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Personal Care Services Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Personal Comfort Items Not Covered  
Physical, Occupational, and Speech Therapy Covered Speech Therapy: Members age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply. Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Physician, Registered Nurse Practitioner, or Physician Assistant Services Covered  
Podiatry Services Covered Members are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply.
Prayer or Spiritual Healing Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits here:
http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Prescription Drugs Covered Benefit managed by Envolve Pharmacy Solutions. http://www.usscript.com
Preventative Care Services Covered Services for children and adults include, but are not limited to: preventative health assessment visits, well child care, screenings (e.g. pap smears, mammograms, total serum cholesterol, etc.), and immunizations. Some limitations may apply.
Prosthetic and Orthotic Devices Covered Some limits apply. Under age 21 refer to CCS guidelines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Radial Keratotomy Not Covered  
Radiation Therapy Covered Under age 21 refer to CCS guidelines here:
http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Radiology Services (high tech imaging) Covered MRI, MRA, CAT and PET benefit managed by NIA. www.radmd.com
Radiology Services (other than high tech imaging) Covered  
Reconstructive Surgery (non-cosmetic) Covered Some limits apply. Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Rehabilitative Services Covered  
Rural Health Clinic Covered  
Services not allowed by federal or state law Not Covered  
Sexually Transmitted Diseases (STD) - screening and treatment Covered  
Skilled Nursing Facility (SNF) Covered  
Specialist Physician Conslutations Covered  
Sterilization Services Covered Only for members age 21 and older. Consent form is required with claim submission (some exceptions may apply).
Targeted Case Management Services Covered by Medi-Cal Fee-For-Service Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx
Temporomandibular Joint Disorder (TMJ) - Medical Treatment Covered  
Transplant Services - Kidney Covered Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Transplant Services - Other Major Organs Covered by Medi-Cal Fee-For-Service Upon acceptance by approved transplant program member is dis-enrolled from California Health & Wellness. Under age 21 refer to guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx
Urgent Care Center Services Covered  
Vision - Other than Optical Lenses Covered Benefit managed by Envolve Vision Care. Some limitations may apply.
Vison - Optical Lenses Covered