Central California Alliance for Health

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MEDI-CAL SUMMARY OF BENEFITS

Benefits are for full scope Medi-Cal Beneficiaries.

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• Services must be obtained from a participating Medi-Cal provider.

• Read the Evidence of Coverage for Specific Benefits.

• Benefits are subject to Alliance Utilization Management.

Follow the links for more information about your health plan and coverage:

  Health Education Benefits

  Provider Directory

  Provider Directory (Merced)

  Member Handbook

  Where to apply for benefit coverage

Category Description	Comments and Limitations
HOSPITAL SERVICES
Inpatient Room and Services Inpatient physical, occupational and speech therapy Intermediate or Skilled Nursing Services Emergency Room (services in and out of the plan’s service area and with non-participating providers)	All non-emergency hospital services require prior authorization.
PROFESSIONAL SERVICES
PHYSICIAN SERVICES Office Visits Physician services in the hospital Outpatient surgery Immunizations Periodic Physical Examinations	You must get services from your Primary Care Provider (PCP). If your PCP cannot provide the service, he or she will refer you to another provider. Some services require prior authorization.
PREGNANCY AND MATERNITY CARE Prenatal care (office visits) Normal delivery, cesarean section, complications of pregnancy, and medical services	Members may get prenatal and maternity care from any OB/GYN within the Service Area that accepts Medi-Cal and the Alliance.
OTHER HEALTH CARE SERVICES
AMBULANCE SERVICES	Covered when medically necessary.
BLOOD AND BLOOD PRODUCTS (includes collection and storage of autologous blood)	Covered when medically necessary.
DENTAL	Covered through Denti-Cal (1-800-322-6384), not the Alliance.
DIAGNOSTIC X-RAY/LAB PROCEDURES	Covered when medically necessary. Some services require prior authorization.
DURABLE MEDICAL EQUIPMENT (including original and replacement orthotics and prosthetics)	Covered when medically necessary. Prior authorization may be required.
COMMUNITY-BASED ADULT SERVICES (CBAS)	Covered when medically necessary. Prior authorization is required.
FAMILY PLANNING SERVICES Medical, Professional and Counseling Services FDA-approved contraceptive drugs and devices	Members may get these services from any provider that accepts Medi-Cal and the Alliance. Some FDA-approved over-the-counter items, such as condoms, foams and jellies are covered with a prescription
HEARING AIDS Audiology Exam and Hearing Aid Instrument	Covered when medically necessary. Prior authorization is required for hearing aids.
HOME HEALTH CARE	Covered when medically necessary. Prior authorization is required.
HOSPICE (for a terminal illness)	Covered when medically indicated and as decided by the Member.
ACUPUNCTURE AND CHIROPRACTIC SERVICES	Acupuncture and chiropractic services are covered for members who are: • Under 21 years of age • Residing in a skilled or intermediate nursing facility, or • Pregnant. Chiropractic services are also covered for any member if provided at a Federally Qualified Health Center (FQHC) that offers these services in accordance with clinic policy.
MENTAL HEALTH SERVICES Outpatient Mental Health Services Services for the treatment of mild or moderate mental health conditions. Inpatient and Specialty Mental Health Services Inpatient mental health services and services for the treatment of severe mental health conditions.	These services are provided through Beacon Health Strategies, 1-855-765-9700. These services are covered through County Mental Health Departments, not the Alliance. Santa Cruz County: 1-800-952-2335 Monterey County: 1-888-258-6029 Merced County: 1-888-334-0163
BEHAVIORAL HEALTH TREATMENT (BHT) FOR AUTISM SPECTRUM DISORDER (ASD)	These services are for members under 21 years of age who have a diagnosis of Autism Spectrum Disorder (ASD). Prior authorization is required. These services are provided through Beacon Health Strategies, 1-855-765-9700.
NON-EMERGENCY MEDICAL TRANSPORTATION	Benefit limited to transportation to and from covered medical appointments for members who: • Have a physical or medical condition that prevents them from riding in a bus or car; • Must be transported lying down; • Are in a wheelchair and not able to move out of the chair into a seat or to push the chair themselves. Members who feel they meet the above criteria should call 800-700-3874 ext. 5625.
PRESCRIPTION DRUGS 30-day supply; 90-day supply for maintenance drugs.	Members must get their prescriptions at a network pharmacy. Dual eligible Alliance members (members with both Medicare and Medi-Cal) will have most of their medications covered through their Medicare Part D or Medicare Advantage Plan. There are some medications that are excluded from Medicare Part D that the Alliance would still be responsible for.
NUTRITIONAL FORMULAS AND SUPPLEMENTS	Covered when medically necessary. Prior authorization is required.
REHABILITATIVE (PHYSICAL, OCCUPATIONAL AND SPEECH) AND HABILITATIVE THERAPY	The initial evaluation visit requires a referral from the member's Primary Care Provider. Any subsequent visits/treatments require prior authorization from the Alliance.
SUBSTANCE ABUSE DISORDER SERVICES	Covered through each County under fee-for-service Medi-Cal, not the Alliance.
URGENT CARE	Provided or arranged by your PCP
VISION	All members may get a routine eye exam every 2 years. Glasses (lenses and frames) are covered every 2 years only for members under 21 years of age and those who are in a skilled or intermediate nursing facility. Routine vision services for Alliance members are provided through Vision Services Plan (VSP) at 1-800-438-4560. Members must receive these services from a contracted provider.