Summary of Covered Services for Alliance Medi-Cal

Members with a Share of Cost must meet it each month before becoming eligible for benefits.

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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 (covers services in and out of the plan’s service area and with non-participating providers)

All non-emergency hospital services require prior authorization.

You may be billed for or asked to pay at time of  service from out-of-area providers who do not participate in Medi-Cal
PROFESSIONAL SERVICES  

PHYSICIAN SERVICES
Office Visits
Physician services in the hospital
Outpatient surgery
Immunizations
Periodic Physical Examinations

 
PREGNANCY AND MATERNITY CARE

Prenatal care (office visits)

Normal delivery, cesarean section, complications of pregnancy, and medical services
 
OTHER HEALTH CARE SERVICES  
AMBULANCE SERVICES  
BLOOD AND BLOOD PRODUCTS (includes collection and storage of autologous blood)  
DENTAL Covered through Denti-Cal (1-800-322-6384), not the Alliance. Dental services are only available through Denti-Cal for Medi-Cal beneficiaries who are under 21 years of age; residing in a skilled or intermediate nursing care facility; or beneficiaries who are pregnant, if not receiving the services could harm the health of the mother of fetus.
DIAGNOSTIC X-RAY/LAB PROCEDURES  
DURABLE MEDICAL EQUIPMENT
(including original and replacement orthotics and prosthetics)
 
FAMILY PLANNING SERVICE

Medical, Professional and Counseling Services

FDA Approved Contraceptive drugs and devices
Covers some FDA approved over-the-counter items such as condoms, foams and jellies.
HEARING AIDS             
Audiology Exam and Hearing Aid Instrument
 
HOME HEALTH CARE  
HOSPICE (for a terminal illness)  
ACUPUNCTURE AND CHIROPRACTIC SERVICES Not covered through the Alliance. These benefits are only available through fee-for-service Medi-Cal to beneficiaries who are under 21 years of age or who residing in a skilled or intermediate nursing care facility.

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.


 


 

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

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) must receive the majority of their prescriptions through their Medicare Part D drug plan or Medicare Advantage Plan. There are a few classes of drugs that are excluded from Medicare Part D that the Alliance would still be responsible for.

REHABILITATIVE (PHYSICAL, OCCUPATIONAL AND SPEECH) THERAPY The initial evaluation visit requires a referral from the member'ís Primary Care Provider. Any subsequent visits/treatments would require prior authorization from the Alliance.
SUBSTANCE ABUSE SERVICES Covered under fee-for-service Medi-Cal, not the Alliance
URGENT CARE Covered by or arranged by your PCP
VISION Members who are under 21 years of age or who are residing in a skilled or intermediate nursing care facility are able to get an eye exam and glasses every two years.

All other Alliance Medi-Cal members are covered only for an eye exam every two years. Glasses are not a covered benefit for these members.

Vision services for Alliance members are provided through Vision Services Plan (VSP) at 1-800-438-4560.

 

 

 

 

 

 

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