Medi-Cal Program. Benefit. Benefits Chart

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1 Chart Please note that the table below is only a summary. More details about benefits can be found in the section of the Medi-Cal Evidence of Coverage booklet. All health care is arranged through your doctor. In order for your health care to be paid for by the Alliance, your doctor and the Alliance have to say you need it. For most care, your doctor or provider has to be a part of the Alliance network. Help with The chart includes the following: 1. The first column in the chart lists the type of benefit that your plan covers. 2. The second column tells you more about the benefit and services that are covered by your plan. It also tells you about any limits of the benefit and other information you should know. Benefit Cancer Clinical Trials Cataract Spectacles and Lenses Dental Care related to dental care Topical Fluoride Varnish Drugs Prescribed by a Dentist Dental for Radiation Treatment Dental Anesthesia Diabetes Management and Treatment Covered Under certain conditions, services that relate to cancer clinical trials are covered. Contacts or glasses and other lenses that are needed after cataract surgery. Most dental care is not a benefit through the Alliance. Dental services are provided by Denti-Cal for members under the age of 21, pregnant, or living in a skilled nursing facility. Other members may also be able to get these services. (See Contact List for phone number.) The Alliance does cover the dental care listed below. For children younger than 6 years of age, we cover topical fluoride varnish up to 3 times in a 12-month period. This service may be obtained at an office visit with your doctor. Any drugs prescribed by a dentist are covered by the Alliance. If you have cancer in your jaw or neck and require radiation treatment, we cover dental exams and treatment. For dental care that you get through Denti-Cal, we provide general anesthesia under certain conditions. Exams, supplies, meters, and classes for the treatment of diabetes. Page 1 of 7

2 Dialysis Care Drug and Alcohol Abuse Durable Medical Equipment (DME) Family Planning Foot Care Genetic Testing and Counseling HIV Testing and Counseling Health Education Hearing Visits and Aids Home Health Care Hospice Care Hospital Inpatient Medical Transportation Mental Health Organ Transplants Outpatient Care Outpatient Imaging, Lab Tests, and Special Procedures Outpatient Pharmacy Dialysis care from an Alliance provider in Alameda County. We cover hospital stays for up to 3 days per episode for the medical treatment of withdrawal symptoms. All other drug and alcohol abuse care is obtained through the Alameda County Behavioral Health Plan (ACCESS). (See Contact List for phone number.) DME for use in your home if it is prescribed by an Alliance doctor. This includes wheelchairs and oxygen. We cover care that prevents or delays pregnancy. This includes most birth control methods. We cover medically necessary foot care services for some members. See the section of this booklet for more information. If you want to know more about genetic testing and counseling, see your doctor. We cover private HIV consults and testing from your doctor and clinics listed in the Confidential HIV Testing Sites section of the Provider Directory. You may also get this care at other places that accept Medi-Cal. You may contact the Office of AIDS Administration for a list of test sites where you will not be named and the test remains private. (See Contact List for phone number.) Our health programs can help you learn how to protect and improve your health. This includes classes and pamphlets. We cover hearing aids. Some members can get hearing visits. See the section of this booklet for more information. We cover approved medical care given to a member in their home. All approved end-of-life care. All approved care that you get when you are in a hospital in Alameda County. This includes room, drugs, treatments, tests, nurse, and doctor care. Emergency ambulance service and non-emergency ambulance service when authorized. Mental health care is not a benefit through the Alliance. Mental health care is obtained through Alameda County Behavioral Health Plan (ACCESS). (See Contact List for phone number.) Kidney and corneal transplants for members over the age of 21. For other kinds of transplants, the Alliance covers some types of care. All care that you get in a doctor s office or clinic. We cover imaging, lab tests, and special procedures to help find out what is wrong, and for treatment. This includes X-rays and MRIs. We cover drugs that are on the Alliance formulary and other items when prescribed by an Alliance doctor and dispensed at an Alliance network Page 2 of 7

3 Phenylketonuria (PKU) Pregnancy and Maternity Care Prosthetic and Orthotic Devices related to prosth. & orth. devices Internally Implanted Devices External Devices Reconstructive Surgery Sexually Transmitted Diseases Skilled nursing / Intermediate / Subacute Facility Care Therapeutic Abortion Therapeutic Enteral Formula Vaccines Vision Care pharmacy. More details about special types of drugs and limits on certain drugs are in the section of this booklet. Testing and treatment of PKU are covered. This includes formulas and special food products that are part of a PKU diet. We cover all health care before the birth of a baby, during the birth of a baby and after the birth of a baby. We cover the prosthetic and orthotic devices that are dispensed by an Alliance provider in Alameda County. We cover items implanted during a covered surgery. These items must be approved by the FDA. We cover prosthetic devices to restore normal function under certain conditions. We cover reconstructive surgical service performed to correct or repair abnormal structures of the body caused by certain conditions in order to improve function or to create as normal a look as possible. You may get private testing and treatment for sexually transmitted diseases (STDs). We cover skilled nursing, intermediate, and subacute nursing care for the month of admission plus the next month in a place that we contract with. If you need the above types of care for more than the month of admission plus the next month, you will be moved to Fee-For-Service Medi-Cal. Therapeutic abortions performed by providers who accept Medi-Cal. We cover therapeutic enteral formulas for members who have specific health problems. All approved vaccines are covered for children and adults. This includes the HPV vaccine. We cover vision care for some members. This service is obtained through a separate vision plan. See Attachment A and the section of this booklet for more information Page 3 of 7

4 Wait Times for Appointments and The information below amends your Alliance Medi-Cal Combined Evidence of Coverage (EOC) and Disclosure Form. This explains the wait time that you can expect for an appointment or service. If you have any questions, please call: Member CRS/TTY: 711 or Monday Friday, 8 a.m. - 5 p.m. Type of Appointment or Service Urgent Care that do not require a Prior Authorization that require a Prior Authorization Non-urgent Care For the diagnosis or treatment of injury, illness, or other health problem. Non-urgent Specialist Care Appointments with specialist physicians Non-urgent Mental Health Care Non-urgent appointments with a nonphysician mental health care provider Non-urgent appointments for ancillary services For the diagnosis or treatment of injury, illness, or other health condition Preventive and Follow-up Care Follow-up Standing referrals for chronic problems Wait Time Within 48 hours of request for appointment Within 96 hours of request for appointment Within 10 business days of request for appointment Within 15 business days of the request for appointment * Within 10 business days of the request for appointment * Within 15 business days of the request for appointment * May be scheduled in advance in line with medical standards of practice and expert advice of the provider. Page 4 of 7

5 Pregnancy Cardiac problems Mental health problems Lab and radiology services Telephone Triage or Screening By calling your Primary Care Physician Telephone triage or screening is a system that prioritizes medical treatment based on urgency. Triage or screening is offered 24 hours a day, 7 days a week. Wait time does not exceed 30 minutes. * Exceptions: - The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee. - Preventive care services and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Extra Covered by the Alliance for Medi-Cal Members On July 1, 2009, the California Department of Health Care (DHCS) advised all people who receive Medi-Cal that Medi-Cal will no longer pay for some benefits. This change only affects people who are age 21 and older. Alameda Alliance for Health Will Cover Some Cut by the State for Alliance Medi-Cal Members Many of the extra benefits cut by the State are needed by our members. These benefits may improve our members overall health and comfort. As your health plan, the Alliance wants to help you get the care you need. The extra benefits must be medically necessary and authorized: that are needed to protect life, prevent illness or disability, or to relieve severe pain, in keeping with Alliance guidelines and review. Page 5 of 7

6 The Alliance will cover the benefits below for all adult Medi-Cal members when there is a medical need: Speech therapy Audiology service Incontinence creams and washes Some psychology and podiatry visits (see chart below for details) As always, your doctor or clinic will work with the Alliance to decide when these benefits are needed. Below is a list of the benefits cut by the State and an account of what the Alliance will cover for adult Medi-Cal members: Medi-Cal Cut by the State for Some Adults Ages 21 and Over* Audiology Alameda Alliance for Health Benefit Review for Alliance Medi-Cal Members Covered when medically necessary. Dental Not covered for adult members with Alliance Medi- Cal only. Incontinence Creams and Washes Podiatry Psychology Speech Therapy Acupuncture Members who have their Medicare with Alliance CompleteCare receive dental benefits in These benefits may change in future years. Covered when authorized by the Alliance based on medical necessity. Covered for two problems when authorized by the Alliance based on medical necessity: Problems of the feet that relate to or are caused by chronic disease. Problems of the feet, which impair the ability to walk. Covered for some cases (like pre-bariatric surgery) when authorized by the Alliance based on medical necessity. Covered when authorized by the Alliance based on medical necessity. Not covered Page 6 of 7

7 Medi-Cal Cut by the State for Some Adults Ages 21 and Over* Alameda Alliance for Health Benefit Review for Alliance Medi-Cal Members Chiropractic Not covered Remember: The cut in extra benefits is ONLY for Adult Medi-Cal members. There are no changes to benefits for children. *The State has not cut the benefits listed above for people who receive Medi-Cal as described below: Under the age of 21; or Living in a skilled nursing facility (Level A or B; this includes subacute care facilities); or Pregnant. (If you are pregnant, you can still receive benefits. You can also receive other benefits listed above to treat problems that, if left untreated, might pose a risk for the pregnancy or baby. This includes dental exams, cleanings, and gum treatment. Dental and other benefits may also be obtained up to 60 days after the baby is born;) or Receive benefits through the California Children s (CCS) program; or Receive benefits through a Program of All-Inclusive Care for the Elderly (PACE). Eye Exams Eye exams once every two years are available to all Medi-Cal beneficiaries, including those in regular Medi-Cal. The eye exam benefit was temporarily cut, and then restored retroactive to July 1, Questions or Comments? If you have questions about these extra benefits or would like more information, please contact: Member CRS/TTY: 711 or Monday Friday, 8 a.m. - 5 p.m. Page 7 of 7