Summary of Benefits

Summary of Benefits

The services listed below are covered by the CalOptima Medi-Cal program. It is important to work with your Primary Care Provider (PCP) to get the medical care you need. For more information, see your CalOptima Member Handbook or call your health network or CalOptima's Customer Service Department.

SERVICES:

HOW TO GET SERVICES:

Adult Preventive Services:
History and physical exam, adult immunizations, annual mammography exams for women over age 50, blood pressure, cholesterol and/or cancer screenings, and TB screening.

Call your Primary Care Provider (PCP).

Community-Based Adult Services:
CBAS provides services and support to eligible Medi-Cal members to keep them healthy and help them live safely at home.

Talk to your doctor to find out if you qualify for CBAS. If your doctor thinks you may benefit from the services provided through the CBAS program, he or she will refer you to CalOptima for an evaluation.

Doctor Office Visits:
Visits, examinations, treatments, and consultations.

Call your PCP. You should be seen within 10 working days from the date of your request.

Durable Medical Equipment (DME):
Equipment such as wheelchairs or artificial limbs.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Emergency Care:
Medical care in the emergency room.

Go to the nearest emergency room. Show your ID card(s) and ask the facility to call your health network within 24 hours.

Emergency Transportation:
Emergency ambulance is available if your medical condition is life-threatening.

Call 911 for an emergency ambulance.

Non-Emergency Medical Transportation (NEMT):
Transportation such as ambulance, litter van, or wheelchair van service is available when your medical or physical condition makes it impossible for you to use a regular bus or car.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Home Health Care:
Health or supportive care provided in the member's home by health care professionals. Services include wound care, IV antibiotics, physical therapy, and other services that require a licensed professional and can safely be provided in the home.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Hearing Aid(s):
A small battery-operated device worn in or behind the ear to increase sound waves to help a deaf or hard-of-hearing person hear sounds more clearly.

Must be ordered by your PCP and authorized by your health network. You should get your hearing aid(s) within 15 working days from the date your health network approved the request. Annual benefit limitations may apply.

Hospice Care:
Care designed to give support to people in the final phase of a terminal illness with a focus on comfort and quality of life, rather than cure. The goal is to keep the patient as comfortable and pain free as possible.

Must be ordered by your PCP and authorized by your health network. Your hospice care should start within 15 working days from the date your health network approved the request.

Hospital Care/Inpatient Care:
Services such as acute care, critical care units or labor and delivery, including cesarean section and room and board.

Must be ordered by your PCP and authorized by your health network.

Immunizations (shots):
Injection used to help the body prevent or fight off a disease.

Call your PCP.

Laboratory Services:
Services such as blood work, ultrasound, computed tomography (CT) scan or X-rays.

Must be ordered by your PCP and authorized by your health network, except in emergencies. You should get services within 15 working days from the date your health network approved the request.

Limited Allied Health Services:
Chiropractic services, faith or spiritual healing, occupational therapy, speech therapy, podiatry or audiology.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Medical Supplies:
Supplies such as diapers or feeding tubes.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Medications:
A substance used to treat a disease or to restore health.

See the CalOptima Pharmacy Directory for a list of CalOptima's network pharmacies.

Newborn (baby) Care:
Inpatient newborn medical care provided under the mother's coverage.

Call your child's PCP.

Nursing Facility Services:
Daily room and board in a 24-hour nursing facility. Length of stay is authorized by the treating doctor.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Occupational Therapy:
Mental or physical activities to help recovery from disease or injury. Prescriptions are limited to no longer than 6 months.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Pediatric Preventive Services/Child Health and Disability Prevention (CHDP):
Checkups, shots, hearing, vision, dental and other exams given to children under the age of 21. Services also include infant and child health services through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

Call your child's PCP.

Physical Therapy:
Exercises and physical activities to help condition muscles and restore strength and movement.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Prenatal Care:
Services during pregnancy and delivery, including Perinatal Support Services (PSS).

Call your PCP.

Specialty Care Services:
Referrals to specialty services, such as orthopedics, neurology and ear, nose and throat (ENT).

Must be ordered by your PCP and authorized by your health network. You should be seen within 15 working days from the date your health network approved the request.

Speech Therapy:
Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.

Must be ordered by your PCP and authorized by your health network. You should get services within 15 working days from the date your health network approved the request.

Vision Care:
Services are provided to eligible members through Vision Service Plan (VSP).

Routine eye exam for eligible members every 24 months or as medically necessary.

When medically necessary, eyeglasses and contact lenses are covered every 24 months if you are:

1) Under the age of 21;
2) An adult living in a licensed nursing home;
3) Living in an Intermediate Care Facility-Developmentally Disabled (ICF-DD); or
4) Pregnant and your doctor decides that not having these services will harm your baby.

Call CalOptima's Customer Service Department to see if you are eligible for vision care services.

If you are enrolled in Kaiser Permanente, call Kaiser’s Member Services Department for information on how to get vision care services.

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