Healthy Families Services for Children |
| NOTE: Benefits are provided if the insurance plan determines them to be medically necessary. |
| Healthy Families Benefits |
Services for Children |
Costs to Member
(co-payment) |
| Physician Services |
• Office, home visits
• Allergy testing and treatment |
• $5 per visit
• $5 per visit
• No charge if under 24 months |
| Preventive Care |
• Periodic health examinations (including well-baby care)
• Variety of voluntary family planning services
• Prenatal care
• Vision and hearing testing
• Immunizations
• Venereal disease tests
• Confidential HIV/AIDS counseling and testing
• Annual Pap smear exams
• Health education services |
• No charge (including office visits) |
Prescription Drugs
|
• 30 day supply of brand name or generic drugs, including prescriptions for one cycle of tobacco cessation drugs
• 90 day supply of maintenance drugs
• While in the hospital
• FDA-approved contraceptive drugs and devices |
• $5 per prescription
• $5 per prescription
• No charge
• No charge |
| Hospital |
• Inpatient: room and board nursing care and all medically necessary
services
• Outpatient: diagnostic, therapeutic, and surgical services performed
at a hospital or outpatient facility
|
• No charge |
| Emergency Health Care Services |
• 24-hour emergency for illness, injury, or severe pain requiring immediate diagnosis and treatment to avoid placing the subscriber in danger of loss of life, serious illness, or disability
• Provided both in and out of the health plan’s service area and participating facilities |
• $5 per visit unless hospitalized
• No coverage will be provided if the services received are not an emergency |
| Maternity |
•Prenatal and postnatal care, inpatient and newborn nursery care |
•No charge |
| Medical Transportation |
•Emergency ambulance transportation to the hospital, and medically necessary non-emergency transportation to transfer a member from a hospital to another hospital or facility, or facility to home. |
•No charge |
| Diagnostic X-ray and Laboratory Services |
• Inpatient and outpatient |
• No charge |
| Durable Medical Equipment |
• Medical equipment appropriate for use in the home, oxygen and oxygen equipment, insulin pumps and all related necessary supplies |
• No charge |
| Mental Health (In addition to these benefits some services are also provided by the California Children’s Services (CCS) program and by County Mental Health Departments. Families must meet residential requirements and members under the age of 19 must have a medical condition that is covered by CCS to be eligible for CCS services. Members who are under 19 years of age and diagnosed as having a Serious Emotional Disturbance (SED) will receive services from their County Mental Health Department.) |
• Diagnosis and treatment of mental illness. Outpatient and inpatient services are provided without limit for serious mental illnesses. All non-serious mental illnesses are limited to 20 outpatient and 30 inpatient hospital services |
• No charge for inpatient services
• $5 per visit for outpatient services |
Alcohol and
Drug Abuse |
• Inpatient: As medically appropriate to remove toxic substances from the system
• Outpatient: 20 visits per benefit year (Some plans may choose to increase the number of visits in a benefit year if outpatient services are determined medically necessary) |
• No charge for inpatient services
• $5 per visit for outpatient services |
| Physical, Occupational, Speech Therapy |
• Therapy may be provided in a medical office or other appropriate outpatient setting, hospital, skilled nursing facility, or home. Plans may require periodic evaluations as long as therapy, which is medically necessary, is provided. |
• No charge for inpatient services
• $5 per visit for outpatient services |
| Home Health Care |
• Must be prescribed or directed by the attending physician or other appropriate authority designated by the plan |
• No charge |
| Skilled Nursing Care |
• Services provided in a licensed, skilled nursing facility, 100 days each benefit year |
• No charge |
