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Health Insurance Project | 2/19/15 Angela Reyes

Medi-Cal

Insurance & Co-Payments

Health Net for Medi-Cal beneficiaries is one of health care options the state of California

offers, specifically for Los Angeles County and Sacramento County. Medi-Cal is

Californias Medicaid health program in which the government pays for medical services for

people with limited income. The benefits covered are free of cost, including prescription

drugs. The Health Net Medi-Cal booklet states that Medi-Cal members should not be asked

to pay for prescription drugs, and they are advised to contact Health Net if asked to pay. A

list of approved prescription drugs are approved. If the doctor needs to prescribe drug not on

the list, there needs to be pre-authorization from Health Net.

Benefits (no waiting periods)

Services covered that do not require prior authorization include the following:

PCP doctor visits -- routine visits, exams, treatments, shots, and Child Health

Disability Prevention Program visits

Emergency services -- ambulance, medical screening, exam, evaluation

Urgently needed services

Family planning services, Prenatal Care, Maternity Care, Newborn Care

Sexually transmitted diseases services

HIV testing

Pregnancy termination Routine prenatal care (in-network)

Certified Nurse Midwife/OB-GYN visits (in-network)

Audiology services

Speech therapy services

Podiatry services (require pre-authorization except when in emergency)

Incontinence creams, washes, and related products

Dental services (LA County or Sacramento County)

Optometric Exams -- routine exam every 2 years and medically necessary exams for

diagnosis, treatment, or prevention of eye disease

Health education and prevention counseling (as part of PCP visit)

Diabetes Services medical equipment, prescription drugs, diabetes-related supplies

Asthma Services nebulizers, inhaler spacers, and peak flow meters for asthma

treatment and management

Cancer Screenings

Home Health

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Hospice Care -- limited to terminally ill members expected to live 6 months or less;

not considered Long Term Care

Hospital care -- inpatient/outpatient/rehabilitative services, intensive care, operating

room, discharge planning, blood/urine tests, throat cultures

Mental Health Services -- outpatient only: individual/group psychotherapy,

psychological testing, lab work, drugs, supplies, psychiatric consultation

Surgery -- inpatient/outpatient procedures when medically necessary, reconstructive

surgery/prosthetic devices to restore normal appearance after mastectomy,

lumpectomy, lymph node dissection, congenital defects, trauma, infection, tumor, or

disease

Child Health Disability Prevention Program (CHDP) all routine visits, exams,

treatments, and shots covered

Health Net does not cover:

Acupuncture

Eye appliances

Optical lenses and frames for members over age 21

Services related to California Childrens Services (CCS)-eligible conditions

Choice of Doctor

Each member is assigned a Primary Care Provider (PCP), which may or may not be the

doctor requested. The doctor must work within the Molina Health Plan or in network with

Health Net. A list of approved providers is sent to the members home in a packet as well as

being available online. A PCP can be assigned to all members of ones family enrolled in

Medi-Cal, or a different PCP can be assigned to each family member separately. Members

also have the option of choosing non-physician practitioners, linked with a supervising PCP.

This includes certified nurse midwives, certified nurse practitioners, and physician assistants.

Personal Experience

I have currently been enrolled in this health plan as of September 2014, yet I have not used

my health insurance for medical purposes. I have, however, used my benefits to get a routing

dental exam with x-rays, cleaning, and a tooth composite with no out-of-pocket cost. I have

also received an eye exam free of cost. I did choose to also get an exam for contact lens

fitting which I had to pay for out of pocket since it is an additional exam to the routine exam.

After previously paying a years worth of medical coverage, not through and employer, I am

thankful for the Medi-Cal program. Being a member of Health Net Medi-Cal gives me peace

of mind in that I will not have to worry about major costs when I need to visit the doctor.