- Participating Physician Groups (PPG)
The following services, including ancillary services, are available to members for the prevention, diagnosis and treatment of illness or injury.
Visits for the following services are covered as medically necessary:
- Routine adult and pediatric examinations
- Specialist consultations
- Injections and allergy tests and treatments
- Physician services in or out of the hospital
All eligible American Indians have the right to medical services from American Indian Health Programs (AIHP) facilities. Members do not need a referral from their primary care physician (PCP) to obtain care at these facilities. AIHP providers can operate as PCPs for American Indian members and provide referrals directly to network providers. AIHP services are covered by Health Net Medi-Cal plans and only apply to American Indian members. Members have the right to disenroll from the plan at any time, without cause.
The following information about coverage for emergency services is from the Member Handbook.
Emergency services are health services needed to evaluate or stabilize an emergency medical condition. An emergency medical condition can involve one or more of the following symptoms:
- Difficulty in breathing
- Seizures (convulsions)
- Unusual or excessive bleeding
- Severe pain
- Possible ingestion of poison, or medicine overdose
- Suspected broken bones
If a medical emergency occurs, members should be directed to go to the nearest emergency room for care or call 911. Members are encouraged to use the 911 emergency response system as appropriate. Members are required to notify their primary care physician (PCP) as soon as they are able. Emergency services are available 24 hours a day, seven days a week.
Emergency services are covered under this health plan when they are provided in the United States. No services are covered outside of the United States, except for emergency services requiring hospitalization in Canada or Mexico.
Long-term care coverage is a managed health care benefit. Services provided when medically necessary include, but are not limited to, the following:
- Room and board
- Physician and nursing services
- Medication administration
Home Health Care
The following home health care services are covered when medically necessary, referred by the member's primary care physician (PCP), and not covered under a carve-out or waiver program:
- Part-time skilled nursing services
- Visits by a registered nurse (RN)
- Diagnostic and treatment services, which can reasonably be provided in the home, including nursing care
- Rehabilitation, physical, occupational, or other therapies
Members do not need a referral or prior authorization to receive the family planning services listed below. Members may also see a provider who is not a Health Net participating physician without obtaining a referral or prior authorization from their primary care physician (PCP). Members may see licensed California providers who are practicing in another county from their county of residence.
A full range of family planning services is covered for members of child-bearing age that enable them to determine the number and spacing of their children. These services include all methods of birth control approved by the U.S. Food and Drug Administration (FDA), including:
- Contraceptive pills, including emergency contraceptives.
- Members may receive up to a 12-month supply dispensed at one time for FDA-approved, self-administered hormonal contraceptives, such as 12 vaginal rings, 36 patches and 13 cycles of oral contraceptives, when dispensed from an onsite clinic and billed by any qualified provider. A qualified provider is a provider who is licensed to furnish family planning services within their scope of practice, is an enrolled Medi-Cal provider, and is willing to furnish family planning services to a Medi-Cal enrollee as specified in Title 22, California Code of Regulations, Section 51200. A physician, physician assistant (under the supervision of a physician), certified nurse midwife, nurse practitioner, and pharmacist are authorized to dispense medications. Pursuant to the California Business and Professions Code (B&P Code), Section 2725.2, if contraceptives are dispensed by a registered nurse (RN), the RN must have completed required training pursuant to B&P Code Section 2725.2(b), and the contraceptives must be billed with evaluation and management (E&M) procedure codes 99201, 99211 or 99212 with modifier TD (used for behavioral health RN) as directed in the DHCS Medi-Cal Provider Manual.
- Contraceptive devices (intrauterine device (IUD), Depo-Provera and diaphragm).
- Vasectomy and tubal ligation.
- Pregnancy testing and counseling.
Members may choose any Health Net participating provider or certified nurse midwife within their participating physician group (PPG) for maternity care services. Members do not need to be referred by their PCPs, but may ask their PCPs to recommend a maternity care provider. Covered professional maternity care services include:
- Prenatal services.
- Postpartum services.
- Nutrition assessment and information.
- Health education assessment and information.
- Psychosocial assessment.
The following hospital services are covered:
- Semi-private accommodations, including all hospital services for mother and child.
- Hospital services for at least 48 hours following vaginal delivery, or at least 96 hours following a delivery by cesarean section. The coverage for the inpatient hospital stay may be less if the decision to discharge the mother and her newborn is made by the treating physician in consultation with the mother.
- When a delivery occurs in the hospital, the stay begins at the time of delivery (in the case of multiple births, at the time of the last delivery).
- When a delivery occurs outside a hospital, the stay begins at the time the mother is admitted.
- Newborn coverage is limited to the month of birth and the following month if the child does not enroll in the plan.
Federally qualified health center (FQHC) services must be made available to all Medi-Cal beneficiaries, including those enrolled in managed care plans. A Medi-Cal member who seeks care from an FQHC must choose a primary care physician (PCP) at an FQHC that contracts with Health Net. This does not apply to services that do not require prior authorization from Health Net or the member's PCP, such as emergency services, family planning services, nurse midwife services, sexually transmitted infection (STI) treatment, and confidential HIV testing and counseling services.
Health Net does not cover FQHC services if:
- The member receives services in an FQHC that is a participating provider with Health Net, but is not the FQHC that was chosen by the member or was assigned to the member as the primary care location
- The member receives services in an FQHC that is not a participating provider with Health Net
The following are covered when medically necessary:
- Room and board in a semi-private room, or if medically necessary, in a private room
- Surgical procedures
- Laboratory and X-ray, including radiation therapy
- Use of operating room, special cardiac care units, intensive care, recovery room
- All other medically necessary hospital services, including medications and nursing services
The following are covered for diagnosis and treatment:
- Laboratory tests
- X-ray procedures
- Other medically necessary tests, such as electrocardiograms (EKGs) and electroencephalograms (EEGs)
- Prostheses (for example, artificial arms and legs)
- Prosthetics and orthotic devices (subject to utilization controls)
- Orthopedic and conventional shoes when provided by a prosthetic and orthotic supplier when at least one of the shoes is attached to a prosthesis or brace
- Eyeglasses (subject to utilization controls)
- Medical supplies when prescribed by a licensed practitioner
- Durable medical equipment (DME) (for example, wheelchairs and crutches)
- Blood and blood plasma
- Hospice services for terminally ill members
- Audiology services and hearing aids for hearing disorders
- Podiatry services
- Speech, physical and occupational therapy when the services meet the requirements of Title 22, California Code of Regulations
The Medi-Cal Rx Contract Drug List (CDL) is the list of covered drugs that the Medi-Cal Rx program covers. The Medi-Cal Rx CDL applies to drugs that members can receive at retail pharmacies. To learn about the Medi-Cal Rx program, visit the Medi-Cal Rx website
The following medications are covered by Health Net:
- Medications administered while the member is hospitalized or in an emergency room
- Medications administered in a provider’s office or infusion center billed through the medical benefit
- Home infusion or other medication-related services billed through the medical benefit
The following medications are covered by the Medi-Cal Rx program:
- Self-administered and provider-administered medications listed on the Medi-Cal Rx Contract Drug List (CDL) and billed through a pharmacy claim
- Self-administered and provider-administered medications not listed on the Medi-Cal Rx CDL billed through a pharmacy claim (prior authorization may be required)
- Medications prescribed by a psychiatrist that are on the Medi-Cal Rx CDL and filled at a participating Medi-Cal Rx Pharmacy
- A 72-hour supply of a covered medication in a medical emergency.