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Principal Exclusions and Limitations

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

General Exclusions and Limitations

The following are the general exclusions and limitations for the Health Net or Medi-Cal fee-for-service (FFS) program:

  • Covered services are limited to those services and supplies covered under the Medi-Cal FFS program that are described in Health Net's agreement with the Department of Health Care Services (DHCS) as being Health Net's coverage responsibility. In the event the California legislature passes a law to eliminate or reduce a service that was covered under the Medi-Cal FFS program, or the DHCS amends its Medi-Cal agreement with Health Net to eliminate or reduce a service that was covered under the agreement, benefits under this health plan are similarly eliminated or reduced upon the effective date of the change
  • In order for services to be covered, they must be provided by a participating provider and coordinated by the member's primary care physician (PCP), except for emergency services, family planning services, nurse midwife services, sexually transmitted infection (STI) treatment, confidential HIV testing, and counseling services
  • Coverage is limited to services that are medically necessary
  • Services received in a state or federal hospital are not covered
  • Coverage for hospice services is limited to terminally ill members with a life expectancy of six months or less. Coverage is provided in accordance with the hospice benefit and terms and conditions of eligibility and coverage under the Medi-Cal program and is subject to all exclusions and limitations of coverage under this plan
  • Newborn coverage is limited to the month of birth and the following month if the child is not enrolled. Members must contact the Health Care Options (HCO) office to enroll the child to ensure continuous coverage
  • Children may be entitled to additional services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services Program under certain conditions

A maximum of two visits per calendar month for any single combination of categories of services listed below:

  • Speech and occupational therapy
  • Audiology services
  • Chiropractic services
  • Podiatry services

The following limitations and exclusions also apply to medications:

  • Medications must be approved by the Food and Drug Administration (FDA), prescribed by a participating provider, and dispensed at a participating pharmacy. Covered behavioral health medication prescribed by a psychiatrist does not need to be prescribed by a participating provider in order to be covered, but must be dispensed by a participating pharmacy
  • Medication coverage is limited to generic medications when a generic equivalent is available. The medication benefit is generally limited to a maximum 30-day supply of medication at any one time
  • Limitations and exclusions of medications can be found under the applicable Recommended Drug List (RDL). Medications that are medically necessary but are not on the RDL, or are restricted, require prior authorization

Exclusions

The following are not covered by Health Net or the Medi-Cal FFS program:

  • Experimental procedures
  • Cosmetic surgery (except when required to repair trauma, congenital defects or disease-related disfigurement)
  • Personal comfort or convenience items
  • Services to reverse surgically induced infertility
  • Infertility treatment
  • Private-duty nurses (except when medically necessary)
  • Circumcision (except when medically necessary)
  • Custodial care while confined to a facility or home
  • Chronic kidney dialysis when a member is eligible for coverage under Medicare
  • Non-emergency services provided outside of the county of residence
  • Non-medical transportation services, such as taxis, buses and cars

Exceptions Due to Extraordinary Circumstances

Health Net makes all reasonable attempts to provide coverage for services, but is not responsible for:

  • Delay or failure to render service due to major disaster or epidemic affecting facilities or staff
  • Interruption of services due to war, riot, labor disputes, or destruction of facilities

Failure to provide service when a member has refused a recommended service for personal reasons or when participating physicians believe no professionally acceptable alternative treatment exists.

Determinations of medical necessity of treatment are subject to review by a medical director, who is to consider all opinions and make a final decision about whether the services are covered.

The following are not covered by Health Net, but are covered by and coordinated through the Medi-Cal fee-for-service (FFS) program:

  • Some medications to treat behavioral health conditions, HIV and AIDS
  • Most major organ transplants, except kidney transplants for adults (evaluations must be authorized by the health plan)
  • Alcohol and medication treatment services
  • Outpatient heroin detoxification services
  • Dental services and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) supplemental dental services for certain beneficiaries
  • California Children's Services (CCS) program services
  • AIDS
  • Direct observation treatment (DOT) for tuberculosis
  • Alpha-fetoprotein (AFP) screening
  • Blood coagulation factors

The following are not covered by Health Net, but are covered by and coordinated through the Medi-Cal fee-for-service (FFS) program:

  • Some medications to treat behavioral health conditions, HIV and AIDS
  • Most major organ transplants, except kidney transplants for adults (evaluations must be authorized by the health plan)
  • Alcohol and medication treatment services
  • Outpatient heroin detoxification services
  • Dental services and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) supplemental dental services for certain beneficiaries
  • California Children's Services (CCS) program services
  • Long-term care services for members past the month after the month of admission to a skilled nursing facility (SNF) or an intermediate care or long-term care facility
  • Waiver program services (Home and Community Based Services (HCBS), AIDS, and Multipurpose Senior Services Program (MSSP))
  • Direct observation treatment (DOT) for tuberculosis
  • Alpha-fetoprotein (AFP) screening
  • Blood coagulation factors
Last Updated: 08/05/2021