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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

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

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.

Last Updated: 11/19/2021