CalOptima Community Network Summary of Benefits

CalOptima Community Network Summary of Benefits

The services listed below are covered by the CalOptima Medi-Cal program. It is important to work with your Primary Care Provider (PCP) to get the medical care you need. For more information, see your CalOptima Member Handbook or CalOptima Community Network Member Handbook or call CalOptima's Customer Service Department.

SERVICE

HOW TO GET SERVICE

Adult Preventive Services

History and physical exam, adult immunizations, annual mammography exams for women over age 50, blood pressure, cholesterol and/or cancer screenings, and TB screening

Call your PCP.

Community-Based Adult Services

CBAS provides services and support to eligible Medi Cal members to keep them healthy and help them live safely at home

Talk to your doctor to find out if you qualify for CBAS. If your doctor thinks you may benefit from the services provided through the CBAS program, he or she will refer you to CalOptima for an evaluation.

Doctor Visits

Visits, examinations, treatments, and consultations

Call your PCP. You should be seen within 10 working days from the date of your request.

Durable Medical Equipment (DME)

Equipment such as wheelchairs or artificial limbs

Must be ordered by your PCP and authorized by CCN. You should receive service within 15 working days from the date CCN has approved the request.

Emergency Care

Visits in the emergency room

Go to the nearest emergency room. Show your ID card(s) and ask the facility to call CCN within 24 hours.

Emergency Transportation

Emergency ambulance is available if your medical condition is life-threatening.

Call 911 for an emergency ambulance.

Non-Emergency Medical Transportation (NEMT)

Transportation, such as ambulance, litter van, or wheelchair van services, is available when your medical or physical condition makes it impossible for you to use a regular bus or car

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN approves the request.

Home Health Care

Health or supportive care provided in the member's home by health care professionals. Services include wound care, IV antibiotics, physical therapy, and other services that require a licensed professional and can safely be provided in the home.

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN receives the request.

Hearing Aid(s)

A small battery-operated device worn in or behind the ear to increase sound waves to help a deaf or hard-of-hearing person hear sounds more clearly

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN approves the request.

Hospice Care

Care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort and quality of life, rather than cure. The goal is to keep the patient as comfortable and pain-free as possible

Must be ordered by your PCP and authorized by CCN. You should receive service within 15 working days from the date CCN has approved the request.

Hospital/Inpatient Care

Services such as acute care, critical care or labor and delivery, including cesarean section and room

and board

Must be ordered by your PCP and authorized by CCN.

Immunizations (shots)

Injection used to help the body prevent or fight off

a disease

Call your PCP.

Laboratory Services

Services such as blood work, ultrasound, Computed Tomography (CT) scan or X-rays

Must be ordered by your PCP and authorized by CCN, except in emergencies. You should get services within 15 working days from the date CCN receives the request.

Limited Allied Health Services

Acupuncture, chiropractic services, faith or spiritual healing, occupational therapy, speech therapy, podiatry or audiology

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN approves the request.

Medical Supplies

Supplies such as diapers or feeding tubes

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN approves the request.

Medications

A substance used to treat a disease or to restore health.

See the CalOptima Pharmacy Directory for a list of CalOptima's network pharmacies. You are not responsible for Medi-Cal drug costs.

Newborn (baby) Care

Inpatient newborn medical care provided under the mother's coverage

Call your child's PCP.

Nursing Facility Services

Daily room and board in a 24-hour nursing facility. Length of stay is authorized by the treating doctor

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN receives the request.

Occupational Therapy

Mental or physical activities to help recovery from disease or injury. Prescriptions are limited to no longer than six months

Must be ordered by your PCP and authorized by CCN. You should receive service within 15 working days from the date CCN has approved the request.

Outpatient Mental Health Services:

These services are for the treatment of mild to moderate mental health conditions, which include*:



  • Individual and group mental health testing and treatment (psychotherapy);
  • Psychological testing to evaluate a mental health condition;
  • Outpatient services that include lab work, drugs and supplies;
  • Outpatient services to monitor drug therapy; and
  • Psychiatric consultation.

You can still get specialty mental health services from county mental health plans.



Not Covered:



  • Mental health services for relational problems are not covered. This includes counseling for couples or families for conditions listed as relational problems*.

*As defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM)

Outpatient mental health services are now a benefit covered by CalOptima. You can call 1-855-877-3885 or ask your Primary Care Provider (PCP) for the name of a plan mental health provider.

Pediatric Preventive Services/ Child Health and Disability Prevention (CHDP)

Checkups, shots, hearing, vision, dental and other exams given to children under the age of 21. Services also include infant and child health services through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program

Call your child's PCP.

Physical Therapy

Exercises and physical activities to help condition muscles and restore strength and movement

Must be ordered by your PCP and authorized by CCN. You should receive service within 15 working days from the date CCN receives the request.

Prenatal Care

Services during pregnancy and delivery, including Perinatal Support Services (PSS)

Call your PCP.

Specialty Care Services

Referrals to specialty services, such as orthopedist, neurology, and ear, nose and throat (ENT)

Must be ordered by your PCP and authorized by CCN. You should be seen within 15 working days from the date CCN receives the request.

Speech Therapy

Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior

medical treatment

Must be ordered by your PCP and authorized by CCN. You should get services within 15 working days from the date CCN receives the request.

Substance Use Disorder Preventive Services:

Alcohol misuse screening services are now a benefit covered by CalOptima for all members ages 18 and older. These services for alcohol misuse cover Screening, Brief Intervention, and Referral to Treatment (SBIRT).



Covered Services:



  • One expanded screening for risky alcohol use per year
  • Three 15-minute brief intervention sessions to address risky alcohol use per year

Not Covered:



  • CalOptima does not cover services for major alcohol problems, but you may be referred to the County Alcohol and Drug Program.

You can call 1-855-877-3885 or ask your Primary Care Provider (PCP) for the name of a plan mental health provider.

Vision Care

Services are provided to eligible members through Vision Service Plan (VSP). Routine eye exam for eligible members every 24 months or as medically necessary. When medically necessary, eyeglasses and contact lenses are covered every 24 months if you are: 1) Under the age of 21; 2) An adult living in a licensed nursing home; 3) Living in an Intermediate Care Facility Developmentally Disabled (ICF-DD); or 4) Pregnant and your doctor decides that not having these services will harm your baby.

Call CCN to see if you are eligible for vision care services.

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