Your Benefits

Summary of Benefits and Coverage Table

CalOptima PACE offers a variety of program benefits, covered by Medicare and Medi-Cal. Your specific Interdisciplinary Team will work with you and your family to determine which benefits are best for you.

The following table is intended to help you compare coverage benefits and is a summary only. There are no co-payments for PACE services.

Category

Services and Limitations

Deductibles

None

Lifetime Maximums

None

Professional Services

  • Physician services, including primary care providers and medical specialists, routine physicals, preventive health care, sensitive services, outpatient surgical services and outpatient mental health
  • Basic dental coverage (routine preventive services, including exams, X-rays and cleanings). Cosmetic dentistry is not included.
  • Vision care. Prescription eyeglasses and corrective lenses after cataract surgery.
  • Audiology services. Hearing exams and hearing aids
  • Routine podiatry
  • Medical social services/case management
  • Rehabilitation therapy. Includes physical, occupational and speech therapies

Outpatient Services

Coverage for surgical services, mental health, diagnostic x-ray and laboratory service

Hospitalization Services

Coverage for semi-private room and board and all medically necessary services, including general medical and nursing services, psychiatric services, operating room fees, diagnostic or therapeutic services, laboratory services, X-ray, dressings, casts, anesthesia, blood and blood products, drugs, and biologicals. Not covered are private rooms or private duty nursing, unless medically necessary, and non-medical items.

Emergency Health Coverage

Coverage for emergency services. CalOptima PACE does not cover emergency services outside the United States, except for emergency services requiring hospitalization in Canada or Mexico

Ambulance Services

Coverage for Ambulance Transportation.

Prescription Drug Coverage


Coverage for medications from the PACE formulary when prescribed by a PACE physician.

Durable Medical Equipment


Provision of Durable Medical Equipment as necessary

Mental Health Services


Coverage of Mental Health Services as necessary

Chemical Dependency Services

Coverage of Chemical Dependency Services as necessary

Home Health Services

Coverage of Home Health Services as necessary

Other

  • Medicare-covered skilled nursing facility. Coverage provided for semi-private rooms only.
  • Home care services
  • Day center services (including nutrition, hot meals, escort and transportation)
  • Necessary materials, supplies and services for management of diabetes mellitus
  • End-of-life care

Services must be either pre-approved or obtained from specified doctors, hospitals, pharmacies and other health care providers who contract with CalOptima PACE.

Prior authorization is never required for emergency, preventive or sensitive services.

Date Revised June 7, 2017

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