MEDI-CAL LIMITATIONS AND EXCLUSIONS a) Acupuncture Services
Eligible members may receive acupuncture services through fee for service Medi-Cal.
b) Adult Day Health Care
Services which a member gets through the adult day health care program are not covered.
c) CCS Services
California Children Services is a medical program that treats children with certain physically handicapping conditions and who need specialized medical care. As part of the services provided through the Medi-Cal Program, children needing specialized medical care may be eligible for the CCS Program. A Medi-Cal member must be under the age of 21 and their PCP must suspect or identify a possible CCS-eligible condition.
The PCP must refer the member to the local CCS Program to be eligible for the Program.
If the CCS Program determines the member’s condition is eligible for CCS services, the member will continue to stay enrolled with SFHP, but will receive treatment for the CCS- eligible condition through the specialized network of CCS providers and CCS approved specialty centers. SFHP will continue to provide primary care and preventive services that are not related to the CCS-eligible condition. SFHP will also work with the CCS program to coordinate care provided by both the CCS Program and SFHP. The CCS Program will provide all of the services necessary to treat the CCS-eligible condition and SFHP will provide all medically necessary covered services not covered by CCS.
d) Chiropractic Services
Eligible members may receive Chiropractic services through fee for service Medi-Cal.
e) Cosmetic Services
Plastic surgery or other cosmetic services to change the member’s appearance are not covered. This exclusion does not apply to services covered under ―Reconstructive Surgery‖ in Section 4-7.
f) Custodial care
Services primarily for custodial, maintenance, or domiciliary care or rest or to change a person’s environment are not covered.
g) Dental Care
Services that are normally done by a dentist, orthodontist, or oral surgeon, and dental appliances are not covered. The exclusion does not apply to medically necessary covered services, such getting the member’s jaw ready for radiation treatment, where the
member’s PCP may refer the member to a dentist.
Children under age 21 may receive dental care through Denti-Cal.
h) Diets/Vitamins/Food
Special foods or diet items, including vitamins, minerals, food supplements, nutritional services and food item for special diets are not covered.
i) Experimental or Investigational Services
Experimental or Investigational cares are services that:
Are not seen as safe and effective by generally accepted medical standards to treat a condition; or
Require approval by a governmental authority prior to use and such approval has not been granted when the service is to be rendered.
Experimental or Investigational services are not covered, unless the conditions of Title 22 of the California Code of Regulations, Section 51303 (h) are met and prior authorization is received.
Members may request an Independent Medical Review (IMR) for denied requests for Experimental or Investigational services. See Section 5-8 for more information.
j) Hair Loss or Growth Treatment
Services to make hair grow or for hair loss are not covered benefits.
k) Infertility Services and Conception by Artificial Means
Infertility services and treatments including in-vitro fertilization, gamete intrafallopian transfer (G.I.F.T), embryo transport, donor semen, and non-medically necessary amniocentesis are not covered.
l) Personal Care Services
Services that are not medically necessary, such as help with activities of daily living are not covered. Or, services that can be done by people whom do not need a medical license or do not have to be supervised by a nurse. This exclusion does not apply to services covered under ―Skill Nursing Facility Care‖ in section 4-7.
m) Prayer Healing
Eligible members may receive prayer healing services through fee-for-service Medi-Cal.
n) Reversal of Sterilization
Services to reverse voluntary surgical birth control (tubal-ligation for women and vasectomy for men) are not covered.
o) Routine Foot Care Services
Routine foot care services that are not medically necessary are not covered benefits.
p) Sexual Reassignment Surgery
Sexual reassignment surgery, including hormone therapy associated with sexual reassignment surgery, is not a covered benefit.
q) Surrogacy
A surrogacy arrangement occurs when a woman (the ―surrogate‖) agrees to become pregnant and give the baby to someone else to rise. Services for anyone related to the member in a surrogacy arrangement, except for services covered in this manual that are provided to a member who is a surrogate, are not covered.
r) Testing
Any examinations, testing or treatments for purposes of obtaining or maintaining a career, education, employment or insurance, marriage or adoption, are not covered, even if it is prescribed by a participating provider.
s) Travel and Lodging Costs
Travel and lodging costs related to covered services are not covered. This exclusion does not apply if the member’s medical group authorizes care from a non-SFHP provider and SFHP authorizes the costs ahead of time. This exclusion does not apply to services covered under ―Medical Transportation‖ in Section 4-5.
t) Limitations and Reductions
The California Department of Managed Health Care (DMHC) has the right to recover money from a third party payer, such as:
Services covered by an employer;
Services covered by government agencies;
Services covered by Medicare;
Services covered by the veteran’s administration;
Services covered by other health insurance plan as their primary insurance;
The amount recovered by DHS will never be more than the amount a third party pays.
HEALTHY FAMILIES COVERED BENEFITS