Benefits Grid
The benefits grid outlines covered and non-covered services for California Health & Wellness members – services given on or before December 31, 2023.
If you have questions about what’s in store for 2024 visit here.
| Service | Coverage | Details and Limitations |
|---|---|---|
| Abortion | Covered | |
| Acupuncture | Covered | Contact the Member Services line for benefit information at 1-877-658-0305 |
| Alcohol and Substance Abuse Treatment Services (including drugs used for treatment and outpatient heroin detoxification services) | Covered by Medi-Cal Fee-For-Service | Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Allergy Services (testing and desensitization) | Covered | Limits applicable when office visits billed in conjunction with allergy services |
| Ambulance - Emergency Transportation | Covered | Ground, Rotary Wing, Fixed Wing |
| Ambulance - Non-Emergency Transportation | Covered | Ground, Rotary Wing, Fixed Wing |
| Ambulatory Surgery Center - ASC | Covered | |
| Anesthesia Services | Covered | |
| Artificial Insemination | Not Covered | |
| Audiology Services | Covered | Members age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Under age 21 refer to California Children's Services (CCS) guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Bariatric Surgery | Covered | Only covered in a Centers for Medicare & Medicaid Services Certified Center of Excellence. Other limitations may apply. |
| Biofeedback | Not Covered | |
| Birthing Centers | Covered | Limitations may apply |
| Blood and Blood Derivative Products | Covered | Designated providers for contrack blood factors. Other limitations may apply. |
| Blood Pressure Equipment | Covered | Covered only for documented malignant hypertention or end stage renal disease. |
| Bone Density Testing | Covered | One test per year for specified diagnoses. Not covered if for screening purposes only. |
| Breast Pumps | Covered | |
| California Children's Services (CCS) Program medical services for children with certain special health problems | Covered by California Children's Service Program | Refer to CCS limits here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx Only for members under age 21. |
| Clinical Trials | Covered | Member and trial must meet specific medical criteria. |
| Certified Nurse Midwife | Covered | |
| Chemotherapy | Covered | Under age 21 refer to CCS guidelines: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Chiropractic Services | Covered by Medi-Cal Fee-For-Service | Only covered by the Health Plan when services are rendered at an Federally Qualified Health Center (FQHC) and Rural Health Center (RHC). Please bill the state Medi-Cal program for services rendered at any other place of service. For more information, please use the following link: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Child Health and Disability Prevention (CHDP) Services | Covered | |
| Christian Science Practitioners | Covered by Medi-Cal Fee-For Service | Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Circumcision | Routine/Elective: Not Covered Medically Necessary: Covered |
|
| Comprehensive Perinatal Services Program | Covered | Limitations may apply. |
| Cosmetic Surgery (not medically necessary) | Not Covered | |
| Dental (medical providers/medical services related to dental services) | Covered | Certain prescription drugs, laboratory services, pre-admission physical examinations, facility fees/anesthesia, both inpatient and outpatient. |
| Diabetic Services | Covered | Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Dialysis | Covered | Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Directly Observed Therapy (DOT) | Covered by Medi-Cal fee-for-service and County Health Department | DOT is specific TB (tuberculosis) treatment rendered by Local Health Departments. Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Durable Medical Equipment | Covered | |
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) | Covered | Only for members under age 21 |
| Emergency Room Services | Covered | |
| Enteral and Parenteral Nutrition | Covered | |
| Erectile Dysfunction Drugs and Therapies | Not Covered | |
| Experimental Services (other than those provided in covered clinical trials) | Not Covered | This includes, but is not limited to drugs, equipment, procedures or services that are in a testing phase undergoing laboratory and/or animal studies prior to testing in humans. |
| Family Planning Services (and supplies) | Covered | Limitations may apply |
| FQHC - Federally Qualified Health Center Services | Covered | |
| Fluoride Varnish (non-dental provider) | Covered | Only for members under age 6. Covered 3 times in a 12 month period. Service is provided by physicians, nurses, and other medical personnel. |
| Gender Reassignment Surgery | Covered | Procedures that are not medically necessary are not covered. Members age 18 and over. |
| Health Education | Covered | |
| Hearing Aids and Repairs | Covered | Limitations may apply. Under age 21 refer to the CCS guidlines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Hearing Screenings | Covered | Member age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply. Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| HIV Testing and Counseling | Covered | |
| Home and Community Based Services (HCBS) - Waiver Programs | Covered by Medi-Cal Fee-For-Service | Rever to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Home Health Care Services | Covered | Limitations may apply |
| Hospice Care | Covered | Limitations may apply |
| Hospital Services - Inpatient | Covered | |
| Hospital Services - Outpatient | Covered | |
| Hyperbaric Oxygen Therapy - HBO | Covered | Limitations may apply, depending on diagnosis, requency, and provider type. Under 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Hysterectomy | Covered | Not covered if performed only to make a member permanently sterile. |
| Immunizations (adults and children) | Covered | Vaccines for Children program only for children. Other limitations may apply. |
| Incontinence Creams and Washes | Covered | Members age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply. |
| Indian Health Programs | Covered | |
| Infertility (diagnosis and treatment) | Not Covered | |
| Injectible Medications | Covered | Limits apply to certain medications. |
| Interpreter Services | Covered | |
| Investigational Services | Covered | Including, but not limited to drugs, equipment, procedures or services for which laboratory and animals studies have been completed and for which human studies are in progress but testing is not complete, and the efficacy and safety of such services in human subjects are not yet established, and the service is not in wide usage. Other limitations may apply. |
| Laboratory and Pathology Services (Inpatient and Outpatient) | Covered | |
| Laboratory Services - State Serum Alphafetoprotein Testing Program | Covered by Medi-Cal Fee-For-Service | Administered by the Genetic Disease Branch of California Department of Public Health |
| Local Educational Agency (LEA) Services | Covered by Medi-Cal Fee-For-Service | Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Local Health Department | Covered | Directly Observed Therapy (DOT) is covered by Medi-Cal Fee-For-Services |
| Long Term Care (LTC) | Covered by Medi-Cal Fee-For-Service | Upon acceptance by state for LTC, member is dis-enrolled from California Health & Wellness Plan. Long-term care (LTC) is care in a facility for longer than the month of admission plus one month. These health care facilities include skilled nursing facilities, subacute facilities, pediatric subacute facilities, and intermediate care facilities. Refer to Med-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx Please note: Hospice services are not considered LTC. |
| Mammography (screening) | Covered | Females only. Unless medically necessary, only covered for those age 40 and older. |
| Mental Health Services | Covered by Medi-Cal Fee-For-Services (with Exceptions *) | Refer to Medi-Cal for limits here: * Exceptions covered by California Health & Wellness include certain lab, radiology, pharmacy, Medicare/Medi-Cal crossover claims, FQHC, RHC, IHS, and out of state providers (not border states). Specific diagnoses applicable to Inpatient Hospital and Home Health. |
| Non-Emergency Medical Transportation (NEMT) - other than ambulance | Covered | Benefit managed by LogistiCare: http://www.logisticare.com Limitations may apply. |
| Non-Medical Equipment | Not Covered | |
| Obstetrical/Gynecological Services | Covered | |
| Ostomy Supplies | Covered | |
| Oxygen and Respiratory (services, supplies, equipment) | Covered | |
| Outpatient Cardic Rehabilitation Service | Covered | |
| Pain Management | Covered | Limits include, but are not restricted to, specific diagnoses |
| Pap Smears (routine/preventative) | Covered | Age 21 & older |
| Pediatric Day Health Care | Covered by Medi-Cal Fee-For-Service | Refer to Medi-Cal for limits http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Personal Care Services | Covered by Medi-Cal Fee-For-Service | Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Personal Comfort Items | Not Covered | |
| Physical, Occupational, and Speech Therapy | Covered | Speech Therapy: Members age 21 and older are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply. Under age 21 refer to CCS guidelines here:http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Physician, Registered Nurse Practitioner, or Physician Assistant Services | Covered | |
| Podiatry Services | Covered | Members are subject to the state's Optional Benefits Exclusion (OBE) coverage guidelines. Other limitations may apply. |
| Prayer or Spiritual Healing | Covered by Medi-Cal Fee-For-Service | Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Prescription Drugs | Covered | Benefit managed by Medi-Cal Rx. |
| Preventative Care Services | Covered | Services for children and adults include, but are not limited to: preventative health assessment visits, well child care, screenings (e.g. pap smears, mammograms, total serum cholesterol, etc.), and immunizations. Some limitations may apply. |
| Prosthetic and Orthotic Devices | Covered | Some limits apply. Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Radial Keratotomy | Not Covered | |
| Radiation Therapy | Covered | Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Radiology Services (high tech imaging) | Covered | MRI, MRA, CAT and PET benefit managed by NIA. www.radmd.com |
| Radiology Services (other than high tech imaging) | Covered | |
| Reconstructive Surgery (non-cosmetic) | Covered | Some limits apply. Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Rehabilitative Services | Covered | |
| Rural Health Clinic | Covered | |
| Services not allowed by federal or state law | Not Covered | |
| Sexually Transmitted Diseases (STD) - screening and treatment | Covered | |
| Skilled Nursing Facility (SNF) | Covered | |
| Specialist Physician Conslutations | Covered | |
| Sterilization Services | Covered | Only for members age 21 and older. Consent form is required with claim submission (some exceptions may apply). |
| Targeted Case Management Services | Covered by Medi-Cal Fee-For-Service | Refer to Medi-Cal for limits here: http://www.dhcs.ca.gov/services/Pages/AllServices.aspx |
| Temporomandibular Joint Disorder (TMJ) - Medical Treatment | Covered | |
| Transplant Services - Kidney | Covered | Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Transplant Services Over Age 21 | Covered | |
| Transplant Services Under Age 21 | Services are covered by California Children's Services (CCS) | Under age 21 refer to CCS guidelines here: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx |
| Urgent Care Center Services | Covered | |
| Vision - Other than Optical Lenses | Covered | Benefit managed by Envolve Vision Care. Some limitations may apply. |
| Vison - Optical Lenses | Covered |