Essential Health Benefits
Medi-Cal provides a comprehensive set of health benefits which may be accessed as medically necessary.
Essential Health Benefits Summary
A one-page Essential Health Benefits Summary is available for download.
Outpatient (Ambulatory) Services
- Physician services
- Hospital outpatient & outpatient clinic services
- Outpatient surgery (Includes anesthesiologist services.)
- Allergy care
- Treatment therapies (chemotherapy, radiation therapy, etc.)
- Emergency Room services
- All inpatient and outpatient services that are necessary for the treatment of an emergency medical condition, including dental services, as certified by the attending physician or other appropriate provider.
- Ambulance services
- Inpatient hospital services
- Anesthesiologist services
- Surgical services (bariatric, reconstructive surgery, etc.)
- Organ & tissue transplantation
Maternity and Newborn Care
- Prenatal care
- Delivery and postpartum care
- Breastfeeding education
- Nurse midwife services
- Licensed midwife services
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Mental health and Substance Use Disorder (SUD) Services
- Outpatient mental health services
- Outpatient specialty Mental health services
- Inpatient specialty mental health services
- Outpatient substance use disorder services
- Residential treatment services
- Voluntary inpatient detoxification
- Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class.
- Beneficiaries may receive up to a 100-day supply of many medications.
Programs such as physical and occupational therapy (known as Rehabilitative & Habilitative Services) and devices
- Physical therapy
- Speech therapy
- Occupational therapy
- Cardiac rehabilitation
- Pulmonary rehabilitation
- Skilled nursing facility services (90 days)
- Medical supplies, equipment and appliances (including implanted hearing devices)
- Durable medical equipment
- Hearing aids
- Home Health Services
- Outpatient laboratory and X-ray services
- Various advanced imaging procedures are covered based on medical necessity.
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Preventive and Wellness Services and Chronic Disease Management
- United States Preventive Services Task Force A & B recommended preventive services
- Advisory Committee for Immunization Practices recommended vaccines
- Health Resources and Service Administration's Bright Futures recommendations
- Preventive services for women recommended by the Institute of Medicine
- Family planning services
- Smoking cessation services
- Behavior health treatment for children under 21
Pediatric Services Including Oral and Vision Care
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a Medi-Cal benefit for individuals under the age of 21 who have full-scope Medi-Cal eligibility. EPSDT provides periodic screenings to determine health care needs and, in addition to the standard Medi-Cal benefits, a beneficiary under the age of 21 may receive extended services as medically necessary.
- Emergency dental services
- Dental implants and implant-retained prostheses
- Basic preventive, diagnostic, and repair services
- EPSDT and pregnant women receive extended dental benefits.
- Routine eye exam once in 24 months
- Eyeglasses for eligible individuals under the age of 21 and pregnant women through postpartum
Non-Emergency Medical Transportation Services
Ambulance, litter van, or wheelchair van only when ordinary public or private conveyance is medically contra-indicated and transportation is required for obtaining needed medical care for a Medi-Cal benefit.
Long Term Services and Supports
- Skilled Nursing Facility services (91+ days)
- Personal Care Services
- Self-Directed Personal Assistance Services
- Community First Choice Option
- Home and Community Based Services
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Last modified on:
10/24/2017 4:58 PM