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Essential Health Benefits

Medi-Cal provides a comprehensive set of health benefits which may be accessed as medically necessary.

Essential Health Benefits Summary

One page essential health benefits summary (pdf)

Outpatient (Ambulatory) Services

  • Physician services
  • Hospital outpatient & outpatient clinic services
  • Outpatient surgery (Includes anesthesiologist services.)
  • Podiatry
  • Chiropractic
  • Allergy care
  • Treatment therapies (chemotherapy, radiation therapy, etc.)
  • Dialysis/hemodialysis

 

Emergency Services

  • 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

 

Hospitalization

  • 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

 

Prescription Drugs

  • 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
  • Acupuncture
  • Cardiac rehabilitation
  • Pulmonary rehabilitation
  • Skilled nursing facility services (90 days)
  • Medical supplies, equipment and appliances (including implanted hearing devices)
  • Durable medical equipment      
  • Orthotics/prostheses
  • Hearing aids
  • Home Health Services

 

Laboratory 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.

Other

Dental

  • Emergency dental services
  • Dentures
  • Dental implants and implant-retained prostheses
  • Basic preventive, diagnostic, and repair services
  • EPSDT and pregnant women receive extended dental benefits.

 

Vision

  • 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: 10/11/2017 1:46 PM