Know the Benefits
The GHPP provides complete services to its clients. Unlike other programs, the GHPP covers services even it is not related for the treatment of the GHPP eligible medical condition. The approval of these services is subject for individual review based on medical need.
GHPP services include the following:
Special Care Center (SCC) Service
The GHPP Special Care Centers are a system that:
- Provides coordinated care to clients with specific genetic conditions
- Multi-disciplinary and multi-specialty teams which consists of doctors, nurses, social workers, and other health team members
- Provides family centered planning
- Facilitates timely and appropriate care
The GHPP SCCs are located throughout California and usually connected with tertiary level medical centers. Each SCC must comply with the GHPP program standards to become an approved provider.
The GHPP Special Care Centers consist of:
Hospital StayAn acute hospital stay is a benefit of the GHPP. Continued authorization of hospital stay is subject for review. However, the following admission will not be covered by the GHPP:
- Sub acute facility admission
- Skilled nursing home admission
- Intermediate care facility admission
Outpatient medical care services consist of:
- Primary care physicians (PCPs)
- Specialty physicians such as cardiologists, endocrinologists, orthopedists
- Infusion centers
- Transfusion centers, such as for blood transfusions
- Diagnostic Centers, such as X-ray, MRI, etc
These services must be coordinated with the client’s special care center. With the exception of the PCP, all other services must have a referral submitted by the Special Care Center. The provider of the outpatient care must have a Medi-Cal provider ID number.
Pharmaceutical benefits include the following:
Medications prescribed by your doctor (Oral, topical, Subcutaneous, etc)
Home infusion therapy, such as intravenous antibiotics
Certain medications are not covered by the GHPP such as:
Certain over the counter medications such as multivitamins
Medications not approved by the Food and Drug Administration
Medications that are not included in the Medi-Cal formulary
Some of the medications if you are enrolled with Medicare Part D
If you are enrolled with Medicare Part D, you lose your drug coverage through the GHPP. Medicare Part D Frequently Asked Questions
In-patient surgeries, such as hip repair
Out-patient surgeries, such as cyst removal
Organ transplants, such as a lung transplant
Approval for surgery will be reviewed individually for medical necessity. The GHPP may not cover a surgery if there is no documented medical need.
Nutrition Products and Medical Foods
Approval of nutrition products is based on criteria of which all must be met first before these products are authorized.
Nutrition products include:
Replacement formulas/products, such as Phenex-2, Phenyl Free-1
Elemental formulas, such as Peptamen Jr
Calorie dense products, such as Ensure, Boost plus, Two Cal HN
Nutrition additives, such as Polycose, MCT oils, Duocal
Medical foods, such as low protein foods
Metabolic formula and medical foods are only a benefit for clients with a metabolic disorder.
Durable Medical Equipments (DMEs)
GHPP benefits includes the rental, repair, or purchase of durable medical equipments. Example of DMEs include:
Home oxygen delivery, such as oxygen concentrator, portable tanks
Medical DME, such as portable commode, feeding pumps, Intrapulmonary Percussive Ventilator machines
Rehab DME, such as wheelchairs, scooters
Orthotics such as Ankle Foot Orthosis
Each DME has different criteria for approval. The provider of the DME must have a Medi-Cal provider ID number.
Other services that are covered by the GHPP are:
Home health services, such as skilled nursing visits
Therapy services, such as Physical Therapy, Occupational Therapy, and Speech Therapy
Mental health services, such as psychotherapy counseling
Medical supplies, such as insulin syringes, diapers, etc.
These services also have criteria to be followed for approval. The provider of these services must have a Medi-Cal provider ID number.