Essential Health Benefits
Medi-Cal provides a comprehensive set of health benefits which may be accessed as medically necessary.
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
- Doula services
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
- Medi-Cal Peer Support Services (select counties)
Prescription Drugs
- Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class.
- Members may receive up to a 100-day supply of many medications.
Dental
The Medi-Cal Dental Program provides free or low-cost dental services to children and adults who receive Medi-Cal. Services covered by Medi-Cal Dental include:
- Diagnostic and preventive dental hygiene (e.g., exams, x-rays, and teeth cleanings, molar sealants)
- Orthodontics for children who qualify
- Tooth extractions
- Sedation for dental services
- Fillings and crowns
- Root canal treatments (anterior/posterior)
- Scaling and root planning
- Complete and partial dentures, and relines
For more information on covered benefits, please visit the Smile, California website.
Programs such as physical and occupational therapy (known as Rehabilitative & Habilitative Services) and devices
- Physical therapy
- Speech therapy / Audiology
- Occupational therapy
- Acupuncture
- Cardiac rehabilitation
- Pulmonary rehabilitation
- Skilled nursing facility services (90 days)
- Disposable Medical supplies (Continuous Glucose Monitoring "CGM" Systems and Disposable Insulin Delivery Systems for diabetics, Self-monitoring blood pressure devices and blood pressure cuffs)
- 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.
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 member under the age of 21 may receive extended services as medically necessary. Members under the age of 21 also have access to preventive dental care and vision care.
Other
Vision
- Routine eye exam once in 24 months
- Eyeglasses and contact lenses
Enhance Care Management (ECM)
ECM provides comprehensive care management to select high-need Medi-Cal members.
Community Health Workers (CHW) Services
Medi-Cal covers CHW services as a preventive benefit to: help members prevent disease, disability, and other health conditions or their progression; prolong life; and promote physical and mental health.
Transportation Services
Medi-Cal offers transportation to and from appointments for services covered by Medi-Cal. This includes transportation to medical, dental, mental health, or substance use disorder appointments, and to pick up prescriptions and medical supplies.
Nonemergency Transportation Services: Transportation by ambulance, litter van, or wheelchair van only when ordinary public or private conveyance is medically contra-indicated and transportation is required for a Medi-Cal benefit.
Nonmedical Transportation Services: Transportation by private or public vehicle for people who do not have another way to get to their appointment.
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
