Healthy Kids - Summary of Covered Services
There is no deductible assosciated with your coverage.
Maximum Copays are $250.00 per family per benefit year.
The benefit year is January 1 - December 31.
There are no annual or lifetime finacial benefit maximums for any health benefits covered under the plan.
| Category Description |
Member Copayment & Limitations |
| HOSPITAL SERVICES |
|
| Inpatient Services |
|
| Room and Board |
No Copayment |
| Doctor Visits |
No Copayment |
| Bone Marrow Transplants |
No Copayment |
Skilled Nursing Care (up to 100 calendar
days/year) |
No Copayment |
| Surgeon and Anesthesiologist services |
No Copayment |
| |
|
| PROFESSIONAL SERVICES |
|
| Physician Services |
|
| Office Visits |
$5/visit |
| Allergy testing/Treatment |
$5/visit |
| Periodic Physical Examinations |
No Copayment |
| Well-Baby and Well-Child Care |
No Copayment |
| |
|
| Ambulance Services (as medically necessary) |
No Copayment |
| |
|
| Blood and Blood Products(includes collection and storage of autologous blood) |
No Copayment |
| |
|
| Urgent Care Services |
$5/visit |
| |
|
| Family Planning Services |
|
| Medical, Professional, and Counseling Services |
No Copayment |
| Contraceptive Devices including Norplant; by prescription |
No Copayment (over-the-counter items are not covered; for example: condoms, jellies, or foams) |
| |
|
| Diagnostic X-Ray/Lab Procedures |
No Copayment |
| |
|
| Durable Medical Equipment (including orthotics and prosthetics) |
No Copayment |
| |
|
| Home Health Care |
No Copayment |
| |
|
| Hospice |
No Copayment |
| |
|
| Physical/Occupational/Speech Therapy (medically necessary) |
|
| Inpatient |
No Copayment |
| Outpatient |
$5/visit |
| |
|
| Pregnancy and Maternity care |
|
| Prenatal Care (office visits) |
No Copayment |
| Normal delivery; cesarean section, complications of pregnancy and medical services |
No Copayment |
| Hospital and Related Services |
No Copayment |
| |
|
| SPECIAL SERVICES |
|
| Prescription Drugs |
|
| Outpatient |
$5 Copayment / 30 day supply |
| Inpatient |
$5 Copayment - 90 day supply |
| |
|
| Mental Health |
|
| Inpatient |
No Copayment - 30 days per benefit year |
| Outpatient |
$5/visit - 20 visits per benefit year (no visit limit for treatment of Severe Mentall Illness (SMI) or Severe Emotional Disturbance (SED) conditions. |
| |
|
| Substance Abuse |
|
| Inpatient |
No Copayment - 30 days per benefit year |
| Outpatient |
$5/visit - 20 visits per year |
| |
|
| Acupuncture and Chiropractic |
$5/visit - 20 visits per year for each |
| |
|
| Biofeedback |
$5/visit |
| |
|
| Hearing Aid |
|
| Audiological Exam |
No Copayment |
| Hearing Aid Instrument |
Once every 36 months |
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Vision Services
You do not need a referral from your physician for routine vision services. Examples of routine vision services are:
- Routine examinations - $5.00 copayment
- Glasses - $5.00 copayment
Both of these services are available every twelve months or more frequently, if medically necessary.
You can receive these services from any PHC vision service provider. PHC does require that your vision service provider receive authorization before providing the service.
Refer to website for a list of vision providers.
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How to Obtain Mental Health Services
Mental health services are provided by the United Behavioral Health (UBH). Members who access mental health services must follow the UBH authorization requirements. To access mental health services and find out about mental health providers, please call UBH at 800-718-8430. In a psychiatric emergency, please call 911 or go to the nearest emergency room for help. Some conditions requiring mental health treatment may be California Children's Services (CCS) eligible conditions. Children eligible for CCS would receive these services through the CCS Program. Please see page 64 of the Evidence of Coverage (EOC) for more information on the CCS Program.
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How to Obtain Dental Benefits
Your dental benefits are provided through Delta Dental of California. Your eligibility for dental benefits starts the same day as your medical benefits.
Make the best use of your dental benefits by:
- Getting regular checkups;
- Following your dentist's advice about regular brushing and flossing;
- Using only network dentists; and
- Seeking treatment before you have a major problem.
To get dental services, please call one of the Delta Dental providers listed in the Dental Care Provider section of your Healthy Kids Provider Directory to make an appointment. Please make sure to let the office know when you call that you are a PHC Healthy Kids Program member.
If you have a question or grievance about eligibility, covered services, the denial of dental services or claims, policies, procedures and operations of the dental program, or the quality of dental services performed by a network dentist, you may contact Delta Dental's Customer Service toll free number at 877-580-1042, Monday through Friday, 7:15 a.m. to 5:00 p.m. For emergency situations, they are available 24 hours a day, seven days a week. The hearing impaired may contact Delta Dental's Customer Service through their TDD number by calling 800-735-2929.
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Prenatal Care
If you are pregnant or think you are pregnant, it is important to go to your doctor to get prenatal care as soon as possible. This way, both you and your baby can be as healthy as possible. You can go to the PHC Healthy Kids doctor of your choice for prenatal care; you do not need a referral from your Primary Care Provider to see an obstetrician.
If you would like information on having a healthy pregnancy and how to enroll in our Growing Together Program, call our Care Coordination Department at 707-863-4276 or 800-809-1350. Our Care Coordination staff can help you:
- With your questions about pregnancy
- Sign-up for childbirth preparation classes
- Find a program to support members with substance abuse problems
- Quit smoking
- Get transportation to prenatal visits
- Earn free gifts by going to routine prenatal care visits
- With breastfeeding questions
- Find an OB/GYN
After you have your baby, you will need to see your doctor 6 weeks later. This is an important time to let your doctor see how your body is changing after delivery and make sure that you and your baby are doing well. A few days after you give birth, call your doctor's office to ask for a postpartum appointment.
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