Benefits

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The covered services chart lists most services you can get as a PHC member. Refer to your handbook for a complete list of covered services.

Some services require Prior Approval. Those services will have Prior Approval in the “What is covered” column. Services that require Prior Approval are covered if they are medically necessary with Prior Approval from your PCP or PHC.

Limited Benefits

These services are listed as Limited Benefits in the List of Covered Services Chart in this Section. These benefits are limited to children (up to 21 years of age), and certain groups over 21 years of age. Not everyone will qualify for a Limited Benefit.

Some Limited Benefits have extra coverage through PHC or Health Centers. See Section 3 in your Handbook for more information.

Members with Limited Medi-Cal

Some members have coverage for emergency-only or pregnancy-only. That means that only the benefits for emergency services and pregnancy services in the List of Covered Services that follow applies to members who have limited Medi-Cal. All other health care, even if that health care is a Medi-Cal benefit, is not covered by PHC or the Medi-Cal program.

Click here for the list of benefits

Behavioral Health Treatment (BHT) for Autism Spectrum Disorder

Treatment includes applied behavior analysis and other evidence-based services. This means the services have been reviewed and have been shown to work. The services should develop or restore, as much as possible, the daily functioning of a Member with ASD.

BHT services must be:

  • Medically necessary; and 
  • Prescribed by a licensed doctor or a licensed psychologist; and
  • Approved by the Plan; and
  • Given in a way that follows the Member's Plan-approved treatment plan.

You may qualify for BHT services if:

  • You are under 21 years of age; and
  • Have a diagnosis of ASD; and
  • Have behaviors that interfere with home or community life. Some examples include anger, violence, self-injury, running away, or difficulty with living skills, play and/or communication skills.

You do not qualify for BHT services if you:

  • Are not medically stable; or
  • Need 24-hour medical or nursing services; or
  • Have an intellectual disability (ICF/ID) and need procedures done in a hospital or an intermediate care facility.

If you are currently receiving BHT services through a Regional Center, the Regional Center will continue to provide these services until a plan for transition is developed.

You can call the PHC Member Services Department if you have any questions or ask your Primary Care Provider for screening, diagnosis and treatment of ASD.

Cost to Member: There is no cost to the Member for these services.

California Children’s Services (CCS)

CCS is a program that helps manage the health care of children, under the age of 21, with certain disabilities or medical conditions. PHC works with CCS to help your child get the care they need.

CCS has local offices in each county that has staff that can help you if you think your child is eligible to join CCS.

To contact CCS and to get more information about how CCS works, call the PHC Member Services Department and ask for the local CCS office number for your Home County.

If your child already has CCS and you need help getting care for your child, please call the PHC Care Coordination Department at 800-809-1350.

Care Coordination

Includes case management services (described below), and help when you need to access health care.

Call the PHC Care Coordination Department at (800) 809-1350 for more information.

Case Management Services

Includes case management for pregnancy care, diabetes, people who are Seniors and Persons with Disabilities and other PHC members who could benefit from case management.

You do not need Prior Approval from your PCP or PHC to get case management services.

Call the PHC Care Coordination Department at 800-809-1350 to learn about PHC’s Case Management Services.

Child Health and Disability Prevention (CHDP)

Children under 21 years old can get preventative services from their PCP. CHDP services help keep kids from getting sick and include regular checkups, shots, education and counseling, vision and hearing tests. 

You can call CHDP at 800-993-2437 if you have any questions.

Circumcision (routine)

​Routine circumcision is covered without Prior Approval for a child under four (4) months of age.

Denti-Cal (Dental Services)

Dental care is covered by Denti-Cal.

Call 800-322-6384 to find a Denti-Cal dentist and make an appointment.

Your Health Center may offer some dental benefits. Talk to your PCP at the Health Center for more information. See Section 3 in your Handbook for more information.

Durable Medical Equipment (DME)

Includes things like apnea monitors, nebulizers, prosthetics, wheelchairs and other supplies.

Requires Prior Approval from your PCP and PHC.

Click here for more information

Emergency Care

Includes medical care for life-threatening conditions. Go to the nearest hospital or call 911.

You do not need Prior Approval to get emergency care.

Family Planning Services

Includes birth control, pregnancy testing and counseling, Sexually Transmitted Disease (STD) testing and treatment, and other services. You can go to your PCP for these services or any Medi-Cal certified Family Planning Provider.

You do not need Prior Approval to get Family Planning Services.

Health Education

Includes classes for asthma, diabetes, smoking cessation (how to stop smoking), and weight loss.

Ca​ll the PHC Care Coordination Department at 800-809-1350 to learn more about our health education benefits.​

Home Health Care

​Includes medical care you get at home. 

You can get home health care with Prior Approval from your provider and PHC.

Hospice

Includes care and counseling for people with a terminal illness.

You need Prior Approval from your provider to be in hospice.

Some other services, like inpatient care, may need Prior Approval from PHC.

Inpatient Hospital Care

Includes medical care when you have been admitted to the hospital.

If the hospitalization is arranged by your provider, you need Prior Approval from PHC.

Prior Approval is not required when you are admitted to a hospital for an emergency. Once your health has become stable, your provider must ask PHC for Prior Approval for “post-stabilization” care.

Medical Supplies

​Includes supplies that are not reused, such as catheters, bandages, gloves and other medically necessary supplies.

Medical supplies require Prior Approval from your PCP.

Mental Health Care

PHC covers the treatment of mild to moderate mental health conditions, which includes:

  • Individual and group mental health testing and treatment (psychotherapy);
  • Psychological testing to evaluate a mental health condition;
  • Outpatient services that include lab work, drugs, and supplies;
  • Outpatient services to monitor drug therapy; and
  • Psychiatric consultation

 

Moderate and severe mental health needs are covered by your home county’s Mental Health Plan. See Section 6 in your Handbook to learn more about your Mental Health benefits.

You should talk to your PCP or Beacon if you have questions about Mental Health. Your PCP or Beacon can arrange for medically necessary mental health care. Your PCP can provide some mental health care within their scope of practice, and Beacon can help you find a mental health provider near you.

 

PHC and Beacon work with county Mental Health Plans to coordinate your care. 

PHC or State Medi-Cal will cover drugs you need for your mental health condition. See Section 11 in your Handbook for information on how to fill a prescription.


When you need mental health care, or if you have questions about your mental health benefits you can call Beacon toll-free at (855) 765-9703, 24 hours a day, 7 days a week. 

For Healthy Kids Mental Health Benefits click here

Minor Consent Services

Minor Consent Services means those Covered Services of a sensitive nature for minors (members under the age of 18) that do not need parental consent or permission to access, related to:

  • Sexual assault and rape
  • Drug or alcohol abuse for children 12 years old and older
  • Pregnancy and Abortion services
  • Family Planning
  • STD in children 12 years and older; and
  • Outpatient Mental Health care for children 12 years of age or older who are mature enough to participate intelligently and where either (1) there is a danger of serious physical or mental harm to the minor or others, OR (2) the children are the alleged victims of incest or child abuse.

You can go to your PCP directly, or any Medi-Cal provider for minor consent services. You do not need Prior Approval. All members have the right to confidentiality when getting these services.

Outpatient Hospital Services

Includes medical services you get in the outpatient department of a hospital. 

Covered services can include:

  • Services in the emergency room or outpatient clinic, such as observation services or outpatient surgery
  • Lab and diagnostic tests
  • X-rays and other radiology tests
  • Medical supplies such as splints and casts
  • Certain screenings and preventative services
  • Certain drugs that you can’t give yourself

Outpatient surgery is arranged by your provider, and needs Prior Approval from PHC.

Podiatry (foot care from a doctor of podiatry)

​Podiatry services are covered when medically necessary. You need Prior Approval from your PCP.

Prenatal Care

You can get care when you are pregnant and after your baby is born.

Your PCP can help you get prenatal care or get you to a provider who specializes in prenatal care.

Call the PHC Growing Together Prenatal Program (GTPP) at 800-809-1350 to get help with your pregnancy care.

You can get extra help, like gift certificates for going to your pregnancy care appointments.

Prescription Drugs

See Section 11 in your Handbook to learn about Prescription Drug coverage.

You need to go to a pharmacy in PHC’s network, unless you have an emergency.

Some prescriptions need Prior Approval from PHC.

PHC uses generic drugs unless the use of a brand drug is medically necessary.

Primary Care Services

​Primary care services are also referred to as general medical care. Call your PCP to make an appointment.

Regional Center Services

Members with developmental disabilities may be eligible for services from Regional Centers. 

If you need information about Regional Center services, or you need a referral to a Regional Center, call your PCP or the PHC Care Coordination Department.

Sensitive Services

Includes services for Family Planning, STD testing and treatment, AIDS/HIV testing, and Abortion (ending pregnancy) counseling and services.

You can go to your PCP directly, or any Medi-Cal provider for sensitive services. You do not need Prior Approval.

All members have the right to confidentiality when getting these services.

Skilled Nursing Care

Includes services you need when you are in a skilled nursing facility.

You need Prior Approval from your PCP and PHC to get skilled nursing care.

Specialty Care

Includes care you get from a specialty provider, like a cardiologist, podiatrist, or oncologist.

You need Prior Approval from your PCP to get specialty care.

Substance Use Disorder Services

No one intends to become addicted to alcohol or other drugs. But when it happens to you or to someone in your family, it is important to get help right away. Alcohol and other drug addiction are diseases, just like heart disease and diabetes. There are some very effective treatments which can help chemically dependent people and their families cope with the problems of substance abuse. 

Alcohol misuse screening services are covered for all members ages 17 and older. These services for alcohol misuse cover Screening, Brief Intervention, and Referral to Treatment (SBIRT):​​

  • One expanded screening for risky alcohol use per year
  • Three 15-minute brief intervention sessions to address risky alcohol use per year

If you or someone you care about is suffering from alcohol or other drug dependency, you can call:

Del Norte County - (707) 464-4813

Humboldt County - (707) 476-4054

Lake County - (707) 274-9101 (North Lake);  (707) 994-7090 (South Lake)

Lassen County - (530) 251-8108

Marin County - (415) 755-2345

Mendocino County - (707) 472-2637

Modoc County - (530) 233-6319

Napa County - (707) 253-4412 (Adults); (707) 255-1855 (Teens)

Shasta County - (530) 225-5200 or (530) 225-5936

Siskiyou County - (530) 841-4890

Solano County - (707) 784-2220

Sonoma County - (707) 565-7450

Trinity County - (530) 623-1362

Yolo County - (916) 403-2970

Members with KFHP (Kaiser) should call: (800) 464-4000

Transportation - Non-emergency medical

​You can use non-emergency medical transportation (NEMT) when you cannot get to your medical appointment by car, bus, train, or taxi, and the plan pays for your medical or physical condition. NEMT is an ambulance, litter van or wheelchair van. NEMT is not a car, bus, or taxi. PHC allows the lowest cost NEMT for your medical needs when you need a ride to your appointment. That means, for example, if a wheelchair van is able to transport you, PHC will not pay for an ambulance. NEMT can be used when:

  • Medically needed;
  • You can’t use a bus, taxi, car or van to get to your appointment;
  • Requested by a PHC provider; and
  • Approved in advance by PHC.

To ask for NEMT, please call PHC’s Care Coordination Department at (800) 809-1350 at least one business day (Monday-Friday) before your appointment. Or call as soon as you can when you have an urgent appointment. Please have your member ID card ready when you call. Limits of NEMT: You may use NEMT if you meet the terms above.

What Doesn’t Apply? Getting to your medical appointment by car, bus, taxi, or plane. Transportation will not be provided if the service is not covered by PHC. A list of covered services is in this member handbook. If you are being taken from a hospital to a Skilled Nursing Facility (also called Long Term Care) your provider does not need Prior Approval from PHC. If the transportation is for another reason, your provider needs Prior Approval from PHC.

  • Non-emergency medical transportation is covered with Prior Approval from PHC for transportation to any covered Medi-Cal service. This includes some services that are not provided by PHC. Some examples are:
  • Specialty mental health care provided by your Home County (if prescribed by your specialty mental health provider)
  • Dental care provided by your dentist (if prescribed by your dental provider)
  • Dialysis provided at a dialysis center (if prescribed by your provider)

Cost to Member: There is no cost when transportation is authorized by PHC.

Transportation - Non-medical

​For non-medical transportation to and from PHC-covered appointments/services, click here.

Vision Care

Routine Eye Exam

Every 24 months or as medically necessary.

  • Lenses  - Every 24 months, or as medically necessary
  • Frames - Every 24 months.

You can see any vision care provider that is contracted with PHC. Refer to your provider directory for a list of contracted vision providers. No referral is necessary.

Women, Infants and Children (WIC)

WIC gives pregnant women and new mothers nutrition information and coupons to buy healthy foods. Ask your provider to find out more about WIC. 

Call the WIC Local Office locator at (888) 942-9675 (WIC-Works) to locate the nearest WIC office near you. ​

X-Rays and Lab Services

Includes services when you get an x-ray or lab services like a blood draw.

You need Prior Approval from your PCP to get an x-ray or lab services.

You need to get Prior Approval from PHC for scans called CT, PET and others.