Cost and Benefits

Cost

You do not have to pay for covered services. Your covered services are at no cost to you if they are medically necessary and provided by a Partnership provider. For a list of covered services, go to "Benefits and services" of the Member Handbook (click here).

You have to get prior authorization (pre-approval) before you visit a provider outside of our network. If you do not get
pre-approval you may have to pay for services. This does not apply to emergency or sensitive services. Sensitive services include:

    • Pregnancy testing and counseling
    • HIV/AIDS prevention and testing
    • Sexually transmitted infections testing and treatment
    • Sexual assault care
    • Outpatient abortion services

For more information about sensitive services see the "Sensitive care" section of the Member Handbook (click here).

Visit our Provider Directory for a list of Partnership providers (click here).

Long-term care and a share of cost

You may have to pay a share of cost each month for your long-term care services. Your share of cost depends on your income and resources. This cost is decided by your local Medi-Cal office. Each month you will pay up to your share of cost amount for your own health care. After that, your benefits and services will be covered by Partnership.

Benefits

Routine and preventive care are covered services, as well as medically necessary services when given by a Partnership provider. Routine care helps you stay healthy and helps keep you from getting sick. Routine care includes preventive care. Preventive care includes routine checkups and helps prevent health problems or finds them before they become worse. Medically necessary services are reasonable services needed to protect your life, keep you from getting very ill or disabled, or reduces severe pain from a diagnosed disease, illness or injury.

Some services need pre-approval from your provider and Partnership.

Partnership covers the basic health benefits and services listed below. Click the benefit or service for more information including if a pre-approval is needed.

Members with Limited Medi-Cal

Coverage for some members only includes breast and cervical cancer treatment and/or long-term care services. This is decided by your local Medi-Cal office.

Visit your Member Handbook for a list of covered services (click here).

Alcohol and Drug Treatment

Alcohol and drug treatment is a covered service based on medical need. It can include in-home treatment, help with quitting, help with staying sober, and case management.

If you live in one of these counties and have Medi-Cal, Partnership pays for these services through Partnership's Wellness and Recovery program: Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, or Solano. Partnership works with Carelon Behavioral Health for these services. Call Carelon Behavioral Health at (855) 765-9703. TTY users call 
(800) 735-2929 or 711.

If you have Medi-Cal and live in one of the counties listed below, contact your local county behavioral health department to ask about alcohol and drug treatment.

Butte: (530) 891-2810
Colusa: (888) 793-6580
Del Norte: (707) 464-4813
Glenn: (800) 507-3530
Lake: (707) 274-9101 (North Lake); (707) 994-7090 (South Lake)
Marin: (888) 818-1115
Napa: (707) 253-4063 (Adults); (707) 255-1855 (Teens)
Nevada: (888) 801-1437
Placer: (888) 886-5401
Plumas: (800) 757-7898
Sierra: (530) 993-6746
Sonoma: (707) 565-7450
Sutter: (530) 822-7200
Tehama: (800) 240-3208
Trinity: (530) 623-1362
Yolo: (916) 403-2970
Yuba: (530) 822-7200

You can also call Partnership at (800) 863-4155. TTY users call (800) 735-2929 or 711.

Behavioral Health Treatment (BHT)

Partnership covers behavioral health treatment (BHT) services. BHT includes services and treatment programs, such as applied behavior analysis and evidence-based behavior intervention programs that develop or restore, to the maximum extent possible, the functioning of an individual under 21 years old.

Examples of BHT services include behavioral interventions, cognitive behavioral intervention packages, comprehensive behavioral treatment, and applied behavioral analysis.

BHT services must be:

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

You may qualify for BHT services if:

  • You are under 21 years of age; 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 Partnership Member Services Department if you have any questions or ask your primary care doctor. 

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, seniors, 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 your local CHDP office if you have any questions.

Circumcision (routine)

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

Continuity of Care

If you had to change your health plan, switch from fee-for-service Medi-Cal, or you had a doctor who is no longer in-network, you may be able to keep your doctor even if they are not with Partnership. This is called continuity of care.

If you need to get care from a doctor who is not a Partnership doctor, call us to ask about continuity of care. You may be able to get continuity of care for up to 12 months if:

You saw the doctor on an ongoing basis before enrollment with Partnership

You went to the doctor for a non-urgent visit at least once during the 12 months before your enrollment with Partnership

The doctor will work with Partnership and agrees to Partnership's contract requirements and payment

The doctor meets Partnership's professional standards

The doctor is a part of the Medi-Cal program

To learn more, call Member Services at (800) 863-4155. TTY users can call the California Relay Service at
(800) 735-2929 or call 711.

​Diabetes Prevention Program

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program designed to prevent or delay the onset of type 2 diabetes among individuals diagnosed with prediabetes. The program lasts one year and can continue for an additional year for those members who qualify. The program uses approved lifestyle changes including, but not limited to the following:

 Provides a peer coach; 

 Teaches self-monitoring and problem solving;

 Provides encouragement and feedback;

 Provides informational materials to support goals; and

 Tracks routine weigh-ins to help accomplish goals.

Members who are interested in DPP must meet program eligibility requirements. Contact PHC for additional program and eligibility 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, abortion, 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 Population Health Department at (855) 798-8764 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.

Medi-Cal Dental Program (Dental Services)

Dental services are covered through the Medi-Cal Dental Program. If you have questions or want to learn more about dental services, call the Medi-Cal Dental Program at (800) 322-6384. TTY users call (800) 735-2922 or 711. You may also visit the Medi-Cal Dental Program website or the Smile California website.

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 Carelon Behavioral Health (formerly Beacon Health Options) if you have questions about Mental Health. Your PCP or Carelon Behavioral Health can arrange for medically necessary mental health care. Your PCP can provide some mental health care within their scope of practice, and Carelon Behavioral Health can help you find a mental health provider near you.

PHC and Carelon Behavioral Health 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.

For information about alcohol and drug treatment, and our Wellness and Recovery Program, click here.

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

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 Program (GTP) at (855) 798-8764 to get help with your pregnancy care.

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

Provisional Postpartum Care Extension Program

The Provisional Postpartum Care Extension (PPCE) Program provides extended coverage for Medi-Cal members who have a maternal mental health condition during pregnancy or the time period after pregnancy.

Partnership HealthPlan of California cover's maternal mental health care for women during pregnancy and for up to two months after the end of pregnancy. The PPCE program extends that coverage for up to 12 months after the diagnosis or from the end of the pregnancy, whichever is later.

To qualify for the PPCE program, your doctor must confirm your diagnosis of a maternal mental health condition within 150 days after the end of pregnancy. Ask your doctor about these services if you think you need them. If your doctor thinks you should have the services from PPCE, your doctor completes and submits the forms for you.

Prescription Drugs

See Section 4 in your Handbook to learn about Prescription Drug coverage.

Medi-Cal offers pharmacy services as one of the program's many benefits. Starting January 1, 2022, your pharmacy benefit will be provided by the Department of Health Care Services (DHCS) instead of Partnership HealthPlan of California (PHC). Your prescription medications will be covered by Medi-Cal Rx.  Read More

You can call the Medi-Cal Rx Call Center Line at (800) 977-2273, 24-hours a day, 7-days a week, or 711 for TTY, Monday through Friday, 8 a.m. to 5 p.m.

You can find a list of pharmacies that work with Medi-Cal Rx in the Medi-Cal Rx Pharmacy Directory at https://medi-calrx.dhcs.ca.gov/home/.

Preventive (Well-Care) Services

Talk to your doctor about how you can stay healthy.
These are some of the services you and your family can get.

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.

Transportation - Non-medical

For non-medical transportation to and from PHC-covered appointments/services, please call PHC at (866) 828-2303 (Monday-Friday, 7 a.m.- 7 p.m.) at least 5 business days before your appointment. For urgent appointments, please call as soon as possible. Please have your member ID card ready when you call.

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 Transportation Services department at (866) 828-2303 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.

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.

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.