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Health Insurance Project | 2/19/15

Angela Reyes

Insurance & Co-Payments
Health Net for Medi-Cal beneficiaries is one of health care options the state of California
offers, specifically for Los Angeles County and Sacramento County. Medi-Cal is
Californias Medicaid health program in which the government pays for medical services for
people with limited income. The benefits covered are free of cost, including prescription
drugs. The Health Net Medi-Cal booklet states that Medi-Cal members should not be asked
to pay for prescription drugs, and they are advised to contact Health Net if asked to pay. A
list of approved prescription drugs are approved. If the doctor needs to prescribe drug not on
the list, there needs to be pre-authorization from Health Net.
Benefits (no waiting periods)
Services covered that do not require prior authorization include the following:
PCP doctor visits -- routine visits, exams, treatments, shots, and Child Health
Disability Prevention Program visits
Emergency services -- ambulance, medical screening, exam, evaluation
Urgently needed services
Family planning services, Prenatal Care, Maternity Care, Newborn Care
Sexually transmitted diseases services
HIV testing
Pregnancy termination
Routine prenatal care (in-network)
Certified Nurse Midwife/OB-GYN visits (in-network)
Audiology services
Speech therapy services
Podiatry services (require pre-authorization except when in emergency)
Incontinence creams, washes, and related products
Dental services (LA County or Sacramento County)
Optometric Exams -- routine exam every 2 years and medically necessary exams for
diagnosis, treatment, or prevention of eye disease
Health education and prevention counseling (as part of PCP visit)
Diabetes Services medical equipment, prescription drugs, diabetes-related supplies
Asthma Services nebulizers, inhaler spacers, and peak flow meters for asthma
treatment and management
Cancer Screenings
Home Health

Hospice Care -- limited to terminally ill members expected to live 6 months or less;
not considered Long Term Care
Hospital care -- inpatient/outpatient/rehabilitative services, intensive care, operating
room, discharge planning, blood/urine tests, throat cultures
Mental Health Services -- outpatient only: individual/group psychotherapy,
psychological testing, lab work, drugs, supplies, psychiatric consultation
Surgery -- inpatient/outpatient procedures when medically necessary, reconstructive
surgery/prosthetic devices to restore normal appearance after mastectomy,
lumpectomy, lymph node dissection, congenital defects, trauma, infection, tumor, or
Child Health Disability Prevention Program (CHDP) all routine visits, exams,
treatments, and shots covered
Health Net does not cover:
Eye appliances
Optical lenses and frames for members over age 21
Services related to California Childrens Services (CCS)-eligible conditions

Choice of Doctor
Each member is assigned a Primary Care Provider (PCP), which may or may not be the
doctor requested. The doctor must work within the Molina Health Plan or in network with
Health Net. A list of approved providers is sent to the members home in a packet as well as
being available online. A PCP can be assigned to all members of ones family enrolled in
Medi-Cal, or a different PCP can be assigned to each family member separately. Members
also have the option of choosing non-physician practitioners, linked with a supervising PCP.
This includes certified nurse midwives, certified nurse practitioners, and physician assistants.
Personal Experience
I have currently been enrolled in this health plan as of September 2014, yet I have not used
my health insurance for medical purposes. I have, however, used my benefits to get a routing
dental exam with x-rays, cleaning, and a tooth composite with no out-of-pocket cost. I have
also received an eye exam free of cost. I did choose to also get an exam for contact lens
fitting which I had to pay for out of pocket since it is an additional exam to the routine exam.
After previously paying a years worth of medical coverage, not through and employer, I am
thankful for the Medi-Cal program. Being a member of Health Net Medi-Cal gives me peace
of mind in that I will not have to worry about major costs when I need to visit the doctor.