California law states that health plans must provide many basic health care services, and certain other services. Plans must only provide services when the services are medically necessary.
Basic Health Care Services
Basic services include doctor and hospital services. Health plans must cover inpatient services—when you have to stay overnight in the hospital. They must also cover outpatient services, such as minor surgery in a surgery center. Other basic services are:
- Laboratory tests to diagnose problems. These include blood tests, STD (sexually transmitted diseases) tests, and pregnancy tests. This also includes some cancer screening tests.
- Diagnostic services, like x-rays and mammograms
- Preventive and routine care, like vaccinations and checkups
- Mental health care for some serious problems
- Emergency and urgent care—even if you are outside your health plan's service area
- Rehabilitation therapy, such as physical, occupational and speech therapy
- Some home health or nursing home care after a hospital stay
- Pregnancy care, unless you have an individual health plan and were age 19 or older and were pregnant when you joined the plan
Exclusion Period for Pre-Existing Conditions
If you have a pre-existing condition, basic health care services for the condition may not be covered for a period when you first join a plan. This is called an “exclusion period”.
- An exclusion period cannot apply to anyone under age 19
- Individual health plans can have an exclusion period for up to 12 months
- Group health plans can have an exclusion period for up to 6 months (or up to 12 months for a group with 1 to 2 employees)
Other Benefits that Health Plans Must Cover
- Standing referrals for patients with AIDS (This means that you do not have to get a referral and approval each time you see an AIDS specialist.)
- Diabetes services and supplies
- Routine costs of clinical trials for cancer treatment
- Prosthetic devices or reconstructive surgery after a mastectomy (removal of a breast)
- Prosthetic devices to restore a method of speaking for a patient after a laryngectomy (removal of the vocal cords). This does not include electronic voice-producing machines.
- Reconstructive surgery to correct or repair birth defects, developmental abnormalities (something that is not normal in the way a child grows), trauma or injury, infection, tumors, or disease. The purpose of the surgery must be to improve function (the way a part of the body works) or to create as normal an appearance as possible.
- Services related to diagnosis, treatment, and management of osteoporosis (weak bones), including bone mass measurement and other FDA-approved tests and medications
- General anesthesia for dental procedures in certain cases
Services that Are Not Required
Most medical health plans do not cover dental care, eyeglasses, and hearing aids. Some plans do cover prescription drugs and durable medical equipment, such as wheelchairs and oxygen, but what is covered differs from plan to plan.
Diabetes Services and Supplies
If you have diabetes (insulin-using diabetes, non-insulin-using diabetes, or gestational diabetes), your health plan must cover the following, even if you can get them without a prescription:
- Blood glucose monitors and testing strips
- Blood glucose monitors designed for people with vision problems
- Insulin pumps and supplies needed to use the pump, in certain cases
- Urine strips to test for ketones
- Lancets and lancet puncture devices
- Pen delivery systems for taking insulin, in certain cases
- Podiatric devices to prevent or treat foot problems related to diabetes
- Insulin syringes
- Visual aids, except eyeglasses, to help people with vision problems take the proper dose of insulin
- Out-patient training, education, and medical nutrition therapy to help a person with diabetes use the covered equipment, supplies, and medications properly
If your health plan covers prescription drugs, it must cover the following diabetes drugs:
- Other prescription drugs to treat diabetes