Summary of Benefits

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Summary of Benefits

Medi-Cal / Healthy Families / Healthy Kids

Summary of Benefits for
Medi-Cal, Healthy Families, and Healthy Kids

SCFHP members must receive all covered services by a contracted SCFHP provider in their primary care provider network.

Exceptions are emergency care and out-of-network care. Out-of-network care must be specifically authorized in advance by SCFHP or the appropriate network; emergency care does not require advance authorization.

Covered services must be provided and authorized, where necessary, in accordance with SCFHP policies and procedures, as outlined in the Provider Manual, or as required by the member's primary care provider network. SCFHP makes final determinations of coverage in accordance with the member's Evidence of Coverage.

Evidence of Coverage Documents

Here are the EOC documents for SCFHP’s three lines of business: Medi-Cal Managed Care, Healthy Families and Healthy Kids. EOCs are available in English, Spanish and Vietnamese.

Medi-Cal
English * Spanish * Vietnamese

Healthy Families
English * Spanish * Vietnamese

Healthy Kids
English * Spanish * Vietnamese

For additional information about covered benefits, authorization requirements or other SCFHP policies and procedures, please contact SCFHP Provider Services, by email or call at (408) 874-1788.

This chart is only a summary of basic benefits.

Summary of Benefits
Click here for pdf version

Click on the links below to view basic summaries of benefits for Medi-Cal Managed Care, Healthy Families and Healthy Kids. This chart is only a summary of basic benefits. See EOC documents for full descriptions of covered benefits.

Acupuncture * Alcohol Abuse Treatment *Ambulance * Audiology * Biofeedback* Blood * CAT scan * C.C.S. * Chiropractic * Circumcism * Contraceptives * Dental care * Dental surgery facility fee and anesthesia only * Dialysis * Durable medical equipment * Elective abortion * Emergency services * Employment /School Physical * Gynecology & family planning services * Hearing aid * Home health * Home health post partum * Hospice * Hospitalization * Immunizations * Infertilit y * Infusion Fluids/Meds (outpatient) * Laboratory * Mammography * Medical nutritional therapy * Medical supplies *Medications * Mental health * MRI * Obstetrical services & prenatal care * Occupational therapy * Orthotics * Oxygen * Physical therapy * Podiatry * Prayer and spiritual healing * Preventive Care * Prosthetics * Pulmonary Function Tests * Pulmonary Therapy * Radiology * Skilled nursing facility * Specialists office visit & second opinion * Speech therapy * Substance abuse * Surgery * Transplants * Vision Care

Benefit	Medi-Cal Managed Care	Healthy Families/Kids
Abortion	Self-referral - within provider group	Self-referral - within provider group
Acupuncture	Refer to Medi-Cal/EDS	Self-referral 20 visits* $5/visit
Alcohol abuse treatment	Refer to Medi-Cal/EDS	Inpatient: Covered
Alcohol abuse treatment		Outpatient: Covered $5/visit
Ambulance	Emergent: No Authorization Required	Emergent: No Authorization Required
Ambulance	Non-emergent: Covered	Non-emergent: Covered
Amniocentesis / Genetic Counseling	Covered	Covered
Audiology	Covered	Covered
Biofeedback	Not covered	Covered 8 visits* $5/visit
Blood	Autologous: Not Covered	Autologous: Covered
Blood	Outpatient Transfusion: Covered	Outpatient Transfusion: Covered
CAT scan	Covered	Covered
C.C.S.	Refer to CCS	Refer to CCS
Chemotherapy	Covered	Covered
Chiropractic	Refer to Medi-Cal/EDS	Self-referral 20 visits* $5/visit
Circumcision	Routine Newborn: Not Covered	Routine Newborn: Not Covered
Circumcision	Medically Necessary: Covered	Medically Necessary: Covered
Contraceptives	Formulary Prescriptions and specific over-the-counter: No Authorization Required	Formulary Prescriptions only: No Authorization Required
Dental care	Refer to Medi-Cal/EDS	Healthy Families - Refer to member's dental plan.
Dental care		Healthy Kids - Delta Dental 1-877-580-1042
Dental surgery facility fee and anesthesia only	Covered	Covered
Dialysis	Covered	Covered
Durable medical equipment	Covered	Covered
Emergency services	No Authorization Required	No Authorization Required $5/visit
Employment / School Physical	Not Covered	Not Covered
Gynecology & family planning services:	Office visits and Family planning services: Self Referral	Office visits and Family planning services: Self Referral $5/visit (except preventive & family planning services)
Gynecology & family planning services:	Gynecological Procedures: Covered	Gynecological Procedures: Covered $5/Visits
Hearing aid	Covered	Covered
Home health	Covered	Covered- OT/PT/ST $5/visit:
Home health post partum	Covered	Covered
Hospice	Covered	Covered
Hospitalization	Covered	Covered
Immunizations Identified by the (ACIP)	Covered	Covered
Infertility	Not covered	Not covered
Infusion Fluids/Meds (outpatient)	Covered	Covered
Laboratory	Covered	Covered
Mammography	Covered	Covered
Medical nutritional therapy	Covered	Covered
Medical supplies	Covered	Covered
Medications	Formulary Prescriptions: No Authorization Required	Formulary Prescriptions: No Authorization Required $5 copay
	Formulary Over-the Counter: No Authorization Required	Over the Counter: Not Covered
	Injectibles: Covered	Injectibles: Covered
Mental health	Refer to Medi-Cal/EDS	Covered- Inpatient 30 days* (except unlimited for SED & SMI)
Mental health		Covered- Outpatient 20 visits* $5/visit (except unlimited for SED & SMI)
MRI	Covered	Covered
Obstetrical services & prenatal care	Self Referral	Self Referral
	Stress Tests: Covered	Stress Tests: Covered
	Ultrasounds: Covered	Ultrasounds: Covered
Occupational therapy	Covered	Covered Outpatient $5/visit
Orthotics	Covered	Covered
Out-Of-Area-Care	Covered	Covered
Oxygen	Covered	Covered
Physical therapy	Covered	Covered Outpatient $5/visit
Podiatry	Initial consult: RAF Procedures: PAR	Initial consult: RAF Procedures: PAR $5/visit
Prayer and spiritual healing	Refer to Medi-Cal/EDS	Not covered
Preventive Care	No Authorization Required when performed by the Primary Care Physician	No Authorization Required when performed by the Primary Care Physician
Prosthetics	Covered	Covered
Pulmonary Function Tests	Covered	Covered
Pulmonary Therapy	Covered	Covered
Radiology & Radiation Treatment	Covered	Covered
Skilled nursing facility	Covered Month of admission and following month. (After benefit limit Refer to Medi-Cal/EDS)	Covered 100 days*
Specialists services & second opinions	RAF to initiate treatment PAR to continue treatment	RAF to initiate treatment PAR to continue treatment $5/visit
Speech therapy	Covered	Covered Outpatient $5/visit
Sterilization	Covered	Covered
Sterilization Reversal	Not covered	Not covered
Substance abuse	Refer to Medi-Cal/EDS	Inpatient: Covered
Substance abuse	Refer to Medi-Cal/EDS	Outpatient: Covered 20 visits* $5/visit
Surgery Transplants	Covered Kidney: Covered
Surgery Transplants	Other: Refer to Medi-Cal/EDS	Covered
Vision Care	Refractions: Self Referral to "Optometrists" only. 1 exam every 24 months	Refer to Vision Plan 'VSP" 800-877-7195
	Lenses: Refer to Medi-Cal/EDS
	Frames: Self Referral Once every 2 years
	Medically Necessary Contact Lenses: Covered Post cataract surgery

There is a $250 maximum copayment per family, within a benefit year, for the Healthy Families and Healthy Kids Program.
The Healthy Families and Healthy Kids benefit year is July 1 through June 30.

PAR = Prior Authorization Request. Prior authorization from SCFHP is required for coverage.
RAF = Referral Authorization Form. Written authorization from the primary care physician is required for coverage.
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