Benefits & Services

Benefits are provided only for services that are medically necessary.

Call our Member Services Department at 1-888-839-9909 if you have any questions.

Click here to access the Healthy Families Member Handbook. (PDF)

Summary of Healthy Families Benefits

This matrix is intended to be used to help you compare covered benefits and is a summary only. The Benefit Description section of your Member Handbook should be consulted for a detailed description of covered benefits and limitations.

Benefits*	Services	Cost to Member (co-payment) Income Category A	Cost to Member (co-payment) Income Categories B & C
Inpatient Hospital Services	Room and board, nursing care, and all medically necessary ancillary services.	No co-payment	No co-payment
Outpatient Hospital Services	Diagnostic, therapeutic, and surgical services performed at a hospital or outpatient facility.	No co-payment except $5 per visit for physical, occupational and speech therapy performed on an outpatient basis. $5 per visit for emergency health care services (waived if the member is hospitalized).	No co-payment $10 per visit for physical, occupational and speech therapy performed on an outpatient basis. $15 per visit for emergency health care services (waived if the member is hospitalized
Professional Services	Services and consultations by a physician or other licensed health care provider.	$5 per office or home visit except No co-payment for hospital inpatient professional services No co-payment for surgery, anesthesia, or radiation, chemotherapy, or dialysis treatments No co-payment for members 24 months of age and younger No co-payment for vision or hearing testing, or for hearing aids	$10 per office or home visit except No co-payment for hospital inpatient professional services No co-payment for surgery, anesthesia, or radiation, chemotherapy, or dialysis treatments No co-payment for members 24 months of age and younger No co-payment for vision or hearing testing, or for hearing aids
Preventative Health Care Services	Periodic health examinations, Well Baby Care, routine diagnostic testing and laboratory services, immunizations, and services for the detection of asymptomatic diseases.	No co-payment	No co-payment
Diagnostic, X-Ray and Laboratory Services**	Laboratory services, and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, and treat members.	No co-payment	No co-payment
Diabetic Care**	Equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin using diabetes, and gestational diabetes as medically necessary, even if the items are available without prescription.	$5 co-payment per office visit Co-payment for prescriptions as described in the “Prescription Drug Program” Section	$10 co-payment per office visit Co-payment for prescriptions as described in the “Prescription Drug Program” Section
Prescription Drug Program**	Drugs prescribed by a licensed practitioner.	$5 per prescription for up to 30-day supply for brand name or generic drugs. $5 per prescription for up to 90-day supply of maintenance drugs. No co-payment for prescription drugs provided in an inpatient setting. No co-payment for drugs administered in the doctor’s office or in an outpatient facility. No co-payment for FDA-approved contraceptive drugs and devices.	$10 co-payment per prescription for up to 30-day supply for generic drugs. $15 co-payment per prescription for up to 30-day supply for brand name drugs unless there is no generic equivalent or if the use of a brand name drug is medically necessary. $10 co-payment per prescription for up to 90-day supply for maintenance generic drugs purchased either through a participating pharmacy or through the plan’s mail order program. $15 co-payment per prescription for up to 90-day supply for maintenance brand name drugs purchased either through a participating pharmacy or through the plan’s mail order program unless there is no generic equivalent or if the use of a brand name drug is medically necessary, then $10 copayment applies. No co-payment for prescription drugs provided in an inpatient setting. No co-payment for drugs administered in the doctor’s office or in an outpatient facility. No co-payment for FDA-approved contraceptive drugs and devices.
Durable Medical Equipment**	Medical equipment appropriate for use in the home which primarily serves a medical purpose, is intended for repeated use, and is generally not useful to a person in the absence of illness or injury.	No co-payment	No co-payment
Orthotic and Prosthetics**	Original and replacement devices as prescribed by a licensed practitioner.	No co-payment	No co-payment
Cataract Spectacles and Lenses**	Cataract spectacles and lenses, cataract contact lenses, or intraocular lenses that replace the natural lens of the eye after cataract surgery.	No co-payment	No co-payment
Maternity Care	Professional and hospital services relating to maternity care.	No co-payment	No co-payment
Family Planning Services	Voluntary family planning services	No co-payment	No co-payment
Medical Transportation Services**	Emergency ambulance transportation and non-emergency transportation to transfer a member from a hospital to another hospital or facility, or facility to home.	No co-payment	No co-payment
Emergency Health Care Services**	Emergency services are covered both in and out of the plan’s service area and in and out of the plan’s participating facilities.	$5 per visit (waived if the member is admitted to the hospital)	$15 per visit (waived if the member is admitted to the hospital.)
Inpatient Mental Health Services - Mental health care in a participating hospital when ordered and performed by a participating mental health professional for the treatment of a mental health condition.
Basic Mental HealthCare Services	Diagnosis and treatment of a mental health condition. 30 days per benefit year. Additional days may be authorized by the Plan. Plans, with the agreement of the subscriber or applicant or other responsible adult if appropriate, may substitute for each day of inpatient hospitalization any of the following: 2 days of residential treatment, 3 days of day care treatment, or 4 outpatient visits	No co-payment	No co-payment
Severe Mental Illness (SMI)	Inpatient mental health care services for the treatment of severe mental illnesses. Unlimited days.	No co-payment	No co-payment
Serious Emotional Disturbance (SED) Services	Inpatient mental health care services for the treatment of SED conditions. Unlimited days. On or before day 30; the Plan may refer the member to the county mental health department for continued treatment of the SED condition. The Plan and the county mental health department will coordinate services to ensure that all medically necessary services and treatment are provided to a member with a SED condition. The member will remain enrolled in the Healthy Families Program and will continue to receive primary care, specialty care, and all other services for medical conditions not related to the SED condition from the Plan.	No co-payment	No co-payment
Outpatient Mental Health Services - Mental health care when ordered and performed by a participating mental health professional.
Basic Mental HealthCare Services	This includes the treatment of children who have experienced family dysfunction or trauma, including child abuse and neglect, domestic violence, substance abuse in the family, or divorce and bereavement. Family members may be involved in the treatment when medically necessary for the health and recovery of the child. 20 visits per benefit year. Additional visits may be authorized by the Plan.	$5 per visit	$10 per visit
Severe Mental Illness (SMI)	Outpatient mental health care visits for the treatment of severe mental illnesses. Unlimited visits.	$5 per visit	$10 per visit
Serious Emotional Disturbance (SED) Services	Outpatient mental health care visits for the treatment for SED condition. Unlimited visits. The Plan may refer the member to the county mental health department for treatment of SED. The Plan and the county mental health department will coordinate services to ensure that all medically necessary services and treatment are provided to a member with an SED condition. The member will remain enrolled in the Healthy Families Program and will continue to receive primary care, specialty care, and all other services for medical conditions not related to the SED condition from the Plan.	No co-payment	No co-payment

Inpatient Alcohol / Drug Abuse Services	Hospitalization to remove toxic substances from the system. Call L.A. Care’s toll-free behavioral health hotline at 1-866-908-0677. We will help you find the kind of help that is right for you.	No co-payment	No co-payment
Outpatient Alcohol / Drug Abuse Services	Crisis intervention and treatment of alcoholism or drug abuse. Benefit is limited to 20 visits per benefit year. Call L.A. Care’s toll-free behavioral health hotline at 1-866-908-0677. We will help you find the kind of help that is right for you.	$5 per visit	$10 per visit
Home Health Care Services	Services provided at the home by health care personnel.	No co-payment, except $5 per visit for physical, occupational, and speech therapy	No co-payment, except $10 per visit for physical, occupational, and speech therapy
Skilled Nursing Care	Services provided in a licensed skilled nursing facility. Benefit is limited to a maximum of 100 days per benefit year.	No co-payment	No co-payment
Physical, Occupational, and Speech Therapy**	Therapy may be provided in a medical office or other appropriate outpatient setting.	$5 per visit when performed in an outpatient setting No co-payment for inpatient therapy	$10 per visit when performed in an outpatient setting No co-payment for inpatient therapy
Blood and Blood Products**	Includes processing, storage, and administration of blood and blood products in inpatient and outpatient settings.	No co-payment	No co-payment
Health Education	Includes education regarding personal health behavior and health care, and recommendations regarding the optimal use of health care services.	No co-payment	No co-payment
Hospice	For members who are diagnosed with a terminal illness and who elect hospice care instead of traditional health care services.	No co-payment	No co-payment
Organ Transplants**	Coverage for organ transplants and bone marrow transplants which are not experimental or investigational.	No co-payment	No co-payment
Reconstructive Surgery**	Performed on abnormal structures of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors, or disease and are performed to improve function or create a normal appearance.	No co-payment	No co-payment
Phenylketonuria (PKU)**	Testing and treatment of PKU.	No co-payment	No co-payment
Clinical Cancer Trials	Coverage for a member’s participation in a cancer clinical trial, phase I through IV, when the member’s physician has recommended participation in the trial, and member meets certain requirements.	$5 co-payment per office visit Co-payment for prescriptions as described in the “Prescription Drug Program” Section	$10 co-payment per office visit Co-payment for prescriptions as described in the “Prescription Drug Program” Section
California Children’s Services (CCS)	CCS is a California medical program that treats children who have certain physically handicapping conditions and who need specialized medical care. Services provided through the CCS Program are coordinated by the county CCS office. If the member’s condition is determined to be eligible for CCS services, the member remains enrolled in the Healthy Families Program and continues to receive medical care from plan providers for services not related to the CCS eligible condition. The member will receive treatment for the CCS eligible condition through the specialized network of CCS providers and/or CCS approved specialty centers.	No co-payment
Deductibles	No deductibles will be charged for covered benefits.
Lifetime Maximums	No lifetime maximum limits on benefits apply under this plan

* Benefits are provided only for services which are medically necessary.
** These services may be covered and paid for by the California Children’s Services (CCS) program, if the member is found to be eligible for CCS services.

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