California PHP

Cardiac and Pulmonary Rehabilitation Services

You pay nothing for cardiac and pulmonary rehabilitation services.  Referral required.  Certain cardiac and pulmonary rehabilitation procedures require authorization.

You pay nothing for cardiac and pulmonary rehabilitation services.  Referral required.

Diabetes Self-Management Training

You pay nothing for diabetes self-management training.  Referral and authorization required.

You pay nothing for diabetes self-management training.  Referral required.

Diagnostic Services/

Labs/Imaging

You pay nothing for the following services:

• Diagnostic radiology services, e.g., MRI, CT, PET scans
• Lab services
• Diagnostic tests and procedures
• Outpatient x-rays
• Colonoscopy, sigmoidoscopy, endoscopy
• Radiation therapy

Referral required.  The following services require authorization:

• Certain diagnostic procedures and tests
• Certain diagnostic radiological services
• Certain therapeutic radiological services

The following services do not require authorization:

• Lab
• X-rays

You pay nothing for the following services:

• Diagnostic radiology services, e.g., MRI, CT, PET scans
• Lab services
• Diagnostic tests and procedures
• Outpatient x-rays
• Colonoscopy, sigmoidoscopy, endoscopy
• Radiation therapy

Referral required.

Emergency Services

You pay $25 copay per emergency room visit.

Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network.

Emergency care is only covered within the United States.

You pay $100 copay per emergency room visit.

Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network.

Emergency care is only covered within the United States.

Home and Bathroom Safety Devices and Modifications

Home and bathroom safety devices and modifications are not covered.

You pay nothing for home and bathroom safety devices and modifications that include, but are not limited to, temporary ramps over stairs, grab bars, shower chairs, high rise toilets or toilet seats, bed rails, etc. as necessary.  Benefit includes minor home modifications to have covered items installed and/or doorways widened.  Benefit is limited to $5,000 per year.  Referral and authorization required.

In-Home Support Services (IHSS)

You pay nothing for up to 16 hours a week of IHSS for up to two (2) weeks.  IHSS is available to members after inpatient discharge from an acute hospital or skilled nursing facility.  Authorization required.

You pay nothing for up to 16 hours a week of IHSS for up to two (2) weeks.  IHSS is available to members after inpatient discharge from an acute hospital or skilled nursing facility.  Referral and authorization required.

Kidney Disease Education Services

You pay nothing for up to six (6) sessions of kidney disease education services per lifetime.  Referral and authorization required.

You pay nothing for up to six (6) sessions of kidney disease education services per lifetime.  Referral required.

Special Supplemental Benefits for the Chronically Ill

For members who have been diagnosed with AIDS-related neuropathy, you pay nothing for up to two (2) one (1)-hour therapeutic massages per month to increase blood circulation.  Referral and authorization required.

For members who have been diagnosed with AIDS-related neuropathy, you pay nothing for up to two (2) one (1)-hour therapeutic massages per month to increase blood circulation.  Referral and authorization required.

For members who have been diagnosed with diabetes, you pay nothing for up to two (2) diabetic meals per day.  Nutritious diabetic meals help members who have diabetes and do not have access to appropriate food to manage and control their disease.  Referral and authorization required.

Special Supplemental Benefits for the Chronically Ill (continued)

For members who have been diagnosed with congestive heart failure (CHF), you pay nothing for up to two (2) low-sodium meals per day.  Nutritious low-sodium meals help enrollees who have CHF and do not have access to appropriate food to manage and control their disease.  Referral and authorization required.

For members who have been diagnosed with asthma or chronic pulmonary conditions and live in a residence that is infested with cockroaches, mice or rats, you pay nothing for pest control services up to the annual benefit limit of $1,000.  Pest control for individuals who have asthma and other chronic pulmonary diseases reduces asthma symptoms.  Referral and authorization required.

Special Supplemental Benefits for the Chronically Ill (continued)

For members who have been diagnosed with asthma or chronic pulmonary conditions and live in an environment whose air quality contributes to asthma and breathing problems, you pay nothing for an air filter device(s) and filter replacements up to the annual benefit limit of $200.  An air filter for individuals who have asthma and other chronic pulmonary diseases reduces asthma symptoms.  Referral and authorization required.

For members who need daily living assistance and hygiene support and are unable to do their own laundry, you pay nothing for laundry service up to the monthly benefit limit of $156.  Authorization required.

Supervised Exercise Therapy (SET) for Peripheral Artery Disease (PAD)

You pay nothing for up to 36 sessions over a 12-week period if the SET program requirements are met.  Referral and authorization required.

You pay nothing for up to 36 sessions over a 12-week period if the SET program requirements are met.  Referral required.

Transportation

You pay nothing for unlimited round trips to plan-approved locations.

Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.

You pay nothing for up to 24 round trips to plan-approved locations.

Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.

Vision Care

You pay nothing for Medicare-covered vision care services.  Referral and authorization required for the following:

• Diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.
• For members who at high risk for glaucoma, one glaucoma screening each year.
• For members with diabetes, one diabetic retinopathy screening each year.
• One (1) pair of eyeglasses or contact lenses after cataract surgery that includes insertion of an intraocular lens.

You pay nothing for Medicare-covered vision care services.  Referral required for the following services.  Authorization required as noted below.

• Diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.  Authorization required for treatments and procedures.
• For members who at high risk for glaucoma, one glaucoma screening each year.
• For members with diabetes, one diabetic retinopathy screening each year.

Vision Care

(continued)

You pay nothing for supplemental vision care benefits.  No referral or authorization required for the following:

• One (1) routine eye exam every year.
• One (1) pair of eyeglasses (lenses and frames or lenses) or contact lenses every year.

$250 plan coverage limit for eyewear every year.

• One (1) pair of eyeglasses or contact lenses after cataract surgery that includes insertion of an intraocular lens.  Authorization required.

You pay nothing for supplemental vision care benefits.  No referral or authorization required for the following:

• One (1) routine eye exam every year.
• One (1) pair of eyeglasses (lenses and frames or lenses) or contact lenses every year.

$400 plan coverage limit for eyewear every year.