California PHP

You pay nothing for limited Medicare-covered dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth). Referral and authorization required.

You pay nothing for preventive dental services:

•     Cleaning (up to 2 every year)

•     Dental x-ray(s) (1 every year)

•     Fluoride treatment (up to 2 every year)

•     Oral exams (unlimited)

You pay nothing for comprehensive dental services such as the following:

•     Restorative services

•     Endodontics

•     Periodontics

•     Prosthodontics, removable

•     Maxillofacial prosthetics

•     Implant services

•     Prosthodontics, fixed

•     Oral and maxillofacial surgery

•     Adjunctive general services

Comprehensive dental services are limited to

$1,200 every year.

No referral or authorization required for preventive or comprehensive dental services.

You pay nothing for limited Medicare-covered dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth). Referral and authorization required.

You pay nothing for preventive dental services:

•     Cleaning (up to 2 every year)

•     Dental x-ray(s) (1 every year)

•     Fluoride treatment (up to 2 every year)

•     Oral exams (unlimited)

You pay nothing for comprehensive dental services such as the following:

•     Restorative services

•     Endodontics

•     Periodontics

•     Prosthodontics, removable

•     Maxillofacial prosthetics

•     Implant services

•     Prosthodontics, fixed

•     Oral and maxillofacial surgery

•     Adjunctive general services

Comprehensive dental services are limited to

$1,550 every year.

No referral or authorization required for preventive or comprehensive dental services.

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.

You pay $50 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 nothing for the following every year:

•     One routine hearing exam

•     One fitting/evaluation for hearing aid(s)

No referral or authorization required.

You pay nothing for up to two prescription hearing aids every year. $2,500 plan coverage limit for hearing aids every year. Referral and authorization required.

You pay nothing for the following every year:

•     One routine hearing exam

•     One fitting/evaluation for hearing aid(s)

No referral or authorization required.

You pay nothing for up to two prescription or over- the-counter hearing aids every year. $2,500 plan coverage limit for hearing aids every year. Referral and authorization required.

You pay:

•     $100 copay per day for days 1 through 6.

•     $0 copay per day for days 7 through 90.

•     $0 copay per day for lifetime reserve days 91 through 150.

Plan covers 90 days each benefit period. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

Plan also covers 60 lifetime reserve days. Lifetime reserve days are “extra” days that the plan covers. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

If you get authorized inpatient care at an out-of– network hospital after your emergency condition is stabilized, your cost is the cost sharing you would pay at a network hospital.

Referral required for elective admission. Authorization required.

You pay:

•     $80 copay per day for days 1 through 6.

•     $0 copay per day for days 7 through 90.

•     $0 copay per day for lifetime reserve days 91 through 150.

Plan covers 90 days each benefit period. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

Plan also covers 60 lifetime reserve days. Lifetime reserve days are “extra” days that the plan covers. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

If you get authorized inpatient care at an out- of–network hospital after your emergency condition is stabilized, your cost is the cost sharing you would pay at a network hospital.

Referral required for elective admission. Authorization required.

You pay:

•     $100 copay per day for days 1 through 6.

•     $0 copay per day for days 7 through 90.

•     $0 copay per day for lifetime reserve days 91 through 150.

Plan covers 90 days each benefit period. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

Plan also covers 60 lifetime reserve days. Lifetime reserve days are “extra” days that the plan covers. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

There is a 190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit does not apply to inpatient mental health services provided in a psychiatric unit of a general hospital.

Referral required for elective admission. Authorization required.

You pay:

•     $80 copay per day for days 1 through 6.

•     $0 copay per day for days 7 through 90.

•     $0 copay per day for lifetime reserve days 91 through 150.

Plan covers 90 days each benefit period. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

Plan also covers 60 lifetime reserve days. Lifetime reserve days are “extra” days that the plan covers. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

There is a 190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit does not apply to inpatient mental health services provided in a psychiatric unit of a general hospital.

Referral required for elective admission. 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.

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.

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.

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.

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.

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.

For members who have a medical plan of care for complex diagnoses such as cancer, end-stage renal disease, mental illness/cognitive impairment, wound management, etc. that requires multiple and frequent transportation to and from providers and facilities, you pay nothing for unlimited transportation. Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.