What does Healthy Families cover?

Healthy Families offers low-cost health, dental and vision care through contracts with selected insurance plans. Each county in California has different plans to choose from.

Benefits

The Healthy Families Program offers comprehensive health, dental and vision coverage through insurance plans. The benefits in all Healthy Families' insurance plans are similar. The benefits may be administered differently.

Enrolled child has access to all covered services that are medically necessary.

Please see the Immunization Schedule (pdf 243 KB) for a schedule of recommended childhood immunizations and the Preventive Health Screenings (pdf 345 KB) chart to review guidelines for preventive pediatric health care services.

See the Summary of Benefits to know which health, vision and dental services are offered by the plans that participate in Healthy Families.

Is there an additional cost for my child to get these services?

Yes. In addition to the monthly premiums, you pay a co-payment of $5 to $15 at the time of services for a child's benefits. Some services are free. No individual charge will exceed $15 for a child's benefits.

The maximum co-payment amount per benefit year that you pay for health care services is $250 per family. A benefit year is from October 1 to September 30. Keep all your receipts for the co-payments you make at the time of receiving health care services. Let your health plan know if you reach the maximum $250 for the benefit year of coverage. Then you will not have to make any more $5 - $15 co-payments for health care services until the next benefit year of coverage.

Scheduling Appointments

When your child is enrolled in Healthy Families, you should be able to schedule appointments within the following timeframes:

• 48 hours when you request an urgent care appointment for services that do not require prior authorization
• 96 hours when you request an urgent appointment for services that do not require prior authorization
• Ten (10) business days when you request non-urgent primary care appointments
• Ten (10) business days when you request an appointment with non-physician mental health care providers,
• Fifteen (15) business days when you request an appointment with a specialist,
• Fifteen (15) business days when you request a nonurgent appointment for ancillary services for the diagnosis or treatment of injury, illness, or other health condition.

Note: Health care providers can be flexible in making appointments if a longer wait time is not harmful to the member’s health.

Family Planning Services

Family Planning Services include counseling, surgical procedures for sterilization as permitted by state and federal law, diaphragms and other approved devices pursuant to the prescription drug benefit, and voluntary termination of pregnancy.

Pregnancy Covered

Healthy Families covers pregnancy-related services under the program. To apply for the baby, a new Healthy Families application must be submitted. See "What if you are pregnant?"

Pregnant members in Healthy Families Program may qualify for no-cost Medi-Cal coverage for their pregnancy related services. If the pregnant member is enrolled in no-cost Medi-Cal, the baby will be insured by no-cost Medi-Cal for the first year. For information on no-cost Medi-Cal, call your local County Department of Social Services, a local Medi-Cal provider, or call 1-866-848-9166.

California Children's Services

California Children's Services (CCS) is a statewide program that treats children under 21 years of age (under age 19 if enrolled in Healthy Families) who have certain physical limitations and/or chronic medical, dental, or vision conditions.

If a medical, dental, or vision provider suspects that your child has a CCS-eligible condition, the provider must refer your child to the CCS program in your county. The county CCS program will determine if a Healthy Families member has an eligible condition. For a list of CCS-eligible conditions, visit http://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx or call your county health department.

If the Healthy Families member is eligible for CCS services, the local CCS program will pay for specific services and equipment that the CCS program has authorized if the services are provided by CCS-approved providers for treating your child’s CCS-eligible medical condition. However, the Healthy Families Program health, dental or vision plan shall provide all medically necessary covered services to your child until the county CCS establishes eligibility for your child and CCS is providing the necessary CCS services to your child. It is important that the services are authorized by the CCS program before your child receives them. If the services are not authorized by CCS, the CCS program will not pay for the care. For all other medical, dental, and vision care, the Healthy Families member will remain enrolled in the Healthy Families Program and receive services through the Healthy Families health, dental, and/or vision plan(s). Talk to your child’s medical, dental, or vision care provider if you have questions about CCS.

If you think your child may have an eligible medical, dental, or vision condition, you can contact your local county CCS program directly and request an evaluation. You can find the CCS office in your county by contacting your local county health department.

If your child is already receiving services through CCS, tell your child’s primary medical, dental, or vision care provider when you enroll your child in the Healthy Families Program so that the services your child receives are coordinated between CCS and your Healthy Families plan.

Important Note: If your child is referred to the CCS program in your county and the CCS program determines that your child is eligible for CCS services, your child must receive an authorization for services from CCS and the services must be provided by a CCS-approved provider.

For more information about the CCS program, contact your local county health department or visit http://www.dhcs.ca.gov/services/ccs/.

Are Mental Health Services Covered?

Children enrolled in Healthy Families receive mental health services through two delivery systems:

• Health Plan
  Children receive mental health services through participating health plans.

• Local County Department of Mental Health
  Children needing specialized mental health services for Serious Emotional Disturbances (SED) may receive care from their local county department of mental health.

  If your child's provider suspects that a SED condition exists, your child will be referred to the county mental health department for assessment. If the county determines your child has SED, care for the SED will be provided by the county mental health department. However, the Plan shall provide all medically necessary covered services until the county mental health department establishes eligibility for your child with SED and the county mental health provides medically necessary services to treat the SED. The Plan and the county mental health department will coordinate services to ensure that medically necessary services and treatment are provided to your child with SED. Your child will remain enrolled in the Healthy Families health plan and will continue to receive all other medically necessary care not related to the SED from the health plan.

  If your child already receives services from the local county department of mental health, please contact your health providers after you have enrolled in the Healthy Families Program. Your health plan and provider will coordinate care with the local county mental health department. If you have questions about mental health services, talk to your child's health provider.