Summary of Benefits

See what benefits are offered in Healthy Families.

• Health Benefits
• Optional Health Benefits (offered by some plans, but not others)
• Vision Benefits
• Dental Benefits

NOTE: Copayments

The HFP has increased copayments for applicable covered services for members who are in Income Categories B & C. This copayment increase does not apply to members in Income Category A. Members in the Income Category A (see the HFP Income Categories A, B, and C Table) shall pay no more than $5 copayment for applicable covered services as described in this Benefit Descriptions Section of the plan's Combined Evidence of Coverage and Disclosure Form or Certificate of Insurance Booklet.

Health Benefits

Benefits *	Services	Costs to Member (co-payment) Category A	Costs to Member (co-payment) Category B & C
Physician Services	Office visits Home visits Inpatient/outpatient care	$5 per visit $5 per visit No charge under 24 months of age	$10 per visit $10 per visit No charge under 24 months of age
Preventive Care Services	Periodic health examinations (including well-baby care) Variety of voluntary family planning services Prenatal care Vision and hearing testing Immunizations Sexually transmitted disease (STD) testing Confidential HIV/AIDS counseling and testing Annual Pap smear exams Health education services	No charge (including office visits)	No charge (including office visits)
Prescription Drugs**	30 day supply of brand name or generic drugs, including prescriptions for one cycle of tobacco cessation drugs 90 day supply of maintenance drugs purchased through a participating pharmacy or through the plan's mail order for generic or brand name drugs While in hospital FDA approved contraceptive drugs and devices	$5 per prescription $5 per prescription No charge No charge	$10 per prescription for generic drugs $15 per prescription for up to 30 day supply for brand name drugs or $10 if there is no generic equivalent or if the use of a brand name drug is medically necessary $10 per prescription for generic drugs $15 per prescription for brand name drugs or $10 if there is no generic equivalent or if the use of a brand name drug is medically necessary No charge No charge
Inpatient and Outpatient Hospital Service	Inpatient: room and board, nursing care, and all medically necessary services Outpatient: diagnostic, therapeutic, and surgical services performed at a hospital or outpatient facility	No charge except $5 per visit for physical, occupational and speech therapy performed on an outpatient basis $5 per visit unless hospitalized.	No charge except $10 per visit for physical, occupational and speech therapy performed on an outpatient basis $15 per visit unless hospitalized.
Emergency Health Care Services**	24-hour emergency for illness, injury, or severe pain requiring immediate diagnosis and treatment to avoid placing the subscriber in danger of loss of life, serious illness, or disability Provided both in and out of the health plan's service area and participating facilities	$5 per visit unless hospitalized No coverage will be provided if the services received are not an emergency	$10 per visit unless hospitalized No coverage will be provided if the services received are not an emergency
Family Planning Services	Voluntary Family Planning Counseling and surgical procedures for sterilization, as permitted by state and federal law. Coverage for diaphragms and other federal Food and Drug Administration approved devices pursuant to the prescription drug benefit. Voluntary termination of pregnancy	No charge	No charge
Maternity Care	Prenatal and postnatal care, inpatient and newborn nursery care	No charge	No charge
Medical Transportation Services**	Emergency ambulance transportation to the hospital, and medically necessary non-emergency transportation to transfer a member from a hospital to another hospital or facility, or facility to home.	No charge	No charge
Diagnostic X-ray and Laboratory Services **	Inpatient and outpatient laboratory services, and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, and treat members.	No charge	No charge
Durable Medical Equipment **	Medical equipment appropriate for use in the home, oxygen and oxygen equipment, insulin pumps and all related necessary supplies.	No charge	No charge
Inpatient and Outpatient Mental Health Care Services*** Mental Health Care	Diagnosis and treatment of a mental health condition. If you think your child may have a mental health condition, then your health plan will give you information on how to get services for your child. Inpatient and outpatient services This includes, but is not limited to, the treatment of a member who has 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 member Inpatient and outpatient mental health care services for the treatment of Severe Mental Illness (SMI). SMI means: Schizophrenia, schizoaffective disorder, bi-polar disorder (manicdepressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa.	No charge for inpatient services $5 per visit for outpatient services	No charge for inpatient services $10 per visit for outpatient services
Inpatient and Outpatient Mental Health Care Services*** Serious Emotional Disturbance (SED)	Diagnosis and treatment for SED condition. Inpatient and outpatient services for the treatment of a member determined by the county to have a 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 SED 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 from the Plan. The plan shall provide all medically necessary covered services until the county mental health department establishes eligibility for a member with SED and the county mental health department provides the medically necessary services to treat SED.	No charge for SED treatment	No charge for SED treatment
Inpatient and Outpatient Alcohol and Drug Abuse	If you think your child may have an alcohol or drug abuse problem, then your health plan will give you information on how to get services for your child. Inpatient: As medically appropriate to remove toxic substances from the system Outpatient: Crisis intervention and treatment of alcoholism or drug abuse	No charge for inpatient services $5 per visit for outpatient services	No charge for inpatient services $10 per visit for outpatient services
Physical, Occupational, Speech Therapy **	Therapy may be provided in a medical office or other appropriate outpatient setting, hospital, skilled nursing facility, or home. Plans may require periodic evaluations as long as therapy, which is medically necessary, is provided.	No charge for inpatient therapy $5 per visit for outpatient services	No charge for inpatient therapy $10 per visit for outpatient services
Home Health Care Services	Services must be provided at the home by health care personnel.	No charge except $5 per visit for physical, occupational and speech therapy	No charge except $10 per visit for physical, occupational and speech therapy
Skilled Nursing Care	Services provided in a licensed skilled nursing facility, 100 days each benefit year	No charge	No charge

* Benefits are provided if the insurance plan determines them to be medically necessary.

** These services may be provided by the California Children’s Services (CCS) program. Families must meet residential requirements and members under the age of 19 must have a medical condition that is covered by CCS to be eligible for CCS services.

*** Members who are under 19 years of age and diagnosed as having a Serious Emotional Disturbance (SED) will receive services from the County Mental Health Department. 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 SED.

Optional Health Benefits

Not all health insurance plans provide these benefits. For information on which insurance plans cover these services, see Choosing Plans and Providers.

Optional Benefits	Services	Costs to Member (co-payment) Category A	Costs to Member (co-payment) Category B & C
Acupuncture	20 visits per benefit year	$5 per visit	$10 per visit
Chiropractic	20 visits per benefit year	$5 per visit	$10 per visit
Biofeedback	Insurance plans vary (see the Health Plan Outlines for more information)	$5 per visit	$10 per visit

Vision Benefits

Vision Benefits *	Services	Costs to Member (co-payment) Category A	Costs to Member (co-payment) Category B & C
Eye Examinations	Once every 12 months	$5 per examination	$10 per examination
Prescription Glasses	Once every 12 months	$5 per glasses, frames, or lenses	$10 per glasses, frames, or lenses

* Benefits are provided if the insurance plan determines them to be medically necessary.

Dental Benefits

Dental Benefits *	Services	Costs to Member (co-payment) Category A	Costs to Member (co-payment) Category B & C
Preventive Care (Teeth Cleanings, Topical Fluoride)	Limited to 2 in a 12 month period	No charge	No charge
Fillings	As needed	No charge	No charge
Sealants	As needed only for permanent 1st and 2nd molars	No charge	No charge
Diagnostic Services	X-rays (Bitewing, Full-mouth, and Panoramic) Consultations	No charge	No charge
Major Services	Root canals Oral Surgery Crowns and bridges Dentures	$5 per canal No charge except for $5 per bony impaction $5 $5	$10 per canal No charge except for $10 per bony impaction $10 $10
Orthodontia Services	Provided to subscribers under the age of 19 through the California Children's Services Program (CCS) when condition meets the CCS program criteria	No charge	No charge

* Benefits are provided if the insurance plan determines them to be medically necessary.

Note: The Benefits Charts on the preceding pages are only a summary of benefits provided by each health plan in the Healthy Families Program. These summaries are for information only. This is not a contract. For exact terms and conditions of the health care benefits, provisions, exclusions, and limitations for each plan, refer to the Evidence of Coverage booklet or Certificate of Insurance available from each health plan. You may also call the phone number listed on each health plan's description page.