Members: Programs: Healthy Kids: Benefits and Services
Benefits and Services
The Healthy Kids program provides medical, dental, and vision coverage. San Francisco Health Plan offers members:
- Doctor Visits - over 2,500 providers to choose from
- Dental Care
- Vision Care (Glasses & Eye Exams) - over 200 vision service providers
- Hospital and Emergency Room Care - six of the best San Francisco hospitals
- Prescription Drugs - over 200 pharmacies throughout San Francisco
- Regular Check-ups and Immunizations (shots)
- OB/GYN Services and Pregnancy Care
- Family Planning
- Substance Abuse Programs
- Mental Health Services
- Specialty Care - over 2,000 specialists in our network
Summary Of Benefits
This matrix is intended to be used to help you compare coverage benefits and is a summary only. The Evidence of Coverage(
) should be consulted for a detailed description of coverage benefits and limitations.
|
Benefit |
Covered Services
|
Member Pays |
|---|---|---|
Deductible |
$0 | |
| Yearly co-Payment Maximum |
$250 per family or household | |
| Lifetime Maximum |
0 | |
| Professional Services |
Doctor visits, inpatient and outpatient medical and surgical services |
$5/visit |
| Outpatient Services |
In a doctor’s office, surgery center, or other designated facility |
$5/visit |
|
Chemotherapy, dialysis, and radiation |
No co-payment | |
| Hospital Inpatient Services |
Medically necessary facility charges room and board, general nursing care, ancillary services including operating room, intensive care unit, prescribed drugs, laboratory, and radiology during inpatient stay |
No co-payment |
| Hospital Outpatient Services |
Medically necessary facility charges, general nursing care, ancillary services including operating room, prescribed drugs, laboratory, chemotherapy, and radiology |
No co-payment |
| Emergency Health Coverage |
24-hour care for sudden, serious and unexpected illness including psychiatric screening, examination and treatment, injury or condition requiring immediate diagnosis in and out of the Plan |
$15 co-payment waived if member is hospitalized |
| Ambulance Services | Ambulance transportation when medically necessary | No co-payment |
| Prescription Drug Coverage |
Brand name or generic drugs (30-34 day supply); 90-100 day supply of maintenance drugs (oral and injectable); tobacco cessation drugs for 1 cycle per benefit year with completion of an SFHP approved tobacco cessation program |
$5 per 30-day supply |
|
Inpatient drugs and drugs administered in a doctor’s office |
No co-payment | |
| Contraceptives |
FDA approved drugs and devices including Norplant and radiology |
No co-payment |
| Durable Medical Equipment |
Equipment suitable for use in the home, such as blood glucose monitors, apnea monitors, asthma-related equipment and supplies |
No co-payment |
| Mental Health Services |
Inpatient (limited to 30 days per benefit year), 2 days of residential treatment may be substituted for 1 day of inpatient care; 3 days of day care may be substituted for 1 day of inpatient care; outpatient visits may be substituted |
No co-payment |
|
Other services provided through the local mental health department with referral. Please note, treatment for the diagnosis of severe emotional disturbances and severe mental illness are excluded from the benefits limitations. |
$5/visit | |
|
Outpatient visits (up to 20 per benefit year) |
$5/visit | |
|
Group therapy |
$5/visit | |
| Chemical Dependency Services - Inpatient |
Inpatient detoxification |
No co-payment |
| Chemical Dependency Services - Outpatient |
Crisis intervention and alcohol or drug abuse treatment as medically necessary (up to 20 visits) |
$5/visit |
| Home Health Services |
Medically necessary skilled care (not custodial) |
No co-payment |
|
Home visits, physical, occupational and speech therapy |
$5/visit | |
| Diagnostic X-ray and Laboratory Services |
Therapeutic radiological services, ECG, EEG, mammography, other diagnostic laboratory and radiology tests, laboratory tests for the management of diabetes |
No co-payment |
| Biofeedback |
Up to 8 visits per benefit year with a referral |
$5/visit |
| Transplants |
Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ |
No co-payment |
| Hospice |
Medically necessary skilled care; counseling, drugs and supplies; short-term inpatient care for pain control and system management; bereavement services, physical, speech and occupational therapies; medical social services short-term inpatient and respite care |
No co-payment |
| Hearing Aids/Services |
Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, repairs |
No co-payment |
| Eye Exams/Supplies |
Refractions to determine the need for corrective lenses; dilated retinal eye exams; cataract spectacles and lenses |
No co-payment |
Note: There are no co-payments for preventive visits or for members under the age of 24 months for well-baby care and office visits. There are no co-payments for members who are documented Alaska Natives or Native Americans.
Accessibility Statement