Benefits and Covered Services

Benefits and Services

The Healthy Kids HMO program offers medical, dental, and vision care. Medical care is provided by San Francisco Health Plan. Covered services include:

  • Doctor Visits
  • Hospital & Emergency Room Care
  • Prescription Drugs
  • Regular Check-Up’s and Immunizations (shots)
  • OB/GYN Services and Pregnancy Care
  • Family Planning
  • Substance Abuse Programs
  • Mental Health Services
  • Specialty Care
  • Dental Care – Through Delta Dental
  • Vision Care  – Through  VSP

See the Evidence of Coverage and the Healthy Kids HMO  Summary of Benefits for details on the program benefits and limits.

See the New Consumer Protection Law Notice (AB72) for information about protection from surprise medical bills.

This glossary of health coverage and medical terms has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan.

Note: There are no co-pays for preventive visits or for members under the age of 24 months for well-baby care and office visits. There are no co-pays for members who are documented Alaska Natives or Native Americans.

Benefits*Covered ServicesMember Pays (Co-payment)
Alaskan Native/ Native American Enrollees $0 $0
Deductible No deductibles will be charged for covered benefits $0
Yearly Co-Payment Maximum $250
Lifetime Maximum No lifetime maximum limits on benefits apply under this plan $0
Hospitalization Services

Inpatient
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
Hospitalization Services
Outpatient
Medically necessary facility charges, general nursing care, ancillary services including operating room, prescribed drugs, laboratory, chemotherapy, and radiology No co-payment except $10 per visit for physical, occupational and speech therapy performed on an outpatient basis.
$15 per visit for emergency health care services (waived if the member is hospitalized)
Professional Services Doctor visits, inpatient and outpatient medical and surgical services $10 per office or home
visit except
No co-payment for hospital inpatient professional services
No co-payment for surgery, anesthesia, or radiation, chemotherapy, or dialysis treatments
No co-payment for members 24 months of age and younger
No co-payment for vision or hearing testing, or for hearing aids
Outpatient Services In a doctor ’s office, surgery center, or other designated facility $10
Preventive Health Care Services Periodic health examinations, Well Baby Care, routine diagnostic testing and laboratory services, immunizations, and services for the detection of asymptomatic diseases. No co-payment
Diagnostic, X-Ray, and Laboratory Services ** Laboratory services, and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, and treat members. No co-payment
Diabetic Care ** Equipment and supplies for the management and treatment of insulin- using diabetes, non-insulin diabetes, and gestational diabetes as medically necessary, even if the items are available without prescription. $10 co-payment per office visit
Co-payment for prescriptions as described in the “Prescription Program” section
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 ** Drugs prescribed by a licensed practitioner $10 co-payment per prescription for up to 90 day supply for generic drugs.
$10 co-payment per prescription for up to a 30-day supply of most brand drugs or up to a 90-day supply for brand drugs to treat chronic conditions.
$15 co-payment per prescription for brand name drugs with a generic equivalent.
No co-payment for prescription drugs provided in an inpatient setting.
No co-payment for drugs administered in the doctor’s office or in an outpatient facility
No co-payment for FDA- approved contraceptive drugs and devices.
Contraceptives FDA approved drugs and implanted devices. 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
Orthotics and Prosthetics ** Original and replacement devices as prescribed by a licensed practitioner. No co-payment
Maternity Care Professional and hospital services relating to maternity care No co-payment
Family Planning Services Voluntary family planning services No co-payment
Mental Health Care Diagnosis and treatment of a mental health condition.
This includes, but is not limited to inpatient mental health care services for the treatment of Severe Mental Illnesses (SMI).
No-co-payment
Serious Emotional Disturbance (SED) Services Inpatient mental health care services for the treatment for a member determined by the county to have a SED condition.
The plan shall provide all medically necessary covered services until the county mental health department establishes eligibility for a subscriber child with SED and the county mental health department provides the medically necessary services to treat the SED
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 Kids HMO 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.
No-co-payment
Basic Mental Health Care Services This includes, but is not limited to, the
treatment of children who have 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 child.
This includes, but is not limited to outpatient mental health care services for the treatment of Severe Mental Illnesses (SMI).
$10 per visit
Serious Emotional Disturbance (SED) Outpatient mental health care visits
services for the treatment of a member determined by the county to have a SED condition.
The plan shall provide all medically necessary services until the county mental health department establishes eligibility for a member child with SED and the county mental health department provides the medically necessary services to treat the SED.
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 Kids HMO 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.
No co-payment
Inpatient Alcohol/Drug Abuse Treatment Hospitalization to remove toxic substances from the system No co-payment
Outpatient Alcohol/Drug Abuse Treatment Crisis intervention and alcohol or drug abuse treatment as medically necessary. $10 per visit
Home Health Services Services provided at the home by health care personnel. No co-payment except
$10 per visit for physical, occupational, and speech therapy
Skilled Nursing Care Services provided in a licensed skilled nursing facility.
Benefit is limited to a maximum of 100 days per benefit year.
No co-payment
Physical, Occupational, and Speech Therapy ** Therapy may be provided in a medical office or other appropriate outpatient setting. $10 per visit when performed in an outpatient setting
No co-payment for inpatient therapy
Blood and Blood Products ** Includes processing, storage, and administration of blood and blood products in inpatient and outpatient settings No co-payment
Health Education Includes education regarding personal health, behavior, and health care, and recommendations regarding the optimal use of health care services No co-payment
Diagnostic X-ray and Laboratory Services Therapeutic radiological services, ECG, EEG, mammography, other diagnostic laboratory and radiology tests and laboratory tests. 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
Organ 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
Reconstructive Surgery ** Performed on abnormal structures of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors, or disease and are performed to improve function or create a normal appearance No co-payment
Phenylketonuria (PKU) ** Testing and treatment of PKU No co-payment
Clinical Cancer Trials Coverage for a member’s participation in a cancer clinical trial, phase I through IV, when the member’s physician has recommended participation in the trail, and member meets certain requirements $10 co-payment per office visit
Co-payment for prescriptions as described in the “Prescription Drug Program” section
California Children’s Services Program
(CCS)
CCS is a California medical program that treats children who have certain physically handicapping conditions and who need specialized medical care. Services provided through the CCS Program are coordinated by the county CCS office.
If the member’s condition is determined to be eligible for CCS services, the member remains enrolled in the Healthy Kids HMO Program and continues to receive medical care from plan providers for services not related to the CCS eligible condition.
The member will receive treatment for the CCS eligible condition through the specialized network of CCS providers and/or CCS approved specialty
No co-payment
Biofeedback Up to 8 visits per Benefit Year with a referral $10 per visit
Hearing Aids/Services Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, repairs
Eye Exams/Supplies Eye examinations, frames and lenses, supplemental care for low- vision benefits $5 per visit
Frame allowance up to $100
Contact Lenses Medically necessary contact lenses shall be covered in full. No co-payment for medically necessary contact lenses.
An allowance of $110 will be provided toward the cost of an examination, contact lens evaluation, fitting costs and materials for elective contact lenses. Contact lenses are limited to once each twelve month benefit period, beginning October 1st of each year.
Cataract Spectacles and Lenses ** Cataract spectacles and lenses, cataract contact lenses, or intraocular lenses that replace the natural lens of the eye after cataract surgery No co-payment
Oral Surgery Bony impaction- per tooth
Root recovery – per tooth
$10
Endodontics Apicoectomy performed in conjunction with root canal
Retreatment of previous root canal
$10 per canal
Periodontics Osseous or muco-gingival surgery $10 per quadrant
Crowns and Bridges Porcelain crown, porcelain fused to metal crown, full metal crown, and gold onlays or ¾ crowns Pontics $10 per crown or other pontics
Dentures Complete maxillary denture
Complete mandibular denture
Partial acrylic upper or lower denture with clasps
Partial upper or lower denture with chrome cobalt alloy lingual or palatal bar, clasps and acrylic saddles
Removable unilateral partial denture
Laboratory reline
Denture duplication
$10 each

*Benefits are provided only for services which are medically necessary
** These services may be covered and paid for by the California Children’s Services (CCS) program, if the member is found to be eligible for CCS services.