Revised: January 2004 Approval: ___________

Abortion (Voluntary) Benefit Coverage (Health & Saf. Code §§ 123462-123468) Abortions are a covered benefit, regardless of the gestational age of the fetus. Abortion services can be accessed without prior authorization. Services may be required to be provided by in-network providers but where in-network services are not available, IPAs must arrange out-of-network access. Benefit Exclusion Non-legal abortions. Examples of Covered Benefits 1. 2. 3. 4.

Spontaneous, missed or septic abortions, any trimester. Incidence of rape or incest resulting in a pregnancy. Abortion in the case of fetal demise. Elective abortions.

Examples of Non-Covered Benefits 1. None.

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A-100.1

Revised: February 2009 Approval: ___________

Acquired Immune Deficiency Syndrome (AIDS) Benefit Coverage (DHCS Contract 04-35765, Amend 10, Exhibit A, Attach. 8 § 11) (DHCS Contract 04-35765, Amend 10, Exhibit A, Attach. 9 § 9C) (Health & Saf. Code, § 1367.46) (Ins. Code, § 10123.91) Members have coverage to access confidential Human Immunodeficiency Virus (HIV) counseling and testing through the provider network, and out-of-network local health department and family planning providers. Diagnostic and treatment services for the treatment of HIV disease or AIDS are covered. NOTE: 1. Children less than 21 years of age who are confirmed HIV positive must be referred to the California Children’s Services (CCS) Program. 2. Adult Members with a diagnosis of AIDS or symptomatic HIV disease must be referred to the Home and Community Based Services (HCBS) Waiver Program. Benefit Exclusion Patients with an established diagnosis of symptomatic HIV disease or AIDS and who have been accepted into the CCS program. Examples of Covered Benefits 1. Confidential HIV counseling and testing for Members age 12 and older. 2. HIV testing on newborns. 3. Diagnostic and treatment services for individuals with HIV prior to acceptance in the CCS program. 4. Routine prenatal HIV testing. 5. Routine HIV screening. Examples of Non-Covered Benefits 1. Services available through CCS. 2. Services provided through the Medi-Cal HIV/AIDS Home and Community Based Services (HCBS) Waiver Program.

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A-200.1

Revised: January 2010 Approval: ___________

Acupuncture Services Definition (Cal. Code Regs., tit. 22, § 51074.5) Acupuncture services mean the stimulation of a certain point or points on or near the surface of the body by the insertions of needles to prevent, modify, or alleviate the perception of severe, persistent and chronic pain resulting from a generally recognized medical condition. Benefit Coverage (Cal. Code Regs., tit. 22, § 51308.5) (DHCS Contract 04-35765, Amend. 10, Exhibit E, Attach. 1, § 25K) Not a covered benefit under Medi-Cal Managed Care. Benefit Exclusion Acupuncture is not covered through the Medi-Cal Managed Care Program. Acupuncture services may be available to youth up to the age of 21, through the Medi-Cal Fee-For-Service (FFS) system. Examples of Non-Covered Benefits 1. Acupuncture. 2. Acupressure.

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A-300.1

Revised: January 2012 Approval: ___________

Allergy Testing and Serum Benefit Coverage (Cal. Code Regs., tit. 22, § 51305) Allergy testing and allergy treatment, including antigens and serums, are covered when determined as medically necessary. All allergy testing services and antigen injections generally require prior authorization through the contracted IPA. Benefit Exclusion Allergy testing and treatment without prior authorization unless pre-approved by contracted IPA. Examples of Covered Benefits 1. Allergy testing as appropriate. 2. Administration of allergens when medically necessary, following the authorization guidelines noted above. 3. Radioallergosorbent test (RAST) only if skin testing is unsuccessful and/or the Member is unable to tolerate skin testing due to an existing skin condition. Examples of Non-Covered Benefits 1. Services for allergy testing or treatment when prior written authorization is not obtained, unless pre-approved by IPA. 2. Routine RAST testing, except as noted above. 3. Continued allergy therapy if the Member is non-compliant (does not follow physician orders) and/or does not keep routine appointments. 4. Cytotoxicity testing/Bryan’s test. 5. Urine auto-injection. 6. Skin titration/Rinkel method. 7. Provocative and neutralizing testing (subcutaneous). 8. Sublingual provocative test. 9. Serum allergy/histamine release tests.

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A-400.1

Revised: July 2015 Approval: ___________

Ambulance Benefit Coverage (Cal. Code Regs., tit. 22, § 51323) Ambulance transportation services are covered when the patient's medical and physical condition is such that transport by ordinary means of public or private conveyance is medically contraindicated, and transportation is required for the purpose of obtaining needed medical care. Transportation to patient’s home setting from facility or hospital is also covered when ambulance transportation is required due to patient’s medical and physical condition. Benefit Exclusion Ambulance services are not covered when the services are not medically indicated or are for patient convenience. Examples of Covered Benefits 1. Emergency medical transportation is covered for emergency medical conditions, without prior authorization, to the nearest facility capable of meeting the medical needs of the patient for medically necessary conditions. 2. Non-emergency medical transportation, with prior authorization, necessary to obtain needed medical care. 3. Air transportation, in an emergency, is covered when the medical condition of the patient precludes other means of medical transportation and the patient is inaccessible to ground transport or the nearest hospital capable of meeting the patient's needs. Examples of Non-Covered Benefits 1. Ambulance transportation for the patient's convenience rather than for medical necessity (e.g., patient’s medical condition does not require professional medical care during transport). 2. Ambulance services to provide transportation to the patient's PCP for routine care when transportation by public or private vehicles would not endanger the patient's health. 3. Ambulance transport when a patient is unable to locate friends or family to take him or her home from the hospital.

See: Transportation (for routine transportation)

IEHP Medi-Cal Benefit Manual

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A-500.1

Revised: July 2000 Approval: ___________

Apnea Monitors Benefit Coverage (Cal. Code Regs., tit. 22, §§ 51321 & 51521) Apnea monitors are a covered benefit through Durable Medical Equipment (DME) when determined to be medically necessary and prior authorization is obtained from the contracted IPA. Benefit Exclusion Apnea monitors are not covered when prior authorization has not been obtained from the contracted IPA, unless pre-approved. Examples of Covered Benefits Situations that may require the use of an Apnea Monitor include, but are not limited to the following: 1. 2. 3. 4. 5.

An infant with a sibling death from Sudden Infant Death Syndrome (SIDS). History of near-miss SIDS. Respiratory problems associated with premature birth. Infants discharged with a tracheostomy. Infants with gastroesophageal reflux associated with bradycardia (slow heart rate).

Examples of Non-Covered Benefits 1. Apnea monitors when prior authorization has not been obtained, unless preapproved.

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A-600.1