Senate Bill 810 Chapter 5 Benefits


Any eligible individual may choose to receive services under the system from any willing professional health care provider participating in the system. No health care provider may refuse to care for a patient solely on any basis that is specified in the prohibition of employment discrimination contained in the Fair Employment and Housing Act (Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code).


A resident of the state in a family with an annual or monthly net nonexempt household income equal to or less than 200 percent of the federal poverty level is eligible for no-cost Medi-Cal and shall be entitled to not less than the full scope of benefits available under the Medi-Cal program, pursuant to Section 14021 of, and Article 4 (commencing with Section 14131) of Chapter 7 of Division 9 of, the Welfare and Institutions Code, as provided on January 1,  2009   2010  .


Covered benefits under this chapter shall include all medical care determined to be medically appropriate by the individual’ s health care provider, but are subject to limitations set forth in Section 140503. Covered benefits include, but are not limited to, all of the following:
(a) Inpatient and outpatient health facility services.
(b) Inpatient and outpatient professional health care provider services by licensed health care professionals.
(c) Diagnostic imaging, laboratory services, and other diagnostic and evaluative services.
(d) Durable medical equipment, appliances, and assistive technology, including prosthetics, eyeglasses, and hearing aids and their repair.
(e) Rehabilitative care.
(f) Emergency transportation and necessary transportation for health care services for disabled and indigent persons.
(g) Language interpretation and translation for health care services, including sign language for those unable to speak, or hear, or who are language impaired, and Braille translation or other services for those with no or low vision.
(h) Child and adult immunizations and preventive care.
(i) Health education.
(j) Hospice care.
(k) Home health care.
(  l  ) Prescription drugs that are listed on the system’ s formulary. Nonformulary prescription drugs may be included if standards and criteria established by the commissioner are met.
(m) Mental and behavioral health care.
(n) Dental care.
(o) Podiatric care.
(p) Chiropractic care.
(q) Acupuncture.
(r) Blood and blood products.
(s) Emergency care services.
(t) Vision care.
(u) Adult day care.
(v) Case management and coordination to ensure services necessary to enable a person to remain safely in the least restrictive setting.
(w) Substance abuse treatment.
(x) Care of up to 100 days in a skilled nursing facility following hospitalization.
(y) Dialysis.
(z) Benefits offered by a bona fide church, sect, denomination, or organization whose principles include healing entirely by prayer or spiritual means provided by a duly authorized and accredited practitioner or nurse of that bona fide church, sect, denomination, or organization.
(aa) Chronic disease management.
(ab) Family planning services and supplies.
(ac) For persons under 21 years of age, early and periodic screening, diagnosis, and treatment services, as defined in Section 1396d(r) of Title 42 of the United States Code, whether or not those services are covered benefits for persons who are 21 years of age or older.


The commissioner may expand benefits beyond the minimum benefits described in this chapter when expansion meets the intent of this division and when there are sufficient funds to cover the expansion.


The following health care services shall be excluded from coverage by the system:
(a) Health care services determined to have no medical indication by the commissioner and the chief medical officer.
(b) Surgery, dermatology, orthodontia, prescription drugs, and other procedures primarily for cosmetic purposes, unless required to correct a congenital defect, restore or correct a part of the body that has been altered as a result of injury, disease, or surgery, or determined to be medically necessary by a qualified, licensed health care provider in the system.
(c) Private rooms in inpatient health facilities where appropriate nonprivate rooms are available, unless determined to be medically necessary by a qualified, licensed health care provider in the system.
(d) Services of a health care provider or facility that is not licensed or accredited by the state except for approved services provided to a California resident who is temporarily out of the state.


(a) During the initial two years of the system’s operation, the commissioner shall not impose a deductible payment or copayment other than for treatment by a specialist if no referral was made by the primary care provider pursuant to Section 140601. The commissioner shall determine the amount of the copayment or deductible imposed pursuant to this subdivision. The commissioner and the Healthcare Policy Board shall review the deductible and copayment provisions annually, commencing in the third year of the system’s operation, to determine whether they should be included in the system.
(b) Commencing in the third year of the system’s operation, the commissioner may impose a deductible payment and copayment pursuant to the determination made under subdivision (a), except as specified under subdivisions (c) and (d). The amount of the deductible payment and the copayment combined shall not exceed two hundred fifty dollars ($250) per person each year and five hundred dollars ($500) per family each year, except the deductible payment and copayment for treatment by a specialist without a referral from the primary care provider pursuant to Section 140601 shall not be subject to this limitation and shall be established by the commissioner.
(c) No copayments or deductible payments may be established for preventive care as determined by a patient’s primary care provider.
(d) No copayments or deductible payments may be established when prohibited by federal law.
(e) No deductible payments or copayments may be imposed on a person who is eligible for benefits under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), except for treatment by a specialist without a referral from the primary care provider pursuant to Section 140601.
(f) The commissioner shall establish standards and procedures for waiving copayments or deductible payments for a person who demonstrates, to the commissioner’s satisfaction, that the person lacks the financial means to pay the copayment or deductible. Waivers of copayments or deductible payments shall not affect the reimbursement of health care providers.
(g) Any copayments established pursuant to this section and collected by health care providers shall be transmitted to the Treasurer to be deposited to the credit of the Healthcare Fund.
(h) Nothing in this division shall be construed to diminish the benefits that an individual has under a collective bargaining agreement.
(i) Nothing in this division shall preclude employees from receiving benefits available to them under a collective bargaining agreement or other employee-employer agreement that are superior to benefits under this division.