Medicaid Benefits: Online Database

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Acute Care Services

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: California (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes	$1/visit	Specified surgical procedures		Fee for service	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$1/visit		Adult day treatment for elderly and disabled limited to 6-12 hours/day, 5 days/week	Fee for service	CN & MN
Federally Qualified Health Center Services
Yes	$1/visit	Specified services		Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes			Limitations vary by type of admission and services rendered	Competitively bid rate, negotiated rate, contracted capitation rate or prospective all-inclusive rate using historical costs and peer groups	CN & MN
Outpatient Hospital Services
Yes	$5/non-emergency visit in ER, $1/visit for other services			Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes	$1/visit	Specified services	Residential habilitation treatment covered only for developmentally disabled, substance abuse treatment providers must be state-approved	Residential treatment facilities paid standard per diem by facility bed size, substance abuse services paid fee for service or negotiated rate	CN & MN
Rural Health Clinic Services
Yes	$1/visit			Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service	CN & MN
Chiropractor Services
Yes	$1/visit		2 visits/month included in limits with other specified practitioners in any outpatient setting, x-rays not covered	Fee for service	CN & MN
Dental Services
Yes	$1/visit	Specified services including periodontal, crowns and root canals, pre-denture services, services for nursing facility residents	$1,800 cap on services/year but cap doesn't apply to emergency services, maxillofacial surgery or to residents of nursing facilities; crowns not covered	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes	$1/visit	Specified services		Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service, some services performed in outpatient hospital setting paid 80% of fee	CN & MN
Nurse Practitioner Services
No
Optometrist Services
Yes	$1/visit		1 refractive exam/2 years, orthoptics not covered	Fee for service	CN & MN
Physician Services
Yes	$1/visit	Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy not personally rendered		Fee for service, some services performed in outpatient hospital setting paid 80% of fee	CN & MN
Podiatrist Services
Yes	$1/visit	Specified services including any services for nursing facility residents	Limitations vary by type of service	Fee for service	CN & MN
Psychologist Services
Yes	$1/visit		2 service sessions/month included in limits with other specified providers in any setting	Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes	$1/Rx		6 Rxs/month	AWP-17%, plus $7.25 dispensing fee, non-traditional pharmacies receive an $8.00 dispensing fee	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes	$1/visit	Treatment plan	Rehab potential required	Fee for service	CN & MN
Physical Therapy Services
Yes	$1/visit	Treatment plan	Rehab potential required and to prevent hospitalization	Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
Yes	$1/visit		Physician order required, 2 speech pathology visits/month included in limits with other specified practitioners in any setting	Fee for service	CN & MN
Products and Devices
Dentures
Yes		Yes	1 denture/5 years, 1 reline/year	Fee for service	CN & MN
Eyeglasses
Yes		Yes	1 pair eyeglasses/2 years, special lenses not covered, interim replacement for lost or broken eyeglasses allowed once in 2 years	Products provided by state's volume purchase contractor, dispensing provider paid fee for service	CN & MN
Hearing Aids
Yes		New or replacement hearing aid, repair costing more than $25	Hearing loss must exceed specified decibel criteria	Fee for service	CN & MN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items, depending on cost		Fee for service for most products, incontinence supplies available through state's volume purchase contracts	CN & MN
Prosthetic and Orthotic Devices
Yes		Specified services or items	Limited to services and items to restore function	Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
No
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes		Portable x-ray services other than in nursing facilities	Limits on individual billings for paneled lab tests, lab services for renal dialysis and hemodialysis centers not billable by labs	Fee for service, portable x-ray services paid reasonable charge	CN & MN
Targeted Case Management
Yes				Cost based payment	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes			Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	$1/visit	Initiation and continuation of care		Fee for service	CN & MN
Hospice Care
Yes		Yes	Services must generally comply with Medicare guidelines	Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
Yes			Plan of care required, 283 hours/month	Fee for service using hourly rates, or negotiated rates	CN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes			See service-specific FN	Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes				Prospective cost based per diem	CN & MN
Inpatient Psychiatric Services, under age 21
Yes		Admission		Prospective cost based all-inclusive per diem using peer groups or negotiated rate with county-operated facilities	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Admission	7 hosp leave days/hospitalization, 73 therapeutic leave days/year	Private facilities paid standard per diem by facility size, cost based payment for public facilities	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent	30 treatment absences in 120 days for rehab therapy, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year	Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes		Yes	Cost of care must be less than in inpatient hospital	Prospective cost based per diem for facility, negotiated rate for practitioners	CN & MN

Notes: his State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the federal poverty level. Beneficiaries in this group must pay an income-based monthly premium. Irrespective of the amounts shown on the tables, copayments are not required for any service for beneficiaries younger than age 19 or for which the program’s payment is $10.00 or less.