Medi-Cal Plan Benefits and Programs (2024)

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Doctor visits

Hospital care

Vision care

Medical care

There are no copays for covered services, including:

• Primary care doctor visits
• Immunizations and wellness visits
• Specialist visits
• Mental health and substance use disorder services
• Urgent and emergency care
• Lab and X-ray services
• Pregnancy services
• Family planning
• Hospital care
• Children’s services, including dental and vision care
• Physical and occupational therapy
• Speech and hearing services
• Home health care services
• Care coordination services
• Disease management for asthma, diabetes and more

Some services may require a referral or prior authorization before you can get them. See referrals and preapprovals section below for more information.

Referrals and preapprovals

Referrals

Your primary care provider (PCP) gives you routine care, like checkups and care when you’re sick. Your PCP may need to send you to a specialist for some types of care or treatment. This is called a referral. Your PCP will work with you to choose a specialist to give you the care you need.

Some types of services are known as self-referral services. That means you can get these services without a referral from your PCP. See your member handbook for a list of these services. Make sure you tell your PCP and specialist as much as you can about your health. This will help them make sure you get the right care. You may also need preapproval from us to get this care.

Preapprovals (also called prior authorizations)

For some services, your provider will need to get a preapproval, or an OK, from us before you get them. Your PCP will work with us to get the preapproval. Getting a preapproval may take five days or up to 14 days if we need more information from you. If urgent, it will take no more than 72 hours. See your member handbook for services that require preapproval.

You can get these covered services without preapproval:

• PCP visits
• Emergency services
• Preventive care services (well-visits)
• Family planning services
• Sexually transmitted disease (STD) services

Pharmacy and prescription drugs

Starting on January1, 2022 you will receive your Medi-Cal covered prescriptions through Medi-Cal Rx instead of Anthem and IngenioRx .

The Department of Health Care Services (DHCS) will change your pharmacy benefit. Your prescription medications will be covered by “Medi-Cal Rx.” This does not change your Medi-Cal eligibility or benefits.

If you are eligible for both Medicare and Medi-Cal, Medi-Cal Rx may cover prescriptions Medicare does not, so you should talk to your doctor or pharmacy if you have any questions.

DHCS is working with a new contractor, Magellan Medicaid Administration, Inc. (Magellan) to provide Medi-Cal Rx services. There will be no change in how you pay for your medications. For most Medi-Cal beneficiaries, there is no cost.

There is nothing you need to do at this time.
Anthem, your doctors, and pharmacies know about the changes and know what to do. Most people in Medi-Cal will not need to do anything. In addition, most people will be able to use the same pharmacy they do now on January 1, 2022. If your pharmacy does not work with Medi-Cal Rx, you may need to choose another pharmacy.

New Medi-Cal Rx services will provide:

• Outpatient drugs (prescription and over-the-counter).
• Certain nutrition products.
• Medical supplies.

On or before December 31, 2021, if you have questions about your medication or other pharmacy services, please call Anthem’s Customer Care Center Monday through Friday, 7 a.m. to 7 p.m. toll free at 800-407-4627 (TTY 711), or 888-285-7801 (TTY 711) for members in Los Angeles.

If you have questions about these changes or have Medi-Cal Rx general questions, contact the Medi-Cal Member Help Line at 800-541-55555 (TTY 800-430-7077), Monday through Friday, 8 a.m. to 5 p.m.

After January 1, 2022, visit Medi-CalRx.dhcs.ca.gov or call Customer Service at 800-977-2273 24 hours a day, seven days a week or 711 for TTY Monday through Friday, 8 a.m. to 5 p.m. for more details about these changes.

Your other Anthem Medi-Cal benefits will remain the same.

Dental care

Vision care

We offer vision benefits to all members through Vision Service Plan (VSP).

Children and young adults under age 21 get:

• One eye exam and one pair of glasses every two years

Adults over 21 years of age get:

• One eye exam every two years
• A yearly eye exam if you have diabetes
• Medically necessary contact lenses and eyesight aids

To find an eye doctor or ask questions about vision benefits, call VSP at 1-800-877-7195 (TTY 711).

Transportation services

A big part of staying healthy is making it to all of your appointments. We can help you get rides to covered health care appointments at no cost.

Care management programs

Managing your health care can be overwhelming. You might need some extra support coordinating your care and services. We’re here to help. We have no-cost programs to connect you with someone who can help you manage the care and services you already get, plus find even more supports in your community.

Medi-Cal for Kids and Teens (EPSDT)

The Department of Health Care Services (DHCS) is responsible to provide no-cost, all-encompassing, EPSDT services to Medi-Cal beneficiaries under the age of 21. EPSDT services are now referred to as Medi-Cal for Kids & Teens in the state of California.

Medi-Cal Kids & Teens covered services

• Free checkups
• Mental health services, including drug and alcohol treatments and therapies
• Developmental and autism spectrum disorder screening, ACEs/Trauma screening
• Behavioral health screenings and care, including Dyadic (parent/caregiver and child) services
• Depression screening, maternal postpartum and, for members aged 12 and older
• Oral Health screenings, fluoride varnish, and supplementation
• Dental checkups and follow-up services
• Vision services
• Hearing services
• COVID-19 testing and treatment
• Medical equipment and supplies, including durable medical equipment (DME)
• Medications
• Immunizations
• Lab testing, including blood lead testing
• Physical, occupational, and speech therapy
• Home health services (HHS), including nursing care
• Hospital and residential treatment
• Sexual and reproductive health services and pregnancy checkups for teens and young adults
• All services that your doctor determines are needed for physical, dental, and/or mental problems

For additional language options for outreach brochures and Medi-Cal rights materials please visit the DHCS Medi-Cal for Kids & Teens Resources page. For more information on Medi-Cal for Kids and Teens program, please visit the DHCS website.

Brochures and guides

Outreach Brochures - English
Outreach Brochures - Spanish
Outreach Brochures - English
Outreach Brochures - Spanish
Medi-Cal Your Rights Guide - English
Medi-Cal Your Rights Guide - Spanish

Long-Term Services and Supports (LTSS)

Do you need extra help with daily living? You may qualify for programs that can help you live in the comforts of your own home or community as independently as possible, for as long as possible.

Timely access to care

We want to make sure you get the care you need when you need it. Find out how long you’ll typically wait to see your doctor when you call for an appointment.

• Access to care – English
• Access to care – Spanish
• Access to care – Arabic
• Access to care – Armenian
• Access to care – Chinese
• Access to care – Farsi
• Access to care – Khmer
• Access to care – Korean
• Access to care – Russian
• Access to care – Tagalog
• Access to care – Vietnamese

Healthy Rewards

Earn rewards for healthy activities

Healthy Rewards is a no-cost, optional program for eligible members enrolled in our health plan. The program encourages you to seek the care you need to create a healthy lifestyle. Members can enroll in the Healthy Rewards program and earn dollars for making healthy choices.

Learn which healthy activities qualify

Anthem Healthy Rewards incentives:

• Up to $40 for refilling high blood pressure medication
• $25 for attending an annual childhood or adolescent wellness visit
• $50 for completing a breast cancer screening every two years
• $25 for completing an annual chlamydia screening
• $50 for completing a cervical cancer screening every three years
• $25 for refilling antidepressant medication
• $25 for ADHD medication management
• $25 for children receiving immunizations (shots) on time
• $25 for a diabetic A1c screening
• $5 for completing a What do you know about diabetes? quiz

New Baby, New Life℠ incentives:

• Earn $25 in rewards for attending a prenatal visit in the first trimester or within 42 days of enrollment in your Anthem health plan.
• Earn $50 in rewards for attending a postpartum visit 7 to 84 days after delivery.
• Earn up to $60 in rewards for bringing your child to at least six well-child checkups by 15 months of age.

Limitations and restrictions apply. Benefits may change.

Register or log in now to start earning rewards.

Log in to Healthy Rewards

Redeem or check your earned rewards

You can redeem Healthy Rewards or see what you have earned through the Benefit Reward Hub online. You also can call the Customer Care Center Monday through Friday from 7 a.m. to 7 p.m. toll free at 800-407-4627 (TTY 711), or 888-285-7801 (TTY 711) for members in Los Angeles. A representative can help you sign up, check your rewards, or redeem earned rewards.