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This is yourSummary of Benefits.2020Health Net Seniority Plus Amber I (HMO D-SNP) H0562: 055Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego,San Francisco and Tulare counties, CAH0562 055 20 13065SB M Accepted 09012019
This booklet provides you with a summary of what we cover and the cost-sharing responsibilities. Itdoesn’t list every service that we cover or list every limitation or exclusion. To get a complete list ofservices we cover, please call us at the number listed on the last page, and ask for the “Evidence ofCoverage” (EOC), or you may access the EOC on our website at ca.healthnetadvantage.com.You are eligible to enroll in Health Net Seniority Plus Amber I (HMO D-SNP) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to paytheir Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanentlyreside in the service area of the plan (in other words, your permanent residence is within the HealthNet Seniority Plus Amber I (HMO D-SNP) service area counties). Our service area includes thefollowing counties in California: Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, SanDiego, San Francisco and Tulare. You do not have End-Stage Renal Disease (ESRD). (Exceptions may apply for individuals whodevelop ESRD while enrolled in a Health Net commercial or group health plan, or a Medicaid plan.) For Health Net Seniority Plus Amber I (HMO D-SNP), you must also be enrolled in the CaliforniaMedicaid plan. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaideligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by theState of California for full-dual enrollees. Please contact the plan for further details.The Health Net Seniority Plus Amber I (HMO D-SNP) plan gives you access to our network of highlyskilled medical providers in your area. You can look forward to choosing a primary care provider (PCP)to work with you and coordinate your care. You can ask for a current provider and pharmacy directoryor, for an up-to-date list of network providers, visit ca.healthnetadvantage.com. (Please note that,except for emergency care, urgently needed care when you are out of the network, out-of-area dialysisservices, and cases in which our plan authorizes use of out-of-network providers, if you obtain medicalcare from out-of-plan providers, neither Medicare nor Health Net Seniority Plus Amber I (HMO D-SNP)will be responsible for the costs.)This Health Net Seniority Plus Amber I (HMO D-SNP) plan also includes Part D coverage, whichprovides you with the ease of having both your medical and prescription drug needs coordinatedthrough a single convenient source.
Summary of BenefitsJANUARY 1, 2020–DECEMBER 31, 2020BenefitsHealth Net Seniority Plus Amber I (HMO D-SNP) H0562: 055Premiums / Copays / CoinsurancePremiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility categoryand/or the level of Extra Help you receive.Monthly Plan PremiumYou pay 0 - 32 based on your level of Medicaid eligibility(You must continue to pay your Medicare Part B premium, if nototherwise paid for by Medicaid or another third party.)DeductibleMaximum Out-of-PocketResponsibility(does not includeprescription drugs) 0 deductible for covered medical services 350 deductible for Part D prescription drugs (applies to drugs on Tiers2, 3, 4 and 5) 5,250 annuallyThis is the most you will pay in copays and coinsurance for medicalservices for the year.Inpatient HospitalCoverage* 0 copay per stay.Outpatient HospitalCoverage* Outpatient Hospital: 0 copay per visit Observation Services: 0 or 30 copay per visit Ambulatory Surgical Center: 0 copay per visitDoctor Visits* Primary Care: 0 copay per visit Specialist: 0 copay per visit 0 copay for most Medicare-covered preventive servicesOther preventive services are available.Preventive Care* (e.g. flu vaccine, diabeticscreening)Emergency Care 0 or 30 copay per visitYou do not have to pay the copay if admitted to the hospital immediately.Urgently Needed Services 0 copay per visitDiagnostic Services/Labs/ Lab services: 0 copayImaging* Diagnostic tests and procedures: 0 copay Outpatient X-ray services: 0 copay Diagnostic Radiology services (such as, MRI, MRA, CT, PET): 0 copayServices with an * (asterisk) may require prior authorization from your doctor.Services with a (square) may require referral from your doctor.
BenefitsHealth Net Seniority Plus Amber I (HMO D-SNP) H0562: 055Premiums / Copays / CoinsuranceHearing Services* Hearing exam (Medicare-covered): 0 copay Routine hearing exam: 0 copay (1 every calendar year) Hearing aid: 0 copay (2 hearing aids total, 1 per ear, per calendaryear)Dental Services* Dental services (Medicare-covered): 0 copay per visit Preventive Dental Services: 0 copay (including oral exams, cleanings,fluoride treatment, and X-rays). Comprehensive dental services: Additional comprehensive dentalbenefits are available.Vision Services* Vision exam (Medicare-covered): 0 copay per visit Routine eye exam: 0 copay per visit (up to 1 every calendar year) 400 max allowance for eyeglass frames (or contact lenses in lieu offrames) every 2 years. 120 max allowance for progressive eyeglass lenses or lens upgradesevery 2 years (upgrades limited to progressive lenses only).Individual and group therapy: 0 or 10 copay per visitMental Health Services*Skilled Nursing Facility*Physical Therapy* For each benefit period, you pay 0 or, 0 copay per day, for days 1 through 20 50 copay per day, for days 21 through 100 0 copay per visitAmbulance* Ground ambulance services: 0 or 50 copay (per one-way trip) Air ambulance services: 0% or 5% coinsurance (per one-way trip)Transportation* 0 copay (per one-way trip)Up to 50 one-way trips to plan-approved locations each calendar year.Mileage limits may apply.Medicare Part BDrugs* Chemotherapy drugs: 0% or 20% coinsurance Other Part B drugs: 0% or 20% coinsuranceServices with an * (asterisk) may require prior authorization from your doctor.Services with a (square) may require referral from your doctor.
Part D Prescription DrugsDeductible Stage 350 deductible for Part D prescription drugs (applies to drugs on Tiers2, 3, 4 and 5).The Deductible Stage is the first payment stage for your drug coverage.This stage begins when you fill your first prescription in the year. Whenyou are in this payment stage, you must pay the full cost of your Part Ddrugs until you reach the plan’s deductible amount.Once you have paid the plan’s deductible amount for your Part D drugs,you leave the Deductible Stage and move on to the next payment stage(Initial Coverage Stage). If you receive “Extra Help” to pay for yourprescription drugs, your deductible amount will be either 0 or 89depending on the level of “Extra Help” you receive.Initial Coverage Stage (after After you have met your deductible (if applicable), the plan pays its shareyou pay your Part Dof the cost of your drugs and you pay your share of the cost. Youdeductible, if applicable)generally stay in this stage until the amount of your year-to-date “totaldrug costs” reaches 4,020. “Total drug costs” is the total of allpayments made for your covered Part D drugs. It includes what the planpays and what you pay. Once your “total drug costs” reach 4,020 youmove to the next payment stage (Coverage Gap Stage).Standard RetailRx 30-day supplyMail OrderRx 90-day supplyTier 1: Preferred Generic 0 copay 0 copayTier 2: Generic 20 copay 60 copayTier 3: Preferred Brand 47 copay 141 copayTier 4: Non-PreferredDrug 100 copay 300 copay26% coinsuranceNot available 0 copay 0 copayTier 5: SpecialtyTier 6: Select Care Drugs
Part D Prescription DrugsCoverage Gap StageDuring this payment stage, you receive a 70% manufacturer’s discounton covered brand name drugs and the plan will cover another 5%, soyou will pay 25% of the negotiated price and a portion of the dispensingfee on brand-name drugs. In addition the plan will pay 75% and you pay25% for generic drugs. (The amount paid by the plan does not counttowards your out-of-pocket costs).You generally stay in this stage until the amount of your year-to-date“out-of-pocket costs” reaches 6,350. “Out of pocket costs” includeswhat you pay when you fill or refill a prescription for a covered Part Ddrug and payments made for your drugs by any of the followingprograms or organizations: “Extra Help” from Medicare; Medicare’sCoverage Gap Discount Program; Indian Health Service; AIDS drugassistance programs; most charities; and most State PharmaceuticalAssistance Programs (SPAPs). Once your “out-of-pocket costs” reach 6,350, you move to the next payment stage (Catastrophic CoverageStage).If you qualify for “Extra Help” this stage doesn’t apply-If you are noteligible for “Extra Help”, call the plan or refer to the Evidence ofCoverage (EOC), Chapter 6, for outpatient prescription drug cost-sharinginformation.Catastrophic StageDuring this payment stage, the plan pays most of the cost for yourcovered drugs. For each prescription, you pay whichever of these isgreater: a payment equal to 5% coinsurance of the drug, or a copayment( 3.60 for a generic drug or a drug that is treated like a generic, 8.95 forall other drugs).Important Info:Cost-sharing may change depending on the level of help you receive,the pharmacy you choose (such as Standard Retail, Mail Order, LongTerm Care, or Home Infusion) and when you enter another of the fourstages of the Part D benefit.For more information about the costs for Long-Term Supply, HomeInfusion, or additional pharmacy-specific cost-sharing and the stages ofthe benefit, please call us or access our EOC online.Low income subsidy (LIS) is extra help you receive from Medicare. Tofind out if you qualify, visit Medicare.gov or call Member Services at1-800-431-9007 (TTY: 711).
Additional Covered BenefitsBenefitsHealth Net Seniority Plus Amber I (HMO D-SNP) H0562: 055Premiums / Copays / CoinsuranceOpioid TreatmentProgram Services* Individual setting: 0 or 10 copay per visit Group setting: 0 or 10 copay per visitChiropractic Care* Chiropractic services (Medicare-covered): 0 copay per visitMedical Equipment/Supplies* Durable Medical Equipment (e.g., wheelchairs, oxygen): 0% or 15%coinsurance Prosthetics (e.g., braces, artificial limbs): 0% or 15% coinsurance Diabetic supplies: 0 copayFoot Care (Podiatry Services) Foot exams and treatment (Medicare-covered): 0 copay per visit Routine Foot care: 0 copay per visit (12 visits every calendar year.)Wellness Programs Fitness program: 0 copay 24-hour Nurse Connect: 0 copay Supplemental smoking and tobacco use cessation (counseling tostop smoking or tobacco use): 0 copayFor a detailed list of wellness program benefits offered, please refer tothe EOC.Worldwide EmergencyCare 50,000 plan coverage limit for supplemental urgent/emergentservices outside the U.S. and its territories every calendar year.Services with an * (asterisk) may require prior authorization from your doctor.Services with a (square) may require referral from your doctor.
Comprehensive Written Statement for Prospective EnrolleesThe benefits described in the Premium and Benefit section of the Summary of Benefits are covered byour Medicare Advantage plan. For each benefit listed, you can see what our plan covers. What you payfor covered services may depend on your level of Medicaid eligibility. Coverage of the benefitsdescribed in this Summary of Benefits depends upon your level of Medicaid eligibility. No matter whatyour level of Medicaid eligibility is, Health Net Seniority Plus Amber I (HMO D-SNP) will cover thebenefits described in the Premium and Benefit section of the Summary of Benefits. If you havequestions about your Medicaid eligibility and what benefits you are entitled to, call Department of HealthCare Services (DHCS)/Medi-Cal toll-free at 1-800-541-5555 (TTY: 1-866-784-2595).Our source of information for Medicaid benefits is http://www.medi-cal.ca.gov/contact.asp. All Medicaidcovered services are subject to change at any time. For the most current California Medicaid coverageinformation, please visit http://www.medi-cal.ca.gov/contact.asp or call Member Services for assistance.A detailed explanation of California Medicaid benefits can be found in the California Summary ofServices online at ionalCOHSDefinitionTwo-PlanState PlanServiceCategoryGMCServiceSan BenitoMedi-Cal Benefits and Covered ices andAcupunctureServicesX1 X1 X1 X1 X1 X1Acupuncture services shall be limited totreatment performed to prevent, modify oralleviate the perception of severe,persistent chronic pain resulting from agenerally recognized medical condition.AcuteAdministrativeDaysIntermediateCare FacilityServicesX5 X5 XAcute administrative days are covered,when authorized by a Medi-Cal consultantsubject to the acute inpatient facility hasmade appropriate and timely dischargeplanning, all other coverage has beenutilized and the acute inpatient facilitymeets the requirements contained in theManual of Criteria for Medi-CalAuthorization.Blood andBloodDerivativesBlood andBloodDerivativesA facility that collects, stores, anddistributes human blood and bloodderivatives. Covers certification of bloodordered by a physician or facility wheretransfusion is given.XXXX5 X5 X5XXX
XXXXXXCertifiedPediatric NursePractitionerServicesCovers the care of mothers and newborns Xthrough the maternity cycle of pregnancy,labor, birth, and the immediate postpartumperiod, not to exceed six weeks; can alsoinclude primary care services.XXXXXChild Healthand DisabilityPrevention(CHDP)ProgramA preventive program that delivers periodic Xhealth assessments and provides carecoordination to assist with medicalappointment scheduling, transportation,and access to diagnostic and treatmentservices.XX4 XXXChildhood LeadPoisoning CaseManagement(Provided by theLocal CountyHealthDepartments)A case of childhood lead poisoning (forpurposes of initiating case management)as a child from birth up to 21 years of agewith one venous blood lead level (BLL)equal to or greater than 20 μg/dL, or twoBLLs equal to or greater than 15 μg/dL thatmust be at least 30 and no more than 600calendar days apart, the first specimen isnot required to be venous, but the secondmust be venous.X6CaliforniaService is not California Children Services (CCS) meansChildrencovered under those services authorized by the CCSServices (CCS) the State Plan program for the diagnosis and treatment ofthe CCS eligible conditions of a ric SA certified family nurse practitioners whoprovide services within the scope of theirpractice.Two-PlanCertified Family CertifiednurseFamily NursePractitioners'practitionerServicesGMCSan BenitoDefinitionImperialState PlanServiceCategoryRegionalServiceServices provided by chiropractors, acting X1 X1 X1 X1 X1 X1within the scope of their practice asauthorized by California law, are covered,except that such services shall be limitedto treatment of the spine by means ofmanual manipulation.
ImperialSan BenitoXProcedure used to treat kidney failure covered only as an outpatient service.Blood is removed from the body through avein and circulated through a machine thatfilters the waste products and excess fluidsfrom the blood. The “cleaned” blood is thenreturned to the body. Chronic means thisprocedure is performed on a regular basis.Prior authorization required when providedby renal dialysis centers or communityhemodialysis units.XXXXXCommunityBased AdultServices(CBAS)XCBAS Bundled services: An outpatient,facility based service program that deliversskilled nursing care, social services,therapies, personal care, family/caregivertraining and support, meals andtransportation to eligible Medi-Calbeneficiaries.CBAS Unbundled Services: Componentparts of CBAS center services deliveredoutside of centers, under certainconditions, as specified in paragraph 94.XXXXXComprehensive ExtendedPerinatalServices forServicesPregnantWomenPregnancyRelated andPostpartumServicesComprehensive perinatal services means Xobstetrical, psychosocial, nutrition, andhealth education services, and relatedcase coordination provided by or under thepersonal supervision of a physician duringpregnancy and 60 days following delivery.XXXXXDental ServicesProfessional services performed orprovided by dentists including diagnosisand treatment of malposed human teeth, ofdisease or defects of the alveolar process,gums, jaws and associated structures; theuse of drugs, anesthetics and physicalevaluation; consultations; home, office andinstitutional calls.Drug Medi-Cal SubstanceSubstanceAbuseAbuse Services TreatmentServicesMedically necessary substance abusetreatment to eligible isGMCRegionalDefinitionCOHSState PlanServiceCategoryTwo-PlanService
COHSRegionalImperialSan BenitoDefinitionTwo-PlanState PlanServiceCategoryGMCServiceDurable Medical DMEEquipmentAssistive medical devices and supplies.Covered with a prescription; priorauthorization is required.XXXXXXEarly andPeriodicScreening,Diagnosis, andTreatment(EPSDT)Services andEPSDTSupplementalServicesPreliminary evaluation to help identifypotential health issues.XXXXXXEnhanced CaseManagement(ECM), asdefined inparagraph 95XA service consisting of those “ComplexCase Management” and “Person-CenteredPlanning” services including thecoordination of beneficiaries’ individualneeds for needed long-term care servicesand supports.XXXXXErectileDysfunctionDrugsFDA-approved drugs that may beprescribed if a male patient experiences aninability or difficulty getting or keeping anerection as a result of a physical edby the GeneticDisease Branchof DHCS)A simple blood test recommended for allpregnant women to detect if they arecarrying a fetus with certain geneticabnormalities such as open neural tubedefects, Down Syndrome, chromosomalabnormalities, and defects in theabdominal wall of the fetus.Eyeglasses,Contact Lenses,Low VisionAids, ProstheticEyes and OtherEye AppliancesEPSDTEyeglasses,ContactLenses, LowVision Aids,ProstheticEyes, andOther EyeAppliancesEye appliances are covered on the written X1,3 X1,3 X1,3 X1,3 X1,3 X1,3prescription of a physician or optometrist.
ImperialSan BenitoFederallyFQHCQualified HealthCenters (FQHC)(Medi-CalCoveredservices only)XAn entity defined in Section 1905 of theSocial Security Act (42 United States CodeSection 1396d(l)(2)(B)).XXXXXHearing AidsXHearing aids are covered only whensupplied by a hearing aid dispenser onprescription of an otolaryngologist, or theattending physician where there is nootolaryngologist available in thecommunity, plus an audiological evaluationincluding a hearing aid evaluation whichmust be performed by or under thesupervision of the above physician or by alicensed audiologist.XXXXXHome andCommunityBased WaiverServices (Doesnot includeEPSDTServices)Hearing AidsGMCRegionalDefinitionCOHSState PlanServiceCategoryTwo-PlanServiceHome and community-based waiverservices shall be provided and reimbursedas Medi-Cal covered benefits only: (1) Forthe duration of the applicable federallyapproved waiver, (2) To the extent theservices are set forth in the applicablewaiver approved by the HHS; and (3) Tothe extent the Department can claim andbe reimbursed federal funds for theseservices.Home HealthAgencyServicesHome HealthHome health agency services are covered XServices-Home as specified below when prescribed by aHealth Agency physician and provided at the home of thebeneficiary in accordance with a writtentreatment plan which the physician reviewsevery 60 days.XXXXXHome HealthAide ServicesHome HealthCovers skilled nursing or other professional XServices-Home services in the residence including parttime and intermittent skilled nursingHealth Aideservices, home health aide services,physical therapy, occupational therapy, orspeech therapy and audiology services,and medical social services by a socialworker.XXXXX
ImperialSan BenitoHospice CareHospice CareCovers services limited to individuals who Xhave been certified as terminally ill inaccordance with Title 42, CFR Part 418,Subpart B, and who directly or throughtheir representative volunteer to receivesuch benefits in lieu of other care ces andOrganizedOutpatientClinic ServicesClinic Servicesand HospitalOutpatientDepartmentServices andOrganizedOutpatientClinic ServicesXA scheduled administrative arrangementenabling outpatients to receive theattention of a healthcare provider. Providesthe opportunity for consultation,investigation and minor treatment.XX XXXHumanImmunodeficiency Virusand AIDS nalDefinitionCOHSState PlanServiceCategoryTwo-PlanServiceHuman Immunodeficiency Virus and AIDSdrugs that are listed in the Medi-CalProvider ManualX7Except for previously sterile women, anonemergency hysterectomy may becovered only if: (1) The person whosecures the authorization to perform thehysterectomy has informed the individualand the individual's representatives, if any,orally and in writing, that the hysterectomywill render the individual permanentlysterile, (2) The individual and theindividual's representative, if any, hassigned a written acknowledgment of thereceipt of the information in and (3) Theindividual has been informed of the rightsto consultation by a second physician. Anemergency hysterectomy may be coveredonly if the physician certifies on the claimform or an attachment that thehysterectomy was performed because of alife-threatening emergency situation inwhich the physician determined that prioracknowledgement was not possible andincludes a description of the nature of theemergency.X
ImperialSan BenitoIndian HealthServices (MediCal coveredservices only)XIndian means any person who is eligibleunder federal law and regulations (25U.S.C. Sections 1603c, 1679b, and 1680c)and covers health services provideddirectly by the United States Department ofHealth and Human Services, Indian HealthService, or by a tribal or an urban Indianhealth program funded by the IndianHealth Service to provide health servicesto eligible individuals either directly or bycontract.XXXXXIn-HomeMedical CareWaiver Servicesand NursingFacility WaiverServicesIn-home medical care waiver services and Xnursing facility waiver services are coveredwhen prescribed by a physician andprovided at the beneficiary's place ofresidence in accordance with a writtentreatment plan indicating the need for inhome medical care waiver services ornursing facility waiver services and inaccordance with a written agreementbetween the Department and the providerof service.XXXXXXXXXXGMCRegionalDefinitionCOHSState lServicesInpatientHospitalServicesCovers delivery services andhospitalization for newborns; emergencyservices without prior authorization; andany hospitalization deemed medicallynecessary with prior authorization.XIntermediateCare FacilityServices for theDevelopmentallyDisabledIntermediateCare FacilityServices forthe DevelopmentallyDisabledIntermediate care facility services for thedevelopmentally disabled are coveredsubject to prior authorization by theDepartment. Authorizations may begranted for up to six months. Theauthorization request shall be initiated bythe facility. The attending physician shallsign the authorization request and shallcertify to the Department that thebeneficiary requires this level of careX5 X5 XX5 X5 X5
IntermediateCare FacilityServices for Care FacilityServices for theDevelopmentallyDisabledNursing.IntermediateCare FacilityServices forthe DevelopmentallyDisabledHabilitativeSan BenitoImperialRegionalCOHSDefinitionTwo-PlanState PlanServiceCategoryGMCServiceIntermediate care facility services for theX5 X5 Xdevelopmentally disabled habilitative (ICFDDH) are covered subject to priorauthorization by the Department of HealthServices for the ICF-DDH level of care.Authorizations may be granted for up to sixmonths. Requests for prior authorization ofadmission to an ICF-DDH or forcontinuation of services shall be initiatedby the facility on forms designated by theDepartment. Certification documentationrequired by the Department ofDevelopmental Services must becompleted by regional center personneland submitted with the TreatmentAuthorization Request form. The attendingphysician shall sign the TreatmentAuthorization Request form and shallcertify to the Department that thebeneficiary requires this level of care.X5 X5 X5Intermediate care facility services for theX5 X5 Xdevelopmentally disabled-nursing (ICF/DDN) are covered subject to priorauthorization by the Department for theICF/DD-N level of care. Authorizations maybe granted for up to six months. Requestsfor prior authorization of admission to anICF/DD-N or for continuation of servicesshall be initiated by the facility onCertification for Special TreatmentProgram Services forms (HS 231).Certification documentation required by theDepartment of Developmental Servicesshall be completed by regional centerpersonnel and submitted with theTreatment Authorization Request form.The attending physician shall sign theTreatment Authorization Request form andshall certify to the Department that thebeneficiary requires this level of care.X5 X5 X5
San BenitoImperialRegionalCOHSDefinitionTwo-PlanState PlanServiceCategoryGMCServiceIntermediateCare ServicesIntermediateCare FacilityServicesIntermediate care services are coveredX5 X5 Xonly after prior authorization has beenobtained from the designated Medi-Calconsultant for the district where the facilityis located. The authorization request shallbe initiated by the facility. The attendingphysician shall sign the authorizationrequest and shall certify to the Departmentthat the beneficiary requires this level ofcare.X5 X5 boratory, XRay Covers exams, tests, and therapeuticservices ordered by a licensed itioners'Services andLicensedMidwifeServicesThe following services shall be covered as Xlicensed midwife services under the MediCal Program when provided by a licensedmidwife supervised by a licensed physicianand surgeon: (1) Attendance at cases ofnormal childbirth and (2) The provision ofprenatal, intrapartum, and postpartumcare, including family planning care, for themother, and immediate care for thenewborn.XXXXX
LocalEducationalAgency (LEA)ServicesLocalEducationAgency MediCal BillingOptionProgramServicesLong Term Care(LTC)MedicalSuppliesMedicalSuppliesSan BenitoImperialRegionalCOHSDefinitionTwo-PlanState PlanServiceCategoryGMCServiceLEA health and mental health evaluationand health and mental health educationservices, which include any or all of thefollowing:(A) Nutritional assessment and nutritioneducation, consisting of assessments andnon-classroom nutrition educationdelivered to the LEA eligible beneficiarybased on the outcome of the nutritionalhealth assessment (diet, feeding,laboratory values, and growth), (B) Visionassessment, consisting of examination ofvisual acuity at the far point conducted bymeans of the Snellen Test, (C) Hearingassessment, consisting of testing forauditory impairment using at-risk criteriaand appropriate screening techniques asdefined in Title 17, California Code ofRegulations, Sections 2951(c), (D)Developmental assessment, consisting ofexamination of the developmental level byreview of developmental achievement incomparison with expected norms for ageand background, (E) Assessment ofpsychosocial status, consisting of appraisalof cognitive, emotional, social, andbehavioral functioning and self-conceptthrough tests, interviews, and behavioralevaluations and (F) Health education andanticipatory guidance appropriate to ageand health status, consisting of nonclassroom health education andanticipatory guidance based on age anddevelopmentally appropriate healtheducation.Care in a facility for longer than the month X5 X5 Xof admission plus one month.X5 X5 X5XMedically necessary supplies whenprescribed by a licensed practitioner. Doesnot include incontinence creams andwashes.XXXXX
RegionalImperialSan BenitoXCovers ambulance, litter van andwheelchair van medical transportationservices are covered when thebeneficiary's medical and physicalcondition is such that transport by ordinarymeans of public or private conveyance ismedically contraindicated, andtransportation is required for the purpose ofobtaining needed medical tate PlanServiceCategoryGMCServiceXXXXXMSSP sites provide social and health caremanagement for frail elderly clients whoare certifiable for placement in a nursingfacility but who wish to remain in thecommunity.MultipurposeSenior Practitioners'Services andNurseAnesthetistServicesCovers anesthesiology services performed Xby a nurse anesthetist within the scope ofhis or her licensure.XXXXXNurse MidwifeServicesXNurse-Midwife An advanced practice registered nurseServiceswho has specialized education and trainingin both Nursing and Midwifery, is trained inobstetrics, works under the supervision ofan obstetrician, and provides care formothers and newborns through thematernity cycle of pregnancy, labor, birth,and the immediate postpartum period, notto exceed six weeks.XXXXXOptometryServi
Health Net Seniority Plus Amber I (HMO D-SNP) H0562: 055 Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tul
