Medi-Cal : Medi-Cal Benefits and Services (2024)

This page explains your covered services as a member of IEHP. Your covered services are at no cost if they are medically necessary and you get the approved services from our provider network. “Medically necessary” means it is reasonable and needed to protect life, to keep you from becoming seriously ill or disabled or to reduce pain from a diagnosed disease, illness or injury.

To learn more about IEHP’s benefits and services, read Chapter 4 of the IEHP Medi-Cal Member Handbook (PDF) or call IEHP Member Services at 1-800-440-IEHP (4347), Monday-Friday, 7 a.m.-7 p.m. and Saturday-Sunday, 8 a.m.-5 p.m. TTY users should call 1-800-718-IEHP (4347).

IEHP offers these types of services:

Some of the services listed are covered only if IEHP or your IPA approves first. Covered services that may need an approval from IEHP or your IPA or medical group first are marked by an asterisk (*).

The plan covers:

• Routine eye exam once every 24 months; IEHP may pre-approve (prior authorization) additional services as medically necessary.
• Eyeglasses (frames and lens) once every 24 months; contact lens when required for medical conditions such as aphakia, aniridia and keratoconus.

Limitations

• Single vision lenses only.
• Members under 18 automatically get polycarbonate lenses.
• Contacts in lieu of glasses only if medically necessary.

The Medi-Cal Dental Program covers some dental services, such as:

• Diagnostic and preventive dental hygiene (e.g., examinations, x-rays and teeth cleanings)
• Emergency services for pain control
• Tooth extractions
• Fillings
• Root canal treatments
• Prosthetic appliances
• Orthodontics for children who qualify

Members can access dental services through providers enrolled in the Medi-Cal Dental Program. They will advise you on the best course of treatment and when these services may be attained.

To learn more about dental services, call the Medi-Cal Dental Program at 1-800-440-IEHP (4347) / TTY 1-800-718-IEHP (4347). You may also visit the Denti-Cal website at www.smilecalifornia.org.By clicking on this link, you will be leaving the IEHP DualChoice website.

Your Medi-Cal benefits include round trip transportation for plan-covered health services and Medi-Cal-covered services, such as mental health, substance abuse and dental, within San Bernardino and Riverside counties.

The plan covers:

• Visits to your primary care doctor, specialists and urgent care clinics.
• Visit for dental, mental health, substance abuse and other services.

Exclusions and Limitations

IEHP does not cover:

• One-way trips and non-medical visits.
• Visits to Social Security, Workers Compensation Claims, Personal Injury cases, Courts, Parole or Probation or Social Services Offices.

IEHP offers two types of transportation:

1. Bus passes* for Non-Medical Transportation (NMT): approved when you do not have any physical or medical issue that does not allow you to travel by bus, car, taxi or other forms of public transportation.
2. Uber for Non-Medical Transportation (NMT): approved when your area doesn’t support bus passes or you are crossing counties. For this type of transportation, you need to wait for your ride at the curb.
   • Non-Emergency Medical Transportation (NEMT): approved when your medical or physical issue does not allow you to travel by bus, car, taxi or other forms of public transportation. For this type of transportation, your doctor must submit a Physicians’ Certification Statement online.

Effective March 1, 2020, transportation for routine medical visits including Behavioral Health and Substance Use must be scheduled five business days before your appointment. To set up transportation, call IEHP Transportation Department at 1-800-440-IEHP (4347) (option two), Monday-Friday, 8 a.m.-5 p.m. TTY users should call 1-800-718-IEHP (4347) (option two).

*For bus passes, call our transportation vendor Call the Car (CTC) at 1-855-673-3195 select option 1. Once you get your bus pass, you can use this for all of your health care visits.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. To download a free copy click Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website.

For some types of care, your PCP or specialist will need to ask IEHP for permission before you get the care. This is called asking for prior authorization, prior approval or pre-approval. It means that IEHP must make sure that the care is medically necessary or needed based on appropriateness of care and services and existence of coverage. Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled or reduces severe pain from a diagnosed disease, illness or injury.

For some services, you need pre-approval (prior authorization). Under Health and Safety Code Section 1367.01(h)(2), IEHP will decide routine pre-approvals within 5 working days of when IEHP gets the information reasonably needed to decide.

For requests in which a provider indicates or IEHP determines that following the standard timeframe could seriously jeopardize your life or health or ability to attain, maintain or regain maximum function, IEHP will make an expedited (fast) pre-approval decision. IEHP will give notice as quickly as your health condition requires and no later than 72 hours after receiving the request for services.

If IEHP does not approve the request, IEHP will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision. IEHP will contact you if IEHP needs more information or more time to review your request.

If you now go to providers who are not in the IEHP network (out-of-network), in certain cases you may get continuity of care and be able to go to them for up to 12 months. If your providers do not join the IEHP network by the end of 12 months, you will need to switch to providers in the IEHP network. If you are a new member, you may request to keep getting medical services from an out of network provider if you were getting this care before enrolling in IEHP. IEHP will decide if this treatment with an out of network provider is medically appropriate. Continuity of care does not extend to durable medical equipment, transportation, ancillary services, carved out services or services not covered by Medi-Cal.

To learn more about continuity of care and eligibility qualifications, call IEHP Member Services at 1-800-440-IEHP (4347).