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What services are covered in MCAP?

MCAP covers all your medically necessary services from your start date of coverage in the MCAP until the end of the month following the 60th day after your pregnancy has ended. MCAP cannot cover any medical services you receive after your enrollment ends.

Enrollment in MCAP prior to October 1, 2016, coverage includes:

MCAP Services for Pregnant Women and New Mothers
NOTE: Benefits are provided if the insurance plan determines them to be medically necessary. Benefits, exclusions and limitations described in this handbook are representative and not intended to be all-inclusive or comprehensive. Refer to the health plan’s Evidence of Coverage or Certificate of Insurance for further detail.
MCAP Benefits Services for Women Exclusions/Limitations
Physician and Professional Services
  • Services and consultations by a physician or other licensed health care provider
  • Hospital and skilled nursing facility visits
  • Professional Office Visits
  • Allergy testing and treatment
  • Hearing test, hearing aids and services
  • Eye examinations/refractions, to determine need for corrective lenses, dilated retinal eye exams.
  • Medically necessary home visits
  • Batteries, ancillary equipment other than included in the original covered hearing aids purchase
  • Replacement parts or repair for hearing aids after the covered one-year warranty period
  • Replacement of hearing aid more than once in any 36-month period
  • Surgically implanted hearing devices
Preventive Care
  • Periodic exams, routine diagnostic testing and laboratory services
  • Cancer screening tests
  • Direct patient care nutrition services, nutritional assessment
Maternity Care
  • Prenatal care, postnatal care
  • Inpatient delivery, complications of pregnancy
Hospital Services
  • Inpatient or outpatient general services and related supplies
  • Personal, comfort items
  • Private room unless medically necessary
Diagnostic X-ray and Laboratory Services
  • Diagnostic services necessary to evaluate, diagnose and treat
  • X-ray, laboratory procedures
  • Electrocardiography, electro-encephalography
  • Prenatal diagnosis of genetic disorders of the fetus in high risk pregnancies
  • Lab test for management of diabetes, including cholesterol, triglycerides, microalbuminuria, HDL/LDL and Hemoglobin A-1 (Glycohemoglobin)
  • Radiation therapy, chemotherapy, dialysis treatment
Prescription Drugs
  • Medically necessary prescription drugs
  • Injectable medication, needles, syringes
  • Insulin, glucagon, testing and delivery systems
  • Oral and injectable contraceptive drugs, prescriptive contraceptive devices
  • Experimental, investigational drugs
  • Patent or over-the-counter medicines
  • Medicines not requiring a prescription (Insulin and smoking cessation drugs are not excluded from coverage.)
  • Appetite suppressants, other diet drugs or medicines
  • Health plan may specify generic equivalent drugs be dispensed where no contraindication exists
Health Education Services
  • Effective services including information regarding personal health
  • Recommendations on optimal use of services, organizations affiliated with the health plan
  • Health services related to tobacco use prevention, cessation
Emergency Health Care Services
  • 24-hour emergency care for illness, injury or severe pain requiring immediate diagnosis and treatment to avoid placing the subscriber in danger of loss of life, serious illness or disability
  • Provided both in and out of the health plan's service area and participating facilities
Medical Transportation
  • Emergency ambulance for emergency services to first hospital accepting subscriber for care
  • Ambulance, transport services provided through "911" response system
  • Medically necessary non-emergency transportation to transfer a member from a hospital to another hospital or facility, or facility to home. Prior authorization from the Health Plan is required.
  • Coverage for transportation by airplane, passenger car, taxi or other form of public conveyance
Durable Medical Equipment
  • Equipment appropriate for use in the home
  • Oxygen and oxygen equipment
  • Blood glucose monitors, insulin pumps, related supplies
  • Nebulizer machines, tubing, related supplies
  • Ostomy bags, urinary catheters and supplies
  • Comfort, convenience items
  • Disposable supplies (Ostomy bags, urinary catheters and related supplies consistent with Medicare coverage guidelines are not excluded from coverage.)
  • Experimental or research equipment
  • Sauna baths, elevators, other non-medical devices
  • Modifications to home or automobile
  • Deluxe equipment
  • More than one piece of equipment that serves the same function
  • Health plan may determine whether to rent or purchase
Mental Health Care
  • Diagnosis and treatment of a mental health condition
  • Diagnosis and treatment for Severe Mental Illnesses (SMI) and Serious Emotional Disturbances (SED) conditions
  • Maximum of 30 inpatient days and 20 outpatient visits per benefit year for basic mental health care services (does not apply to SMI and SED).
  • Unlimited days and visits for SMI and SED.
  • Certain appropriate substitutions of residential treatment, day care or outpatient treatment may be substituted for inpatient hospitalization.
  • Some health plans may choose to provide group therapy sessions.
Alcohol and Drug Abuse Treatment
  • Health education services and crisis intervention related to alcohol, drug abuse
  • Inpatient: As medically appropriate to remove toxic substances from the system
  • Outpatient: 20 visits per benefit year
  • Some health plans may choose to provide additional medically necessary visits
Skilled Nursing
  • Medically necessary prescribed services by a health plan physician or nurse practitioner in a licensed skilled nursing facility on a 24-hour basis
  • Skilled nursing benefit is limited to a maximum 100 days per benefit year
Home Health Services
  • Health services provided in home by health care personnel
  • Prescribed or directed by attending physician or appropriate designee of the health plan
  • No custodial care
  • Discretion of attending physician or appropriate designee of the health plan to choose between mutually appropriate health care settings
  • Health plans utilize case management to consider cost-effective choice of mutually appropriate alternative health care settings
Blood and Blood Products
  • Inpatient and outpatient processing, storage, administration of blood and blood products
  • Collection and storage of autologous blood when medically indicated
Family Planning Services
  • Counseling and surgical procedures for sterilization, as permitted by state and federal law.
  • Coverage for diaphragms and other federal Food and Drug Administration approved devices pursuant to the prescription drug benefit.
  • Voluntary Termination of Pregnancy

Note: The Benefits charts on this Web site are only a summary of benefits provided by each health plan in MCAP. These summaries are for information only. This is not a contract. For exact terms and conditions of the health care benefits, provisions, exclusions, and limitations for each plan, refer to the Evidence of Coverage booklet or Certificate of Insurance available from each health plan. Call the phone number listed on each health plan's description page in Plans and Providers.

Enrollment after October 1, 2016, coverage includes benefits listed here. You may also contact the Benefits Division at 1-800-541-5555 for benefits related questions. To review your vision benefits, click here.

Enrollment after July 1, 2017 – Coverage under Medi-Cal Managed Care includes benefits listed here. You may also contact the Benefits Division at 1-800-541-5555 for benefits related questions. For more information on how to select your health or dental plans you can click here.

Services for Your Baby

If you submit the required Infant Registration Form, your baby will be covered from the date of birth through the DHCS Medi-Cal health care delivery system unless your baby is enrolled in employer-sponsored insurance or no-cost Medi-Cal. For a list of benefits and services available for your baby, see Services Available to Your Baby Through the DHCS California Departments of Health Care Services.

See Services Available to Your Baby Through the Medi-Cal Access Infant Program