California law says that health plans must provide many basic services, and certain other services. Plans must only provide services when the service is medically necessary.

Basic Services

Basic services include doctor and hospital services. Health plans must cover inpatient services—when you have to stay overnight in the hospital. They must also cover outpatient services, such as minor surgery in a surgery center. Other basic services are:

• Laboratory tests to diagnose problems. These include blood tests, STD (sexually transmitted diseases) tests, and pregnancy tests. This also includes some cancer screening tests.
• Diagnostic services, like x-rays and mammograms
• Preventive and routine care, like vaccinations and checkups
• Mental health care for some serious problems
• Emergency and urgent care—even if you are outside your health plan's service area
• Rehabilitation therapy, such as physical, occupational and speech therapy
• Some home health or nursing home care after a hospital stay

Other Benefits that Health Plans Must Cover

• Standing referrals for patients with AIDS (This means that you do not have to get a referral and approval each time you see an AIDS specialist.)
• Diabetes services and supplies
• Routine costs of clinical trials for cancer treatment
• Prosthetic devices or reconstructive surgery after a mastectomy (removal of a breast)
• Prosthetic devices to restore a method of speaking for a patient after a laryngectomy (removal of the vocal cords). This does not include electronic voice-producing machines.
• Reconstructive surgery to correct or repair birth defects, developmental abnormalities (something that is not normal in the way a child grows), trauma or injury, infection, tumors, or disease. The purpose of the surgery must be to improve function (the way a part of the body works) or to create as normal an appearance as possible.
• Services related to diagnosis, treatment, and management of osteoporosis (weak bones), including bone mass measurement and other FDA-approved tests and medications
• General anesthesia for dental procedures in certain cases

Services that Are Not Required

Most medical health plans do not cover dental care, eyeglasses, and hearing aids. Many plans do cover prescription drugs and durable medical equipment, such as wheelchairs and oxygen, but what is covered differs from plan to plan.

Diabetes Services and Supplies

If you have diabetes (insulin-using diabetes, non-insulin-using diabetes, or gestational diabetes), your health plan must cover the following, even if you can get them without a prescription:

• Blood glucose monitors and testing strips
• Blood glucose monitors designed for people with vision problems
• Insulin pumps and supplies needed to use the pump, in certain cases
• Urine strips to test for ketones
• Lancets and lancet puncture devices
• Pen delivery systems for taking insulin, in certain cases
• Podiatric devices to prevent or treat foot problems related to diabetes
• Insulin syringes
• Visual aids, except eyeglasses, to help people with vision problems take the proper dose of insulin
• Out-patient training, education, and medical nutrition therapy to help a person with diabetes use the covered equipment, supplies, and medications properly

If your health plan covers prescription drugs, it must cover the following diabetes drugs:

• Insulin
• Other prescription drugs to treat diabetes
• Glucagon