Benefit Explanation And Limitations
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- Sybil Wiggins
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1 Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please contact: Provider Relations 1(415) x7084 8:30am-5pm on business days At a minimum, SFHP covers the core benefits and services specified in our agreement with the California Department of Health Care Services. SFHP Healthy Workers members may be charged for co-pays only as designated in the Healthy Workers Evidence of Coverage. This list is not intended to be an all-inclusive list of covered and non-covered benefits. All services are subject to benefit coverage, limitations, and exclusions as described in the plan coverage guidelines. Some services require prior authorizations according to general or specific medical necessity criteria. Members are not responsible for any cost-sharing for covered services.
2 Abortion Acupuncture Not Alcohol Abuse Screening, Brief Intervention, Referral to Treatment (SBIRT) Alcohol and Substance Abuse Treatment Services [including drugs used for treatment, outpatient heroin detox, and Voluntary Inpatient Detox (VID)] Not Details at: This is an Essential Health Benefit described in HSC Sec and Title 28 CCR Allergy Services (testing and desensitization) Ambulance Emergency Transportation Ambulance Non-Emergency Transportation Ambulatory Surgery Center ASC Anesthesia Services Artificial Insemination Not Audiology Services Bariatric Surgery Medical Criteria and Limitations apply. Behavioral Health Therapy for Autism Spectrum Disorders Biofeedback Not Birthing Centers Limitations apply. Blood and Blood Derivative Products Bone Density Testing (DXA) Breast Milk Pumps Cancer Clinical Trials Member and trial must meet specific medical criteria. Certified Nurse Midwife Chemotherapy Chiropractic Services Not Christian Science Practitioners Not Circumcision Not Medically necessary circumcision is covered. Routine or elective circumcision is not covered. Cosmetic or Elective Surgery (not medically necessary) Not Dental (dental providers and services) Liberty Dental 2
3 Dental (medical providers and services related to dental services) Certain prescription drugs, laboratory services, pre-admission physical examinations, anesthesia. Diabetic Services Dialysis Dietitian Services Not Directly Observed Therapy (DOT) for Tuberculosis Durable Medical Equipment Emergency Room Services Enteral and Parenteral Nutrition Erectile Dysfunction Drugs and Therapies Not Experimental and Investigational Services Not Including, but not limited to, services and drugs not approved for therapeutic use in human patients, and services for which efficacy and safety have not been established in human subjects. Family Planning Services Including out of network, from qualified providers. Federally Qualified Health Center (FQHC) services Fluoride Varnish (non-dental provider) Not Gender Reassignment Surgery Procedures that are not medically necessary are not covered. Limited to members 18 & over. Golden Gate Regional Center Services Not Health Education Hearing Aids and Repairs Hearing Screenings and Evaluations HIV Testing and Counseling HIV/AIDS Waiver Home Blood Pressure Cuffs One monitor every 5 years of Omron Series 3, Omron Series 5, or Omron Series 10. Home and Community Based Services (HCBS) Waiver Programs Home Health Care Services Hospice Care Hospital Services - Outpatient and Inpatient 3
4 Hyperbaric Oxygen (HBO) Therapy Hysterectomy Not covered if solely for sterilization. Immunizations In-Home Supportive Services Not Incontinence Creams and Washes Infertility (diagnosis and treatment) Not Injectable Medications Interpreter Services Interpreter services are contracted as a provider service. Laboratory and Pathology Services Laboratory Services State Serum Alphafetoprotein Testing Program Administered by the Genetic Disease Branch of California's Department of Public Health. Providers must submit proof of insurance with their sample, or the member may be billed in error for the service. Lactation Services The ICD-CM diagnosis code on the claim should be a specific diagnosis of the infant. Lead Poisoning Case management (children) Refer to San Francisco Department of Public Health. Local Educational Agency (LEA) Services Described in Title 22 CCR, Sec (b). Long Term Care (LTC) Mammography (for screening) Females only. Maternity and Newborn Care Newborn is covered for first 31 days. Coverage does not extend to dependents after 31 days. Mental Health (Non-Specialty) Refer patients to San Francisco Community Behavioral Health Services. Mental Health (Specialty) (CBHS) Refer patients to San Francisco Community Behavioral Health Services. Health & Safety Code Sections and require coverage of Severe Mental Illness (SMI) and Severe Emotional Disturbance (SED). Non-Medical Equipment Not Nurse Help Line (24/7) 1(877) for all SFHP members. Members assigned to Kaiser call 1(415) Obstetrical and Gynecological Services Occupational Therapy 4
5 Ostomy Supplies Oxygen and Respiratory Services Pain Management Pap Smear / Cervical Cancer Screening Females only. (routine and preventative) Pediatric Day Health Care Not Personal Care Services Not Phenylketonuria (PKU) Screening and Treatment Physical Therapy Podiatry Services Prayer and Spiritual Healing Not Prescription Drugs by DPH. Preventive Care Services Prosthetic and Orthotic Devices Radiology Services (diagnostic, interventional, and therapeutic) Reconstructive Surgery (non-cosmetic) Post-mastectomy reconstructive surgery is covered. Rehabilitation Services Second Opinions Sexual Reassignment Surgery Sexually Transmitted Infections (STI) screening and treatment Skilled Nursing Facility Services Long-Term Care limitations may apply. See Long-Term Care. (outpatient and inpatient) Speech Therapy Sterilization Services Targeted Case Management (TCM) Tobacco Cessation Services Transplant Services Kidney and Cornea Transplant Services Other Major Organs 5
6 Transportation (emergency) Transportation (non-emergency, for medical purposes) Tuberculosis Urgent Care Center Services Vision This benefit is managed by VSP. See: Women, Infants and Children (WIC) 6
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