"Healthy Families Plan: Details"
This post includes material from the California Managed Risk Medical Insurance Board,
MRMIB. A summary of the benefits of the Healthy Families Plan, and information about
family contribution requirements.
Healthy Families Plan Benefits Summary
Medical Benefits (Using CALPERS HMO design as benchmark plan)
Hospital
Inpatient hospital services per admission, including physician and
nursing services, no charge
Outpatient hospital services per visit, including physician and
nursing services, no charge
Surgical services: Inpatient, no charge
Outpatient per visit, no charge
Laboratory and radiological services, chemotherapy and renal
dialysis, no charge
Disposable medical supplies while inpatient or which are provided
during visit, no charge
Blood and blood products, no charge
Maternity services, no charge
Physician Services per Visit, $5
Prenatal care, no charge
Well baby and well child exams, no charge
Immunizations, no charge
Allergy testing and treatment, per visit, $5
Disposable medical supplies provided in doctor's office, no charge
Gynecological exam, $5
Hearing exams and testing, $5
Vision screening including eye refractions: one visit per benefit
year, $5
Laboratory and radiological services, no charge
Prescription Drugs, per 30 day supply
(including biologicals, oral contraceptives and diaphragms)
Mental Health
Inpatient: Up to 30 days per benefit year, no charge
At the health plan's discretion, inpatient days may be
substituted as follows: two days of residential treatment
for one day of hospitalization, or three day treatment
program days for one day of hospitalization
Outpatient: Up to 20 visits per benefit year, $5
Substance Abuse Services
Inpatient: Limited to Detoxification, no charge
Outpatient: Limited to 20 visits per benefit year, $5
Durable Medical Equipment, no charge
(including prosthetics and orthotics)
Home Health, no charge
Rehabilitation and Physical, Occupational and Speech Therapy
Inpatient: Subject to periodic review for medical necessity, no
charge
Outpatient: Subject to periodic review for medical necessity, $5
Hospice, no charge
Skilled Nursing Facility Care: up to 100 days per benefit year, no
charge
(custodial care is not covered)
Emergency Care and Urgent Care Services, $5
(use of Emergency Room for non-emergency services is not a benefit)
Ambulance Services: as medically necessary, no charge
Chiropractic: up to 20 visits per benefit year, $5
Maximum annual and lifetime benefits, no maximum
Family annual copayment maximum, $250
No deductibles permitted; No pre-existing condition exclusions permitted
Dental Benefits (Using DPA managed dental plan as model for all
services except orthodontia)
Diagnostic and preventive services, including x-rays, exams, cleanings,
no charge
Basic benefits such as fillings, topical fluoride, sealants, no charge
Crowns, $50
Bridges, partials, dentures, $50
Orthodontia: limited to medically necessary orthodontia, no charge
Annual deductible, maximum annual benefit, none
Vision Benefits (Using DPA state employee plan design as a model)
Eye refractions (exams): once each 12 month period, $10
Spectacle lenses and frames: once each 12 month period, $25
Healthy Families
Family Contribution Requirements
Community Provider Family Value More Expensive
Plan Packages Packages
100-150% fpl $4 per child 7$ per child $7 per child
to max of $8 to max of $14 to max of $14
(plus cost above price to state of (plus cost above price to
Family Value Plan, if applicable) state of Family Value Plan)
151-200% fpl $6 per child $9 per child $9 per child
to max of $18 to max of $27 to max of $27
(plus cost above price to state of (plus cost above price to
Family Value Plan, if applicable) state of Family Value Plan)
Family Value Package = lowest cost combination of health, dental and vision plans in a
geographic region. May also include plans within X% or $X of the lowest cost combination.
Community Provider Plan = combination of health, dental and vision plans which includes
the health plan in each area with highest percentage of traditional and safety net
providers.
*Prepayment discount: When three months are paid in advance, fourth month is free.
Family Size
2 3 4
100% fpl $10,610 $13,330 $16,050
200% fpl $21,220 $26,660 $32,100
"fpl" = Federal poverty level