Hospital services will be given to you for injury or illnesses that need hospitalization including its recurrences and complications. x Hospital services are given at CCRMC
unless the participating provider
(Attending Doctor) is a CPN doctor and chooses to admit patients to another participating hospital;
x A Kaiser Permanente doctor will give services at a Kaiser Permanente hospital; x Sometimes a participating doctor may
refer you to a hospital that is not a participating hospital because of a special medical need; except in an emergency, these services must be okayed in advance by CCHP.
CCHP shall provide or arrange for the following services if medically necessary:
Inpatient Hospital Services
x Semi-private room and board, unless a private room is medically necessary,
including customary furnishings,
equipment, and meals (including special diets as medically necessary);
x General nursing care and special duty nursing when medically necessary; x Use of operating room, special treatment
rooms, delivery room, newborn nursery and related facilities;
x Intensive care unit and services;
x Drugs, medications, biologicals and oxygen administered in the hospital; x Surgical and anesthetic supplies,
dressings and cast materials, surgically implanted devices and prostheses, other medical supplies and medical appliances and equipment administered in the hospital;
x Hospital ancillary services including diagnostic laboratory, X-ray and therapy services including, but not limited to
electrocardiography and
electroencephalography;
x Radiation therapy, chemotherapy and renal dialysis;
x Skilled Rehabilitative Services including physical therapy, speech therapy,
occupational therapy and other
rehabilitation services which are
expected to result in the significant improvement of your condition within a reasonable and generally predictable period of time or to establish an effective maintenance program in connection with a specific disease state or condition; x Other diagnostic and therapeutic services
as medically appropriate, including respiratory therapy;
x Coordinated discharge planning
including the planning of such continuing care as may be needed; x Blood and blood products, as well as the
administration of blood and blood products, including the cost of in- hospital blood processing.
Inpatient Doctor Services
x All doctor and paramedical personnel services asked for or directed by the attending doctor and rendered, including general medical, specialists, surgical and
obstetrical care, referral and
consultation;
x Surgical procedures both major and minor, as found to be medically necessary.
Inpatient Maternity Care
x CCHP covers hospital and doctor services relating to pregnancy and interrupted pregnancy as any other medical condition;
CONTRA COSTA HEALTH PLAN
Medi-Cal Evidence of Coverage & Disclosure Form x Inpatient hospital maternity care covers
normal delivery, Cesarean section, complications or medical conditions arising from pregnancy or resulting childbirth.
Newborn Care
Coverage for subscriber’s baby starts at birth, and continues for the month of birth and the following month, for no less than thirty (30) days. Charges or expenses related
to the testing and treatment of
phenylketonuria (PKU) are covered.
To continue newborn coverage beyond this period:
x The baby must be enrolled in CCHP as a Medi-Cal subscriber before the end of this period;
x It is a good idea to notify your Eligibility Worker when you become pregnant; x You must get a Social Security Number
for the baby and call your Eligibility Worker after the baby is born to add your baby to Medi-Cal;
x Once your newborn is added to Medi- Cal, call the Health Care Options Contractor (HCO) at 1-800-430-4263 to enroll the baby in CCHP.
Length of Hospital Stay for Deliveries and Mastectomies
x CCHP does not restrict benefits for any maternity hospital stay to less than forty- eight (48) hours in the case of a normal vaginal birth, or to less than ninety-six (96) hours in the case of a cesarean section;
x If you and your doctor agree after meeting, you and your baby may be allowed to go home before the forty- eight (48) hour/ ninety-six (96) hour time periods;
x If the doctor orders a follow up, CCHP will give a follow-up visit within forty- eight (48) hours of the time you were
you, the doctor will decide if the visit is at your home or at one of our facilities. For mastectomies and lymph node dissections, the length of stay is to be decided by your doctor after meeting with you. The doctor’s decision will be in line
with sound clinical principles and
procedures.
Emergency Medical Treatment for Alcohol and Substance Abuse Overdose
x Treatment may include the removal of toxic substances from the body;
x Treatment may also be for overdose or adverse reactions to alcohol, narcotic
substances, tranquilizers, sedatives
and/or psychotropic substances;
x Treatment will continue only until you are medically stable;
x Except for this coverage, CCHP does not cover inpatient alcohol and substance abuse treatment.
Skilled Nursing Facility Care
Subject to all inpatient hospital service provisions, medically necessary Skilled Nursing Facility care services for the treatment of an illness or injury, including subacute and/or custodial care, will be covered:
x When given in a participating Skilled Nursing Facility and;
x When prescribed by your PCP, and; x Okayed by CCHP.
This benefit is covered for month of admission and following month after which patient can be disenrolled from CCHP and converted to Fee-For-Service Medi-Cal for continued coverage. Hospice is not long term care.
To the extent required by law, CCHP does not require you to be placed only in a Skilled Nursing Facility which is a
CONTRA COSTA HEALTH PLAN
Medi-Cal Evidence of Coverage & Disclosure Form
Rev. 08.21.14 EOC-30 Medi-Cal 2014-2015_EOC
a Skilled Nursing Facility following a hospital admission.
Subacute Care
New payment methods, cost controls and advances in technology have led to shorter hospital stays and increased use of alternative or subacute settings for care. One of these alternatives for patients who need nursing care is a Skilled Nursing Facility. Other types of subacute care are covered to the same extent as described above in Skilled Nursing Facility Care. If you have any questions about CCHP’s subacute care policy, please call the Authorizations Unit at 1-877-661-6230 (press 4).
BENEFITS AVAILABLE ON AN