Medical and Dental Benefits

Emergency services are those health services that are provided by CMSP network or non-network providers for a medical condition manifesting itself by acute symptoms of recent onset and severity (including, without limitation, severe pain), such that a prudent layperson, possessing an average knowledge of health care and medicine, could reasonably believe that the absence of immediate medical attention could reasonably result in any of the following:

• • Placing your health in serious jeopardy
  • Serious impairment of bodily function
  • Other serious medical consequences
  • Serious and/or permanent dysfunction to any bodily organ or part

CMSP members with a medical emergency should call 911 or go to the nearest emergency room. Emergency services within California and designated border state areas of Arizona, Oregon and Nevada provided by network and non-network providers to CMSP members are covered by CMSP. Emergency services do not require prior authorization by AMM. However, the provider may need to submit medical records to AMM documenting the emergency. CMSP members should call AMM at 1-877-589-6707 after the emergency so follow-up care can be planned.

CMSP will NOT pay for, or reimburse CMSP members for, non-emergency medical services provided by a non-contracting non-CMSP/AMM Network Provider. In addition, CMSP will NOT pay any providers who provide services, including emergency medical services, outside of California and the designated border state areas of Arizona, Nevada and Oregon.

Specific services that are NOT covered by the program include:

• Pregnancy-related services (contact your county eligibility office); infertility services (contact F-PACT); long-term care facility services (contact your county eligibility office); acupuncture services; optometry services (including eyeglasses and contact lenses); cosmetic services; sexual reassignment services; public transportation such as airplane, bus, car, or taxi rides; and, methadone maintenance services
• All services provided outside of the State of California and designated border state areas
• Services provided by providers that do not participate in the CMSP network administered by Advanced Medical Management (excluding emergency services) and the MedImpact Healthcare Systems pharmacy network
• Organ transplants for persons who are eligible for CMSP emergency services only under aid code 50

If a CMSP member needs or desires medical care which is not covered by CMSP, the member must pay for the care or make other arrangements with the provider.

Some CMSP members have a monthly Share of Cost (SOC) obligation, depending on income and family size. With this SOC obligation, a CMSP member must pay, or agree to pay, part of their monthly income towards medical and prescription drug expenses before CMSP will pay for certain CMSP Health Benefits. The CMSP member will be mailed a Notice of Action from the county which includes their SOC amount, if any.

A specific set of primary care benefits are excluded from the Share of Cost requirements. The added benefit provides the following coverage during the member’s CMSP eligibility period:

Primary care and/or specialty care services (with no SOC or copayment) at an in-network provider for:

• Medical office visits with a primary care doctor and/or specialist or for physical therapy services
• Preventive health screenings: annual physical, specific lab tests and cancer screenings
• Specific diagnostic tests and minor office procedures

Prescription drug coverage with a $5.00 copay for each prescription (maximum benefit limit of $1,500 in prescription costs)

Aid Code 50 (Undocumented) Members

For undocumented members, CMSP coverage is limited to services that are medically necessary to address an emergency medical condition as a specific set of primary care benefit services.

The added benefit provides the following coverage during the member’s CMSP eligibility period:

Primary care and/or specialty care services (with no SOC or copayment) at an in-network provider for:

• Medical office visits with a primary care doctor and/or specialist or for physical therapy services
• Preventive health screenings: annual physical, specific lab tests and cancer screenings
• Specific diagnostic tests and minor office procedures

Prescription drug coverage with a $5.00 copay for each prescription (maximum benefit limit of $1,500 in prescription costs)

Advanced Medical Management

(877) 589-6807

Types of Inquiries: Medical, Dental, Selecting a PCP, Grievances and Appeals

Hours of Availability: Monday through Friday, 8 a.m. to 5 p.m. PST