Medical and Dental Benefits

The information on this page only pertains to the CMSP benefit program. If you’re looking for more information on the Connect to Care program, click the button below:

Services

Advanced Medical Management is responsible for CMSP medical and dental benefits administration. Further information on benefit administration is available at the Advanced Medical Management website at https://cmsp.amm.cc.

To download the CMSP Member Guide, click here.

Find a medical or dental provider.

A wide array of inpatient and outpatient benefits are provided through the CMSP Benefit. Covered services are subject to prior authorization requirements, medical necessity and clinical guidelines, provider network requirements, and/or benefit limits may apply. Please see sections about emergency services, Share of Cost (SOC) requirements, members, and primary care benefit services.

CMSP Covered Services without a SOC (if applicable):

Adult Immunizations
Colorectal Cancer Screening
EKG, Osteoporosis, & DEXA Scan
Mental Health Services (mild to moderate)
Outpatient Substance Use Disorder Services
Physical Therapy
Specified Prescription Medications with a $5 Copay per Prescription ($1500 maximum benefit limit)
Preventative Health Screenings
Primary Care & Specialist Office Visits
Routine Screening & Laboratory Testing
Obesity Counseling (performed by a physician)
Screenings for HIV, HPV, Hepatitis B & C, & STI Screenings
Specified Ultrasound of Head, Neck, Trunk, Upper & Lower Extremities
Specified X-rays of Head, Neck, Chest, Trunk, Upper & Lower Extremities
Tobacco Use Counseling & Intervention (performed by a physician)
Various In-Office Minor Medical Procedures

CMSP Covered Services that May Require a SOC (if applicable):

Acute Inpatient Hospital Care (including acute inpatient rehabilitation & mental health)
Adult Day Health Care
Blood & Blood Derivatives
Chiropractic Services
Chronic Hemodialysis Services
Dental Services (including diagnostic & preventative care, oral surgery & selected endodontic, restorative & prosthodontics services)
Durable Medical Equipment (DME)
Emergency Ambulance Services & medically necessary transportation from the acute hospital to other facilities for medically necessary, specialized, or tertiary care
Family Planning Services, including sterilization (when no other coverage, including F-PACT)
Home Health Agency Services
Outpatient Hospital & Clinic Services
Infusion Therapy
Inpatient & Outpatient Heroin Detoxification Services (excluding methadone maintenance)
Laboratory and Radiology Services
Medical Supplies dispensed by Physicians, Licensed Pharmacies, or Durable Medical Equipment dealers & prosthetic or orthotic providers
Non-Emergency Medical Transportation when medically necessary
Outpatient Audiology Services (including hearing aids)
Outpatient Occupational Therapy & Physical Therapy Services
Outpatient Rehabilitation Services in a Rehabilitation Facility
Physician Services
Podiatry Services
Prescription Drug Services provided by Licensed Pharmacists (CMSP pharmacy services, excluding home infusion therapy, are provided under contract between the CMSP Governing Board & MedImpact)
Prosthetic & Orthotic Appliances
Psychiatric Services (inpatient & outpatient) provided by a licensed, in network psychiatrist
Transplants
Vision Services including eye exams & prescription glasses

Emergency Services

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.

Excluded Services

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:

Acupuncture, including Podiatry-Related Acupuncture Services
Breast & Cervical Cancer Treatment Services when covered by another payer (Breast & Cervical Cancer Treatment Program/Medi-Cal)
Contact Lenses that are not medically necessary
Cosmetic Services
Family Planning Services when covered by other payers (F-PACT)
Hepatitis C Medications when covered by other payers
Long Term Care
Mental Health & Substance Use Disorder Services provided by non-contracted providers
Methadone Maintenance Services
Pregnancy & Infertility Related Services
Public Transportation, such as airplane, bus, car, or taxi rides
Sexual Reassignment Services
Skilled Nursing Facility Services
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

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.

Monthly Share of Cost

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)

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

Medical and Dental Benefits

For Applicants & Members

The information on this page only pertains to the CMSP benefit program. If you’re looking for more information on the Connect to Care program, click the button below: