Good health is a way of life in California. Because we know how important maintaining your health is to you, the Personal CaliforniaCare Plan was developed to help you stay well - and to give you the right level of care when you need it.
CaliforniaCare is a Health Maintenance Organization (HMO) plan developed by Blue Cross of California and CaliforniaCare Health Plans to provide you with health care that won't cost you a lot of money. A Health Maintenance Organization, or HMO, is a network of doctors and hospitals that have contracted with a health care services provider to offer its members comprehensive health care without the paperwork and expense of conventional health care plans. By contracting with physicians and hospitals we can provide you with comprehensive health care for a set fee, no matter how many times you visit your physician.
CaliforniaCare also offers you a choice in your HMO. The CaliforniaCare Plan offers all the comprehensive benefits of an HMO plan with no deductibles and low co-payments. CaliforniaCare Saver Plan offers the same outstanding benefits at a lower cost with a $1,500 annual deductible.
Next choose a Primary Care Physician from the PMG(s) or IPA(s) selected on your application. Covered family members may pick any physician within the PMG or IPA they have chosen. The Primary Care Physician will be the person to call first whenever medical care is needed - from routine visits to emergency situations. That's all there is to it! If you need specialized treatment, your Primary Care Physician coordinates the referral.
The chart below is intended as a reference to help you decide whether or not Personal CaliforniaCare is right for you. All benefits are subject to the exclusions or limitations summarized later in this brochure and as described in full detail in your Service Agreement that you will receive from Blue Cross if you are accepted for coverage under this plan.
| Choice of Provider | Only Participating Medical Group (PMG) or Independent Practice Association (IPA) selected at enrollment and any referrals from PMG or IPA to other providers or specialists. |
| Calendar Year Deductible | None for CaliforniaCare Plan, $1,500 for CaliforniaCare Saver Plan |
| Co-payment Limit (member's maximum out-of-pocket expenses per calendar year)* | Member only: $2,000 Two-party or Family: $4,000 combined limit |
| Lifetime Protection | No maximum. |
| Service | Co-pay | Benefit |
|---|---|---|
| Physician office visits, specialist/consultant services and allergy testing, injections and treatment | $10 | 100% after co-payment |
| Inpatient care: Room accommodations‡ Ancillary services‡ | None | 100% for covered charges rendered in a contracting hospital§ when authorized by your PMG. |
| Inpatient care: Professional Services | None | 100% for inpatient surgery & anesthesia, radiation therapy, patient physician visits. |
| Normal pregnancy care/delivery & Ceasarean section (subject to $1,000 deductible) (Conception must occur on or after Effective Date of Coverage.) | None | 100% for covered professional services after deductible. 100% for covered inpatient hospital and ancillary services after deductible. |
| Elective abortion | $250 none | 100% for covered professional services after co-payment 100% for covered inpatient services |
| Complications of pregnancy including therapeutic abortion | None None | 100% for covered professional services 100% for covered inpatient services |
| Family planning services/Tubal ligation | $250 None | 100% for covered professional services after co-payment 100% for covered inpatient services. |
| Family planning services/Vasectomy | $150 None | 100% for covered professional services after co-payment 100% of covered inpatient services |
| Organ transplants & hemodialysis‡ | None | 100% for covered professional services (See "Exclusions & Limitations"). 100% for covered inpatient services (See "Exclusions & Limitations") |
| Mental or nervous disorders† | 20% | 80% for covered inpatient services for substance abuse detoxification only. |
| Mental or nervous disorders† | $25 per visit | 100% for outpatient services up to 20 visits per year after co-payment. |
| Mental or nervous disorders† (Inpatient psychiatric) | No benefit | |
| Rehabilitative care** | None $10 per visit | 100% for covered inpatient services 100% for covered outpatient services after co-payment |
| Ambulance (ground or air)‡ | $50 per transport | No charge for ambulance service if member receving service is admitted as an inpatient |
| Skilled nursing facility‡ | None | 100% for covered expense up to 100 days per year |
| Durable medical equipment‡ (when authorized by both your PMG/IPA and Blue Cross of California) | 20% | 80% for covered rental or purchase charges; covered charges not to exceed $2,000 per member, per year. |
| Professional Services | Inpatient Services | Outpatient Services |
|---|---|---|
| In Area-when authorized by your PMG. No co-payment. Plan pays 100% of customery & reasonable charges | In Area-when authorized by your PMG. No co-pay. Plan pays 100% for covered charges in a contracting hospital. | In Area-when authorized by your PMG. $50 co-pay***. Plan pays 80% for covered charges after co-pay. |
| Out of Area-more than 20 miles from your PMG. 20% co-pay. Plan pays 80% of customary & reasonable charges up to $10,000 per year. | Out of Area-more than 20 miles from your PMG. No co-pay. Plan pays 100% of covered charges up to 21 days per year. | Out of Area-more than 20 miles from your PMG. $100 co-pay***. Plan pays 100% for covered charges up to $5,000 per year after co-pay. |
| Service | Co-pay | Benefit |
|---|---|---|
| Periodic routine check-ups, vision and hearing examinations | $10 | 100% after co-payment. |
| Well baby care, well child care and specified immunizations | $10 | 100% after co-payment. |
| Medical social services and health education. | None | Some services may be subject to a co-payment. Check with your CaliforniaCare Coordinator. |
