Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The basic
minimum scope of benefits offered by participating health plans to subscribers,
dependent subscribers and enrolled dependents must comply with all requirements of
the Knox-Keene Health Care Service Plan Act of 1975 including amendments as well as
its applicable regulations, and shall include all of the benefits and services
listed in this section. Except as required by the applicable statute and
regulations, no other benefits shall be permitted to be offered by a participating
health plan unless specifically provided for in the program contract with the
participating health plan. The basic minimum scope of benefits shall be as follows:
(1) Hospital inpatient care in a hospital licensed
pursuant to subdivision (a) of section
1250 of
the Health and Safety Code, including all of the following benefits and services:
(A) Semi-private room, including meals and general
nursing services; and private room and special diets when prescribed as medically
necessary.
(B) Hospital services,
including use of operating room and related facilities, intensive care unit and
services, labor and delivery room, and anesthesia.
(C) Drugs, medications, and parenteral solutions
administered while an inpatient.
(D)
Dressings, casts, equipment, oxygen services, and radiation therapy.
(E) Respiratory and physical therapy.
(F) Diagnostic laboratory and x-ray
services.
(G) Special duty nursing as
medically necessary.
(H) Administration
of blood and blood products.
(I) Other
diagnostic, therapeutic or rehabilitative services (including occupational, physical
and speech therapy) as appropriate.
(J)
Medically necessary inpatient alcohol and substance abuse detoxification.
(K) General anesthesia and associated facility
charges in connection with dental procedures rendered in a hospital, when the
clinical status or underlying medical condition of a subscriber, enrolled dependent
or dependent subscriber requires dental procedures that ordinarily would not require
general anesthesia to be rendered in a hospital. This benefit is only available to
subscribers, enrolled dependents or dependent subscribers under seven years of age;
the developmentally disabled, regardless of age; and subscribers, enrolled
dependents or dependent subscribers whose health is compromised and for whom general
anesthesia is medically necessary, regardless of age.
Nothing in this section shall require a participating health plan
to cover any charges for the dental procedure itself, including, but not limited to,
the professional fee of the dentist.
(2) Medical and surgical services, provided on an
outpatient basis whenever medically appropriate, including all of the following:
(A) Physician services including consultations,
referrals, office and hospital visits and surgical services performed by a physician
and surgeon.
(B) Diagnostic laboratory
services, diagnostic and therapeutic radiological services and other diagnostic
services that shall include but not limited to nuclear medicine, ultrasound,
electrocardiography and electroencephalography.
(C) Dressings, casts and use of castroom,
anesthesia, and oxygen services when medically necessary.
(D) Blood, blood derivatives and their
administration.
(E) Radiation therapy
and chemotherapy, of proven benefit.
(F)
Comprehensive preventive care of adults and children.
1. Comprehensive preventive care of children shall
be consistent with the Recommendations for Preventive Pediatric Health Care as
adopted by the American Academy of Pediatrics in September of 1987.
2. Comprehensive preventive care services for
adults and children shall in include periodic health evaluations, immunizations and
laboratory services in connection with periodic health evaluations.
3. Immunizations for children shall:
a. Be consistent with the most current version of
the Recommended Childhood Immunization Schedule/United States, jointly adopted by
the American Academy of Pediatrics, the Advisory Committee on immunizations
Practices (ACIP) and the American Academy of Family Physicians, unless the State
Department of Health Care Services determines, within 45 days of the published date
of the schedule, that the schedule is not consistent with the purposes of this
section.
b. Include immunizations
required for travel as recommended by the ACIP.
iv. Immunizations for adults shall include:
a. Immunizations for adults as recommended by the
U.S. Public Health Service.
b.
Immunizations required for travel as recommended by the
ACIP.
(G) General anesthesia and associated facility
charges in connection with dental procedures rendered in a surgery center setting,
when the clinical status or underlying medical condition of a subscriber, enrolled
dependent or dependent subscriber requires dental procedures that ordinarily would
not require general anesthesia to be rendered in a surgery center setting. This
benefit is only available to subscribers, enrolled dependents or dependent
subscribers under seven years of age; the developmentally disabled, regardless of
age; and subscribers, enrolled dependents or dependent subscribers whose health is
compromised and for whom general anesthesia is medically necessary, regardless of
age.
Nothing in this section shall require a participating health plan
to cover any charges for the dental procedure itself, including, but not limited to,
the professional fee of the dentist.
(H) Nothing in this section shall preclude the
reimbursement of physician assistants, nurse practitioners or other advanced
practice nurses who provide covered services within their scope of
licensure.
(3) Family planning
services including a variety of prescriptive contraceptive methods approved by the
federal Food and Drug Administration, and reproductive sterilization.
(4) Comprehensive maternity and perinatal care,
including the services of a physician and surgeon, certified nurse midwife or nurse
practitioner, and all necessary hospital services, including services relating to
complications of pregnancy, are covered services. Nothing in this section shall
preclude the direct reimbursement of nurse practitioners or other advanced practice
nurses in providing covered services.
(5) Emergency care including out-of-area coverage.
Emergency ambulance transportation including transportation provided through the
"911" emergency response system.
(6)
Reconstructive Surgery: Surgery to correct or repair abnormal structures of the body
caused by congenital defects, developmental abnormalities, trauma, infection,
tumors, or disease to do either of the following;
(A) improve function.
(B) create a normal appearance to the extent
possible.
Includes reconstructive surgery to restore and achieve symmetry
incident to mastectomy.
(7) Prescription drugs, limited to drugs approved
by the federal Food and Drug Administration, generic equivalents approved as
substitutable by the federal Food and Drug Administration, or drugs approved by the
federal Food and Drug Administration as Treatment Investigational New Drugs. Also
includes insulin, glucagon, syringes and needles and pen delivery systems for the
administration of insulin, blood glucose testing strips, ketone urine testing
strips, lancets and lancet puncture devices in medically appropriate quantities for
the monitoring and treatment of insulin dependent, non-insulin dependent and
gestational diabetes.
(8) Mental Health
benefits, are covered as follows:
(A) For severe
mental illnesses, and serious emotional disturbances of children, inpatient
services, outpatient services, partial hospitalization services and prescription
medications. Severe mental illnesses include schizophrenia, schizoaffective
disorder, bipolar disorder, major depressive disorders, panic disorder,
obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia
nervosa, bulimia nervosa.
(B) Except as
specified in Subsection (A) above, mental health benefits are limited to the
following:
1. Inpatient care for a period of 10
days in each calendar year.
2. 15
outpatient visits in each calendar year.
(9) Medical rehabilitation and the services of
occupational therapists, physical therapists, and speech therapists as appropriate
on an outpatient basis.
(10) Durable
medical equipment, including prosthetics to restore and achieve symmetry incident to
a mastectomy and to restore a method of speaking incident to a laryngectomy. Covered
services also include blood glucose monitors and blood glucose monitors for the
visually impaired for insulin dependent, non-insulin dependent and gestational
diabetes; insulin pumps and all related necessary supplies; visual aids to assist
the visually impaired with proper dosing of insulin and podiatric devices to prevent
or treat diabetes complications.
(11)
Home Health Services: Health services provided at the home by health care personnel.
Includes visits by Registered Nurses, Licensed Vocational Nurses, and home health
aides; physical, occupational and speech therapy; and respiratory therapy when
prescribed by a licensed practitioner acting within the scope of his or her
licensure.
(12) The following human
organ transplants: corneal, human heart, heart-lung, liver, bone-marrow and kidney
transplantation. Transplants other than corneal shall be subject to the following
restrictions:
(A) Pre-operative evaluation,
surgery, and follow-up care shall be provided at centers that have been designated
by the participating health plan as having documented skills, resources, commitment
and record of favorable outcomes to qualify the centers to provide such
care.
(B) Patients shall be selected by
the patient-selection committee of the designated centers and subject to prior
authorization.
(C) Only anti-rejection
drugs, biological products, and other procedures that have been established as safe
and effective, and no longer investigational, are covered.
(13) Hospice services pursuant to Health and
Safety Code section
1368.2.
(14) This part shall not be construed to prohibit
a plan's ability to impose cost-control mechanisms. Such mechanisms may include but
are not limited to requiring prior authorization for benefits or providing benefits
in alternative settings or using alternative methods.
1. New section
filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A
Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency
language will be repealed by operation of law on the following day.
2.
Certificate of Compliance as to 12-20-90 order including amendment of subsections
(a)(3), (8) and (11), transmitted to OAL on 4-18-91 and filed 5-17-91 (Register 91,
No. 27).
3. Editorial correction of printing error in subsection
(a)(1)(C) (Register 91, No. 27).
4. Amendment of section and NOTE filed
3-22-2002 as an emergency; operative 3-22-2002 (Register 2002, No. 12). A
Certificate of Compliance must be transmitted to OAL by 7-22-2002 or emergency
language will be repealed by operation of law on the following day.
5.
Certificate of Compliance as to 3-22-2002 order, including further amendment of
subsections (a)(1)(I), (a)(9) and (a)(11) transmitted to OAL 7-19-2002 and filed
8-29-2002 (Register 2002, No. 35).
6. Amendment of subsections (a),
(a)(1)(K), (a)(2)(G) and (a)(8)(A), repealer of subsection (a)(12)(C) and subsection
relettering filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No.
32). Amendments to remain in effect for 180 days pursuant to section 21, chapter
794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to
OAL by 2-2-2004 or emergency language will be repealed by operation of law on the
following day.
7. Certificate of Compliance as to 8-4-2003 order
transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No.
10).
8. Amendment of subsection (a)(2)(F) and new subsections
(a)(2)(F)1.-3.iv.b. filed 1-14-2009; operative 2-13-2009 (Register 2009, No.
3).
Note: Authority cited: Sections
12711 and
12712, Insurance
Code. Reference: Sections
12711 and
12712, Insurance
Code.
