Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Plans
offered under this program shall exclude the following benefits unless specifically
provided for in the program contract with the participating health plan:
(1) Services that are not medically necessary.
"Medically necessary" as applied to the diagnosis or treatment of illness is an
article or service that is not investigational and is necessary because:
(A) It is appropriate and is provided in
accordance with accepted medical standards in the state of California, and could not
be omitted without adversely affecting the patient's condition or the quality of
medical care rendered; and
(B) As to
inpatient care, it could not have been provided in a physician's office, in the
outpatient department of a hospital, or in a lesser facility without adversely
affecting the patient's condition or the quality of medical care rendered;
and
(C) If the proposed article or
service is not commonly used, its application or proposed application has been
preceded by a thorough review and application of conventional therapies;
and
(D) The service or article has been
demonstrated to be of significantly greater therapeutic value than other, less
expensive, services or articles.
(2) Any services which are received prior to the
enrollee's effective date of coverage.
(3) Custodial, domiciliary care, or rest cures for
which facilities of a general acute care hospital are not medically required.
Custodial care is care that does not require the regular services of trained medical
or health professionals and that is designed primarily to assist in activities of
daily living. Custodial care includes, but is not limited to, help in walking,
getting in and out of bed, bathing, dressing, preparation and feeding of special
diets, and supervision of medications which are ordinarily
self-administered.
(4) Personal or
comfort items, or a private room in a hospital unless medically necessary.
(5) Emergency facility services for nonemergency
conditions.
(6) Those medical, surgical
(including implants), or other health care procedures, services, drugs, or devices
which are either:
(A) Services, products, drugs or
devices which are experimental or investigational or which are not recognized in
accord with generally accepted medical standards as being safe and effective for use
in the treatment in question.
(B)
Outmoded or not efficacious.
(7) Transportation except as specified in section
2698.301(a)(5).
(8) Implants, except cardiac pacemakers,
intraocular lenses, screws, nuts, bolts, bands, nails, plates, and pins used for the
fixation of fractures or osteotomies and artificial knees and hips; and except as
specified in section
2698.301(a)(6).
(9) Sex change operations, investigation of or
treatment for infertility, reversal of sterilization, and conception by artificial
means.
(10) Eyeglasses, contact lenses
(except the first intraocular lens following cataract surgery), routine eye
examinations, including eye refractions, except when provided as part of a routine
examination under "preventive care for minors," hearing aids, orthopedic shoes,
orthodontic appliances, and routine foot care are excluded.
(11) Long-term care benefits including home care,
skilled nursing care, and respite care, are excluded except as a participating
health plan shall determine they are less costly alternatives to the basic minimum
benefits.
(12) Dental services and
services for temporomandibular joint problems are excluded, except for repair
necessitated by accidental injury to sound natural teeth or jaw, provided that the
repair commences within 90 days of the accidental injury or as soon thereafter as is
medically feasible.
This language shall not be construed to exclude surgical
procedures for any condition directly affecting the upper or lower jawbone, or
associated bone joints.
(13)
Treatment of chemical dependency except as specified in section
2698.301(a)(1)(J).
(14) Cosmetic surgery, except as specifically
provided in section
2698.301(a)(6).
(15)
(A)
Maternity care for a subscriber who (a) enrolled in the program with an effective
date on or after February 1, 2012, and (b) has entered into an agreement to serve as
a paid surrogate mother. For purposes of this section, an agreement to serve as a
paid surrogate mother is an agreement entered into, in advance of the pregnancy,
under which the subscriber agrees to become pregnant and deliver a child for another
person as the intended parent, in exchange for monetary compensation other than
actual medical or living expenses.
(B)
Participating health plans shall not withhold, or seek reimbursement from, a
participating provider who rendered maternity services excluded pursuant to this
section when the provider had not been notified that the Subscriber had entered into
an agreement to serve as a paid surrogate mother.
(b) Benefits which exceed $75,000 in a calendar
year under the program for a subscriber, a subscriber's enrolled dependent or a
dependent subscriber shall be excluded.
(c) Benefits which exceed $750,000 in a lifetime
under the program for a subscriber, a subscriber's enrolled dependent or dependent
subscriber shall be excluded. Benefits received prior to January 1, 1999 shall be
counted toward the $750,000 lifetime maximum.
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 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)(8) (Register 91, No. 27).
4. Amendment of
subsection (a)(14) and NOTE filed 1-14-93; operative 2-16-93 (Register 93, No.
3).
5. Amendment of subsections (b) and (c) filed 12-24-98 as an
emergency; operative 12-24-98 (Register 98, No. 52). A Certificate of Compliance
must be transmitted to OAL by 4-23-99 or emergency language will be repealed by
operation of law on the following day.
6. Certificate of Compliance as to
12-24-98 order transmitted to OAL 4-6-99 and filed 5-10-99 (Register 99, No.
20).
7. Amendment of subsections (a)(7)-(10), (a)(12)-(13), (a)(15) and
(b)-(c) 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.
8. Certificate of Compliance as to 3-22-2002 order, including
further amendment of subsection (a)(13), repealer of subsection (a)(14), subsection
renumbering and amendment of newly designated subsection (a)(15), transmitted to OAL
7-19-2002 and filed 8-29-2002 (Register 2002, No. 35).
9. Amendment of
subsections (a)(11) and (a)(13)-(14), repealer of subsection (a)(15) and amendment
of subsections (b)-(c) 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.
10. Certificate of Compliance as to 8-4-2003
order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No.
10).
11. New subsection (a)(15) filed 12-9-2011 as an emergency;
operative 12-9-2011 (Register 2011, No. 49). A Certificate of Compliance must be
transmitted to OAL by 6-6-2012 or emergency language will be repealed by operation
of law on the following day.
12. Certificate of Compliance as to
12-9-2011 order, including redesignation of subsection (a)(15) as subsection
(a)(15)(A) and new subsection (a)(15)(B), transmitted to OAL 6-6-2012 and filed
7-19-2012 (Register 2012, No. 29).
Note: Authority cited: Sections
12711 and
12712, Insurance
Code. Reference: Sections
12711 and
12712, Insurance
Code.
