Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The basic
scope of benefits offered by participating health plans to subscribers and infants
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, subject to the exclusions
listed in this section and Section
2699.301. 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 scope of
benefits shall be as follows:
(1) Health
Facilities
(A) Inpatient Hospital Services:
General hospital services, in a room of two or more, with customary furnishings and
equipment, meals (including special diets as medically necessary), and general
nursing care. All medically necessary ancillary services such as: use of operating
room and related facilities; intensive care unit and services; drugs, medications,
and biologicals; anesthesia and oxygen; diagnostic laboratory and x-ray services;
special duty nursing as medically necessary; physical, occupational, and speech
therapy, respiratory therapy; administration of blood and blood products; other
diagnostic, therapeutic and rehabilitative services as appropriate; and coordinated
discharge planning, including the planning of such continuing care as may be
necessary.
Exclusions: Personal or comfort items or a private room in a
hospital are excluded unless medically necessary.
(B) Outpatient Services: Diagnostic, therapeutic
and surgical services performed at a hospital or outpatient facility. Includes
physical, occupational, and speech therapy as appropriate; and those hospital
services, which can reasonably be provided on an ambulatory basis. Related services
and supplies in connection with these services including operating room, treatment
room, ancillary services, and medications which are supplied by the hospital or
facility for use during the subscriber's stay at the facility.
(2) Durable medical equipment: Medical equipment
appropriate for use in the home which:
1) is
intended for repeated use;
2) is
generally not useful to a person in the absence of illness or injury; and
3) primarily serves a medical purpose. The health
plan may determine whether to rent or purchase standard equipment. Repair or
replacement is covered unless necessitated by misuse or loss. Oxygen and oxygen
equipment; blood glucose monitors and blood glucose monitors for the visually
impaired as medically appropriate for insulin dependent, non-insulin dependent, and
gestational diabetes; insulin pumps and all related supplies; visual aids, excluding
eyewear, to assist the visually impaired with proper dosing of insulin, and apnea
monitors; podiatric devices to prevent or treat diabetes complications; pulmoaides
and related supplies; nebulizer machines, tubing and related supplies, and spacer
devices for metered dose inhalers; ostomy bags and urinary catheters and supplies.
Exclusions: Coverage for comfort or convenience items; disposable
supplies except ostomy bags and urinary catheters and supplies consistent with
Medicare coverage guidelines; exercise and hygiene equipment; experimental or
research equipment; devices not medical in nature such as sauna baths and elevators,
or modifications to the home or automobile; deluxe equipment; or more than one piece
of equipment that serve the same function.
(3) Medical Transportation Services: Emergency
ambulance transportation in connection with emergency services to the first
hospital, which actually accepts the subscriber for emergency care. Includes
ambulance and ambulance transport services provided through "911" emergency response
system.
Non-emergency transportation for the transfer of a subscriber from
a hospital to another hospital or facility or facility to home when:
(A) medically necessary, and
(B) requested by a plan provider, and
(C) authorized in advance by the participating
health plan
Exclusions: Coverage for transportation by airplane, passenger
car, taxi or other form of public conveyance.
(4) Emergency Health Care Services: Twenty-four
hour emergency care for a medical condition manifesting itself by acute symptoms of
a sufficient severity (including severe pain) such that the absence of immediate
medical attention could reasonably be expected to result in any of the following:
(A) Placing the patient's health in serious
jeopardy.
(B) Serious impairment to
bodily functions.
(C) Serious
dysfunction of any bodily organ or part.
This must be provided both in and out of the health plan service
area and in and out of the health plan's participating
facilities.
(5)
Professional Services: Medically necessary professional services and consultations
by a physician or other licensed health care provider acting within the scope of his
or her license. Surgery, assistant surgery and anesthesia (inpatient or outpatient);
inpatient hospital and skilled nursing facility visits; professional office visits
including visits for allergy tests and treatments, radiation therapy, chemotherapy,
and dialysis treatment; and home visits when medically necessary. In addition,
professional services include:
(A) Eye
Examinations: Eye refractions to determine the need for corrective lenses, and
dilated retinal eye exams.
(B) Hearing
tests, hearing aids and services: Hearing tests, hearing aids and services:
Audiological evaluation to measure the extent of hearing loss and a hearing aid
evaluation to determine the most appropriate make and model of hearing aid. Hearing
aid: Monaural or binaural hearing aids including ear mold(s), the hearing aid
instrument, the initial battery, cords and other ancillary equipment. Visits for
fitting, counseling, adjustments, repairs, etc., at no charge for a one-year period
following the provision of a covered hearing aid.
Exclusions: The purchase of batteries or other ancillary
equipment, except those covered under the terms of the initial hearing aid purchase
and charges for a hearing aid which exceeds specifications prescribed for correction
of a hearing loss. Replacement parts for hearing aids, repair of hearing aid after
the covered one-year warranty period, replacement of a hearing aid more than once in
any period of thirty-six months, and surgically implanted hearing
devices.
(C) Immunizations for
infants: Immunizations consistent with the most current version of the Recommended
Childhood Immunization Schedule/United States adopted by the American Academy of
Pediatrics, the Advisory Committee on Immunization Practices (ACIP), and the
American Academy of Family Physicians. Immunizations required for travel as
recommended by the ACIP, and other age appropriate immunizations as recommended by
the ACIP.
Immunizations for Subscribers: Immunizations for adults as
recommended by the ACIP. Immunizations required for travel as recommended by the
ACIP. Immunizations such as Hepatitis B for individuals at occupational risk, and
other age appropriate immunizations as recommended by the ACIP.
(D) Periodic health examinations for infants:
periodic health examinations, including all routine diagnostic testing and
laboratory services appropriate for such examinations consistent with the most
current Recommendations for Preventative Pediatric Health Care, as adopted by the
American Academy of Pediatrics; and the current version of the Recommended Childhood
Immunization Schedule/United States, adopted by the American Academy of Pediatrics,
the Advisory Committee on Immunization Practices, and the American Academy of Family
Physicians.
The frequency of such examinations shall not be increased for
reasons which are unrelated to the medical needs of the infant including: a
subscriber's desire for physical examinations; or reports or related services for
the purpose of obtaining or maintaining employment, licenses, insurance, or a school
sports clearance.
Periodic Health Examinations for Subscribers: Periodic health
examinations including all routine diagnostic testing and laboratory services
appropriate for such examinations.
The frequency of such examinations shall not be increased for
reasons which are unrelated to the medical needs of the subscriber including: a
subscriber's desire for physical examinations; or reports or related services for
the purpose of obtaining or maintaining employment, licenses, insurance, or a school
sports clearance.
(E) Well baby
care during the first two years of life, including newborn hospital visits, health
examinations and other office visits.
(6) Health education services: Effective health
education services, including information regarding personal health behavior and
health care, and recommendations regarding the optimal use of health care services
provided by the plan or health care organizations affiliated with the plan. Health
education services include services related to tobacco use and drug and alcohol
abuse.
Health education services relating to tobacco use means tobacco
use prevention and education services including tobacco use cessation
services.
(7) Nutrition Services:
Direct patient care nutrition services, including nutritional assessment.
(8) Prescription Drugs: Medically necessary
prescription drugs, when prescribed by a licensed practitioner acting within the
scope of his or her licensure. Includes injectable medication and needles and
syringes necessary for the administration of the covered injectable medication. 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. Prenatal vitamins and fluoride supplements included with
vitamins or independent of vitamins, if such vitamins require a prescription.
Medically necessary drugs administered while a subscriber is a patient or resident
in a rest home, nursing home, convalescent hospital or similar facility when
prescribed by a plan physician in connection with a covered service and obtained
through a plan designated pharmacy. Health plans may specify that generic equivalent
prescription drugs must be dispensed if available, provided that no medical
contraindications exist. The use of a formulary, maximum allowable cost (MAC)
method, and mail order programs by health plans is encouraged.
Contraceptive Drugs and Devices: All FDA approved oral and
injectable contraceptive drugs and prescription contraceptive devices are covered
including internally implanted time release contraceptives such as Norplant.
Exclusions: Experimental or investigational drugs, unless accepted
for use by the standards of the medical community; drugs or medications for cosmetic
purposes; patent or over-the-counter medicines, including non-prescription
contraceptive jellies, ointments, foams, condoms, etc.; medicines not requiring a
written prescription order (except insulin and smoking cessation drugs as previously
described); and dietary supplements (except for formulas or special food products to
treat phenylketonuria or PKU), and appetite suppressants or any other diet drugs or
medications.
(9) Reconstructive
Surgery: Reconstructive surgery to restore and achieve symmetry and surgery
performed to correct or repair abnormal structures of the body caused by congenital
defects, developmental abnormalities, trauma, infection, tumors or disease to do any
of the following:
(A) To improve
function
(B) To create a normal
appearance to the extent possible
(C) To
restore and achieve symmetry incident to mastectomy. Services for this purpose
include reconstructive surgery and associated procedures following a mastectomy
which resulted from disease, illness, or injury, and breast prosthesis required
incidental to the surgery.
(10) Transplants:
Coverage for medically necessary organ transplants and bone marrow
transplants which are not experimental or investigational in nature. Reasonable
medical and hospital expenses of a donor or an individual identified as a
prospective donor if these expenses are directly related to the transplant for a
subscriber.
Charges for testing of relatives for matching bone marrow
transplants. Charges associated with the search and testing of unrelated bone marrow
donors through a recognized Donor Registry and charges associated with the
procurement of donor organs through a recognized Donor Transplant Bank, if the
expenses are directly related to the anticipated transplant of a
subscriber.
(11) Maternity Care:
Medically necessary professional and hospital services relating to maternity care
including: pre-natal and post-natal care and complications of pregnancy; newborn
examinations and nursery care while the mother is hospitalized. Includes providing
coverage for participation in the statewide prenatal testing program administered by
the State Department of Health Services known as the Expanded Alpha Feto Protein
Program.
(12) Family Planning: Voluntary
family planning services including counseling and surgical procedures for
sterilization as permitted by state and federal law, diaphragms, and coverage for
other federal Food and Drug Administration approved devices and contraceptive drugs
pursuant to the prescription drug benefit.
(13) Diagnostic X-ray and laboratory Services:
Diagnostic laboratory services, diagnostic and therapeutic radiological services
necessary to appropriately evaluate, diagnose, treat, and follow-up on the care of
subscribers. Other diagnostic services, which shall include, but not be limited to,
electrocardiography, electro-encephalography, prenatal diagnosis of genetic
disorders of the fetus in cases of high-risk pregnancy, and mammography for
screening or diagnostic purposes. Laboratory tests appropriate for the management of
diabetes, including at a minimum: cholesterol, triglycerides, microalbuminuria,
HDL/LDL and Hemoglobin A-1C (Glycohemoglobin).
(14) 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.
Home health services are limited to those services that are
prescribed or directed by the attending physician or other appropriate authority
designated by the plan. If a basic health service can be provided in more than one
medically appropriate setting, it is within the discretion of the attending
physician or other appropriate authority designated by the plan to choose the
setting for providing the care. Plans shall exercise prudent medical case management
to ensure that appropriate care is rendered in the appropriate setting. Medical case
management may include consideration of whether a particular service or setting is
cost-effective when there is a choice among several medically appropriate
alternative services or settings. Exclusions: Custodial care
(15) Physical, Occupational, and Speech Therapy:
Therapy may be provided in a medical office or other appropriate outpatient setting,
hospital, skilled nursing facility or home. Plans may require periodic evaluations
as long as therapy, which is medically necessary, is provided.
(16) Blood and Blood Products: Processing,
storage, and administration of blood and blood products in inpatient and outpatient
settings. Includes the collection and storage of autologous blood when medically
indicated.
(17) Cataract Spectacles and
Lenses: Cataract spectacles, cataract contact lenses, or intraocular lenses that
replace the natural lens of the eye after cataract surgery are covered. Also one
pair of conventional eyeglasses or conventional contact lenses are covered if
necessary after cataract surgery with insertion of an intraocular lens.
(18) Skilled Nursing: Services prescribed by a
plan physician or nurse practitioner and provided in a licensed skilled nursing
facility when medically necessary. Skilled nursing on a 24-hour per day basis; bed
and board; x-ray and laboratory procedures; respiratory therapy; physical,
occupational and speech therapy; medical social services; prescribed drugs and
medications; medical supplies; and appliances and equipment ordinarily furnished by
the skilled nursing facility. This benefit shall be limited to a maximum of 100 days
per benefit year.
(19) Hospice: The
hospice benefit shall include nursing care, medical social services, home health
aide services, physician services, drugs, medical supplies and appliances,
counseling and bereavement services. The benefit shall also include physical
therapy; occupational therapy, speech therapy, short-term inpatient care, pain
control and symptom management. The hospice benefit may include, at the option of
the health plan, homemaker services; services of volunteers, and short-term
inpatient respite care. The hospice benefit is limited to those individuals who are
diagnosed with a terminal illness with a life expectancy of twelve months or less
and who elect hospice care for such illness instead of the traditional services
covered by the plan.
Individuals who elect hospice care are not entitled to any other
benefits under the plan for the terminal illness while the hospice election is in
effect. The hospice election may be revoked at any time.
(20) Orthotics and Prosthetics: Orthotics and
prosthetics including medically necessary replacement prosthetic devices as
prescribed by a licensed practitioner acting within the scope of his or her
licensure, and medically necessary replacement orthotic devices when prescribed by a
licensed practitioner acting within the scope of his or her license. Coverage for
the initial and subsequent prosthetic devices and installation accessories to
restore a method of speaking incident to a laryngectomy, and therapeutic footwear
for diabetics. Also includes prosthetic devices to restore and achieve symmetry
incident to mastectomy.
Exclusions: Corrective shoes and arch supports, except for
therapeutic footwear and inserts for individuals with diabetes; non-rigid devices
such as elastic knee supports, corsets, elastic stockings, and garter belts; dental
appliances; electronic voice producing machines; or more than one device for the
same part of the body. Also does not include eyeglasses (except for eyeglasses or
contact lenses necessary after cataract surgery).
(21) Mental Health:
(A) Inpatient: Plans must provide services with no
visit limits for severe mental illnesses including Schizophrenia, Schizoaffective
disorder, Bipolar disorder (manic-depressive illness), major depressive disorders,
panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or
autism, Anorexia nervosa, Bulimia nervosa, and services for serious emotional
disturbances in children. Plans must provide coverage for up to 30 days per benefit
year for illnesses that do not meet the criteria for severe mental illnesses, and
for conditions that do not meet the criteria for serious emotional disturbances of a
child.
Plans, with the agreement of the subscriber or applicant or other
responsible adult if appropriate, may substitute for each day of inpatient
hospitalization any of the following: two (2) days of residential treatment, three
(3) days of day care treatment, or four (4) outpatient visits.
(B) Outpatient: Plans must provide services with
no visit limits for severe mental illnesses including Schizophrenia, Schizoaffective
disorder, Bipolar disorder (manic-depressive illness), major depressive disorders,
panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or
autism, Anorexia nervosa, Bulimia nervosa, and services for serious emotional
disturbances in children.
Plans must provide up to 20 visits per benefit year for illnesses
that do not meet the criteria for severe mental illness or serious emotional
disturbances of a child. Participating plans may elect to provide additional visits.
Plans may provide group therapy at a reduced copayment.
(22) Alcohol and Drug Abuse:
(A) Inpatient: Hospitalization for alcoholism or
drug abuse as medically appropriate to remove toxic substances from the
system.
(B) Outpatient: Crisis
intervention and treatment of alcoholism or drug abuse on an outpatient basis as
medically appropriate. Participating health plans shall offer at least 20 visits per
benefit year. Participating health plans may elect to provide additional
visits.
1. New section
filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A
Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency language
will be repealed by operation of law on the following day.
2. Certificate
of Compliance as to 12-12-91 order including amendment of subsections (a)(1) and
(a)(10)(D) transmitted to OAL 4-8-92 and filed 5-20-92 (Register 92, No.
21).
3. Amendment filed 5-20-2003; operative 5-20-2003 pursuant to
Government Code section
11343.4
(Register 2003, No. 21).
Note: Authority cited: Section
12696.05,
Insurance Code. Reference: Sections
12696.05 and
12698.30,
Insurance Code.
