Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The basic
scope of benefits offered by participating carriers as a health benefits plan shall
include all of the benefits and services listed in this section, subject to the
exclusions listed in Section
2699.6203. No other benefits shall be
permitted to be offered by a participating carrier. The basic scope of benefits
shall be as follows:
(1) Those benefits described
in Section 1300.67 of Title 10 of the California Code of Regulations.
(2) Plastic and reconstructive surgical services
limited to the following:
(A) Surgery to correct a
physical functional disorder resulting from a disease or congenital
anomaly.
(B) Surgery to correct a
physical functional disorder following either an injury or incidental to any other
surgery.
(C) Reconstructive surgery and
associated procedures following a mastectomy which resulted from disease, illness,
or injury, and internal breast prosthesis required incidental to the
surgery.
(3) 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 or classified as Group C cancer drugs by the
National Cancer Institute to be used only for the purposes approved by the federal
Food and Drug Administration or the National Cancer Institute.
(4) Mental Health benefits, limited to the
following:
(A) Inpatient care in a health facility
licensed pursuant to Chapter 2 of Division 2 of the Health and Safety Code (Section
1250 et seq.), for a total of ten (10) days in each benefit year,
1. Residential treatment may be substituted for
inpatient care days at a ratio of two (2) residential treatment days to one (1)
inpatient day, and
2. Intensive
outpatient treatment may be substituted for inpatient care days at a ratio of three
(3) intensive outpatient days to one (1) inpatient day.
(B) Twenty (20) outpatient visits in each benefit
year.
(5) Outpatient medical
rehabilitation and the outpatient services of occupational therapists, physical
therapists, and speech therapists for treatment of acute conditions or the acute
phase of chronic conditions if such conditions are subject to continuing significant
improvement within a period of two (2) months.
(6) Durable medical equipment, prosthetic devices,
orthotic devices and oxygen and oxygen equipment, limited to equipment and devices
which:
(A) are intended for repeated use over a
prolonged period,
(B) are not considered
disposable, with the exception of ostomy bags,
(C) are ordered by a licensed health care provider
acting within the scope of his or her license,
(D) are intended for the exclusive use of the
enrollee,
(E) do not duplicate the
function of another piece of equipment or device covered by the carrier for the
enrollee,
(F) are generally not useful
to a person in the absence of illness or injury,
(G) primarily serve a medical purpose,
and
(H) are appropriate for use in the
home.
Medically necessary repair or replacement of covered durable
medical equipment, prosthetic devices, and orthotic devices is a benefit when
prescribed by a physician or ordered by a licensed health care provider acting
within the scope of his or her license, and when not caused by misuse or
loss.
(7) Human organ
transplants, including reasonable medical and hospital expenses of a donor or
individual identified as a prospective donor if the expenses are directly related to
the transplant, other than corneal, shall be subject to the following restrictions:
(A) Preoperative evaluation, surgery, and
follow-up care shall be provided at centers that have been designated by the
participating carrier 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.
(8) Chemical dependency and alcoholism benefits,
limited to the following:
(A) Detoxification of
chemical dependency or alcohol abuse,
(B) Outpatient treatment limited, at the
participating carrier's discretion, to either of the following:
1. A maximum payment of $20 per day, and a maximum
payment of $400 per person for all outpatient chemical dependency and alcoholism
benefits in each benefit year, or
2.
Alternative arrangements that have been approved by the program and are described in
the carrier's evidence of coverage document.
(9) Hospice care when a participating health plan
determines it is a less costly alternative to other of the basic minimum
benefits.
(10) Home health care and home
health services as described in Section
1374.10(b)
of the California Health and Safety Code. This does not preclude a carrier from
providing other health care benefits in the home.
(11) Supplies, equipment, and services for the
treatment and/or control of diabetes, even when such items, tests and services are
available without a prescription, including:
(A)
Supplies and equipment such as:
1.
insulin,
2. syringes,
3. lancets,
4. insulin pumps and all related necessary
supplies,
5. ketone urine testing strips
for type I diabetes,
6. blood glucose
meters, and
7. blood glucose meter
testing strips in medically appropriate quantities for:
a. the monitoring and treatment of insulin
dependent diabetes
b. the monitoring and
treatment of non-insulin dependent diabetes
c. the monitoring and treatment of diabetes in
pregnancy
(B)
Diabetes education programs,
(C)
Laboratory tests appropriate for the management of diabetes, including at a minimum:
cholesterol, triglycerides, microalbuminuria, HDL/LDL and Hemoglobin A-1C
(Glycohemogolobin), and
(D) Dilated
retinal eye exam
(12)
Short-term skilled nursing care provided in a skilled nursing facility or a skilled
nursing bed in an acute care hospital, limited to a maximum of sixty (60) days in
each benefit year.
This benefit does not cover conditions which are long-term or
chronic in nature and require ongoing inpatient skilled nursing care, other than
care for an acute phase of such a condition, or care at the inception of such a
condition which is appropriate for stabilization prior to release from inpatient
care.
(13) 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.
(14) Nothing in this section
shall preclude the direct reimbursement of physician assistants, nurse practitioners
or other advanced practice nurses who provide covered services within their scope of
licensure.
1. Relocation of
article heading and renumbering of former section
2699.630 to section 2699.6200 filed
5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment of
subsection (a) filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No.
21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency
language will be repealed by operation of law on the following day.
3.
Certificate of Compliance as to 5-23-94 order transmitted to OAL 9-16-94 and filed
10-27-94 (Register 94, No. 43).
4. Amendment of subsection (a)(6), new
subsections (a)(6)(A)-(H), (a)(10)-(12) and subsection renumbering filed 5-8-97;
operative 7-1-97 (Register 97, No. 19).
Note: Authority cited: Section
10731, Insurance
Code. Reference: Section
10731, Insurance
Code.
