Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Health
benefits plans offered under this program shall exclude the following benefits:
(1) Services, supplies, items, procedures or
equipment which 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 less costly 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 and/or services 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, products, drugs, or devices which are
either:
(A) 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, or
(B) Outmoded or not
efficacious.
(7)
Transportation except as specified in Section 1300.67(g) of Title 10 of the
California Code of Regulations.
(8)
Implants, except those that are medically necessary and are neither cosmetic,
experimental, or investigational.
(9)
Sex change operations, reversal of voluntary sterilization, conception by artificial
means, and non-prescription contraceptive supplies and devices.
(10) Eye glasses, contact lenses, routine eye
examinations (including eye refractions) except when provided as part of routine
examination under preventive care for minors, hearing aids, orthopedic shoes,
orthodontic appliances, and routine foot care.
(11) Long-term care benefits, including long-term
skilled nursing care in a licesed facility and respite care are excluded except as a
participating health plan shall determine they are less costly alternatives to the
basic minimum benefits. This section does not exclude short-term skilled nursing
care benefits as provided pursuant to Section
2699.6200(a)(12).
(12) Dental Services and dental
appliances.
(13) Treatment of obesity by
medical and surgical means, except for treatment of morbid obesity. In no instance
shall treatment for morbid obesity be provided primarily for cosmetic
reasons.
(14) Cosmetic surgery, except
as specifically provided in Section
2699.6200(a)(2).
(15) Conditions resulting from acts of war
(declared or not).
(16) Treatment for
any bodily injury or sickness arising from or sustained in the course of any
occupation or employment for compensation, profit or gain for which benefits are
provided or payable under any Worker's Compensation benefit
plan.
(b) A health benefit
plan with a point of service option that is offered by a health maintenance
organization or a health benefit plan with a point of service option that is offered
by an exclusive provider organization may exclude the following benefits and
services when the enrollee receives them from providers who do not contract with the
health maintenance organization or exclusive provider organization or when the
enrollee receives them in violation of the health benefit plan's established
procedures:
(1) outpatient prescription
drugs,
(2) human organ
transplants,
(3) treatment for
infertility, including tests,
(4) mental
health benefits,
(5) outpatient chemical
dependency and alcoholism benefits,
(6)
preventive and health education services.
(c) A health benefit plan with a point of service
option that is offered by a health maintenance organization or a health benefit plan
with a point of service option that is offered by an exclusive provider organization
may exclude coverage for durable medical equipment prescribed by a provider who does
not contract with the health maintenance organization or exclusive provider
organization. However, if the prescription is obtained in accordance with
established health plan procedures coverage shall not be excluded.
1. Renumbering and
amendment of former section
2699.631 to section 2699.6203 filed
5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment of section
heading and new subsections (b)-(c) filed 5-2-96; operative 6-1-96 (Register 96, No.
18).
3. Amendment of subsections (a)(1), (a)(11) and (b)(3) filed 5-8-97;
operative 7-1-97 (Register 97, No. 19).
Note: Authority cited: Section
10731, Insurance
Code. Reference: Section
10731, Insurance
Code.
