Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Health
benefit plans offered under this program shall exclude all of the following:
(1) Any benefits specified as excluded within
Section 2699.6700.
(2) Any benefits in excess of limits specified in
Section 2699.6700.
(3) Services, supplies, items, procedures or
equipment, which are not medically necessary as determined by the plan, unless
otherwise specified in Section
2699.6700.
(4) Any benefits that are received prior to the
subscriber's effective date of coverage. This exclusion does not apply to covered
benefits to treat complications arising from services received prior to the
subscriber's effective date of coverage.
(5) Any benefits that are received subsequent to
the time the subscriber's coverage ends.
(6) Experimental or investigational services,
including any treatment, therapy, procedure, drug or drug usage, facility or
facility usage, equipment or equipment usage, device or device usage, or supply
which is not recognized as being in accordance with generally accepted professional
medical standards, or for which the safety and efficiency have not been determined
for use in the treatment of a particular illness, injury or medical condition for
which the item or service in question is recommended or prescribed. This section
does not exclude clinical trials for cancer patients as provided pursuant to
subsection 2699.6700(a)(21).
(7) Medical services that are received in an
emergency care setting for conditions that are not emergencies if the subscriber
reasonably should have known that an emergency care situation did not
exist.
(8) Eyeglasses, except for those
eyeglasses or contact lenses necessary after cataract surgery which are covered
under Subsection
2699.6700(a)(3)(A).
(9) The diagnosis and treatment of infertility is
not covered unless provided in conjunction with covered gynecological services.
Treatments of medical conditions of the reproductive system are not
excluded.
(10) Long-term care benefits
including long-term skilled nursing care in a licensed facility and respite care are
excluded except as a participating health plan shall determine they are less costly,
satisfactory alternatives to the basic minimum benefits. This section does not
exclude short-term skilled nursing care or hospice benefits as provided pursuant to
Subsection 2699.6700(a)(13) and
(a)(18).
(11) Cosmetic surgery that is solely performed to
alter or reshape normal structures of the body in order to improve
appearance.
1. New section
filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate
of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be
repealed by operation of law on the following day.
2. Certificate of
Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register
98, No. 29).
3. Amendment of subsections (a)(8)-(a)(11), new subsection
(a)(13) and amendment of NOTE filed 4-29-2002 as an emergency; operative 4-29-2002
(Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a
Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency
language will be repealed by operation of law on the following day.
4.
Certificate of Compliance as to 4-29-2002 order, including repealer of subsection
(a)(10) and subsection renumbering, transmitted to OAL 10-28-2002 and filed
12-12-2002 (Register 2002, No. 50).
5. Amendment filed 9-15-2008;
operative 10-15-2008 (Register 2008, No. 38).
Note: Authority cited: Sections
12693.21 and
12693.755,
Insurance Code. Reference: Sections
12693.21,
12693.60 and
12693.755,
Insurance Code.
